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Inspection on 13/09/05 for Newbury Manor Nursing Home

Also see our care home review for Newbury Manor Nursing Home for more information

This inspection was carried out on 13th September 2005.

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.

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 has a motivated and committed manager who has been in post for three years. The registered persons have an active role in the running of the home. One relative said " The home has improved considerably since the present owners` took over a few years ago and the manager is marvellous". Another relative commented " The manager has always got time to answer my questions and listen to me". The home has few requirements. No requirements remain from the last inspection all have been met or have been addressed in some way. Record keeping is maintained to a high standard, health and safety issues generally observed. One relative said " Mums quality of life has improved since she came into the home".The home provides good staffing levels everyday and has a low turnover of staff. Staff appear motivated and committed to providing a good standard of care to the residents`. Staff have either received all mandatory training or training has been arranged. One relative commented, " The staff are very supportive, they always give the impression they are listening. They are very friendly. The staff are nice to me and Mum". A resident commented, " The staff are good to me and kind". Another said, " The staff look after me". The home offers an excellent varied range of activity provision both in-house and by accessing community services. This to include swimming and holidays for those who are able. The home has a warm, welcoming, friendly atmosphere. The premises are maintained to a good standard.

What has improved since the last inspection?

An air conditioning unit has been purchased and installed in the treatment room to ensure that medication is stored below 25 OC. New flooring has been provided in ground floor communal areas. Toilets where needed have also been provided with new floorings. Staff are now receiving induction and foundation training. A robust training matrix has been produced. Staff have received infection control training.

What the care home could do better:

Few requirements have been made. A number of areas require `fine tuning` examples being, the reflection of all needs and risks in care plans, addressing minor medication issues and the securing of wardrobes and preventing unauthorised access to the laundry to enhance safety.

CARE HOMES FOR OLDER PEOPLE Newbury Manor Nursing Home Newbury Lane Oldbury West Midlands B69 1HE Lead Inspector Cathy Moore Unannounced 13 September 2005 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 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. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Newbury Manor Nursing Home Address Newbury Lane Oldbury West Midlands B69 1HE 0121 532 1632 0121 533 0727 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Superior Care (Midlands) Ltd. Mrs Susan Tompkins Care Home 47 Category(ies) of OP Old Age (47) registration, with number of places Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Nil Date of last inspection 09.03.05 Brief Description of the Service: Newbury Manor is a purpose built home which was orginally registered in 1997. The current registered persons took ownership in February 2002. The property is situated close to Oldbury town centre. Access to the Midlands motorway network is located within one mile. The home is registered to provide personal and nursing care to a maximum of fourty seven older people. The home has a large car park to the front of the building . The garden area surrounds three sides of the home with a paved patio area and seating. The accommodation is provided on two floors accessed by two passener lifts and consists of thirty-three single en-suite bedrooms and seven double en-suite bedrooms. All bedrooms are fully furnished and tastefully decorated. The home provides two lounges and a dining room on the ground floor and a lounge and dining room on the first floor.There are sufficient assisted toilets and bathrooms throughout the home. Ramps for ease of access and egress to the front and rear of the building. The home provides an excellent range of activities for residents and organises entertainers and events. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between the hours of 07.50 and 16.10 hours. The inspection was the first of the homes two routine statutory inspections for this year. During the inspection the premises were partially assessed to include the lounge and dining room areas, the laundry, bathrooms, toilets and five bedrooms. Three residents’ were selected for case tracking this process included the perusal of their care plans, daily and other records. Eight residents’ and two relatives were spoken to. Three staff files were assessed to include application processes, recruitment and selection procedures and training received. Medication systems were scrutinised as were records pertaining to health and safety and service maintenance of equipment. The manager and nurse on duty were both actively involved in the inspection process. What the service does well: The home has a motivated and committed manager who has been in post for three years. The registered persons have an active role in the running of the home. One relative said “ The home has improved considerably since the present owners’ took over a few years ago and the manager is marvellous”. Another relative commented “ The manager has always got time to answer my questions and listen to me”. The home has few requirements. No requirements remain from the last inspection all have been met or have been addressed in some way. Record keeping is maintained to a high standard, health and safety issues generally observed. One relative said “ Mums quality of life has improved since she came into the home”. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 6 The home provides good staffing levels everyday and has a low turnover of staff. Staff appear motivated and committed to providing a good standard of care to the residents’. Staff have either received all mandatory training or training has been arranged. One relative commented, “ The staff are very supportive, they always give the impression they are listening. They are very friendly. The staff are nice to me and Mum”. A resident commented, “ The staff are good to me and kind”. Another said, “ The staff look after me”. The home offers an excellent varied range of activity provision both in-house and by accessing community services. This to include swimming and holidays for those who are able. The home has a warm, welcoming, friendly atmosphere. The premises are maintained to a good standard. What has improved since the last inspection? 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. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 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 standard(s) 3,4,5. Residents’ and their representatives know when they enter the home that their needs will be met. Prospective residents’ and their relatives all have the opportunity to visit the home prior to admission to assess the quality, facilities and the suitability of the home. EVIDENCE: There was ample written evidence to demonstrate that all residents’ needs are fully assessed before they are offered a placement at the home. Prospective residents’ are given a written acknowledgement confirming that the home can meet their needs. It was noted however, that there was no specific date on this confirmation. There were minutes on the resident files perused to indicate annual formal reviews of their care. All prospective residents’ and or their chosen representatives are invited to visit the home to assess for themselves the services and facilities offered by the home. One relative commented “ I came to look around the home before Mum was admitted. What I looked for was the size of the bedroom, that it was well decorated and that staff could answer my questions”. Another relative said” I came and visited the home before Mum came to live here. I looked at a number of homes but preferred this one”. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7,8,9,10,11. A care plan is in operation for each resident however, more diligence is needed to ensure that all needs and concerns identified are reflected in the residents’ care plans. There was evidence available to demonstrate that the residents’ health care needs are being met. Overall medication systems are robust and adequate fine-tuning in a few areas is required. Residents’ are treated with respect and their privacy is maintained. Residents’ are assured that at the time of their death their previously recorded wishes will be honoured. EVIDENCE: A care plan was included in each of the resident files assessed. Whilst these are of a good standard in terms presentation and indicated relative involvement a number of needs identified were not reflected. Where risk in respect of tissue viability and nutrition had been identified there was no mention of these in the care plan. Similarly, one residents’ assessment documentation revealed that he was prone to dehydration and urinary tract infections. Another resident in their recent review the requirement to not get them up until the day staff came on duty were not mentioned in their care plan. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 10 There was ample evidence to demonstrate that various health care services are being accessed for the residents’ either on a regular or ‘ as needed’ basis. One resident for example who had swallowing difficulties had been recently assessed by a dietician, speech therapist and a consultant specialising in medicine. There was evidence of regular visits by the dentist, chiropodist and optician. Whilst there was evidence to demonstrate daily personal care delivery, the recordings are entered on three different templates making the tracking somewhat difficult. One relative spoken to said, “ The personal care provided to Mum is o.k”. The home since March 2005 has purchased and installed an air conditioning unit in the treatment room to ensure that the rooms temperature and medication stored therein remains under 25 OC. A clinical waste contract has been agreed to dispose of unused/ unwanted medications. Medication administration records viewed did not reveal any staff initial gaps. An updated staff signature list is in operation. The medication administration process observed appeared satisfactory. Medications are only managed and administered by the registered nurses. It is positive that nurses have been nominated for refresher medication training. It was identified that the present medication system requires medication records to be hand written. There was no evidence to suggest that two nurses are involved in this process to verify that information from medication labels is being correctly transferred to the medication record. The manager confirmed that the system is soon to change, as the pharmacy provider is to issue the home with printed medication records. It may however, still be required for short-term medications such as antibiotics prescribed that some medication records will be handwritten. It was noted that where there is a choice of dosage for example, ‘one tablet or two’ that the amount administered is not being entered on the medication record. One residents’ medication that was not prescribed as ‘ when needed’ (PRN) had been refused for most of the month. Staff were observed interacting with residents’. This appeared to be positive, residents were spoken to with respect, choices given. The Preferred form of address of each resident has been determined and recorded on their personal file. Their personal mail is not opened unless they have given their consent. Toilet and bathroom doors were seen to be kept shut whilst in use. Toilet and bathroom doors are all fitted with a suitable lock. Personal care, nursing and medical treatments and assessments are all carried out in privacy for example in the treatment room or residents’ bedroom. One relative said “ Mum is allowed to spend time on her own in her bedroom, she likes her own company at times”. It was noted for dietary reasons personal information pertaining to some residents’ for example those who have diabetes is displayed on a board in the dining room. A discussion was held in respect of this issue. The manager confirmed that the positives of this system out weighed any detriment to Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 11 confidentiality. There was no evidence to suggest that residents’ have given consent to this information being displayed. There was documentation available on each of the residents’ files to demonstrate that their wishes in respect of death and dying had been determined. A number of staff have received bereavement training. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13 Residents’ find that the lifestyle experienced in the home matches their expectations, preferences and satisfies their social and recreational interests and needs. Residents’ are very much encouraged to maintain contact with family and friends. EVIDENCE: There was sufficient evidence to demonstrate that the residents’ preferred rising and retiring times are determined and recorded. One resident said “ I can get up and go to bed when I like”. It was observed that breakfast was available until late morning allowing residents’ to get up and eat at times that are flexible. There was evidence to demonstrate that regular meetings are held for residents’ and relatives to discuss the homes functioning and other aspects. One relative commented “ The staff at all times try to ensure that care provided is to meet the lifestyle of the individual”. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 13 Activity provision is excellent. The home has its own mini bus and has a designated activity co-ordinator who offers a wide range of activities. One relative said “ I am having a meeting with the activities co-ordinator soon. This is to discuss my Mums recreational needs”. An art and craft collection is on display in the ground floor hallway. This collection consists of items that the residents’ have made. Seven residents’ have been taken on holiday by staff this year. Three went to Newquay and four went to Warners’ holiday site at Nottingham. A number of residents’ regularly access the local swimming pool. Certificates of their achievements are on display in the home. On the day of the inspection a canal trip was on offer for those residents’ who wanted to participate. There was no confirmation available to demonstrate that the home had enquired with their insurance company if additional insurance is required for trips and outings. The home offers flexible visiting arrangements. The homes statement of purpose reflects this as follows “ Service users’ are able and encouraged to receive visitors at any reasonable time of the day and no prior arrangement is necessary. Visiting at night ( after 10 pm ) is by appointment for security reasons”. One relative commented “ I visit Mum every day. I am always made to feel welcome by the staff”. Another relative said “ Me or my brother visit everyday. I generally come to see Mum in the morning, my brother visits in the afternoon”. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 14 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 standard(s) NIL No standards in this section were assessed. EVIDENCE: Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19,20,21,24,26. Residents’ live in a safe, well- maintained environment. Residents, have access to safe and comfortable indoor and outdoor communal facilities. Residents’ have sufficient and suitable lavatories and washing facilities. Residents’ have comfortable bedrooms with their own possessions around them. The home overall, is clean, pleasant and hygienic. EVIDENCE: A random tour of the premises was carried out. In general the home is well maintained in respect of maintenance and decoration. Decoration needs are audited on a regular basis and are attended to in order of priority. New curtains have been ordered for communal areas. Wooden flooring has replaced the previous type within the last 12 months and all bedrooms have been redecorated. The home has a handyperson employed on a full time basis allowing work to be attended to consistently. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 16 The home offers communal space living and dining facilities on both floors. The ground floor has a large and small dining room. The home also offers a small visitors room in the entrance area. The lounges and dining rooms are comfortable with domestic style furnishings. The wooden flooring in the ground floor lounge is new. The lounge on the ground floor has a bird cage where two birds live. The first floor lounge also has a bird in a cage, a pet that one resident brought into the home with her. The carpet in the ground floor dining room had been deep cleaned the week before, yet it still appeared to be stained. The manager confirmed that there are plans to replace this carpet. The home has sufficient assisted and non-assisted toilets throughout and a number of assisted bathing facilities, which give residents the choice of a shower or a bath. Flooring in toilets has been replaced recently. Bedrooms viewed were seen to be adequate and comfortable in terms of carpets, fixtures and fittings provided. Bedrooms held a range of residents’ personal possessions giving bedrooms a homely feel. There was documentary evidence available to demonstrate that residents had been offered a key to their bedroom door or a risk assessment had determined safety issues where it would not be advisable to offer a key. Similarly, Residents’ and relatives had confirmed in writing their satisfaction with what was provided in their rooms. One resident said “ I like my bedroom. I do not need anything else in here”. Bedroom 29 is located over the kitchen. Unfortunately the noise from the kitchen extractor emanates into this room. Whilst action has been taken to reduce the noise it has not been totally eliminated. The manager said “ we are at the present time in the process of obtaining quotes to rectify this problem”. A random audit in respect of infection control was carried out. This included viewing a number of bathrooms and toilets. New impermeable flooring has been provided in a number of these rooms. Paper towels, liquid soap and protective clothing were available in all these rooms or close by. It is pleasing that staff received infection control training in February and March 2005. The laundry appeared to be satisfactory. Unfortunately one of the homes washing machines had broken. The registered person is already in the process of obtaining quotes to replace this. Laundry facilities offer sluice wash cycles. The flooring and walls appeared to be satisfactory. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30. Residents’ needs are met by the numbers and skill mix of staff. Residents’ are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: The home provides sufficient staff to meet the needs of the residents. In general a 24 hour day is staffed as follows: Morning : Eight care staff and one Registered Nurse. Weekdays the manager is also on duty. Up to four times per week an additional nurse is rostered. Afternoons: 7 care staff plus one Registered Nurse. Night times: Four carers plus one Registered Nurse. The home has an activities co-ordinator and a handyperson. Catering hours are provided continually throughout the day to 19.00 hours. Domestic and laundry staff are provided every day. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 18 Three staff files were scrutinised. These contained a completed application form detailing employment histories, confirmation of a satisfactory enhanced disclosure/ Protection Of Vulnerable Adults list check and at least two sources of identity. The only concern identified was a reference from a long-term ‘professional’ referee that clearly had not been requested by the home and was not valid as it was dated 1991. There was evidence to demonstrate that new staff are receiving induction and foundation training provided by a company called CSCM. A training matrix is in operation which includes each individual staff members name and courses attended/ due to attend. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,38 Residents’ live in a home which is run and managed by a person who is fit to be in charge. Fine tuning to some areas of health and safety is required to ensure that the safety of residents’ is maintained at all times. EVIDENCE: The present manager has been in post for three years. She is approved by the Commission as a fit person to run and manage the home. The manager has only one unit to complete in order to receive her registered managers award. In general health and safety is observed. Evidence was available to demonstrate the regular servicing of equipment and fire fighting appliances. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 20 There was evidence of bedrail and wheelchair checks. Records made however, do not specify which ones have been checked at any time. It was noted that wardrobes in residents’ bedrooms are not secured or risk assessments undertaken in respect of these. A further concern was identified in that there is no means to prevent unauthorised access to the laundry where potentially high risk equipment is located. Accident analysis is undertaken for each resident. The manager confirmed that she will be extending this to an overall system for the home. Water temperatures are checked regularly with records made of the findings. It was noted that the water temperatures in two toilet areas ( 2 and 7) had not been recorded for a few weeks. The kitchen was not assessed during this inspection. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x x 2 Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? 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 OP4 Regulation 14(1)(d) Requirement The registered persons and manager must ensure that the date is entered on all written acknowlegements to residents which detail how the home will meet their needs. The registered persons and manager must ensure that residents care plans reflect all needs, risks and special requests. The registered persons and manager must ensure that concise records are made which are easy to track are available to evidence the full daily range of personal care delivered to each resident. The registered persons must ensure that where medication records are handwritten that the information being transferred from the medication bottle or packet and written on the prescription is verified by two nurses. The registered persons and manager must ensure that where a choice of dosage is prescribed i.e one tablet or two the number of tablets Timescale for action 1.10.05 2. OP7 15(1) 1.10.05 3. OP8 12(1)(a) 1.10.05 4. OP9 13(2) 1.10.05 5. OP9 13(2) 13.09.05 Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 23 administered is recorded. 6. OP9 13(2) The registered persons and manager must ensure that where medications that are prescribed to be given frequently are refused for longer than 3 days that this is reported to the residents doctor. In this instance the medication was senna. The registered persons and manager must ensure that the permission and consent of each resident (or chosen representative where applicable) who has information about them displayed on the board in the dining room is obtained and a record of this be made on their personal file The registered persons and manager must replace the floor covering in the small ground floor dining room. The registered persons and manager must ensure that the extractor fan in the kitchen can not be heard in bedroom 29. The registered person and manager must not accept predated references. The registered persons and manager must ensure that specific records relating to individual bedrail/wheelchairs are made. The registered persons and manager must ensure that all wardrobes are adequatley secured.In the interim period a documented risk assessment in respect of each wardrobe must be carried out. The registered persons and manager must consult West Midlands Fire Service about installing a suitable lock/bolt on the laundry door to prevent 13.09.05 7. OP10 12(4)(a) 13.10.05 8. OP20 23(2)(d) 1.11.05 9. OP24 16(2)( c) 1.10.05 10. 11. OP29 OP38 19(2) 13(3) 13.09.05 13.10.05 12. OP38 13(3) 13.10.05 13. OP38 13(3) 1.10.05 Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 24 unauthorised entry. 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 OP12 Good Practice Recommendations The registered persons and manager are strongly advised to confirm with their insurance company whether or not additional insurance is required for resident trips, outings and holidays. Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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 Newbury Manor Nursing Home E55 S4864 Newbury Manor N H V248826 130905 Stage 4.doc Version 1.40 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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