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Inspection on 12/01/06 for Netherton Green Nursing Home

Also see our care home review for Netherton Green Nursing Home for more information

This inspection was carried out on 12th January 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides excellent sources of information for prospective and current service users alike and are welcoming to visitors to the site. The assessment process is extensive and completed thoroughly by staff, who use the information derived to develop care plans, which the service users or their representatives are included in their preparation and reviews. The home is well equipped to deliver nursing care and has robust safety procedures to ensure individual frailties are protected from harm. The whole site is well presented and maintained in very good condition with planned programmes to decorate and refurbish in a timely way.

What has improved since the last inspection?

The home has implemented regular reviews of the assessment processes and uses this to inform care planning. Considerable progress has been made in training staff in NVQ level 2 qualification in care. Documentation of hot water monitoring and actions taken has improved to better show the level of control being achieved to maintain a safe supply at all times. Supplies of disposable towels at staff hand wash sites were full at all those observed.

What the care home could do better:

Staff must protect themselves from the risk of needle stick injuries by discontinuing the practice of re-sheathing used hypodermic needles. The practice of keeping an emergency supply of oxygen should be discontinued and only prescribed supplies held.The refurbishment and redecoration programme must continue and the provision of pictures and ornaments in the intermediate care rooms would give an homely feel and be less clinical. The supply of hot water at staff designated hand wash areas should be controlled to a comfortable temperature for washing under running water to further promote good hand washing practice. Because the nursing needs of service users on Saltwells unit the provision of height adjustable beds and footstools should be increased. The documentation of the many supervisions provided to staff must improve if it is to be demonstrated that staff receive appropriate supervision and guidance in the delivery of care to the service users.

CARE HOMES FOR OLDER PEOPLE Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY Lead Inspector Richard Eaves Unannounced Inspection 12th January 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 Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 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. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Netherton Green Nursing Home Address Bowling Green Road Netherton West Midlands DY2 9LY 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) 01384 410120 01384 413460 BUPA Care Homes Limited Susan Maria Dalwood Care Home 120 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability (30), Terminally ill over 65 years of age (30) Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Service users to include up to 60 DE(E), 30 PD, 30 TI(E) and up to 60 OP One service user accommodated on Darby House in the category of OP may also be SI(E) and will remain until such time that the current service users placement is terminated. Two service users accommodated on Darby House in the category of OP may also be DE(E) and will remain until such time that the current service users placements are terminated. One service user accommodated on Darby House in the category of OP may also be LD and will remain until such time that the current service users placement is terminated. One service accommodated at the home may be LD(E). This will remain until such time that the current service users placement is terminated. One service user, named in the variation application dated 13 May 2004, accommodated on Windmill House in the category DE(E) may also be MD(E) and will remain until such time that the current service users placement is terminated. Windmill House to accommodate 30 service users in the category DE(E) who are 60 years and over. 8th August 2005 7. Date of last inspection Brief Description of the Service: Netherton Green Nursing Home is a purpose built home consisting of four separate and spacious bungalows set in attractive landscaped grounds. Each bungalow accommodates up to thirty service users. Netherton Green Nursing Home is a private home owned by BUPA. All bedrooms are single with toilet and bathroom facilities close by and each unit has a large communal lounge/ dining room, which has smaller partitioned off areas, there is also a quiet room with a sink and comfortable chairs which is also available for visitors. A kitchenette is situated off the main lounge/dining area, where drinks are prepared, a fridge and microwave are also available. Administration services are situated in a separate administration block where the Manager who has a responsibility for the complex has her office. A central laundry and kitchen are also situated in this block. The home is situated off Bowling Green Road, Netherton. The home has ample car parking and is accessible by public transport. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the announced inspection during August 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire and records held at the home. The inspection involved a full tour of each of the bungalow units including, bedrooms, communal rooms, service areas and provided an opportunity to speak with many service users. What the service does well: What has improved since the last inspection? What they could do better: Staff must protect themselves from the risk of needle stick injuries by discontinuing the practice of re-sheathing used hypodermic needles. The practice of keeping an emergency supply of oxygen should be discontinued and only prescribed supplies held. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 6 The refurbishment and redecoration programme must continue and the provision of pictures and ornaments in the intermediate care rooms would give an homely feel and be less clinical. The supply of hot water at staff designated hand wash areas should be controlled to a comfortable temperature for washing under running water to further promote good hand washing practice. Because the nursing needs of service users on Saltwells unit the provision of height adjustable beds and footstools should be increased. The documentation of the many supervisions provided to staff must improve if it is to be demonstrated that staff receive appropriate supervision and guidance in the delivery of care to the service users. 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. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 7 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 Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 8 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): 1-6 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home and receive a contract confirming the terms and conditions agreed for their stay at the home. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. A dedicated team provide intermediate care that prepares service users to return home. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 9 EVIDENCE: Primrose The unit has a copy of the homes statement of purpose that includes the units own philosophy, a copy of the service user guide was seen to be issued to each bedroom. All service users receive a contract at the point of admission and a copy is retained. A comprehensive assessment is undertaken using the BUPA Minimum Data Set (MDS) and a range of risk assessments that identify needs and interventions required to address and minimise risks. Some case files also include a behavioural assessment. Each of the assessments is subject to regular review. The sample of files case tracked show the assessment process to be thorough. The unit invites prospective service users to trial the home and take care to carefully integrate new service users to the environment. Windmill The unit has a copy of the homes statement of purpose that includes the units own philosophy, a copy of the service user guide was seen to be issued to each bedroom. All service users receive a contract at the point of admission and a copy is retained. A comprehensive assessment using the BUPA Minimum Data Set (MDS) and a range of risk assessments that identify needs and interventions required to address and minimise risks. Some case files include behavioural assessments as appropriate. Each of the assessments is subject to regular review. A sample of files were case tracked and found the assessment process to be informative and identifying the individually relevant care needs. Prospective service users are introduced to the unit by a number of visits to orientate and familiarise them with the home. Darby The unit has a copy of the homes statement of purpose that includes the units own philosophy, a copy of the service user guide was available in each bedroom. All service users receive a contract at the point of admission and a copy is retained. A comprehensive assessment using the BUPA Minimum Data Set (MDS) and a range of risk assessments that identify needs and interventions required to address and minimise risks. A sample of files inspected show each assessments to be subject to regular review. Prospective service users are given the opportunity to visit the unit prior to accepting a place at the home and the contract provides for a trial period. Saltwells The unit has a copy of the homes statement of purpose that includes the units own philosophy and a copy of the service user guide was seen to be available in each bedroom. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 10 This unit uses an assessment raised by the hospital that is received pre arrival at the home and a confirmation is returned confirming that the unit can meet the assessed needs. All admissions to this unit are for intermediate care and have a discharge strategy in place. Although a shortened process from the BUPA documentation the case files inspected show the assessments to be informative and completed thoroughly. Following discharge the hospital notes are returned while the personal and nursing records are retained on site. Being an intermediate care provider receiving service users direct from hospital there is no opportunity for service users to visit pre-admission. All aspects of the standard for intermediate care are met. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 11 Health care needs of service users are fully met and care planning in the home is overall of a good standard. Arrangements for the administration of medication are good and ensure service users medication needs will be safely met. Service users are treated with respect and their privacy upheld. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: Primrose A sample of service users case files were inspected and case tracked and were observed to have a care plan for each assessed need and these plans gave clear direction for staff. The case files show the involvement of allied medical services such as Optician, Dentist and Chiropodist. Medication is well managed within the unit using the Nomad system predominantly. Evidence of re-sheathing of used hypodermic needles was Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 12 seen. A supply of oxygen was available but not prescribed for any current service users. The monitoring records of room temperature shows that the recommended maximum storage temperature has on occasion been exceeded. Over the period of the inspection staff were observed to interact in a kindly way with respect and thoughtfulness that is sensitive to protecting service users dignity. Policy, procedures and staff training is available in care of the dying. Windmill A sample of three case files were case tracked. The care plans were seen to be drawn from the assessment process were relevant and maintained to a good standard. Allied medical services such as Optician, Dentist and Chiropodist are provided on a frequent basis. Medication is well managed within the unit using the Nomad system provided by Lloyds Chemist. Evidence was observed the some staff continue to resheath used hypodermic needles. Staff were seen to interact in a kindly way with respect and thoughtfulness that is sensitive to protecting service users dignity. Policy, procedures and staff training is provided for the care of the dying. Darby A sample of case files were inspected and case tracked and were seen to include an extensive range of care plans to meet needs identified in the assessment process and providing clear guidance to staff on the delivery of care. One file include a care plan that had good direction to address contingencies that may arise due to specific conditions. The unit has a named nurse and named care key-worker for each service user and this is reflected in good care planning and completeness of recording. The unit has a good supply of pressure relieving equipment and there are no service users with pressure sores. Medication management is good and the unit uses a monitored dosage system for a large proportion of medicines no problems were observed. Service users rights, dignity and respect are given prominence during the induction of new staff and the interaction between staff and service users was observed to be easy thoughtful and considerate meeting this element of the standard. Policy, procedures and staff training is provided for the care of the dying. Saltwells The sample of case files inspected show that the care plans are rehabilitative, subject to at least weekly review, has good contingency planning and is relevant to this acute setting. Medical care and direction is provided from the hospital supported by a GP out of hours service. Allied services to medicine are not frequently required but are arranged on an individual needs basis. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 13 Medicines are provided by the hospital with a 28-day supply the management of which is problem free. Evidence of re-sheathing of used hypodermic needles was observed. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 The home provides well-organised, varied and appropriate social and recreational activities that provide interest and pleasure for the residents. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: Primrose Individual assessments are undertaken of activity pursuit patterns that include sleep pattern, rising and settling times and taking regard of known preferences and capacity for involvement in activities. Activity and stimulation needs are included in care planning and appropriate meaningful activities prescribed. The hobby therapist provides 30 hours of input to the unit a week providing group and individual input. There is currently a knitting group that a number of ladies were observed to be involved, the arts and crafts group produce a range of satisfying items such as hand made cards. Other activities include tea parties, sing-a-longs, entertainments and games. Regular outings are arranged during milder periods and a range of normal activities that the service users would have engaged in when at home such as pub visits. Mealtimes are identified as an important part of the day and the meals are supplemented to ensure a high calorific value is achieved above the normal Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 15 diet to meet increased nutritional needs. Choice for this group is achieved by showing the made up meal and allowing each to select. Windmill The unit has the input of an activities organiser for 6 hours each day to provide activities such as arts and crafts and games, exercising and singing on a daily basis. Entertainments are frequently provided and dog petting sessions are provided and are said to be a favourite among the service users. Service users are enabled to personalise their bedrooms if they wish with photographs and possessions such as ornaments and furniture. Mealtimes are identified as an important part of the day for service users, which continues to give a great deal of satisfaction and staff report that they eat their meals with enthusiasm. The meals provided are supplemented to ensure a high calorific value is achieved above the normal diet to meet increased nutritional needs. Choice for this group is achieved by showing the made up meal and allowing each to select. Darby Life biographies are prepared for each service user that identifies preferred leisure and social interests. The hobby therapist maintains a record of the activities that service users participate in. The home has a 4-week rolling menu as well as a summer and winter menus. There are always choices available at mealtimes and residents can choose an alternative to the menu if they do not like any of the food choices off the menu, a hot alternative is included at each meal setting. Saltwells The unit has a limited entertainment programme due to the concentrated rehabilitation programme. The staff provide group games, bingo and exercise sessions on a daily basis. The unit follows hospital visiting hours to provide for individual rehabilitation programmes to be under taken this policy is implemented flexibly and accommodates any special needs of family members. A main aim of the unit is to assist service users to regain independence and exercising choice is recognised as an important part in this to achieving selfmotivation. The service users spoken with were happy to be in the unit and out of hospital and a number specifically complemented the meals as being excellent and in particular the cooked breakfast having had continental style while in hospital. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The home has a detailed complaints procedure, which is displayed in each of the units and also included in the service user guide. Service users spoken with said if they had any concerns they would not hesitate to discuss them with the unit manager. One concern was raised since the last inspection about gaining access to Saltwells unit and this was resolved at a local level to the satisfaction of the complainant by the installation of a monitor and remote opening from the office. Advocacy services both locally and condition specific services, such as the Alzheimer’s Society are promoted. The EMI units have very active relatives groups. All staff receive adult protection training and the homes policies are well promoted to staff. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home provides a good standard of décor, furnishings and managed services providing a safe, disabled accessible environment and an attractive, and homely place to live. The bedrooms have bathrooms and toilets in close proximity for the convenience of service users. The home is clean, free from odours and hygienic. EVIDENCE: Netherton Green Nursing Home is a purpose-built property, providing accommodation for up to for 120 persons requiring nursing care in 4 bungalow units each of 30 single bedrooms. The home continues to be refurbished, redecorated and repaired on an ongoing basis. The décor, fixtures and furniture are generally completed to high standards. The home has extensive grounds with each unit having its own garden area. Ample car parking is provided. Each bungalow unit was toured they all follow the same design providing bedrooms with a hand wash basin, furnished with good quality furniture including a proportion of nursing beds some older beds were observed to have Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 18 bedrails in single use, Saltwells unit has the highest overall general nursing dependency and take up of bedrail use but has insufficient profiling height adjustable beds, there is also an apparent shortage of foot stools. Heating is by low surface temperature radiators, lighting is overhead and bedside, ventilation is natural from restricted opening windows and a staff call system is available in all service user areas. Individual bedroom doors are not fitted with cold smoke seals. The units are each fitted with two sluice disinfectors. Each of the units were found to be clean and odour free and have a cleaning schedule that details when and how cleaning is done ensuring clean and hygienic environments. Staff hand wash outlets have a hot water supply too hot to allow good hand washing under running water. The sluice room on Windmill requires to be kept secure. Darby unit remains to be refurbished and decorated although they have received new bedding, a new dishwasher and new refrigerator and is identified as next to be done in the programme. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: Each unit is staffed with numbers and skill mix appropriate to the dependency and activity level reflecting the needs of service users. Induction and foundation training is to TOPPS standards and the records show that new staff have attended induction sessions. Mandatory training is provided such as fire safety, moving and handling, basic food hygiene, health & safety, the protection of vulnerable adults and whistle blowing. Staff training files are held on each unit with a master matrix held centrally a copy of which was provided and shows that NVQ trained staff now is 66 with further staff currently enrolled. Recruitment and selection are completed to a good standard and includes all necessary checks such as CRB, POVA and nursing registration. Staff files also show that two references are obtained and a record kept of the interview. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 20 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 – 38 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance, which includes seeking the views of service users and their families. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction but not frequently enough to ensure that the service users will receive consistent quality care. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 21 EVIDENCE: Management of the home changed early in 2005 and the new manager has completed the registration process. While each unit is established to be led by a senior nurse currently two units have vacancies for this position. Temporary organisation arrangements are maintaining consistency and leadership and morale amongst staff on each unit appears to remain good and staff are enthusiastic. The company undertook a survey of relative satisfaction over 2005 and a report was provided that shows a very overall level of satisfaction. A survey of service users satisfaction has also been undertaken but the report of findings has not yet been received. The area managers undertakes monthly regulation 26 visits and provides the commission with copy of the reports. The company has good arrangements for setting and monitoring accounts and financial procedures and the manager has full input in setting each years budget and planning capital expenditure. The home does not undertake appointeeships for the service users but has good accounting arrangements for managing personal allowances left for safe keeping. Supervision arrangements have been established but little progress made to ensure six supervisions are recorded each year. Each unit was able to demonstrate extensive supervised practice in many forms but failed to document these sessions as supervisions. Records required by regulation and the schedules are maintained and kept up to date and stored securely. The home has an up to date health and safety policy for safe working practice with a range of risk assessments. Staff receive training and regular updates in health and safety and fire safety. A fire risk assessment was available and this is subject to review as changes occur. Certification of a range of servicing and annual inspections undertaken of all utilities and equipment in the home are maintained and up to date. The home has an up to date health and safety policy for safe working practice with a range of risk assessments. Staff receive training and regular updates in health and safety and fire safety. A fire risk assessment was available and this is subject to review as changes occur. Certification of a range of servicing and annual inspections undertaken of all utilities and equipment in the home are maintained and up to date. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 22 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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X X 2 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 3 3 3 3 2 3 3 Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Timescale for action 31/03/06 2. OP19 16(2)(c) 3. OP19 23(4)(c) 4. OP19 23(2)(d) The registered person must take action to stop the practice of resheathing used hypodermic needles. Previous timescale of October2005 not met on Saltwells, Primrose and Windmill. The manager must ensure that 31/03/06 those rooms occupied on a short-term basis through the intermediate care arrangement are decorated with pictures and ornaments to give the rooms a homely feel. Previous timescale of October 2006 part met by decoration. The responsible person must 31/03/06 ensure service users are safe from cold smoke by fitting seals to bedroom doors. Previous timescale of December 2005 not met. The registered person must 31/03/06 ensure the programme of refurbishment and redecoration continues. Previous timescale March 2005 part met. Darby outstanding. Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 24 5. OP26 13(3) 6. OP36 18(2)(a) 7. OP9 13(2) 8 9 OP9 OP22 13(2) 23(2)(n) The registered person must ensure that staff handwash outlets are fitted with a means of hot water control to promote good hand washing practice. The registered person must ensure that staff are appropriately supervised on at least 6 occasions each year. Previous timescale December 2005 not met. The registered person must ensure that medicines are stored appropriately by ensuring that the ambient temperature of the medicine storage rooms do not exceed 25°c. The registered person must ensure that only prescribed oxygen is held at the home. The registered person must ensure an adequate provision of nursing equipment in particular sufficient height adjustable beds and footstools for Saltwells unit. 31/03/06 31/03/06 31/03/06 31/03/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Netherton Green Nursing Home DS0000004886.V274820.R02.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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