Inspection on 13/04/06 for Nightingale House

This inspection was carried out on 13th April 2006.

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

The inspector 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

Nightingale House 13/10/09

Nightingale House 14/09/07

Nightingale House 01/10/05

Nightingale House 24/05/05

Nightingale House 03/09/04

Nightingale House 19/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Nightingale House 22 Elgin Road London N22 4UE Lead Inspector Peter Illes Unannounced Inspection 13th April 2006 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 Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Nightingale House Address 22 Elgin Road London N22 4UE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8889 7885 020 8883 7198 Miss Renouka Devi Sisteedhur Mr Roshanlall Sisteedhur Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (9), Old age, not falling within any other category (9), Physical disability (3), Physical disability over 65 years of age (9) Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Limited to 9 people of either gender who fall into the category of old age (OP) who may also have a physical disability (PD(E)) and who may also have a mental disorder (MD(E) 3 of the 9 places may accommodate a person of either gender who is between the age of 59 years and 65 years who may have a physical disability (PD) and may also have a mental disorder (MD). Date of last inspection 1st October 2005 Brief Description of the Service: Nightingale House is a registered care home for nine older service users who may also have a range of additional needs - see conditions of registration. The home has also applied to the Commission for a major variation to its conditions of registration to allow service users with a diagnosis of dementia to be accommodated in future. The home is privately owned and managed by the Sisteedhur family. The home is a large converted three storey domestic premises. There are three single service user bedrooms and three shared situated on the ground and first floors with a lift providing access to the first floor. The home’s communal areas are on the ground floor and consist of a large sitting room and separate dining area. The kitchen, utility room and a toilet are also situated on the ground floor; the second floor consists of the staff sleeping in room/ office. There is a large pleasant garden at the back of the house. The home is situated in a quiet residential street and close to local shops, a library and a public house. The home is also reasonably near the larger range of shops and amenities in Muswell Hill Broadway. The current minimum charge at the home starts at £471 per week and may rise according to the persons assessed needs. Additional charges may be made for personal items such as newspapers and toiletries. A range of information, including CSCI inspection reports, is shared with service users at regular meetings. Inspection reports are also made available to prospective service users and their representatives as part of the referral process. The stated objective of the home is to enable service users to live independent and fulfilled lives as far as they are able, with dignity and privacy in a tranquil and elegant environment. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection the home has appointed the previous deputy manager to become the manager with the previous manager becoming the deputy manager. Both managers are members of the Sisteedhur family and the decision was taken as a positive move to meet the respective managers development needs, career needs and to continue to positively develop the service for the benefit of the service users. This unannounced inspection took approximately six hours. The registered manager was not on duty; the deputy manager was present or available throughout. There were eight service users accommodated at the time of the inspection with the home having one vacancy. The inspection included: discussion with six service users, five of them independently; discussion with the deputy manager; discussion with three members of the care staff independently; a telephone discussion with one relative and a telephone conversation with a placing authority social worker. Further information was obtained from a tour of the premises and documentation kept at the home. What the service does well: What has improved since the last inspection? Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 6 There were five requirements made at the last inspection and all of these had been complied with. The identified improvements made were in the following areas: hand washing facilities in a bathroom, a repair to damaged tiles in a bathroom, redecoration of an identified bedroom, an identified issue relating to staff recruitment and ensuring fire doors are not wedged open. A good practice requirement was made to review and increase activities available to service users. This has also been effectively dealt with leading to an improvement in activity options available to service users. 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. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be confident that their needs will be assessed at the point of admission to the home to ensure they can be effectively met. Service users needs are also kept under review when they have been admitted to ensure that any changing needs are recognised. EVIDENCE: The files for four of the eight service users accommodated were inspected. All four contained a satisfactory range of assessment information that was available at the time of admission with evidence that this was updated on a regular basis. The social worker involved in the admission of one of the service users was spoken to by telephone. She stated that the home had done a good job through the admission process including helping the service user address a particular assessed need at that time. Evidence was seen of multi-disciplinary reviews with input from mental health professionals where appropriate. Evidence was also seen that service users participated in their reviews and Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 9 some service users spoken to confirmed this. Past assessment information and other personal information, the detail of which did not need to be widely shared, is kept in a separated file in a locked filing cupboard. Information on service user’s current needs and how to address these is kept in files that are accessible to all staff. Staff are encouraged to keep themselves up to date with service users needs and wishes and to record relevant information as appropriate. The home does not provide intermediate care. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and aspirations are well set out in their care plans to assist staff to address these in a personalised way. Service users health needs are well monitored and they are supported in addressing these with a range of relevant health professionals. Service users are protected and their needs promoted by effective medication procedures. Service users receive sensitive and individualised support from staff with their personal care and are treated with respect by them. EVIDENCE: The four service users files inspected all contained current care plans and were accessible to all staff. The plans showed individual needs and aspirations that related to the current assessment information seen. The plans also gave guidance to staff on how to assist service users meet these needs and aspirations. The needs recorded included health, medication, personal care, appetite and diet, assistance when travelling in the community and personal care needs as well as a range of individual needs relating to each service user. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 11 There was evidence that the care plans were being regularly reviewed on a monthly basis. Staff spoken to were able to describe service users needs and give examples of how these were met. There was evidence that the home actively addresses the health needs of service users including their physical, mental and emotional health. Evidence seen on files included: weight charts with regular entries; contact with GP’s, including for annual influenza inoculations; contact with hospitals for identified medical conditions and regular contact with a local optician and dentist who had both visit the home since the last inspection. Evidence was also seen of contact with other health professionals as appropriate including National Health Service chiropody appointments for service users with diabetes and appointments with mental health professionals where appropriate. These needs were also appropriately noted on care plans and staff spoken to were able to give examples of how the home addressed these. The relative of one service user was spoken to by telephone. This relative stated that they were very pleased with the attention given to the service user in facilitating contact with medical specialists for a recently diagnosed health condition. Medication and medication administration record (MAR) charts were inspected for four service users and were satisfactory. The inspector was pleased to see that the home had a separate list of medication for each service user kept on their daily file with a key to why each of the medications was prescribed. This was to promote staff’s understanding of prescribed medication and why it was being administered to individual service users. Evidence was seen that the dispensing pharmacist undertakes an annual inspection of the home’s medication procedures. The home had fitted two new medication cupboards since the last inspection, one for medication that is supplied in individual doses by the dispensing pharmacist and the other for lotions and liquid medication. The temperature of both cupboards is monitored on a regular basis. The assistance and support that service users need with their personal care is documented on their care plans. Staff were observed interacting with and assisting service users appropriately and with respect throughout the inspection. Service users spoken to independently indicated that they were satisfied with the way they received personal care and support from staff. One service user stated that they liked to get up early of a morning and another service user stated that they normally went to bed at 9pm but could stay up later if they wished to. Another service user spoken to independently indicated that they found the staff helpful. When asked they also stated that they could not think of anything that they would wish to change with regard to staff support. Shared bedrooms were seen to have screening available to promote privacy for service users. The relative spoken to by telephone indicated that they were satisfied with the care and support given by staff to their service user. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 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 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. The home provides a range of social activities that has been reviewed to better meet service users needs and wishes. Service users are supported to maintain and develop relationships with their relatives and with others to the extent that they wish. The home supports service users to make as many decisions for themselves as they can in order to maximise their independence. The home serves varied and healthy meals that service users enjoy although an identified improvement is need regarding kitchen equipment. EVIDENCE: One service user attends external day services arranged by their referring authority and was at their day service during the inspection. A good practice recommendation was made at the last inspection for the home to review its inhouse range of activities available to service users. There was evidence that this had been done and several service users spoken to commented that activities had improved. A popular addition is a session of morning exercises that a number of service users stated they enjoyed. The inspector was informed that other new sessions that had been introduced were regular bingo games and darts. Other service users also told the inspector that they had Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 13 individual activities that they enjoyed e.g. two service users enjoy playing cards together. Some service users go out for regular morning walks including buying a newspaper if they wish. One service user told the inspector that he could go out for a walk with staff if wished but that he did not want to. A tray containing local library books was seen in the entrance hall and the inspector was informed that the mobile library visited the home every two weeks. The inspector was also shown a new daily activities diary that had been introduced since the last inspection. Staff record in this the activities offered each day and who participated in them. This showed recent entries relating to the activities listed above and also entries for activities such as quizzes and discussions relating to current affairs. The deputy manager stated that the diary will be used to monitor and review future activities provided by the home. Service users continue to have varying contact with their relatives. This varies from no contact to one service user having weekly contact and with others having telephone contact and occasional visits throughout the year. The service user’s relative spoken to by telephone confirmed that they were always made welcome at the home. The inspector was informed that relatives and friends are welcome and encouraged to visit the home. Service users are encouraged to make as many decisions as they can regarding their day-to-day lives. Examples of this include deciding what activities they do and do not wish to take part in and participation in service user meetings where various subjects and preferences are discussed including food and what time they get up of a morning and go to bed at night. The inspector was informed that either service users themselves, their referring authority or their relatives manage service users finances including their personal allowances. The home has a satisfactory menu that was seen with options such as fish and rice and peas to meet different service users cultural preferences. The lunch on the day of the inspection was cheese omelette and vegetables and service users spoken to stated that they liked the food provided. Staff and service users spoken to independently confirmed that individual options to the meals on the main menu were available to the service users on request. The local environmental health department had inspected the kitchen since the last inspection. The report of this visit was seen and was satisfactory. A recommendation had been made at the visit for the home to measure the temperature of food cooked. A record was seen that this was being complied with along with a temperature probe purchased for this purpose. The home had a satisfactory stock of food, including fresh food and vegetables, with food corresponding with the meals shown on the menu. It was noted that although clean the kitchen itself was starting to look significantly worn. The deputy manager stated that the home was planning to refit the whole kitchen in the coming year. Fridge and freezer temperatures continued to be monitored and the record of these was seen to be satisfactory. The inspector noted that the door on the fridge in the kitchen made contact with the floor when it was fully Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 14 opened and had significantly rusted where it made contact. A requirement is made that the fridge door is repaired or replaced to ensure that this does not become a health and safety hazard. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to express their views and concerns about the home and have these acted on positively. Service users are protected by a satisfactory adult protection policy and procedures that staff are familiar with. EVIDENCE: The home had a satisfactory residents charter and separate complaints policy that were both seen clearly displayed in the home’s entrance hall, the complaints policy included the contact details for the Commission. The inspector was informed that no complaints had been received at the home since the last inspection. Service users spoken to indicated that they could raise issues with the manager or staff if they felt the need. The home had a satisfactory adult protection policy and procedure and a copy of the procedure from the local authority that the home is situated in. The deputy manager and the staff spoken to were aware of adult protection issues and in general how they should be dealt with. No disclosures or allegations of abuse have been recorded by the home since the last inspection. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 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, 21, 23 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is safe, well decorated and well maintained. They have access to an adequate number of toilets and bathrooms with a range of equipment that meets their needs. The home was clean and tidy throughout creating a pleasant environment for service users, staff and visitors. EVIDENCE: The home is a converted three storey premises with three double and three single service user bedrooms on the ground and first floors with a lift connecting these two floors. Although somewhat limited by its design the home remains generally well decorated, maintained, safe and meets the current service users needs. The home has a wheelchair accessible ramp built to its front door. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 17 During a tour of the building the inspector was pleased to see that requirements made at the last inspection regarding hand washing facilities and replacing two tiles in the first floor bathroom had been complied with. The inspector was also pleased to see that service user bedroom number six had been redecorated as was also required at the last inspection. The inspector was informed that the home had an ongoing redecoration and replacement schedule with one of the next priorities being to refurbish the kitchen. The inspector also noted that the service user’s bedrooms remained generally satisfactory with privacy screens being seen to be available in the shared rooms. The home had satisfactory laundry facilities and the home was clean, tidy and free from offensive odours. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well qualified and stable staff team, in sufficient numbers, to support service users and to assist in meeting their assessed needs. Service users are also protected by the robust recruitment procedure operated by the home. Staff are offered a range of relevant training to further assist them in their own personal development and in meeting service users needs. EVIDENCE: The home had a satisfactory rota that was seen that showed two care staff and a senior member of staff on duty on both the early and the late shifts. One waking and one sleeping staff cover the night shift. The staff on duty matched those recorded on the rota. The home has sufficient staff to meet the needs of the current service users. The home continues to have a relatively stable staff group that was familiar with the service users needs. The home employs eight care staff in addition to the registered manager and the deputy manager. Two of these have achieved national vocational qualification (NVQ) level 2 in care with one of those now undertaking NVQ level 3 in care; one care staff has also completed NVQ level 3 in care and the remaining five are currently undertaking NVQ level 2 in care. Evidence to substantiate some of the above was sampled and staff spoken to confirmed Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 19 their particular NVQ status. The deputy manager told the inspector she was in the process of completing her registered managers award. The home had recruited one new member of staff since the last inspection and this staff member’s file was inspected. It showed documentation to evidence an effective recruitment procedure including: a completed application form, job description, contract, two written references, proof of identity, residence status and an enhance criminal records bureau (CRB) check taken out by the home and which included a protection of vulnerable adults (POVA) clearance. At the last inspection a requirement was made that the home obtains an enhanced CRB and POVA check for an identified member of staff. The inspector was pleased to see evidence that this had been complied with. Evidence was seen that the new member of staff had undergone an induction process. The member of staff confirmed that this had been useful in enabling her to know the needs of the service users and the basic procedures being operated in the home including health and safety. Evidence was seen that all staff had recently undergone basic training in meeting the needs of people with dementia. Staff spoken to stated that they had found this useful. The deputy manager confirmed that this training was provided to assist support the home’s recent application to vary its conditions of registration to include accommodating people with a diagnosis of dementia. She went on to say that the home was planning to send staff to attend carers meetings held by a local Alzheimer’s Society group to further extend their knowledge in this area. Other staff training documentation was sampled and showed evidence that the eight staff had current training in moving and handling, food hygiene, basic first aid and adult protection. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed effective systems, including formally consulting with service users, to contribute to the home being run in their best interests including safeguarding their financial interests. Staff are well supervised and supported and this assists them with both their own professional development and in meeting service users needs. The home has clear health and safety procedures in place to protect service users and others that work or visit the home although further improvements are needed in identified areas. EVIDENCE: Since the last inspection the home has appointed the previous deputy manager to become the manager with the previous manager becoming the deputy manager. Both managers are members of the Sisteedhur family and the decision was taken as a positive move to meet the respective managers Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 21 development needs, career needs and to continue to positively develop the service. The Commission has now registered the new manager as the registered manager of the home. The registered manager has completed his registered managers award that comprises national vocational qualification (NVQ) level 4 in both care and management. The deputy manager informed the inspector that she has also almost completed the same qualification. Although the registered manager was not present there was a range of evidence throughout the inspection that he is reviewing various aspects of the home to assist in its ongoing development. Both staff and service users spoken to indicated in different ways that they had been kept informed of the changes in the management structure through the relevant period. Evidence was seen that service users are consulted on a regular basis about the service the home provides through monthly service user meetings. One service user told the inspector that the registered manager usually took the notes of these meetings. Evidence was also seen of annual service user questionnaires that had been completed recently. The inspector was informed that these were being analysed and would contribute to the development plan for the home for the next twelve months. As outlined in the Daily Life and Social Activities section of this report, the deputy manager stated that the home does not now control or administer any service users money including their personal allowances. She went on to say that these are now controlled by either the service users themselves, their relatives or representatives or their placing authority. Evidence was seen on staff files randomly selected that staff receive regular recorded supervision. Staff spoken to confirmed that this occurred regularly and that they found this useful. Health and safety is taken seriously by the home. The accident book was inspected and showed two accidents recorded since the last inspection. Evidence was seen to indicate that these were both dealt with appropriately. As again outlined in the Daily Life and Social Activities section of this report, the home had complied with good practice recommendations made by the environmental health officer. Other health and safety documentation inspected included: electrical installation certificate, servicing of fire equipment, servicing of the lift and portable appliance testing. A current gas safety certificate and documentation to evidence an annual safety check against legionella were not available for inspection although the deputy manager was clear that these had been undertaken and were current. A requirement is made about these. The inspector was pleased to note that no fire doors were wedged open during the inspection following a requirement made regarding this at the last inspection. Both service users and staff randomly asked were able to tell the inspector of what they must do should the fire alarm sound. However, there was not a current fire plan or fire risk assessment that could be located during the inspection. A requirement is made that the home locates and reviews both the Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 22 fire plan and fire risk assessment on an annual basis. The home must consult with the fire officer by sending a copy of both documents to the fire authority for comment and implement any resulting recommendations made by that authority. Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 24 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 OP15 Regulation 23(2) Requirement The registered persons must ensure that the door on the fridge in the kitchen is repaired or replaced to ensure that this does not become a health and safety hazard. The registered persons must send a copy of the home’s current gas safety certificate to the Commission and ensure that a copy is kept available for inspection at the home at all times. The registered persons must send a copy of the home’s certificate to evidence that the water system has been tested in the last 12 months to minimise the risk of legionella and must ensure that a copy is kept available for inspection at the home at all times. The registered persons must ensure that the home reviews its fire plan and fire risk assessment on an annual basis. The home must also consult with the fire officer by sending a copy of both documents to the fire authority DS0000010741.V287902.R01.S.doc Timescale for action 31/05/06 2 OP38 13(4) 31/05/06 3 OP38 13(4) 31/05/06 4 OP38 23(4) 31/05/06 Nightingale House Version 5.1 Page 25 for comment and implement any resulting recommendations made by that authority. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Nightingale House DS0000010741.V287902.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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