Inspection on 04/09/06 for Nada Nursing Home

This inspection was carried out on 4th September 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Nada Nursing Home 05/04/07

Nada Nursing Home 26/06/06

Nada Nursing Home 19/01/06

Nada Nursing Home 07/06/05

Nada Nursing Home 27/10/04

Nada Nursing Home 29/04/04

Nada Nursing Home 09/02/04

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

CARE HOMES FOR OLDER PEOPLE Nada Nursing Home 451 Cheetham Hill Road Cheetham Hill Manchester M8 9PA Lead Inspector Geraldine Blow Key Unannounced Inspection 4th October 2006 09:30 X10015.doc Version 1.40 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 Nada Nursing Home DS0000021566.V313107.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 Older People. 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. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nada Nursing Home Address 451 Cheetham Hill Road Cheetham Hill Manchester M8 9PA 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) 0161 720 7728 Mr Pierre Grenade Mr Pierre Grenade Care Home 28 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home is registered for a maximum of 28 service users of either sex over 60 years of age suffering from either mental disorder or dementia. The maximum number of service users requiring nursing care shall be 17 and the maximum number of service users requiring personal care only shall be 11. Registration is subject to compliance with the minimum staffing levels indicated in the Notice served in accordance with Section (25) 3 of the Registered Homes Act 1984 issued on 6th March 2002. Staffing for the service users assessed as requiring personal care only must comply with the minimum levels set out in the Residential Forum Guidelines for Staffing in Care Homes for Older People. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th June 2006 Date of last inspection Brief Description of the Service: Nada Nursing and Residential Care Home provides accommodation with nursing and personal care for a maximum of 28 older people. The care home is able to offer accommodation to 17 older people assessed as requiring nursing care and 11 residents assessed as requiring personal care only. At the time of the inspection there were 21 residents living at the home The home is owned and operated by Mr Pierre Grenade, who is both the registered person and the manager. The home is situated in the Cheetham Hill area of North Manchester close to local shops, Manchester City centre, social, cultural and recreational amenities. The home consists of a converted large detached house with a large, modern extension within its own small grounds. The home is able to offer off-the-road parking for approximately five vehicles in addition to the homes mini-bus. All rooms have wash hand basins and commode chairs. The home has two floors, which can be accessed by a passenger lift. There are six double and sixteen single bedrooms. There are no en-suite rooms. There are a number of communal areas for residents to choose from or, if they Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 5 prefer, they can spend time in their own rooms. The home offers a limited number of in house social activities Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in June 2006. This information includes an Action Plan sent in response to a Statutory Requirement Notice that was issued in September 2006, due to concerns regarding the poor management of medication found at the last inspection. The provider/manager was also requested to provide an improvement plan setting out how he intends to address the shortfalls in the homes practice and management. To help write the report information provided by other agencies was also used. During the unannounced inspection site visit time was spent talking with the owner/manager, the home’s administrator, people who live at the home, observing how staff work with people and taking to staff on duty. Documents and files relating to residents and how the home is run were also seen and a tour of the building was made. The inspection report of June 2006 highlighted a number of areas that the home needed to work on and improve. The home had addressed some of the changes needed from the last inspection report. However, some remain outstanding and have been repeated again in this report. The inspection was an opportunity to look at all the key standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. What the service does well: What has improved since the last inspection? The last inspection report in June 2006 found a number of areas that the home had to put right and change. From the information provided by the provider/ manager and the inspection site visit it was found that some improvements had been made. The last inspection report and previous reports had required that the home’s recruitment practices must be improved in order to protect the residents living Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 7 there. Since the last inspection, the home had recruited one new member of staff. It was pleasing to note that all the necessary safety checks had been made on that person. The last and previous inspection reports made requirements that the smoking lounge must be provided with furnishings and fixtures that are fit for their intended purpose. To meet this requirement the lounge has been redecorated, new flooring has been laid and wooden chairs have been provided. Also the main reception area had been redecorated and so had one of the bedrooms. As required in the last inspection report all residents had been given a written contract which included the terms and conditions of their residency. Also the home had developed a complaint procedure, which was on display in the home, and the provider/manager said all residents had been given a copy. A requirement was made in the last inspection report and previous reports that the home must have a policy on privacy and dignity, which includes such matters as opening personal mail. This requirement had been met. To ensure the safety of the residents and the staff who work at the home a requirement was made that a full risk assessment is carried out on all the residents who smoke. The provider/manager said this had been completed and evidence of this was seen in the residents files looked in. The last inspection report required that there must be sufficient numbers of trained staff employed at the home. From the evidence seen during this visit it appeared that this requirement had been met. Since the last inspection the provider/manager had successfully completed the Registered Managers Award. What they could do better: The provider/manager said that since the last inspection he had reviewed the individual care plans of the residents. However, a number of shortfalls were seen. For example some of the care plans looked at contained outdated information and although the care plans had been signed as being reviewed each month the actual plan of care had not been updated. Since the last inspection the provider/manager said that he had appointed a senior carer to assume responsibility as the activity co-ordinator. However this person had not been given allocated hours for this role and was doing it during their normal work hours. It is recommended that the arrangement be made more formal and allocated hours be made available. Following the last inspection, due to a number of concerns regarding the unsafe systems for the handling of medication a Statutory Requirement Notice Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 8 was issued. A number of improvements to the system had been made and the provider/manager was signing on a daily basis that medication had been given correctly. However some areas of concern were still outstanding with errors noted in the management of medication as detailed in pages 15 and 16 of this report. To ensure that residents are not put at risk the provider/manager must develop and implement a formal system for auditing medication. The last inspection report identified that staff were not receiving the training needed to assist and support them in their work with vulnerable people. Since the last visit staff now have an individual training and development plan and some training had been provided, however staff still have not received all the training needed to carry out their work. In particular the majority of staff have not done the Protection of Vulnerable Adult training. The training is necessary to ensure that the residents are assisted by staff who are competent, appropriately trained and qualified to enable them to provide care that meets the residents’ needs. The last inspection report identified that the home was not promoting residents’ dignity nor was it addressing the wide and diverse range of needs, which includes health and cultural needs. Evidence was seen that a privacy and dignity policy had been developed but the individual plans of care were not seen to promote privacy, dignity or address cultural needs. The last inspection report identified that some fixtures, fittings, carpets and décor were in a poor state of repair and the home did not provide residents with a comfortable homely environment. As already stated in this report some areas had been improved and in particular the dining room had been cleaned and new net curtains fitted. However, the recommendation that the provider/manager conduct an audit of the home’s furnishings and decoration and that a programme of maintenance and renewal of furnishings and decoration be produced had not been met. The provider/manager said that he was in the process of completing the audit. 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. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Information about the home was available to give to prospective residents. EVIDENCE: The Service User Guide and the Statement of Purpose had been updated and a copy of both documents was supplied to the Commission as required in the last inspection report. Evidence was seen that since the last inspection visit residents had been provided with a written statement of the terms and conditions of residency. The provider/manager said that prior to any new admissions taking place he obtained a copy of the care managers’ assessment for the prospective resident. He also said that it was now his intention to undertake a pre admission assessment of needs in order to be sure that the home can meet all the identified needs of the prospective resident. A blank pre admission assessment sheet was seen, however it is recommended that this be reviewed Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 11 in order to be sure it covers all the necessary assessment needs and provides sufficient space to document the residents’ needs. The service did not provide intermediate care. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Plans were in place but required further work to ensure residents’ health, personal and social care needs are fully met. The systems and procedures for dealing with medicines need to improve in order to protect residents. EVIDENCE: A random sample of care plans was examined. It was found that numerous parts of the assessments and plans of care had not be signed or dated by the person completing them. For example a pre admission assessment had not been signed or dated and in one care plan the personal details on admission had been re-written and had not been signed or dated. Documentary evidence was seen that one particular plan of care had been reviewed on a regular basis. However, it was noted that the care plan had not been updated accordingly to reflect changes in care. For example, the plan of Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 13 care stated that the resident required a build up drink ‘ensure’. The provider/manager said that the resident was no longer on the build up drink but the care plan had not been updated to reflect this. Evidence was seen that not all the plans of care had been regularly reviewed. For example, one care file contained a risk assessment for “falls when drunk”. The risk assessment was dated 20/10/05 and there was no evidence that it had been reviewed since that date. One of the plans of care contained inaccurate information. The waterlow assessment stated “below waist spinal”. The provider/manager was asked to explain what this statement referred to and he said that the information was inaccurate. There was no evidence of resident/representative involvement in the development or reviews of the plans of care. The last inspection report identified the importance of promoting and preserving residents’ dignity. Residents were seen to be appropriately dressed and a privacy and dignity policy had been developed and implemented. In addition one care file examined had a standard statement promoting residents’ dignity. However, there was no evidence in the individual plans of care that privacy and dignity was being promoted and maintained. This was discussed with the provider/manager during the inspection visit. As already stated in this report following the last inspection report the home were issued with a Statutory Requirement Notice in relation to management of medication. Some improvements have been made such as the resident’s drug profile sheet had been updated, regular drug fridge temperature was been recorded, details were now been provided of the consistency required for individual residents requiring drink thickeners and contact details of the Speech and Language Therapist were readily available for staff if advice was needed regarding the thickening of drinks. In the action plan provided by the provider/manager in response to the Statutory Requirement Notice he indicated that he was checking on a daily basis that medication was being administered correctly and that he was signing on a daily basis to evidence this. However as detailed below this was not the case and discrepancies were found. The provider said that the home has a photocopy of the GP’s original prescription for reference. However, these were not seen during this inspection and the provider manager did not know where they were kept. A list of staff signature was seen, however there were gaps and not all the staff on the list had provided a signature. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 14 There were hand written alterations to the Medication Administration Sheets (MAR) which had not been signed, counter signed or dated e.g. Erythromycin, Amoxicillin and Ibrufen Gel and handwritten instructions for Lactulose. One resident was prescribed Salbutamol and no recording had been made on the MAR sheet. On examination of 4 residents MAR sheets together with a count the physical stock held for those residents it appeared that medication was not being given but was signed for as being given. For all 4 residents an excess of stock of medication was found The signatures and recording of the amount of medication given for one resident was not easily identified. Although the provider/manager had signed on a daily basis that medication had been given as prescribed it was clear from the evidence found that this was not the case and a clear audit trail could not be evidenced. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Residents were supported to maintain some choices and preferences of lifestyles including choice of meals. Limited activities were provided for residents EVIDENCE: As referenced at in the last inspection report residents said that they have choices in their routines and daily living activities. As already referenced in this report the provider/manager has nominated a senior carer to assume responsibility of activity co-ordinator. However this person performing this role during her normal working hours and it is recommended that that the arrangement is made formal and allocated hours be made available. Since the last inspection visit, a questionnaire has been sent to residents in order to ascertain their social interests. Evidence was seen of a limited activity programme, which includes dominos, bingo and music therapy. The provider/manager described a number of 1 to 1 activities that took place within the home that were not being recorded. These activities included such things as shopping trips and visits to church. It is recommended Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 16 that the results of the activity questionnaire be incorporated into individual social plans of care. The menu board on display in the main lounge allowed residents to identify the meals for the day and provided them with a choice of food. A tour of the kitchen was made. The kitchen was found to be clean and well organised. Adequate supplies of food were seen which included fresh fruit and vegetables. The residents’ spoken to regarding the meals said that they were happy with the meals provided. Since the last inspection a quality catering and food questionnaire had been given to residents which they had completed with the help of the staff. The results from the questionnaire were encouraging. The appearance of the dinning room was much improved since the last inspection. Although the room had not been decorated or the furniture replaced the room and furniture had been thoroughly cleaned, new net curtains had been purchased and the each table had a tablecloth and flowers in place. The provider/manager said that furniture and décor of the dinning room was to be included in the overall audit of the homes’ furnishing and decoration and would be included in the programme of maintenance and renewal of fabric and decoration. It was noted that the cupboards in the dining continued to be used to store bedding as identified in the last inspection report. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service A complaint procedure was in place, however residents were not fully protected from abuse, as staff have not received the appropriate training. EVIDENCE: As required in the last inspection report the provider/manager had developed and implemented a complaint policy. The provider/manager said that all residents have been given a copy of the policy and it was on display within the home. No complaints had been made since the last inspection and the provider/manager and the administrator said that they keep a record of all complaints made which includes copies of correspondence and any investigations. Since the last inspection visit the provider/manager had developed a Protection of Vulnerable Adults (POVA) policy. However this must be reviewed and amended, as it does not accurately reflect the Adult Protection Procedures, ‘No Secrets Guidance’. In order to protect the residents living at the home this must be done as a matter of some urgency. Evidence was seen that some staff members had attended POVA training. All staff must receive POVA training, which includes the actions to be taken in the event of an allegation of abuse. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Some areas of the home are poorly maintained and some furnishings are inadequate to meet residents’ needs. EVIDENCE: As already referenced in this report some areas of the home had been redecorated and this was supported by observations made. However, the provider/manager said that the other areas identified in the last inspection report such as the poor standard of bedroom furniture and carpets had not been replaced. He said he was in the process of undertaking an audit of the homes furnishings and decoration. He said that he would then produce a programme of maintenance and renewal. The provider/manager said that some general repair work had been undertaken within the home. Unfortunately records were not kept of general maintenance work that had been undertaken. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 19 A recommendation has been made that records are kept of all maintenance work undertaken. A requirement was made in the last 2 inspection reports that risk assessments must be undertaken with regard to aids, adaptations and equipment used in the home. Risk assessments had been completed regarding residents not having footrests on their wheel chairs and the provider/manager said that no other equipment was currently being used at this time. A requirement made at the last inspection was that a risk assessment must be completed for those residents who smoke. Evidence was seen that the risk assessment had been competed for those residents whose files were case tracked during the inspection. However the provider/manager said that he had completed the risk assessment of all residents’ who smoke. Generally the home appeared reasonable clean and tidy however there was a slight odour of urine on entering the home. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The homes recruitment procedure appeared to protect the residents. Not all staff had received the required training. EVIDENCE: From reviewing the weekly staff rota and observations it appeared that the home were employing staff in sufficient numbers to meet the needs of the residents accommodated. Since the last inspection the home had recruited one new member of staff. Their personnel file contained all the appropriate documentation as required by Schedule 2 of The Care Homes Regulations 2001 and the appropriate safety checks had been undertaken. This meets the requirement made at in the previous 3 inspection reports. It is hoped that this practise is continued and will be inspected at future inspections. From the evidence seen it appeared that staff were receiving supervision sessions. Since the last inspection visit each member of staff now has an individual training and development record. It was evident from reviewing these records that staff had not received all the appropriate training. Evidence was seen of Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 21 some training being undertaken, which included Fire Awareness and Infection Control. However, the provider/manager must provide the Commission of the arrangements to ensure that all staff are appropriately trained and supported to assist them in their work and meet residents assessed needs. The home had an induction checklist and had a copy of the Skills for Care induction process and said they were using this as there own induction. The new member of staff confirmed that she had completed the checklist but had not had any other induction training. This does not meet the requirement made at the last inspection and therefore it has been reiterated in this report. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management practice of the home had improved but still did not fully maintain the health, safety and welfare of residents and staff. EVIDENCE: The last inspection report evidenced that there was no clear management structure in the home and that the provider/manager appeared to basically oversee the general running of the home. In an attempt to address this situation a job description has been drawn up for the provider/manager and he said that he had verbally spoken to staff to say that any issues have to be addressed directly with him or in his absence with the nurse in charge. In addition, the provider/manager said that he had arranged a meeting, for the Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 23 week beginning the 8 October 2006, to formally inform the staff of the homes management structure. This proposed structure still seems vague and unstructured. The requirement made in the last inspection report has been reiterated that the registered person must clearly demonstrate how the home will be appropriately managed. It is recommended that the Statement of Purpose and the Service User Guide be updated to include this information. Evidence was seen that the provider manager had successfully completed the Registered Managers Award in August 2006. It was encouraging that in an attempt to review the quality of the service questionnaires had been given to residents regarding social activities and the food provided with in the home. In addition, the provider/manager said that some questionnaires had also been sent to GP’s, District Nurses, the Chiropodist and the Optician and he was awaiting a response from them. This process must be expanded on so that the provider/manager can evidence that he has implemented a continuous self-monitoring, objective, quality assurance system to review the service being delivered to the residents. The results of the quality review questionnaires should be analysed and a quality report produced. Evidence was seen that the systems in place did safe guard residents’ financial interests. There was a running balance and receipts were kept if purchases were made on behalf of a resident. The fire logbooks were inspected during this visit and were found to be up to date and accurate. The last fire awareness training was on 13 July 2006. Staff spoken to confirmed that the fire alarms are checked on a weekly basis. Written evidence was provided that the home’s maintenance certificates and records were up to date. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement 1. Care plans must included details of resident’s personal and social needs and these must be recorded on individual files. Previous timescale of 08/12/04 and 07/08/05 had not been met. 2. The registered provider must ensure that the resident’s plan of care are regularly reviewed and update to ensure that the resident’s needs are met. 3. Unless it is impracticable the registered provider must ensure that residents/representatives are consulted regarding their written plan of care. The registered provider must ensure: 1. All information recorded regarding residents medication is accurate. 2. All medication can be accounted for by means of a clear and accurate audit trail. Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 26 Timescale for action 31/10/06 2. OP9 13 23/10/06 3. All medication is administered in accordance with the prescribers current directions. Previous timescale in the Statutory Requirement Notice of 30/9/06 had not been met. The registered person must ensure that care plans are written to include details of how staff will maintain and promote individuals dignity. (Previous timescale of 30/6/06 had not been me. The registered provider must provide an improvement plan of how he intends to improve the physical environment of the home to ensure that the environment is safe and pleasant for residents. The registered person must make sure that staff receive induction to assist them in their work. (Previous timescale of 14/04/06 & 28/7/06 had not been met). 2. Evidence must be provided that all staff have undertaken the necessary and appropriate training needed to assist them in their work with older people. This must include, for example, basic food hygiene, moving and handling and first aid. The registered person must clearly demonstrate how the home will be appropriately managed. (Previous timescale of 30/7/06 had not been met). 3. OP10 12 31/10/06 4. OP19 23 31/10/06 5. OP30 12,13,18 06/11/06 6. OP31 10 & 12 31/10/06 Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP3 OP7 OP9 Good Practice Recommendations It is recommended that the pre admission assessment document is reviewed and updated. It is recommended that all parts of the individual plans of care are singed and dated by the person completing them. The registered person should make sure that handwritten entries on the MAR’s are signed by the member of staff making the entry and countersigned by a second member of staff, to check the accuracy. 1. It is recommended that the home record the 1 to 1 activities that take place residents within the home. 2. It is recommended that the results of the activity questionnaire be incorporated into individual social plans of care. It is recommended that the bedding stored in the cupboard in the dinning room be stored in a more appropriate place. 1. It is recommended that the registered provider reviews and amends the POVA policy to ensure that it accurately reflects the Adult Protection Procedures ‘No Secret Guidance’. 2. It is recommended that all staff receive POVA training which includes the actions to be taken in the event of an allegation of abuse being made. It is recommended that the registered provider keep records of any maintenance work that is undertaken within the home. It is recommended that Statement of Purpose and the Service User Guide be updated to include the management structure of the home. It is recommended that a system for reviewing the quality of the service being provided be implemented and that the results of such a quality review are analysed and a report is produced and published based on the results. 4. OP12 5. 6. OP15 OP18 7. 8. 9. OP19 OP31 OP33 Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Nada Nursing Home DS0000021566.V313107.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!