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Inspection on 23/05/06 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 23rd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 is pleasantly decorated and furnished with an ongoing refurbishment programme. There is good access throughout the building where residents are accommodated and a range of aids and adaptations available for dependent people. Care planning is generally good with all care records regularly reviewed. Service users are treated with respect and are able to retain control over their lives within the home. The home has sufficient staff who receive regular and required training and has an excellent 77% of its care staff qualified to at least National Vocational Qualification level two. There is a comprehensive activity programme identified by its Activity Coordinators, with service users and their relatives stating that their contribution was "invaluable". There is an extensive menu of tasty and nutritious food with a choice of meal always available. The home has an experienced manager who provides strong and effective leadership. There are appropriate procedures in place for the safe recruitment of staff, highlight concerns and to protect vulnerable people.

What has improved since the last inspection?

The Manager has undertaken a service user survey and has provided an action plan to address issues raised within the survey. Staff no longer re-sheath needles as required at the previous inspection.

What the care home could do better:

Staff must to ensure that the admission assessment of service users is complete. Service users must also be involved in the planning and identification of their care needs and this must be recorded. The administration of medicines is generally satisfactory but further improvement is required to safe storage of medicines. Service users must always have the required equipment as identified within their risk assessments for their comfort, safety and well being.

CARE HOMES FOR OLDER PEOPLE Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 23rd May 2006 08:00 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 Netherton Green Nursing Home DS0000004886.V296249.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. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 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 www.bupa.com BUPA Care Homes (CFH Care) 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.V296249.R01.S.doc Version 5.2 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. 12th January 2006 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.V296249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by Mrs Amanda Hennessy and Mrs Mandy Beck. The inspection was carried out between 08.00 and 18.30.The inspection included a tour of each of the units, talking to service users, staff and visitors and a review of records. Twenty-four service users completed questionnaires that asked their views on the home, which positively identified their life at the home. A review of information supplied by the Manager (pre inspection questionnaire) was also reviewed and expanded upon during the visit. Care records were reviewed as part of the “case tracking” of at least three service users on each unit. The manager is Mrs Susan Dalwood. The registered proprietor is BUPA Care Homes. Two of the previous 9 requirements have been met (one requirement was not assessed during this inspection),thirteen new requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 6 Staff must to ensure that the admission assessment of service users is complete. Service users must also be involved in the planning and identification of their care needs and this must be recorded. The administration of medicines is generally satisfactory but further improvement is required to safe storage of medicines. Service users must always have the required equipment as identified within their risk assessments for their comfort, safety and well being. 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.V296249.R01.S.doc Version 5.2 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.V296249.R01.S.doc Version 5.2 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): 3,4,5 Assessments of needs are not always complete which does not provide full assurance that the home would be able to meet all service users needs. Prospective service users have the opportunity to visit the home before deciding to come and live at the home. EVIDENCE: Potential service users (with the exception of Saltwells the Intermediate Care Unit) are encouraged to spend a day at the home whenever possible before they choose to stay on a more permanent basis, when it is not possible for service users to do this relatives are encouraged to visit and see the home for themselves. Each service user has a pre admission assessment of their needs by a senior member of qualified staff before a decision is made that they come to the home. Assessments seen in some files were not completed which would make planning effective care difficult as their needs had not been comprehensively identified. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 9 There is a very low number of staff working on the units that specialise in dementia care who have received formal accredited training this must be addressed so that staff are equipped with all the skills and knowledge they require to meet the needs of service users effectively. Saltwells (Intermediate Care Unit) Saltwells has a dedicated staff group who are experienced in providing intermediate care for service users who require additional care or rehabilitation but do not need to be in hospital. Staff at Dudley Group of Hospitals assess service users needs whilst they are in hospital and a decision is then made that a stay at Netherton Green (Saltwells unit) would be more appropriate. A copy of an assessment of their needs is then forwarded to Saltwells before the service user arrives at Netherton Green. Assessments seen were detailed but did not include all information required by the National Minimum Standards. Medical cover is shared between hospital doctors and a local GP, with a doctor visiting the unit most days. Saltwells also has an Occupational Therapist and Physiotherapist who visit Monday to Friday. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users care is planned but care plans need to be more specific to give assurance that all needs are met. Medicine policies and procedures are generally satisfactory and safeguard service users. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Service users have a plan of care that details both health and social needs. Plans of care detail the type of help that the individual service user require and are regularly updated. It is not always evident that service users (or their representative) are involved in the planning and review of their care, although this can be particularly difficult due to the degree of dementia that some service users have. The manager must consider ways to include all service users in the care planning process. Service users have risk assessments for the risk of pressure sores, moving and handling, nutrition and falls which are reviewed monthly as required. The home has specialist equipment to protect against the risk of pressure sores Service Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 11 users are weighed at the time of their admission and then regularly on Darby, Primrose and Windmill but frequently there is no weight recorded for new service users on Saltwells. All service users have access to community services such as chiropody, dentistry and the optician. There were risk assessments in place that looked at the reduction of pressure sore development, falls, nutrition and moving and handling and are reviewed monthly. The home’s medication policies and procedures are generally satisfactory including the management of controlled drugs. All medication at the home is administered safely by qualified nurses. Medicines are being stored correctly with a few exceptions see requirements section. A previous requirement that the treatment room temperatures are recorded to ensure that medicines are safely stored has not been addressed. Staff do not record the administration of creams and lotions , one relative did express concern that their relative’s skin was sore and that required cream was not regularly applied. Service users were seen to be treated with respect and dignity throughout the inspection and this was concerned by service users spoken to during the inspection and comment cards received prior to the inspection. Care staff were seen to take time to ensure that service users clothing was covered with an apron prior to eating food to prevent spillage, knocking on doors before entering and asking service users about their preferences. Saltwells (Intermediate Care Unit) Service users all have a plan of care and risk assessments which are regularly updated. There is a need to ensure that service users are involved in the identification of their care/ rehabilitation. Several service users spoken to were unsure how long they would stay at Saltwells and what care/ support they would receive during their stay. There is an initial care plan that highlights the need to orientate service users to the unit and an intermediate care pathway, although it is not evident that these instructions have been undertaken, staff need to confirm that this has been done. Some service users care plans are not specific identifying that “The correct sling must be used” or “the correct mattress must be used” other care records for the management of pressure sores were not complete and did not detail required dressings. The lack of explicit instructions could compromise service users safety. The majority of service users have the required pressure relieving equipment but concern was highlighted that service users do not always have the required specialist equipment at the time of their admission and one service user admitted from hospital with pressure sores did not have the required specialist mattress for 10 days. Concern was also expressed about the maintenance of faulty mattresses which had been supplied by Dudley Group of Hospitals and may not give the required protection to the service user. Saltwells have the same medication policies and procedures as the rest of the home although they use the medication record from Dudley Group of Hospitals to ensure consistency for the service user. There were some gaps on the medication administration chart which gives some uncertainty whether the Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 12 service user received all their medication which must be addressed. Service users medication is transferred with them from Dudley Group of Hospitals. A record is made of the receipt of this medication although when or if additional medicines are received this is not recorded as required. Staff need to ensure that they more proactively planning for discharge and identifying problems that the service user may experience when they are discharged, concerns raised to CSCI identified that sometimes service users do not receive sufficient information and help in relation to their medicines. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The home has good social opportunities that meets service user’s expectations and preferences. Services users are able to exercise choice and control over their lives at the home and are able to maintain contact with friends and family. EVIDENCE: The home has three Activity Organisers with each one each allocated to the long stay units (Darby, Primrose and Windmill). There were activities taking place on each unit throughout the day, service users appreciated the activities that take place one Primrose relative said “ The activity organiser is great, there is so much for the residents to do, my Dad is encouraged to play the piano which he particularly enjoys” One unit had booked a singer on the day of the inspection and it was pleasing to see that all of the service users enjoyed this they were observed singing and tapping their hands and feet to the music. All permanent service users have a life history that identifies their preferred social and recreational interests to ensure that social opportunities are suitable for their needs. Staff ensure that they ask service users the time that they prefer to get up and go to bed. Service users spoken to said that they get up and go to bed when Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 14 they want to, choose where they have their meals, what they had to eat and activities that they take part in. Permanent service users have visitors whenever they want to come, there are also a number of service users that go home with their relatives for the weekend or to go shopping or for dinner. There are identified visiting times for the Saltwells (Intermediate Care Unit) as there are more intensive treatment programmes for service users receiving rehabilitation. The home provides a four weekly menu that is regularly updated and offers a choice at each meal. In addition to the identified choice if service users are not happy with the choices being offered they are encouraged to choose something else. The meals supplied at the home appeared to be generous in portions and looked appetising. All service users spoken and comment cards received prior to the to inspection were very complimentary about the food. When one service user was asked about the food he said “The food is very good. I really enjoy having a full English breakfast every day, there is also cereals and toast but I like my full English. “ It was observed particularly on the Dementia Care Units (Primrose and Windmill) that whilst staff are assisting other service users with eating and drinking some have to wait. This means that their meal is in front of them and going cold until someone can assist them. This was discussed with the manager who must consider whether more staff are needed at meal times to avoid this or if a new system needs to be introduced. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 15 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 has appropriate policies and procedures to highlight concerns and complaints to safeguard service users. EVIDENCE: The home has a detailed complaints procedure which is prominently displayed on each unit and is also included in the service user guide. The home have received six complaints, and of which two were also sent to the Commission for Social Care and Inspection. The complaints log identified that all complaints were timely and comprehensively investigated. Service users and their families spoken to said if they had any concerns they would discuss them with the Home Manager. The home have made an Adult Protection referral with all required actions undertaken to safeguard its service users. The home has appropriate policies to ensure that staff who are not suitable to work with vulnerable people do not do so by robust recruitment and selection procedures. Staff have received training in the Protection of Vulnerable Adults. Staff spoken had appropriate knowledge of what is abuse and what actions they must take if any allegation of abuse is made to them. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 16 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 is pleasant, homely and generally well maintained, and odour free making it a homely and comfortable place for its service users to live. Infection control within the home is safeguards its service users. EVIDENCE: The units are generally pleasantly decorated, clean and kept tidy. Most of them had a welcoming homely feel, one unit has been decorated to stimulate the senses of the service users and has paintings of shop fronts, canals and trees. The home has a refurbishment programme and there are plans to refurbish Darby unit shortly. Service users can bring in treasured items from home with many bedrooms decorated with photographs, pictures and smaller times of furniture. Other bedrooms were very sparse, and there is a need for staff to ensure that all service users can have rooms that are homely and have interesting things to look at. Some of the bedrooms on the Dementia Care Units had an offensive odour and this must be addressed by the manager to ensure the comfort for all service users. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 17 The home has a variety of aids and adaptations such as grab rails assisted baths and a wheel in shower available for dependent service users and a full nurse call. A requirement that additional height adjustable beds to aid service users and staff comfort when service users require care in bed, has not been fully addressed. The home’s infection control procedures were reviewed and were found to safeguard service users. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The home has well trained and sufficient staff to meet service users needs. Recruitment and selection procedures are robust and safeguard the service users. EVIDENCE: Staffing levels for each unit generally meet service users needs. There is a need to review the sufficiency of staffing levels of one trained nurse and two care assistants on night duty on each of the dementia care units. The home has more than met the requirement of 50 of its care staff qualified to National level two qualification or above: Saltwells has thirteen of its fourteen (92 ) care staff qualified to a minimum of National Vocational level (NVQ) two in care. Darby has ten of its fifteen (66 ) care staff qualified to a minimum of National Vocational level (NVQ) two in care. Primrose has twelve of its twenty-one (57 ) care staff qualified to a minimum of National Vocational level (NVQ) two in care. Windmill has eighteen of its twenty-one (86 ) care staff qualified to a minimum of National Vocational level (NVQ) two in care. Recruitment and selection of staff is conducted in a safe manner that safeguards service users, all staff files seen had appropriate checks i.e. Protection of Vulnerable Adults checks and Criminal records disclosures. Staff do receive regular training to ensure that their knowledge and skills are kept up to date with current best practice. There are gaps but these are being addressed by the manager. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The home has strong and effective management arrangements giving assurance of the continuing development of the home and the protection of service users. EVIDENCE: The home’s manager is Susan Dalwood who was appointed as Home Manager in April 2005. Mrs Dalwood is a registered general nurse and has held senior management positions in elderly long stay care for ten years. The Manager is supported by an Area Manager and within the home by a Deputy Manager and Unit Managers. The home does have a quality plan, with a review of all areas of the home at least annually. The home manager conducts monthly audits of the incidence of pressure sores and care plans and quarterly audits of accidents and complaints. A service user survey was undertaken in Autumn 2005. A report is Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 20 available of the findings of the survey which also compared findings identified when a survey was undertaken in the Spring 2005. Staff can be rewarded customer service awards with “Personal Best Awards” which are nominated by services users or relatives for care beyond expectations. A survey of staff views on the home and how it is managed has also been undertaken and positively identified the performance of the home and its manager. Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions and detail the reason for the withdrawal and two signatures. Regular external audits of service users personal money are undertaken. Services users are able to control their own finances if they want to and are able to, but the majority of services users have their finances managed by their families or by a Guardianship Order. Staff do not manage service users financial affairs as required by the regulations to safeguard services users financial interests. The home has good statutory training opportunities for fire safety training, moving and handling, infection control, the protection of vulnerable adults and health and safety. Procedures to protect service users include regular checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene and health and safety. Plans are in place for further training that will include first aid and infection control. Maintenance records and contracts were reviewed and were found to be up to date. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 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 Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14 Requirement All service users receive a comprehensive assessment of all their needs prior to coming to the home. All staff working on the Dementia Care units receives Dementia Care training. Service users (or their representative) must be involved in the planning and review of their care. Services users who require wound dressing must have comprehensive instructions of how the wound will be dressed and managed. All service users must be weighed whenever possible at the time of their admission and thereafter regularly as required by their risk assessment. Service users must have all required equipment including specialist pressure relieving as identified by their risk assessment and The registered person must ensure that medicines are stored appropriately by ensuring that DS0000004886.V296249.R01.S.doc Timescale for action 31/05/06 2 3 OP4 OP7 18 15 31/10/06 30/06/06 4 OP7 15 31/05/06 5 OP8 15 31/05/06 6 OP8 15 24/05/06 7. OP9 13(2) 31/05/06 Netherton Green Nursing Home Version 5.2 Page 23 the ambient temperature of the medicine storage rooms do not exceed 25(c. Previous timescale of 31/03/06 Not met 8 9 10 11 12 OP9 OP9 OP9 OP9 OP9 13(2) 13(2) 13(2) 13(2) 13(2) The drugs fridge temperature must be recorded on Darby as required. The date of opening of short life medication must be recorded. There must be no gaps on medication administration records. The administration of creams and lotions must be recorded. Staff must ensure that service users discharge is comprehensively planned for including their needs in relation to medicines. The manager must ensure that 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. The responsible person must 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 ensure the programme of refurbishment and redecoration continues. Previous timescale March 2005 part met. Darby outstanding. The registered person must ensure an adequate provision of nursing equipment in particular DS0000004886.V296249.R01.S.doc 24/05/06 31/05/06 24/05/06 31/05/06 24/05/06 13 OP19 16(2)(c) 31/07/06 14 OP19 23(4)(c) 31/07/06 15 OP19 23(2)(d) 31/07/06 16 OP22 23(2)(n) 30/06/06 Netherton Green Nursing Home Version 5.2 Page 24 17 OP26 13(3) 18 19 OP26 OP27 16(2)(k) 18 20 OP36 18(2)(a) sufficient height adjustable beds and footstools for Saltwells unit. Partially met The registered person must ensure that staff hand wash outlets are fitted with a means of hot water control to promote good hand washing practice. Not assessed The home must be kept free from offensive odour. Night time staffing levels for the dementia care units must be reviewed and meet service users needs. The registered person must ensure that staff are appropriately supervised on at least 6 occasions each year. Previous timescale December 2005 part met. 30/06/06 31/05/06 31/05/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP8 Good Practice Recommendations Staff sign to confirm that the each element on the “orientation” and intermediate care pathway care plans have been met. Staff record the type of equipment required e.g. pressure relieving mattress and size and type of sling and hoist required. Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Netherton Green Nursing Home DS0000004886.V296249.R01.S.doc Version 5.2 Page 26 - 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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