Inspection on 05/04/07 for Nada Nursing Home

This inspection was carried out on 5th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 04/09/06

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 Val Bell Unannounced Inspection 5th April 2007 10:00 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.V334522.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.V334522.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.V334522.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. 4th September 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.V334522.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.V334522.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 4th October 2006 and supporting information provided by the home prior to the visits to the home. Additionally, twenty-one people living in the home provided information by completing satisfaction surveys. The visit to the home forms part of the overall inspection process and the lead inspector conducted two visits during daytime hours on Thursday 5th and Friday 13th April 2007. The opportunity was taken to look at the core standards of the National Minimum Standards (NMS) The inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visit time was spent with people living in the home and discussions were held with a relative, staff and the home manager. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: People have their personal and healthcare needs assessed by care managers and the home prior to their admission. This enables the service and the individual the opportunity to decide if the home can meet the assessed needs. The home adopts the philosophy of respecting people’s dignity and privacy and this was observed from interactions between staff and people living in the home during both visits. The daughter of a man living in the home said that her father was well cared for and was happy living in the home. She added that staff communicate any concerns that they have. People living in the home praised the standard of food provided, saying that they were afforded choice at mealtimes and snacks and drinks at any time. The home is able to cater for special diets, such as diabetic, vegetarian and Halal. The home has robust policies and procedures in place to keep people safe and care is taken to ensure that the right kind of staff are recruited to work with people living in the home. Attention is given to ensuring that regular maintenance checks are carried out by qualified people on the homes electrical and gas equipment and fire and other health and safety records are kept up to date Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: One requirement and twelve good practice recommendations were set during this inspection. One issue of concern, which has been re-iterated in the previous four inspection reports, is the homes failure to develop assessments and care plans that meet the social care needs of people living in the home. Very little written evidence existed to confirm that people are enabled to follow their chosen lifestyles and develop their full potential from experiencing inclusion within their local community. Although care plans had been reviewed monthly there was little evidence recorded that measured the progress of people in achieving their personal goals. Consequently, it was recommended that staff be provided with training in care planning from a person-centred perspective to ensure that people engage in activities and social situations that are right for them as individuals. Further recommendations were made as follows. Current copies of the homes Statement of Purpose and Service User Guide should be forwarded to the Commission. Two people living in the home should have their medication reviewed to ensure that they are receiving the correct levels of medication and Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 8 people living in the home should be asked for their views on the care they receive and the standard of the environment they live in. Recommendations relating to the environment were made as follows. Unused mobility equipment was stored inappropriately and should be removed and some bedroom curtains looked unsightly as they were hanging off their rails. New legislation about smoking in public places comes into force in July 2007 and the home was advised to seek guidance from the environmental health department on how it would affect smoking in the home. Finally, it was recommended that the owner undertake research into dementiafriendly design to ensure that people living in the home that suffer from memory loss can develop more independence in an environment that meets their specific needs. 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. Nada Nursing Home DS0000021566.V334522.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.V334522.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People admitted to the home could be confident that their health and personal care needs would be identified and recorded. EVIDENCE: The inspector was told by the nurse-in-charge that the homes Statement of Purpose and Service User Guide had been updated as recommended since the last inspection although copies were not examined during the visit. A recommendation was made for a copy of these documents to be forwarded to the Commission. Care manager and in-house assessments of need detailing individuals’ health and personal care needs were in place on a sample of three files examined. A recommendation was made to review and update the in-house assessment of need to include a personal history, wherever possible and a social needs assessment. The social needs assessment should include a persons likes and Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 11 dislikes, their social interests, hobbies, relationships and religious and cultural needs. This information will help the staff to know and understand the whole person and will be useful in developing a social needs care plan that maintains individuals preferred lifestyles and provides opportunities for personal growth. Assessments of need should be signed by the individual, wherever possible, to indicate that they have been fully involved in the process. The home did not provide an intermediate care service. Nada Nursing Home DS0000021566.V334522.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home are offered protection from harm by the operation of a safe system of medication administration. Lack of detail relating to social care needs in care plans potentially places the wellbeing and personal fulfilment of people living in the home at risk. EVIDENCE: A sample of three care plans was examined during the visit. It was encouraging to find that some improvements had been made to the system of care planning such as monthly reviews, the recording of outcomes of health appointments and daily records contained more detail. However, further development was needed to achieve the required standard. More attention needs to be paid to developing care plans that focus on meeting the social care needs of people living in the home from a person-centred perspective. It is very important that people have access to regular indoor and community activities to develop their potential and maintain their preferred lifestyle. The purpose of care plan reviews is to accurately measure the progress people Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 13 have made towards achieving their personal goals. The reviews examined failed to take this into account. For example, one of the care plans recorded a personal goal as follows ’he should be encouraged to continue involvement in the Irish society group.’ This persons review made no mention of any progress in this area. Three similar examples were found in the care plan sample and feedback on each one was given to the Registered Mental Nurse on duty on 05/04/07. It is of concern that significant progress in the area of care planning has not been achieved as expected despite requirements set at inspections undertaken over a period of several years. It is recommended that the registered manager undertake a review of care planning in the home and considers providing person-centred care plan training for the staff. It was encouraging to find that significant progress had been made to implement a safer system of medication administration since the last key inspection in October 2006. A sample audit was undertaken of the medication administration records and stock held for four people living in the home. Medication records were clear and accurate and a full audit train was in place. Tablet and liquid medication held for three people living in the home was accurate in line with the balances recorded in the medication records. However, liquid medication for a fourth person did not agree with the amount that should have been in stock according to the medication records. It was not clear whether staff had been administering 2.5mls or 5mls due to the ambiguity of the prescriber’s instructions. This may have accounted for the discrepancy. It was recommended that this person’s medication be reviewed with his general practitioner so that nursing staff have clear instructions on the correct dosage to be administered. One person’s medication was prescribed ‘as required’ although it was noted that the medication was being administered most days. It was also recommended that this be reviewed with the person’s general practitioner. It was pleasing to see that the manager had posted a notice on the office window outlining the philosophy of the home by reminding staff that they must treat people living in the home with dignity and respect at all times. The notice also reminded staff of the standards required of them when delivering personal care. Throughout the two visits to the home staff were observed to treat people living in the home with respect and dignity. Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home were afforded some choices in relation to diet and routines that included limited opportunities for activities of interest. People were provided with a healthy and varied diet. EVIDENCE: The home held records of the activity programme that was provided for people living in the home. The programme had not been updated since the last inspection and still offered a limited range of activities, such as bingo, music, creative modelling, board games and quizzes. Satisfaction surveys returned to the Commission contained confirmation that people attended the activities provided. The home recorded the outcomes for people participating in activities. However, the carer assessed this by observing and recording the group’s reactions. The outcomes and experiences of people participating in activities should be recorded on an individual basis in a person’s care plan. This information should then be considered at individual’s monthly reviews to assess if people are achieving their personal goals. The pre-inspection questionnaire stated that activities outside the home included walks, shopping, attending religious services, visiting relatives and short trips. However, there Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 15 was no recorded evidence of these activities at the time of the site visit. It is recommended that records are held in individual care plans detailing the outcome for people that engage in activities outside the home to provide evidence that people are encouraged to develop and maintain a presence in their local community. Relatives and friends were welcome to visit the home and the daughter of a person living in the home was visiting on the first day of the site visit. She told the inspector that her father was happy living in the home and was well cared for. She added that staff contact her if they have any concerns. People living in the home are afforded choice in what they eat, their daily routines and activities. Two people used a private advocacy service. People were able to bring their own possessions in with them on admission. This gave them the opportunity to personalise their private living space and so reflect their personality and interests. Copies of the home’s weekly menus were available and these confirmed that people living in the home were provided with a healthy and varied diet. Comments from people concerning the standard of catering included, ‘The meals are good’ ‘Meals are delicious’ ‘they always provide whatever you want by changing the meals’ ‘Yes I like the food, especially the soup and mashed potatoes’. The kitchen and food store areas were clean and hygienic. Ample stocks of food were available, including fresh fruit and vegetables. The manager commented that the home emphasises the importance of good nutrition to maintain skin integrity. He pointed out that the home had no incidences of pressure sores. A cooked meal was provided at lunchtime. Choices were catered for and snacks and drinks were available on request. Halal options were included on the menu and the dietary needs (vegetarian) of one person who is of the Hindu faith are catered for. The manager said that people with low weights were referred for nutritional assessment to the dietician on admission. Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The welfare and safety of people living in the home is afforded protection by the policies and procedures in place. EVIDENCE: The home was displaying a complaints procedure that contained the prescribed time limits for responding to and resolving issues of concern. Twenty-one people returned completed satisfaction surveys to the Commission and the information provided evidence that people living in the home knew who to talk to if they had any concerns or complaints. The inspector was told, by the nurse-in-charge, that the home had not received any complaints in the previous twelve months. The home had adopted Manchester City Council’s multi-disciplinary policy on Safeguarding Adults from Abuse and a copy of the procedures to follow in allegations or suspicions of abuse was available to staff. It was encouraging to find that staff had recently attended safeguarding adults training as required at the previous inspection. Since the last inspection a person living in the home had made an allegation of staff sleeping on duty and bullying by night staff against one of the other people at the home. The police and social services had investigated this although the outcome was inconclusive. As a protective measure the manager and one of the registered mental health nurses said that they were doing three spot checks per week during night time hours. At the time of writing this report the manager said that nothing untoward had been found. Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Implementation of a rolling programme of maintenance and refurbishment has provided a safe environment for people living in the home. EVIDENCE: A tour of the home was undertaken with the owner/manager. The environment was found to be clean and hygienic. Following the last inspection the owner had undertaken an audit of the homes furniture, fittings and décor. Up to date records provided evidence that work had been in progress since October 2006 and it was pleasing to note that some of the work undertaken was ahead of schedule. Attention had been paid to re-painting scratched paintwork, the repair of broken floor tiles to remove tripping hazards, re-decoration to specified areas of the home, replacement of broken furniture and new curtains etc. It was disappointing that at the time of Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 18 the site visit, several bedroom curtains were found to be hanging off their rails. Badly fitting curtains are unsightly and do not provide an attractive and pleasant environment for people living in the home. The manager stated that these would be replaced as the rooms were decorated. A bed in use was fitted with wooden bed rails that did not comply with the space restrictions recommended. This constituted a hazard for the potential entrapment of the person using this bed. It was pleasing to note that the owner/manager had these bed rails removed before the end of the site visit. Mobility equipment was being stored under a stair well. This consisted of a number of wheelchairs and Zimmer frames etc. The manager said that the majority of the equipment was no longer needed. It was recommended that the manager make arrangements to have the items removed. There is a designated smoking room on the ground floor. The manager should consult the environmental health officer regarding the smoking regulations that are due to come into force from July 2007. The homes registration certificate and certificate of public liability were displayed correctly. It was very encouraging that the provider had responded well in complying with the requirement made at the last inspection to ensure that the home is safe and well maintained. A lengthy discussion was held with the owner/manager to explore how the homes environment could be further improved for the benefit of the people that live there. As the home provides a service to older people with dementia and/or mental ill health it is recommended that research is undertaken into dementia friendly designs that provide enabling environments for people to have greater independence. Information on this subject can be accessed from The Dementia Services Development Centre at Stirling University www.dementia.stir.org.uk and The Alzheimer’s Society www.alzheimers.org.uk Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures ensure that staff with the right personal qualities, knowledge and skills are employed to work with people living in the home. EVIDENCE: The previous four weeks rotas provided evidence that sufficient staff were being deployed to meet the assessed needs of people living in the home. This comprised of one registered mental nurse and 3 carers during the day and one qualified member of staff and two carers during the night plus a senior person on call. Fifty-five per cent of care staff working at the home had achieved a relevant National Vocational Qualification in care. The personnel file for the newest member of staff, recruited in February 2007 was examined. The file contained the required pre-employment checks, evidence of training and qualifications, interview notes and a work permit. The file was well organised and contained a checklist of contents, which made information easy to locate. This was considered to be an area of good practice. Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 20 Following appointment staff undergo an induction programme and ongoing training in health and safety provided by Manchester Social Services. Training courses had been provided recently in food handling and infection control. The owner/manager and staff team had also recently undertaken training in abuse awareness and the procedures to follow in safeguarding people from abuse. The manager talked about his awareness of the importance of how people are spoken to and the language used. Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people living in the home to express their views about the quality of the service they receive. EVIDENCE: The owner/manager was appropriately qualified and experienced in managing mental health care services. The results of the quality assurance monitoring relating to activities and catering within the home had been analysed and a quality report produced as required at the last inspection. It is recommended that a further quality monitoring survey is undertaken with people living in the home, their relatives and other stakeholders for their views on the quality of the homes internal Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 22 environment e.g. cleanliness, furnishings, furniture, design and layout, facilities etc. People completing surveys should be given the opportunity to express their views anonymously. The results of this survey should be analysed and a quality report produced. The inspector was told that people living in the home collect their personal allowances each Friday. Bedrooms have furniture with lockable drawers for the safekeeping of people’s money. A selection of health and safety records including fire, gas maintenance, emergency lighting, legionella, lift maintenance and the nurse-call system were sampled and found to be up to date. No health and safety shortfalls were identified in the environment during the two site visits conducted as part of this inspection. Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 23 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 16 (2) (m) Requirement Care plans must included details of resident’s social needs and these must be recorded on individual files. This will demonstrate how a person’s need for personal growth will be met. Unless it is impracticable the registered provider must ensure that residents/representatives are consulted regarding their written plan of care. Previous timescales of 08/12/04 and 07/08/05 and 31/10/06 had not been met. Timescale for action 05/06/07 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. Refer to Standard OP1 Good Practice Recommendations The registered person should submit copies of the updated Statement of Purpose and Service User Guide to the Commission for Social Care Inspection. DS0000021566.V334522.R01.S.doc Version 5.2 Page 25 Nada Nursing Home 2. OP3 3. 4. OP7 OP7 5. OP9 6. OP12 7. 9. OP19 OP19 10. OP19 11. OP19 12. OP33 The registered person should review and update the homes assessment of need to include to include a personal history and social needs assessment to ensure that people admitted to the home have their preferred lifestyles identified and recorded. The individual or their representative should sign assessments of need wherever possible. Care plan reviews should take account of a person’s progress towards achieving their goals. The registered person should consider training in personcentred care planning for staff working at the home. Adopting this approach will ensure that individuals are placed at the forefront of the service they receive. The registered person should instigate a review of medication for the two people referred to in this report to ensure that the individuals concerned are receiving the correct levels of prescribed medication. The registered person should ensure that the outcomes and experiences of people engaged in activities in the home and the wider community are recorded in their individual daily records. The registered person should ensure that curtains are properly hung in order to maintain a pleasing and attractive environment for people living in the home. The registered person should consider removing the unwanted mobility equipment from beneath one of the stairways to maintain a clutter-free environment for people living in the home. The registered person should consult their environmental health officer about the restrictions that need to be applied in the home when the smoking regulations come into force in July 2007. The registered person should undertake research into dementia-friendly design that enables people suffering from dementia have greater independence within the home. It is recommended that a system for reviewing the quality of the service being provided be developed to include the views of people using the service and other stakeholders in relation to the care provided and the standard of the homes interior décor. Nada Nursing Home DS0000021566.V334522.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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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