Inspection on 26/04/07 for Miramar Nursing Home

This inspection was carried out on 26th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Miramar Nursing Home 25/04/06

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Miramar Nursing Home Miramar Nursing Home 20 Trusthorpe Road Sutton On Sea Lincs LN12 2LT Lead Inspector Dawn Podmore Key Unannounced Inspection 26th April 2007 09:00 Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Miramar Nursing Home Address Miramar Nursing Home 20 Trusthorpe Road Sutton On Sea Lincs LN12 2LT 01507 442484 01507 443313 elliesmee@yahoo.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Super Care Limited ** Post Vacant *** Care Home 28 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (28) of places Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Mental Disorder requiring Nursing Care, not falling within any other category (MD) 24. Mental Disorder requiring Personal Care, not falling within any other category (MD) 4. The maximum number of service users to be accommodated is 28. Date of last inspection 30th August 2006 Brief Description of the Service: Miramar is a detached property located near to the sea front and the town centre of Sutton on Sea, which has a range of local shops and facilities. The home is registered to provide nursing and residential care to people with mental health needs. Accommodation is provided on 2 floors in 10 single and 9 double bedrooms, with communal areas being situated on the ground floor. A lift allows access to the first floor. A car park is available at the front of the building. There is a purpose-built day centre next to the home but this is currently not in use by service users, though it is used occasionally for accommodation for staff in flats on the second floor. At the time of the inspection the home confirmed that the weekly fees ranged from £361 - £534 depending on the residents assessed needs. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report, is available from the main office. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took any previous information held by C.S.C.I. about the home into account. This included a random inspection, which took place in August 2006. The inspection included a site visit, which took place over five hours. The main method of inspection used was called case tracking. This involves selecting a proportion of residents and tracking the care they receive through the checking of records, discussions with staff that care for them and observation of care practices. A partial tour of the home was also conducted which included looking at some bedrooms, and communal areas. Documentation was sampled and the care records of three residents were examined. Interviews with residents and staff took place; this included the acting manager. Survey forms were also used to gain peoples views on the service they were receiving; nineteen of the twenty one returned to the Commission had been completed with the assistance of staff. On the day of the visit 21 people were living at the home. What the service does well: What has improved since the last inspection? What they could do better: Although care plans, which tell staff about the care and support people require, contained some good information about residents care needs, they need to be improved so that they provide clearer guidance for staff. The main areas for improvement are in relating to any potential risks associated with caring for Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 6 people, such as manual handling, nutrition, and pressure damage. The plans also need to provide a more person centred approach to meeting resident’s needs, such as their leisure and daily living needs as well as how they prefer to be supported. The proprietors need to arrange for the repair or replacement of the window frames at the front of the home and any furniture that is not in a satisfactory condition. The providers should have identified these issues during their visits to the home. There was no evidence that the providers had carried out their monthly visits to the home, which should include assessing the service provided, speaking to residents and staff, and recording any areas that need attention. Staff had received a basic induction to the home, but the content was inadequate. It did not differentiate between nurses and care staff so could lead to peoples needs not being met and staff not being aware of their specific responsibilities. Currently there is no Registered Manager employed and the acting manager will be retiring shortly. To ensure that residents receive a consistent service and the home continues to operate adequately the proprietors need to recruit a manager as soon as possible. There were several other areas that needed some attention. The manual handling assessment form should be reviewed so that it provides clearer guidance to staff. The facilities for residents who smoke should be monitored so that it does not affect other residents. Staff should receive appropriate specialist training and regular supervision sessions. Lastly the providers should summarise the information collected from resident’s surveys and use this information to evaluate the service they provide. This should then be made available to people using the service so that they can see how the provider has addressed any issues they have raised. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to help people decide if the home can meet their needs and to tell them how the home operates. A satisfactory admission procedure ensures that prospective residents are fully assessed before admission to ensure that the home is able to meet their needs. EVIDENCE: Since the last key inspection the home has reviewed the Statement of Purpose and Service Users Guide, which provide people with information about how the home operates. They have been updated so that people can decide if the home offers the type of care they are looking for. A copy of the Service Users Guide was available in each bedroom. The home has an admission policy, which includes assessing resident’s needs before admission. Although residents were unable to remember if they had been assessed before they came to live at the home, records and staff comments confirmed that detailed assessments had taken place. They also showed that people had the opportunity to visit the home prior to admission and had been offered a weekend trial stay. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in care planning and risk assessment documentation puts residents and staff at risk and could lead to peoples needs not being met. Residents are encouraged to have control of their daily lives within their capabilities. EVIDENCE: Each resident had an individual plan, which contains information about his or her care needs, and risks or restrictions associated with their care. However the information was not always comprehensive enough. For example staff comments and the daily records for one of the residents showed that they exhibited some unpredictable behaviour, but the care plan did not contain any guidance for staff about this subject. Comments and records highlighted that another resident was at risk of developing pressure sores and their nutritional intake varied. Although the resident had no pressure sores, and staff comments showed that food supplements were available, there were no assessments regarding nutrition and care plans did not cover these subjects in Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 10 enough detail. Information about how individual residents preferred their care to be delivered was limited and would benefit from additional information. One resident who had limited mobility and used a hoist to transfer did not have an assessment of their manual handling needs. The acting manager immediately completed the assessment therefore an immediate requirement notice was not issued on this occasion. Other files seen contain manual handling assessments, but it was recommended that the content be expanded to provide clearer guidance to staff. Another area that needed further development was regarding people’s day-today lives and social stimulation. Records did not provide sufficient detail about what people preferred to do and how staff would facilitate this. Not all residents are able to make safe and informed decisions and choices due to the complex nature of their needs. Staff said that they tried to make sure that residents were as involved as possible in making choices about their daily lives. Risk assessments regarding people making cups or tea and going out of the home alone were contained in care records. Twenty one residents had completed surveys, most with the assistance of staff, and returned them to the Commission. Comments from these, and from people spoken with on the day, were positive about the care they received. They said, ‘they are always nice to me’ and ‘I have no problems, the care staff are very patient with me and see to all my needs’. Staff demonstrated a good understanding of the resident’s needs and how to minimise any behavioural issues. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are not fully supported to follow their chosen lifestyle although any restrictions placed on them are recorded and explained to them. People living at the home benefit from a well balanced menu, which offers choice. EVIDENCE: At the Random inspection in August it was highlighted that although residents spoken with were satisfied with the amount and variety of activities provided they did not confirm that they were supported to develop any independence skills. Care records seen at the visit did not identify or document how each resident’s life skills and independence was to be promoted or met. At this visit records still did not demonstrate that residents had access to appropriate social stimulation and life skills. Care planning in this subject was limited and in one case there was no plan for social needs at all. The home had a printed sheet that gave care staff ideas about what residents might like to participate in, but the lack of clear documentation made it impossible to see Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 12 which resident had participated in which activity. Residents spoken with confirmed that they went out on walks and played bingo, which they enjoyed, but they did not outline any other stimulation available. Comments in returned surveys included ‘I listen to music all day or watch television’, ‘I get up anytime of day and I do what I want to at all times’, ‘I don’t want to do the things they do, but I do go to the library and shops’ and ‘I go out whenever I feel like it’. There were no relatives at the home on the day of the visit but some residents confirmed that they visited relatives and maintained in contact with people they cared for. Residents were observed eating their lunch in the dining room, the meal appeared to be nutritionally balanced and well presented. The menu for the midday meal was written on a board in the dining room so that residents could see what choices were offered. Staff said that other alternatives were also available if residents did not like what was on the main menu. The acting manager said that since the last inspection residents have been more involved in menu planning at the home, this was confirmed in the content of the minutes of residents meetings. People commented, ‘it’s very good’ and ’I don’t eat much but the food is good’. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory processes for the provision of personal and health care support, which meet the needs and wishes of the residents. EVIDENCE: People said that they were happy with the way staff cared for them and that they supported them to attend hospital and doctors appointments. Records and staff comments showed that residents had access to outside agencies such as doctors, psychiatrists, and had attended hospital appointments as needed. The home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. The midday medication round was observed and the procedure followed showed that medications were being administered safely. Medications were also seen to be stored safely and records were well maintained. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory procedures for handling complaints and people felt confident that any concerns would be addressed appropriately. Residents are protected by the home’s procedures for handling allegations of adult abuse. EVIDENCE: The home has a complaints procedure, which tells residents and relatives how to make a complaint and how it will be handled. This has been revised since the last inspection and is displayed in the home. It is also included in the Service Users Guide, which is available in every bedroom. Information provided stated that the home had received no complaints in the last year. However the Commission received a complaint from a residents in 2006 regarding the behaviour of a resident, this was looked into by social services who felt that the home had handled the issues appropriately. Residents spoken with and those who returned surveys said that they knew how to complain and felt comfortable highlighting any issues they were not happy with. However one person who returned a survey form commented that staff did not always bring them a cup of tea early in the morning when asked to, they said ‘they say I must wait and have it all together’. The last comments was discussed with the acting manager who confirmed that residents could have a drink whenever they wanted one. This was discussed with the acting manager who said that drinks were available at anytime. There are satisfactory procedures in place relating to safeguarding adults. However at the random inspection it was highlighted that staff needed a better Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 15 understanding of adult protection and whistle blowing. Staff comments and records showed that appropriate training had been provided with further sessions planned, this included whistle blowing. The home had highlighted a potential abusive situation to social services and the Commission last year. This was reported, managed and resolved appropriately. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home live in a clean and comfortable environment, but some décor and furniture is in poor condition. EVIDENCE: A partial tour of the home took place; this included 3 bedrooms, kitchens, communal areas and bathrooms. It showed that some areas were looking shabby and in need of redecoration or replacement furniture purchased. For example, the window frames at the front of the building had flaking paint and looked in poor repair. The chairs in the smoking lounge were shabby with tears in the upholstery and the dining room was stark and unwelcoming, with a selection of mismatched furniture. At the key inspection last April it was highlighted that some attention needed to be given to making the home more comfortable and homely, and less institutionalised. With the exception of the small sitting room, which adjoins the games room, the general appearance of the home remains the same. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 17 Residents are able to personalise their own rooms if they wish, and some had done so. Curtains are available in shared rooms to provided residents with privacy. The home was clean, tidy and odour free throughout. There is a small lounge allocated as a smoking room, which was quite smoky when entered. The proprietor needs to make sure that good ventilation is available so that it does not affect other people living at the home. At the key inspection in April 2006 it was pointed out that the staff toilet did not have paper towels available to reduce the risk of cross infection, this had been addressed. Residents said, ‘it always smells nice’, ‘I am quite happy with the environment, it’s lovely and clean’ and ‘my room is very good’. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive a good level of support from a staff team, which had been robustly recruited and well trained. However the induction process for new staff is inadequate, which could lead to peoples needs not being met. EVIDENCE: Staffing rotas showed that there is always a qualified nurse on duty who is assisted by three care assistants during the day two care assistant at night. At the visit in August some care staff were working as domestics due to staff sickness but during this visit separate cleaning staff were on duty. The acting manager said that sometimes care staff filled in for the cook and domestic, but this was allocated outside their carer hours. The home has a good recruitment procedure in place. Records included an application form, 2 satisfactory written references and a C.R.B. (Criminal Records Bureau) certificate. Records were examined regarding staffs induction to the home, which is given to make sure that new staff have all the essential information they need to carry out their job. The content was very basic and did not differentiate Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 19 between qualified and care staff. Neither did it include arrangements for shadowing a member of staff if they had been employed prior to a full C.R.B. clearance being received, this is necessary for anyone employed with just a P.O.V.A (Protection of Vulnerable Adults) check. Records and staff comments confirmed that staff had received essential training, as well as some specialist training. This included: manual handling, fire safety, cross infection, adult protection and equality and diversity. Although most staff had attended specialist training in the past it was recommended that the training plan for 2007 include topics such as mental health subject so that new staff had access to these courses. Information provided by the management team showed that 4 of the 10 care staff employed at the home had completed an N.V.Q. (National Vocational Qualification) course in care. This was confirmed by records and staff comments. This course helps to make sure that carers have the knowledge and skills to provide a good standard of care. Records and staff comments showed that staff support sessions had taken place, but it was difficult to evaluate how regular this had been because all records were stored in one file, which was not indexed. It was recommended that the system be reviewed, so that the home could clearly demonstrate that all staff were receiving regular formal supervision and appraisal. No minutes from staff meetings were available and staff confirmed that there had been no recent meetings. Staff did however say that they felt very well trained and supported. Staff were observed speaking with residents in a patient, kindly and supportive way. Residents commented: ‘I am happy with the staff’, ‘the cleaner is very good’, ‘the carers are all good’, ‘some are better than others, but they are mostly good’ and ‘they are kind and helpful’. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Guidance is being provided to staff to ensure that residents receive a satisfactory standard of care, but there is no Registered Manager to consistently oversee the service provided. Residents say they are generally happy with the service they receive but processes in place do not fully reflect residents views and opinions. Peoples health, safety and welfare needs are protected by clear policies and procedures, and detailed record keeping. EVIDENCE: The home does not have a Registered Manager. Since the last key inspection the acting manager has been overseeing the day to day running of the home but she is due to leave in July 2007. A full time administrator is also employed to take responsibility for the administrative record keeping, booking training and bringing in contractors to service and complete any repairs necessary in the home. It is important that the proprietors recruit a suitable person to Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 21 undertake the manager’s role as soon as possible to ensure that the standard of care remains satisfactory. The company have a basic system in place to find out if people are happy with the way the home is run. This includes: resident meetings and surveys. Although surveys had been carried out in January 2007 the acting manager said that the information gathered had not yet been evaluated. People said that they were satisfied with the way the home operated. Residents and staff said, ‘there has been no real change since the new owners took over, things run smoothly’, the owners come to the home, but they don’t walk round and talk to people’ and ‘we have never seen the new owners’. The provider needs to visit the home at least monthly to ensure that the home is being well managed and people are happy with the service provided. Following the visit they must produce a report highlighting what they found and what people said to them. The acting manager could not provide any evidence that these visits had taken place or that action was being taken to address any areas needing attention, such as the furniture in the smoking lounge. As there is no Registered Manager, the proprietors need to assess the running of the home to ensure that resident’s needs are being met and the environment is satisfactory. There are a range of policies and procedures regarding health and safety available to guide and instruct staff. There is also a system in place to service and maintain the equipment in the home on a regular basis. Information provided to the Commission prior to the visit and sampling on the day of the visit showed that appropriate checks on equipment such lifts and fire equipment had taken place. Records showed that the fire officer had visited the home and made several recommendations and in a follow up visit he reported that all of these had been addressed. Examination of the fire records showed that fire bells had been tested on regular basis and equipment serving was up to date. The Environmental Health Officer visited the home in June. He made several recommendations all of which the acting manager said had been addressed. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 3 X Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1) Requirement Care plans must contain detailed information regarding peoples needs and preferences so that they provide clear guidance to staff as to what care is needed and how it should be delivered so that residents receive appropriate support. Any risks associated with peoples care needs, such as manual handling and pressure, must be assessed and management strategies put in place so that potential risks to residents and staff are minimised. Records must demonstrate what people’s daily living and recreational needs are and how they are being met so that they receive appropriate support and stimulation The previous timescale of 30/11/06 was not fully met. The environment must be maintained at a suitable level so that residents live in a good standard of accommodation. This includes the repair or replacement of window frames DS0000066650.V335767.R01.S.doc Timescale for action 01/08/07 2 YA6 13 (4) (c) &5 01/06/07 3. YA14 15 and 16 (2) (n) 01/07/07 4 YA24 23 (2) (b) & (c) 01/09/07 Miramar Nursing Home Version 5.2 Page 24 5. YA35 18 6. YA37 8 7. YA41 26 and any furniture that is in a poor condition. The manager must be able to 01/07/07 demonstrate that new staff have received an adequate initial induction to the home and its procedures, so that resident’s well being is safeguarded. A suitable manager must be 01/08/07 appointed to be responsible for the day-to-day operation of the home so that residents receive a good service and a consistent level of care. The provider must visit the home 01/06/07 unannounced at least monthly and produce a written report of his findings so that he can evaluate the level of service being provided and any issues needing addressing. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA6 YA24 YA35 YA36 YA39 Good Practice Recommendations The form used to record manual handling assessments should be reviewed to make sure it provides clear instructions for staff. The smoking room should be monitored to make sure that the smoky atmosphere does not affect other residents living at the home. The training plan for 2007 should include specialist subjects, such as mental health awareness, so that any new staff have access to suitable training. The system in place to record staff supervision sessions should be reviewed so that it is easy to evaluate how regular sessions have been provided. The providers should summarise the information collected from resident’s surveys and use this information to evaluate the service they provide. This should then be made available to people using the service so that they DS0000066650.V335767.R01.S.doc Version 5.2 Page 25 Miramar Nursing Home can see how the provider has addressed any issues they have raised. Miramar Nursing Home DS0000066650.V335767.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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