Inspection on 06/12/07 for NewDay Nursing Home

This inspection was carried out on 6th December 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

NewDay Nursing Home 19/01/09

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE NewDay Nursing Home 45 Wynford Road Acocks Green Birmingham B27 6JH Lead Inspector Lisa Evitts Key Unannounced Inspection 6th December 2007 09:45 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 NewDay Nursing Home DS0000069296.V350621.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. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service NewDay Nursing Home Address 45 Wynford Road Acocks Green Birmingham B27 6JH 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) 0121 706 0427 0121 706 0427 Huskards Care Limited Post Vacant Care Home 37 Category(ies) of Dementia - over 65 years of age (37), Old age, registration, with number not falling within any other category (37), of places Physical disability (37) NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with Nursing - N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 37 Physical disability aged 60 and above (PD) 37 Dementia (DE) 37 The maximum number of service users to be accommodated is 37. 2. Date of last inspection None Brief Description of the Service: NewDay is a thirty-seven bedded nursing home situated in the Acocks Green suburb of Birmingham, registered to care for older adults who may have physical disabilities and/or dementia. It is a large converted house with a single storey extension to the rear of the property where the majority of facilities are located. The home has been established for a number of years but has a new owner and name since July 2007. The home has two lounges and dining rooms plus a quiet room and a separate smoking room. Bedrooms are a combination of eight double rooms and twentyone single rooms of which twelve have en-suite facilities consisting of a toilet and wash hand basin and one bedroom has an en-suite shower facility. The home has some assisted bathing facilities and equipment for moving and handling people with limited mobility. The corridors in the extension are wide and have handrails suitable for people with mobility problems, so that they can move around the home freely. Access to the front of the property is via a ramp, which enables people in wheelchairs to access the building. The home is within a short walking distance of shops, bus routes and train services. There is a garden to the rear of the NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 5 home with a patio area, which has a water feature and seating for use by people when the weather permits, however there are some steps to negotiate. Limited off road parking is available to the front of the property. Inside the home there are notice boards containing information about the home, including forthcoming events, which may be of interest to people. The home accepts people for long term and respite care. The fees are not included in the service user guide but are available on request from the home. These fees may be subject to change. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. One inspector undertook this fieldwork visit to the home, over one full day and the acting manager assisted throughout. The Registered Provider was also present. The home did not know that we were visiting on that day. There were 35 people living at the home on the day of the visit and one person was receiving hospital treatment. Information was gathered from speaking to and observing people who lived at the home. Four people were “case tracked” and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. Random questionnaires were sent out in order to gain peoples views about the service. Six people who live at the home and two relatives returned questionnaires. These contained positive comments about the service provided and are included within this report. Four people who live at the home, one staff member and two relatives were spoken to. Prior to the inspection the acting manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and people who live there, improvements and plans for further improvements, which was taken into consideration. Regulation 37 reports about accidents and incidents in the home were reviewed in the planning of this visit. No immediate requirements were made at the time of this visit. What the service does well: People are provided with information about the home so that they can make an informed decision about whether they would like to live there. People have access to a range of Health and Social Care Professionals and this ensures that health care needs are met. Advice is sought from professionals by the home proactively to ensure that people’s needs are addressed. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 7 People are provided with a varied menu, which meets any dietary needs, cultural or personal preferences. There is an open visiting policy so that people can receive their visitors as they choose. Staff receive training to provide them with knowledge and skills to meet the assessed needs of the residents individually and collectively. People are involved in meetings about the home and are involved in care planning. This gives them the opportunity to voice their opinions. Small amounts of personal money can be held by the home and this should ensure that people’s money is safe. People told us: “I am more than satisfied, it meets all his needs” “The care home staff seem to be quite competent in their ability to look after residents” “The care is adequate” “We can come at anytime and you never feel you are in the way” “The food is ok now” “If I had any complaints I would speak to the manager, they are very approachable” “The staff are very good to me” What has improved since the last inspection? What they could do better: NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 8 Care plans must be written to ensure that staff are aware of the current care needs of individual people and their personal preferences. Staff must ensure that medications are administered to people as prescribed. The home must ensure that all the relevant authorities are informed of any incidents that occur within the home in order to safeguard people who live there. The recruitment process needs to be improved so that people are safeguarded from harm. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have sufficient information about the home to enable them to make an informed decision about whether they would like to live there. Pre admission assessments ensure that people know their needs can be met prior to moving in. EVIDENCE: The home has a statement of purpose, which has recently been updated to provide people with current information about the home. This document is available in large print so that people with visual impairments can access the information. The service users guide was in the process of being updated and the provider is planning to make these documents available in alternative languages. This will enable people who’s first language is not English to access information about the home. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 11 The certificate of registration and public liability insurance certificate are on display. A notice informing people they can get a copy of the last inspection report is displayed so that people have access to this information should they choose to see it. Two pre admission assessments for recently admitted people were reviewed and these were found to contain information about their needs for the home to make a decision as to whether they could meet their needs. One of these did not have a date or signature recorded as to when and who had completed the assessment, however the documentation has since been reviewed to include this information. Letters of confirmation are sent to the prospective person to ensure that they know that the home can meet their assessed care needs before they move into the home. There are seven younger adults living at the home, however the home will not admit younger adults in the future as the registration has changed. The home does not offer intermediate care facilities. One relative told us “I am more than satisfied, it meets all his needs”. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide staff with some guidance on aspects of peoples needs but this is not consistent and may result in omissions or inappropriate care being given to people. The management of medication does not ensure that all people receive their medication as prescribed. EVIDENCE: Each person has a care plan written. This is an individualised plan about what the person is able to do independently and states when assistance is required from staff in order for the person to maintain their needs. Two care files were reviewed and two were partly reviewed. The following was found: Risk assessments are completed each month for nutrition and risk of skin soreness. Moving and handling assessments are completed and provided details of equipment to be used and this means that staff know what equipment they should use for individual people to move them safely. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 13 Care plans were not consistent. Some files contained some personal preferences such as “Likes to dress with a matching cardigan and vest” and “prefers male staff to assist” but these were minimal. Care plans did not always provide specific details for staff to follow, for example, type of cushion required or type of continence pad. This does not ensure that people receive their care in a manner, which they would like, and which meets their personal choices and this must be addressed. Care plans were not always updated with current care needs for example when bedrails were added for safety or when people were no longer able to feed themselves. This does not ensure that staff have current information about changes in condition. There seemed to be some confusion about where to document the care needs and the information for staff to follow to meet the needs of people. This made the information difficult to retrieve and it is recommended that staff receive some training in care planning. There were a number of entries on one file regarding difficult to manage behaviour but no care plan had been written so that staff had instructions to follow to minimise this behaviour. Another file did have a plan for difficult behaviour but no triggers for the behaviour were identified so that staff knew what was likely to cause the behaviour. Some care plans had been signed by relatives and this shows that people are involved in making decisions about care. There is evidence that external healthcare professionals such as the GP, optician, social workers, nurse practitioner, tissue viability nurse, physiotherapists and dentists see people. This ensures that people receive specialist care where required. People told us: “Every time I visit he seems well looked after” “The care home staff seem to be quite competent in their ability to look after residents” “The care is adequate” The management of medication was reviewed. Copies of prescriptions are kept so that staff can check that they have received the right medication into the home. Controlled medications were appropriately stored and recorded and balances were correct. A new fridge had been purchased however on occasions the temperature was too high and this does not ensure that medication is stored within its product licence. Six peoples medication was reviewed and five audits on boxed medications were incorrect and this may mean that people have not received their medication as prescribed. The manager stated that staff were to have training in the safe handling of medicines and it was NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 14 recommended that audits of staff competence are completed, so that people receive their medication as prescribed. It is recommended that two signatures are recorded onto hand written Medication Administration Records (MAR) so that staff are sure that the correct drug and dosage is recorded. People were appropriately dressed and had been assisted to wear clothing, make up, jewellery and nail polish to meet their identified choices. Hair care was reflective of personal choices. People are able to make telephone calls using the mobile phone from the home. One person has chosen to have their own telephone line installed at an additional cost so that they can make and receive calls in private. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to choose the activities that they participate in which promotes their individuality and independence. People are offered a choice of meals to meet their dietary, cultural needs or preferences. EVIDENCE: The home has a dedicated activities coordinator who is enthusiastic about her role. There is a weekly activities programme, which consists of newspaper discussions, games, quizzes, music, nail care, movies, garden walks, shopping and one to one time. A forthcoming events programme detailed trips to nature centres, barbeques, trips to the cinema and bowling, bonfire/dawali celebrations with fireworks, Eid celebrations and a Christmas and New Year party. There was evidence of external entertainers visiting the home and church groups to provide music. Progressive mobility were at the home on the day of the visit and this provides people with the opportunity to exercise to music if they choose to. Eight people were booked to see a pantomime in December and others were going in January. Four people attend a lunch club each week and different people attend a local art and craft centre each Wednesday. This enables people NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 16 to maintain links with the community. There is a church service once a month and a nun who visits the home gives Holy Communion. One person is assisted to the temple to pray when he requires and the home have purchased a prayer mat. This enables people to continue with their chosen religion if they wish to do so. A hairdresser visits each fortnight to attend to people’s hair if they choose. Each person has a written record of the activities that they have participated in and there are photographs displayed of events held in the home. There is an open visiting policy, which means that people can see their visitors as they choose. One relative said, “We can come at anytime and you never feel you are in the way”. The home has a four-week rolling menu and this has been reviewed following a number of concerns raised about the standard of food by the people who live at the home. People had also asked for a choice of hot meal in the evening and this had been addressed. There are two choices of hot meal at lunchtime and a hot meal or sandwiches in the evening. Sandwiches and biscuits are available for supper if chosen. It has been agreed that the menu will be reviewed with people every six months. People had requested menu cards for the table so that they knew what the choices were for the day and a member of staff was typing these up. People had been involved in the planning of the Christmas party menu. Dining tables were presented with cloths, placemats, cutlery and serviettes. People were asked if they would like further helpings and staff were observed to sit down to assist people who needed assistance to eat their meals. Staff were observed to be wearing gloves to feed people and it is recommended that this practice cease as it does not promote people’s dignity. People told us: “I do like the food here” “The food is ok now” “I’ve had cornflakes and orange juice for breakfast, that all I want” NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is comprehensive and is accessible to people should they need to make a complaint. The home has policies, procedures and staff training, which should safeguard people from harm if implemented. EVIDENCE: The complaints procedure is displayed in the home and is included in the statement of purpose and service user guide so that people know how to make a complaint if they need to. This procedure is also available in Urdu and Hindi so that people who speak a language other than English can access the information. Since the new provider took over the home in July 2007, there have been five complaints recorded by the home. These were documented along with actions taken to resolve the complaint and any outcomes. We had received one complaint, which had been referred to the provider to investigate under the homes own complaints procedure. One relative said, “If I had any complaints I would speak to the manager, they are very approachable”. People who live at the home were able to tell us who they would talk to and this suggests that people are confident to raise any concerns. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 18 The home has an adult protection policy and a copy of Birmingham local Multi Agency Guidelines so that staff have guidelines to follow in the event of an allegation of abuse. This should safeguard people from harm. It is recommended that the home obtain a copy of Solihull Multi Agency Guidelines, as there are people living in the home who are funded by this authority. The home has a whistle blowing policy so that staff can report any concerns without fear of reprisals. All staff have undertaken adult protection training so that they should have the knowledge to safeguard people in the event of an allegation being made. It was of concern that an incident between two people at the home had been recorded on an incident form but the incident had not been reported to us or to Social Care and Health. The incident was a possible adult protection concern and the manager must ensure that incidents are reported to the relevant authorities so that people are protected. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with a clean and comfortable environment in which to live. EVIDENCE: Access to the home is via a ramp, which enables people in wheelchairs to gain entrance to the home. Entrance to the home is via a doorbell and this ensures that staff know who is entering the building in order to safeguard the people who live there. Inside the home there is a permanent ramp installed so that people no longer have to negotiate a small step from the corridor into the main area of the building. There is a new passenger lift to the first floor. On the day of the visit, a partial tour of the building was undertaken and the home was found to be clean and odour free. There are two lounge areas that are adjoining the dining room in the extension plus a further dining room that is adjacent to the kitchen in the original building. The conservatory was NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 20 decorated with Christmas items and had a pleasant atmosphere. There is a quite lounge, which is equipped with sensory lights. The home has a smoking room which had a number of cardboard boxes stored in there and these were removed at the time of the visit due to being a fire hazard. A number of bedrooms had been redecorated and non-slip flooring had been laid. Shared bedrooms had dividing curtains to maintain peoples dignity and privacy and call facilities were in each room so that people could summon help. Some bedroom doors had pictures on them so that people could identify their own rooms. Chests of drawers were labelled with items of clothing and it is recommended that this cease as it does not provide a homely environment. The exception to this being if this enables people to maintain their independence. One room was noted to have a skylight, which was damaged and made the room dark. It is recommended that this is replaced to promote a homely environment. A number of new beds, mattresses and pressure relieving cushions have been purchased so that people have comfortable surroundings. Two new hoists have been purchased to assist people who need help to move due to mobility difficulties. The provider has further improvements planned for the environment and progress of these will be monitored. One relative told us “There have been some improvements and the home looks different”. The home had received an “Excellent” rating for hygiene standards in the Hygiene Award Scheme from Birmingham City Council. This should ensure that people receive food in a safe manner. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by staff who receive some training to ensure that they have the knowledge to meet individual needs. Lapses in the recruitment procedure do not ensure that people are safeguarded from harm. EVIDENCE: There are five care staff and two trained nurses throughout the day and three care staff and one trained nurse throughout the night. In addition to nursing and care staff the home also employs domestic, laundry, maintenance, kitchen and activity staff to meet all the needs of people living at the home. The home currently had no staff vacancies and was waiting for recruitment checks prior to people starting employment at the home. All of the care staff, with the exception of one who was enrolled onto a course, have completed a National Vocational Qualification (NVQ) level 2 or 3 in care. This should ensure that a knowledgeable and skilled workforce can meet people’s needs individually and collectively. People told us: “The staff are very good to me” “The staff seem to be very helpful and caring” NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 22 Three staff files were reviewed and two of these contained all the required information to ensure that people were safe from harm. The third file did not have any references and the manager was unable to locate these. This is required to ensure that people are safe from harm. A staff-training matrix had been devised but this was not user friendly and did not enable the manager to plan training for the future. It is recommended that this be further developed. Some staff had received training in infection control, first aid, dementia awareness, food hygiene, fire, health and safety. Distance learning packages had been implemented for equality and diversity. Moving and handling, palliative care, tissue viability and Mental Capacity Act training were all planned for the future. Staff receive induction training from an external trainer and there was evidence that new staff were booked onto this training. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider and acting manager are keen to ensure that the home is run in the best interests of the people who live there. They need time to continue with and sustain the improvements, which are in place. EVIDENCE: Since the new provider took over the ownership of the home, the registered manager has left employment. A registered nurse who has worked at the home for six years is acting manager and is in the process of submitting an application to us to become the Registered Manager of the home. She is currently working towards the Registered Managers Award and this will assist her knowledge in the effective leadership of the team. In addition to this she also completes the in house training alongside staff. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 24 The Registered Provider shows a strong commitment to making improvements at the home and presently spends four days a week at the home supporting the acting manager. People who live at the home are invited to attend a monthly meeting so that they can discuss ideas about the home. There was evidence that any concerns were acted upon and actions taken to resolve them. Staff meetings are also held so that they can voice their opinions. Prior to the inspection the acting manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and people who live there, improvements and plans for further improvements, which was taken into consideration. Regulation 26 visit reports are completed and sent to us. These provide us with information about the quality of service and improvements in the home. The home had recently sent out satisfaction questionnaires to people who live at the home, however these were not available to see. The manager has started to complete a number of audits to ensure that standards are met and maintained. The acting manager is aware that an annual report on the quality of service provided should be written. Individual records are maintained for people where the home holds personal monies. Receipts were available to confirm all expenditure on the accounts. The balance of money was found to be correct however it is recommended that two people undertake a monthly audit. Health and safety and maintenance checks had been undertaken in the home to ensure that the equipment was in safe and full working order. Water temperature checks are recorded each month and this assists in the prevention of people accidentally scalding themselves. Maintenance checks are completed on the fire system and equipment and staff receive fire training and drills so that people should be safe in the event of a fire occurring. It is required that the emergency lighting is checked each month to ensure it is in full working order. One person had chosen to have her door propped open. The manager stated that a guard had been ordered so that the door could stay open but would close in the event of a fire so that the person was safe. It is required that a risk assessment is written in respect of this so that staff are aware of the potential risks of the door being propped open. Accident records were reviewed and we are generally informed of accidents or incidents within the home. The exception being the incident discussed in the complaints and protection section of this report. The manager stated that accidents were audited so that any trends or patterns could be identified and action taken. There was no formal documentation for the auditing of accidents and this is recommended. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 2 X X 2 NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must provide specific and current information about peoples needs so that staff have information to follow to provide care, which meets needs and preferences. The management of medication must be reviewed so that people receive their medication as prescribed. Incidents of adult protection nature must be reported to the relevant authorities so that people are safe from harm. Two written references must be obtained to ensure that people are safe from harm. Risk assessments should be written to safeguard people in the event of a fire. Emergency lighting should be checked each month to ensure it is in full working order. Timescale for action 15/02/08 2. OP9 13(2) 31/01/08 3. OP18 13(6) 11/01/08 4. 5. 6. OP29 OP38 OP38 19 Sch 2 13(4)(c) 13 (4)(c) 11/01/08 07/01/08 07/01/08 NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 27 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. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Refer to Standard OP7 OP9 OP9 OP15 OP18 OP19 OP24 OP30 OP31 OP33 OP35 OP38 Good Practice Recommendations Staff should receive training in care planning so that information is easy to retrieve. The manager should audit staff competence in the management of medication so that people receive their medication as prescribed. Two signatures should be recorded on hand written medication charts so that staff are confident that the correct prescription is recorded. Staff should not routinely wear gloves when assisting people to eat their meals. A copy of Solihull multi agency guidelines should be obtained for staff to refer to. Skylights should be repaired or replaced to promote a homely environment. Labels on furniture should be removed to promote a homely environment for people to live in. A staff-training matrix should be devised which enables the manager to plan future training. The acting manager should submit an application to us to become the registered manager of the home. An annual report should be written based on the quality of service provided. Two people should audit personal monies monthly to check for any discrepancies. Documentation of accident audits should be implemented so that trends are monitored. NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI NewDay Nursing Home DS0000069296.V350621.R01.S.doc Version 5.2 Page 29 - 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. 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