Inspection on 28/11/07 for Nairn House

This inspection was carried out on 28th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Nairn House 04/07/06

Nairn House 05/09/05

Nairn House 28/04/05

Nairn House 25/11/04

Nairn House 14/06/04

Nairn House 19/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Nairn House 7 Garnault Road Enfield Middlesex EN1 4TR Lead Inspector Tony Brennan Unannounced Inspection 28th November 2007 10:30 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 Nairn House DS0000027817.V349509.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. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nairn House Address 7 Garnault Road Enfield Middlesex EN1 4TR 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) 020 8367 9513 020 8367 9514 wadeju@bupa.com www.bupa.com BUPA Care Homes (AKW) Ltd Vacant Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61) of places Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One specified service user who is under 65 years of age may be accommodated in the home. The home must advise the registering authority at such times as the specified service user attains 65 years of age or vacates the home. 4th July 2006 Date of last inspection Brief Description of the Service: Nairn House is owned by BUPA. Nairn House is a large purpose-built care home providing accommodation for 61 older people who require residential and nursing care. The service is provided on three floors and is serviced by a passenger lift. Each service user has a single bedroom with en-suite facilities. An office, nurse station, lounge and dining room are situated on each floor, in addition to toilets and bathrooms. The home is located close to shops and with access to public transport. The fees range between £535 and £750 dependent on the source of funding. This report is available through the internet. Copies may also be obtained from the provider of this service. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken as part of the annual inspection programme. I sought to confirm that the three areas for improvement identified at the last inspection had been addressed. Prior to the inspection the home had completed its annual quality assurance assessment. The annual quality assurance assessment provided me with information about the home and how it was seeking to provide the best outcomes for people. I also looked at information received about the home since the last key inspection. The inspection took place over one day. I was assisted by the Senior Nurse in charge of the home with the inspection. I spoke with the five people who live at Nairn House, and three members of staff. I observed care practice and interaction between staff and people living at the home. I toured the building and examined a number of records relating to the care, health and safety and management of the home. I would like to thank the staff that assisted me by answering questions about the running of the home. I would also like to thank the five people who live at the home who discussed their views of the service they receive. What the service does well: I found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The statement of purpose confirmed that the cultural and religious needs of people would be respected. The service makes sure that people the quality and diversity is promoted. Needs identified in the initial assessments of the five people case tracked were highlighted in their risk assessments and care plans with guidance on how needs should be met. Admissions are not made to the home until a fall needs assessment has been undertaken to ensure the best outcomes for people. I found that the care plans of all the people case tracked were detailed and clearly identified how the needs of people would be met. Care plans identify how people should be supported. Detailed nutritional, tissue viability, falls and manual handling assessments have been put in place. Management of risk ensures that safety issues are Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 6 addressed whilst at the same time improving the quality of life for people living at home. The records of medicines received, administered and returned to the pharmacist were all complete. Regular management checks carried out to make sure that medication is administered safely to people. I spoke with people who live at the home who told me that they are provided with regular activities. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. The menu showed that options are offered at each meal. People are able to enjoy the food they prefer and like. Any concerns or complaints about the quality of the service were addressed. The home has an open culture that allows people to express their views, and concerns in a safe and understanding environment. There were comprehensive policies on handling abuse and protection. People feel safe and well supported by the home, which has their protection and safety as a priority. The rota showed that a consistent staffing level was being maintained in the home. There is consistently enough staff available to meet the needs of people living at the home. The annual quality assurance assessment confirmed that the home had achieved Investors in People accreditation. Staff are supported through training to meet the individual needs of people who live in the home. The Nairn House recognises the importance of effective recruitment procedures in the delivery could quality service and to protect individuals. The home has a system for obtaining the views of the quality of the service it provides and ensures that any areas for improvement are addressed. People’s views are sought and provide the bases for improving the quality of the service. Health and safety checks, procedures and training make sure that people living in the home are safe. What has improved since the last inspection? Three areas for improvement were identified at the last key inspection and all were found to have been met. The care plans for the people case tracked were found to reflect their choices and preferences. People are involved in the planning of their care that affects their lifestyle and quality of life. Records also confirmed that training on the equalities and diversity topics had been provided since the last key inspection. The service makes sure that people the equality and diversity is promoted. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 7 Since the last inspection the carpet on the ground floor hallway has been replaced and no longer presented a trip hazard to people. The home provides an accessible and safe environment for people to live in. What they could do better: 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. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 8 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 Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 9 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): 13 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose is an accurate description of the service provided. People’s needs are assessed prior to admission to the home to ensure they receive the care and support they need. EVIDENCE: I found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The statement of purpose also identified the skills and staffing resources available to meet the needs of people. The statement of purpose confirmed that the cultural and religious needs of people would be respected. Records show that people were supported by the home to maintain contact with their church or other community groups. The Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 10 annual quality assurance assessment completed by the home stated, “staff awareness training had been provided an understanding of cultural, ethnic and religious needs of people.” Staff spoken to was able to explain how they would meet these needs sensitively. Records also confirmed that training on the equalities and diversity topics had been provided since the last key inspection. The service makes sure that people the equality and diversity is promoted. People living at the home have varying degrees of disability. The environment has been adapted so that it is accessible. People are able to live as independently as possible. I observed that people were able to move about the home safely. People told me that they had information about the home before they decided to live at Nairn House. People are given information so they can choose whether they wish to live at the home. Needs identified in the initial assessments of the five people case tracked were highlighted in their risk assessments and care plans with guidance on how needs should be met. Admissions are not made to the home until a fall needs assessment has been undertaken to ensure the best outcomes for people. The annual quality assurance assessment stated that there were comprehensive pre admission assessments. It also recorded that with the introduction of the “QUEST” documentation the home has improved the quality of the information gathered about the needs of people. There are detailed assessments of people needs. As part of the assessment process information on the needs of people had been obtained from health professionals. This had been used to inform the home’s own assessment. A person told me, “ staff are very helpful.” The initial assessment for one person case tracked highlighted that they had a history of falls and a need for support with all aspects of the personal care. These needs were dressed in the Persons care plan. The specific nursing support needs of people were identified in their initial assessments. Nursing and care staff spoken to were able to explain the individual needs and preferences of the five people case tracked. Admissions to the home only take place when staff have the necessary skills to meet the assessed needs of perspective residents. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 11 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 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal, social and medical care needs are fully planned for. People who use the service are fully protected by safe procedures for handling medication. Peoples right to privacy is supported. EVIDENCE: I found that the care plans of all the people case tracked were detailed and clearly identified how the needs of people would be met. Care plans were based on initial assessments of the people case tracked. There were clearly defined actions highlighted in the care plans to meet the needs of people. Care plans had been reviewed, and people have been consulted about how their needs should be met. The annual quality assurance assessment explained that since the last inspection more information about the choices and preferences of people have been put into their care plans. The care plans for the people case tracked were Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 12 found to reflect their choices and preferences. People are involved in the planning of their care that affects their lifestyle and quality of life. People I spoke to told me that they felt staff understood the needs. Care plans were personalised, and referred to the cultural needs of people. This included whether or not they wish to take part in religious practices. There were also detailed personal histories that provided information on peoples’ interests and previous occupations. The annual quality assurance assessment highlighted that the home had made “a great effort” to involve people and their relatives in the care planning process. Care plans are reviewed regularly with the involvement of people and their representatives. Detailed nutritional, tissue viability, falls and manual handling assessments have been put in place. The people case tracked all had nutritional assessments. The annual quality assurance assessment stated, “all residents have a nutritional screen using the MUST nutritional screening tool.” These clearly identified where they might be at risk of being malnourished due to medical or other needs. Care plans identified the feeding regimes to be followed for people who are PEG fed. People were being weighed regularly and action taken if their weight changed. Detailed information on the tissue viability needs of people was available. Staff were able to provide the care that people needed. Where a high risk of developing pressure sores had been identified appropriate medical advice had been sought. A system is in place to determine the most appropriate mattresses or pressure relieving cushions for people at risk of developing pressure sores. I saw that this equipment has been provided. Falls and manual handling assessments were found to identify risks to and needs of people living at home. Equipment had been provided to assist people to mobilise safely and independently. Each care plan includes a comprehensive manual handling risk assessment. Management of risk ensures that safety issues are addressed whilst at the same time improving the quality of life for people living at home. The continence needs of people had been assessed and recorded as part of their care plans. Continence assessments had been further developed as a result of the introduction of the “QUEST” system for assessment and care Planning. The continence assessment is now more focused on how individuals can maintain their continence. Diary notes showed that appropriate medical attention and advice is sought. Diary notes also showed that the people case tracked had access to their General Practitioner when necessary. Diary notes also confirmed that where the General Practitioner had recommended specific medical interventions these were followed up. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 13 The records of medicines received, administered and returned to the pharmacist were all complete. I found where the General Practitioner had made changes to peoples medication this was signed by the General Practitioner to confirm the change had been made. I found that the medication for each of the people case tracked was accurately recorded. Medication records are fully completed, contain the required entries, and are signed by appropriate staff to ensure peoples safety. Medicines were stored safely. All medicines are stored at the appropriate temperature. Separate records were maintained for controlled drugs. I found these were complete and the amount of medication held corresponded with those recorded in the controlled drugs book. A regular audit had been carried out of the medication administration system. Regular management checks are carried out to make sure that medication is administered safely to people. Training has been provided on the safe administration of medicines. I spoke with staff and found they were clear about their responsibilities and how to handle medicines safely. Training records also contained certificates confirming that this training had taken place. I was able to observe staff administering medication, and confirmed that this was done safely. Staff understands how to administer medication safely to people living at the home. Nairn House DS0000027817.V349509.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 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are provided with varied activities to meet their needs. People living at the home are supported to maintain contact with relatives and other representatives of their choice. The menu reflects the preferences of people living at the home and offers a balanced diet. EVIDENCE: I spoke with people who live at the home who told me that they are provided with regular activities. I observed that activities were taking place at various times throughout the day. The home is developing a reminiscence programme. People spoken to told me that these activities are provided regularly. One person spoken to said, “ I particularly like the musical entertainment.” People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. I observed that staff spend time talking with people who live at the home and listening to what they had to say. Staff spoken to understood the importance Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 15 of one-to-one contact for people. One person said, “ staff are very friendly. One of the staff is very helpful and takes time to talk with me about the news.” Peoples’ interests were recorded as part of their care plans and in their life histories. A relative spoken to told me that there were no restrictions on visiting the home. People told me that they could see visitors in private if they wish to. Diary notes showed that people had regular contacts with family, friends and the wider community. The menu showed that options are offered at each meal. The menu is varied offering a number of choices of meals. Meals were balanced and nutritious. I spoke with people who were generally pleased with the quality of the food provided. A person who lives at the home said, “ the food is very good”. Another person commented about the choice of food offered and that staff, “ do bring an alternative if whats on the menu is not to your taste.” There was specific guidance in peoples care plans about their dietary needs. I saw that meals were well presented and they were provided in a relaxed manner. People were supported to eat. I observed that this was done at the pace of the people being assisted. Tables were laid out so that people could easily access condiments and individuals were provided with napkins. People are able to enjoy the food they prefer and like. Nairn House DS0000027817.V349509.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 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are confident that their complaints will be listened to, taken seriously and acted upon. The home’s procedures protect people from abuse. EVIDENCE: In the annual quality assurance assessment it was stated, “we have a clearly defined complaints policy with agreed timescales for managing complaints.” Two complaints had been referred by the Commission to the home since last key inspection. Record showed that these had been investigated and resolved appropriately. As part of monitoring the outcomes of people live in the home monthly regulation 26 reports had been sent to me. These consistently showed that any concerns or complaints about the quality of the service were addressed. People with whom I spoke confirmed that they knew how to make a complaint. One person said, “ I have no complaints. I will soon tell them if I did.” Actions had been taken to address issues that had arisen from the complaints. The complaints record showed actions taken to resolve complaints. The home has an open culture that allows people to express their views, and concerns in a safe and understanding environment. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 17 There were comprehensive policies on handling abuse and protection. People living at the home felt confident that any concerns they raised would be handled sensitively and appropriately. A person told me, “ I can tell staff about anything that upsets me.” No adult protection issues have been raised about the home since the last key inspection. I found that staff had received training on adult protection. Staff spoken could recognise the signs of potential abuse, and how they would respond to it. People feel safe and well supported by the home, which has their protection and safety as a priority. Nairn House DS0000027817.V349509.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that provides a safe and homely environment. The home is clean and hygienic. EVIDENCE: I walked round the home and found that it was appropriately furnished. Passenger lifts provided access for people to all floors. I observed that people were able to access all areas in the home safely. The home has the necessary adaptations to support people to move around safely. Since the last inspection the carpet on the ground floor hallway had been replaced and no longer presented a trip hazard to people. The home provides an accessible and safe environment for people to live in. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 19 The annual quality assurance assessment stated, “ we have a rolling decoration programme. Residents rooms have been redecorated together with the communal rooms.” Bedrooms were personalised with items of furniture and pictures belonging to the people who live at the home. I observed that people were provided with the appropriate nursing beds. People who use the service are encouraged and supported to personalise their bedrooms. The maintenance records show that ongoing maintenance of the homes environment was dealt with. I observed, however, that the paintwork in the hallways was chipped and in need of renewal. I discussed this with the estates manager who was present at the home on the day of the inspection. He explained that this would be in the next phase of the decoration work. It is recommended that a redecoration programme is agreed and a copy sent to the Commission. This should detail when and how this work will be completed. All areas of the home need to be decorated to a high standard to provide a pleasant living environment for people. Appropriate measures are in place to prevent cross infection. The home has detailed policies on the prevention of cross infection. Staff have received training on infection control measures. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. Effective infection control measures are in place to ensure the safety of people living at the home. Nairn House DS0000027817.V349509.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Sufficient staff are available at all times to meet the needs of people who live at the home. Staff do have all the skills to meet all the assessed needs of people who live at the home. People who live at the home are protected by the home’s recruitment practices. EVIDENCE: The rota showed that a consistent staffing level was being maintained in the home. This confirmed that sufficient staff are available to meet the needs of people. I spoke with staff who said that sufficient staff were available to meet the needs of people who live at home. People living at the home told me that staff are available to meet their needs. I observed that staff were available at key times of the day (e.g. mealtimes) to assist people. Staff were also observed to spend time with people both individually and in small groups. This allowed more attention to the individual needs of people. There is consistently enough staff available to meet the needs of people living at the home. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 21 The annual quality assurance assessment confirmed that the home had achieved Investors in People accreditation. Staff had recently undergone companies “Personal Best” training programme, and training on how to implement the new care planning system. Staff are supported through training to meet the individual needs of people who live in the home. The annual quality assurance assessment showed that at present 75 of staff have achieved the National Vocational Qualification in care. The home has over 50 of care staff with this qualification. The home has managed to maintain this consistently over the last three inspections. The home ensures that all staff receives relevant training that is focused on delivering improved outcomes for people who choose to service. People told me they felt that staff understood how to meet their needs. Staff spoken to confirmed that they had all the areas of required training. Training records confirmed this. Training records showed that staff had also received training in care planning. Nursing staff spoken to confirm that they had the training necessary to ensure they had up-to-date professional knowledge. This included training on tissue viability, the Gold Standard Framework and the Liverpool Pathways in palliative care. I examined four staff files and found that these contained all the required information relating to their recruitment to protect people. I found that there were no unexplained gaps in the employment history of recently recruited staff. A health check had been carried out to ensure that staff could safely meet the needs of people. The file of one nurse was seen, this had evidence of their current professional registration. The Nairn House recognises the importance of effective recruitment procedures in the delivery of a quality service and to protect people. Nairn House DS0000027817.V349509.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate management structures are in place to ensure that people receive the care they need. People who live at the home are consulted about the quality of the service provided and are encouraged to make suggestions for improvement. People who live at the home have their financial interests protected by the home’s procedures. People who live at the home and staff are protected by the home’s health and safety procedures. EVIDENCE: Since the last key inspection there has been a change in the management of the home. The registered manager has resigned. The deputy manager Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 23 successfully applied for the registered managers post. She is currently going through the registration process with the Commission. The new manager has extensive experience of managing a service for older people. The new manager has maintained and updated her skills regularly. She has a clear understanding of the key principles and focus of the service to make sure that people receive the care they need. The manager has a clear understanding of how to deliver good outcomes for people living at home. The home has a system for obtaining the views of the quality of the service it provides. The home makes sure that any areas for improvement are addressed. A survey of the views of people who live at the home, relatives and professionals was in place. The Company also has a system to monitor all areas of the quality of the home. I have monitored monthly regulation 26 reports these show that the management consistently addresses any issues where improvements may have been identified. People who live at the home and their relatives have meetings on a regular basis to discuss how they wish the home to be run. Staff meetings take place to ensure staff are aware of plans to develop the service. People’s views are sought and provide the bases for improving the quality of the service. The home does not hold money for people who live at the home. The home invoices their families or the relevant social service department for any expenditure made on their behalf. A system is in place to ensure receipts are obtained for any expenditure. People use the service trust the home to handle their money safely. Fire drills were taking place and the fire alarm was tested regularly. I found that the fire risk assessment includes an assessment of all the potential fire risks in the home. I questioned staff on the fire safety procedures and found that they understood fire safety issues. All health and safety policies were available. Certificates for gas, legionella and electrical testing were in date. COSHH guidance was in place and chemicals were stored safely. I discussed health and safety issues with staff and they demonstrated their understanding. The home has an effective system for monitoring accidents to ensure the safety of people who live and work at the home. The temperature of food delivered to and cooked was recorded. The temperatures of the fridges and freezers were recorded and within safe limits. The home has an effective system for monitoring accidents to ensure the safety of people who live at the home. Regulation 37 notifications showed that any safety incidents involving people were reviewed. Appropriate measures are put in place to prevent incidents from reoccurring. There were no discernible patterns of incidents found when recent regulation 37 reports analysed. Health and safety checks, procedures and training make sure that people living in the home are safe. Nairn House DS0000027817.V349509.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 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 Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations The registered persons should make sure that a program for redecoration of the hallways put in place. A copy of this should be sent to the Commission. All areas of the home need to be decorated to a high standard to provide pleasant living environment for people. Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Nairn House DS0000027817.V349509.R01.S.doc Version 5.2 Page 27 - 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. 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