Inspection on 12/05/05 for Nightingale House (Strafford Road)

This inspection was carried out on 12th May 2005.

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

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

Other inspections for this house

Nightingale House (Strafford... 11/06/07

Nightingale House (Strafford... 21/11/06

Nightingale House (Strafford... 26/04/06

Nightingale House (Strafford... 11/10/05

Nightingale House (Strafford... 23/11/04

Nightingale House (Strafford... 15/06/04

Nightingale House (Strafford... 17/11/03

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 10 Strafford Road Twickenham Middlesex TW1 3AE Lead Inspector Simon Smith Unannounced Visit 12 May 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. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Nightingale House Address 10 Strafford Road Twickenham Middlesex TW1 3AE 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) 020 8892 1854 020 8891 5541 Mr Vipin Nayar Mrs Sushma Nayar Care Home 21 Category(ies) of 21 Old age (OP) registration, with number 9 Dementia (DE(E)) of places 1 Mental Disorder (MD(E)) 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Condition of registration of categories of care the Commission has a list of the service users who have dementia or mental health needs. A condition of registration of the categories of care, is that the number of places for dementia and mental health needs are for the existing service users only and the home is not to admit any new service users with these conditions unless another variation is submitted for consideration. Date of last inspection 23.11.04 Brief Description of the Service: Nightingale House has been registered as a care home since 1976 and was purchased by the present owners in 1998. The home provides accommodation for a maximum of 21 older people in single and shared rooms. The registration category of the home currently includes provision for 9 service users who may have dementia. It should be noted that this provision relates to specific service users and is not a permanent amendment to the home’s registration category. The property is situated in a quiet residential area but is within walking distance of Twickenham town centre, which provides a range of shops, pubs and restaurants. The River Thames and mainline rail station are also within easy reach. Information published by the home states, “Our mission is to strive for excellence in providing an ethically sound, individualised, highest quality of care for the older people in a homely environment with support of our highly motivated and trained staff”. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a single afternoon and involved discussion with residents, relatives, a visiting health professional, the owner and staff. The inspector was also able to join 14 residents for a meal. A sample of records was examined, including three staff files and four residents’ files, and a tour of the premises made. The inspector was made welcome throughout the visit and wishes to acknowledge the time and consideration that residents, relatives, the owner and staff provided during the course of the inspection. The Home met 9 of 22 National Minimum Standards assessed at this visit. 8 Standards were almost met and 5 Standards were not met. Some Requirements made at the last inspection had not been met by the home. These included arranging regular staff meetings, the safe storage of dangerous substances and the testing of portable electrical items. Two of four residents’ files contained a written agreement setting out the details of the placement. This agreement must be put in place for all residents and must state which room is to be occupied. The agreement confirms that residents are able to move into the home on a trial basis. Residents and relatives spoken to during the inspection confirmed that they had visited the home before moving in and were made welcome by the owner and staff. The daughter of one resident who had recently moved in said, “Its lovely - we’re really pleased”. Another visitor said of the home, “Mum loves it”. All residents are registered with a local doctor, and are able to keep their existing doctor if they prefer when they move into the home. Other healthcare professionals, such as physiotherapists, chiropodists and opticians, visit the home when necessary. District nurses provide support to care staff in managing some conditions experienced by residents. The inspector was able to speak to a visiting district nurse, who said that staff at the home are friendly and communicate well with visiting nurses about residents’ care. The district nurse said of staff at the home, “They’re excellent”. The home does not employ an activities co-ordinator, although care staff arrange some in-house activities for residents. The range of activities available to residents should improve and the home should make available occasional outings. Residents confirmed that they are able to have visitors whenever they like. All family members spoken to during the inspection said that they are welcomed by staff when they visit and that they are able to talk to their relative in private. Residents are encouraged to celebrate events such as birthdays with parties at the home. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 6 Residents said that they like the food provided by the home and that they can ask for alternatives to the published menu. Residents also confirmed that they can choose where to eat their meals. The food served during the inspection was good and very popular with residents. The Home has a procedure for dealing with complaints. Three residents spoken to during the inspection said they were confident that any complaint they made would be dealt with properly. No complaints have been made about the home to the CSCI in the last year. The owner was not aware of the need to check all new staff against the Protection of Vulnerable Adults (POVA) list. The owner must make sure that checks against the POVA list have been made before staff start work. The owner said that a number of staff have attended training in the recognising and preventing abuse provided by the local authority. The home is on a quiet street close to Twickenham town centre. Work has begun to improve some areas of the home, such as laying new carpets in some areas and repainting where this was needed. A lift reaches all floors of the building and there is a large rear garden. Basic mobility aids are in place around the home. Residents are able to bring furniture and other items with them when they move in and to personalise their bedrooms. Some areas of the home need further improvement. These are detailed in the Requirements of this report and include the storage of potentially dangerous products, installation of window restrictors and privacy screens, and elimination of odours. The bath and flooring must be replaced in one second floor bathroom. All toilets and bathrooms must have soap and hand-drying facilities. There were enough staff on duty to meet the needs of residents during the inspection. Personal care needs were met quickly and discretely. Staff knocked before entering bedrooms and spoke to residents with respect. Residents spoke highly of the owner and staff and the care they provide. Four care assistants have been employed since last inspection. The owner said that the home has developed a package of induction for new staff, although staff files indicated that no-one has yet completed the induction programme. The home must maintain improvement in this area to meet the National Minimum Standards. Staff meetings must also be held more regularly. Three staff files were examined during the inspection. All contained application form, proof of identity and included contracts of employment. The home must improve the quality of references taken up for staff before they begin work. The owner has managed the home since 1998, although recently decided to appoint a new manager. The new manager was due to start work the week after the inspection. The new manager will concentrate on issues relating to 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 7 residents and staff, whilst the owner plans to remain working at the home to provide support and to manage the administration. What the service does well: 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. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 8 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 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 9 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) 2, 4, 5 Residents must be issued with a written agreement that sets out the terms and conditions of their placement. Residents are able to visit the home before moving in. Residents are able to move into the home on a trial basis and to review whether the home meets their needs after six weeks. Residents feel that the home meets their needs. EVIDENCE: Two of four residents’ files contained evidence of a written agreement setting out the terms and conditions of the placement. This document must be put in place for all residents. See Requirement 1. The agreement must specify the room to be occupied. The current agreement states ‘The proprietors will not be responsible for the safety of clients outside the Home’. The document must be amended to reflect that the home has a duty of care towards residents at all times. See Requirement 2. The agreement confirms that the placement is made initially on a six week trial basis, at the end of which a review is held. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 10 Residents and relatives spoken to during the inspection confirmed that they had visited the home prior to moving in and were made welcome by the owner and staff. The daughter of one resident who had recently moved in commented, “Its lovely - we’re really pleased”. Another visitor remarked of the home, “Mum loves it”. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8, 10, 11 Residents’ healthcare needs are met. The home enables access to specialist healthcare resources where necessary. Residents’ privacy and dignity are respected and maintained. EVIDENCE: All residents are registered with a general practitioner locally. Information provided by the home confirms, ‘residents are welcome to maintain their present doctor if they prefer’. Records showed that other healthcare professionals, such as physiotherapists, chiropodists and opticians, visit the home where necessary. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 12 District nurses provide support to the care staff team in managing some healthcare conditions experienced by service users. District nurses are also able to make referrals to specialist community health services if necessary. The inspector was able to speak to a visiting district nurse, who advised that she had visited the home twice weekly since February 2005. The district nurse reported that staff at the home are friendly and liaise well with visiting nurses regarding the care of residents. The district nurse had no concerns regarding the care provided by the home, commenting of care staff, “They’re excellent”. Staff were observed to maintain the privacy and dignity of service users throughout the inspection. Personal care needs were met promptly and with discretion. Staff knocked before entering private accommodation and addressed service users with respect. Aqueous cream was found in one communal bathroom. To ensure that they are used only by the resident for whom they were intended, creams and similar applications must be stored in residents’ bedrooms. See Requirement 3. The home has an appropriate policy regarding the death of a resident. The policy includes guidance for staff in developing a care plan which preserves the privacy and dignity of the resident, maintaining contact with the resident’s friends and family and respecting the religious and cultural needs of the resident. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 The range of activities available to residents should improve. Residents are able to have visitors at any reasonable time. Relatives are made welcome when they visit. Residents enjoy the food provided by the home. EVIDENCE: Comments made by relatives at previous visits have indicated that residents would benefit from a wider range of activities and outings. Care staff arrange a number of in-house activities for residents, although the range of activities available should improve. See Requirement 4. The home does not employ a designated activities co-ordinator. The last inspection report recommended that one member of staff is nominated to arrange activities and that the home offer occasional outings. There was no evidence that this recommendation had been implemented and it is reinstated here. Residents confirmed that they are able to have visitors whenever they like. All family members spoken to during the inspection reported that they are made welcome by staff when they visit and that they are able to talk to their relative 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 14 in private. Residents are encouraged to celebrate events such as birthdays with parties at the home. Residents said that they like the food provided by the home and that they can ask for alternatives to the published menu. Residents also confirmed that they can choose where to eat their meals. The inspector was able to join fourteen residents for tea in the lounge during the afternoon. The food served was good and very popular with residents. One member of staff served food with her hands. This was discussed with the owner, who agreed to make sure that staff use tongs or similar when serving food in future. See Requirement 5. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 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 standard(s) 16, 18 A Complaints procedure is available to residents, relatives and other stakeholders. Residents feel any complaints raised would be properly addressed. The home’s recruitment procedures must improve to ensure the protection of residents. EVIDENCE: The Home has a formal Complaints procedure, which gives details of arrangements for dealing with complaints and concerns. Three residents spoken to during the inspection said they were confident that any complaint they made would be dealt with properly. No complaints have been made about the home to the CSCI in the last year. The home works within the Suspected Abuse of Vulnerable Adults policy developed by the London Borough of Richmond. The owner advised that a number of staff have attended training in the recognition and prevention of abuse provided by the local authority. The owner was not aware of the need to check all new employees against the Protection of Vulnerable Adults (POVA) list. The owner must ensure that staff are appointed only after reference to the POVA list and that she is aware of the requirements to refer a member of staff if necessary. Refer to Requirement 6. (See also Standard 29). 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 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 standard(s) 19, 21, 23, 24, 26 Bedrooms are homely and reflect the preferences of residents. Some improvements have been made to the building since the last inspection, although a number of areas still needed repair or replacement. Potentially dangerous substances were not stored safely in the home. Hand washing/drying facilities must be supplied in all bathrooms to avoid the risk of infection. EVIDENCE: 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 17 The property occupies a corner plot in a residential area, close to the amenities of Twickenham town centre. The home has a garden available to residents. A ramp has been installed to enable wheelchair access to the garden, although this can only be reached through the office. Basic aids to mobility, such as grab rails in bathrooms and double handrails on the stairs, are in place throughout the home. Residents’ accommodation is arranged over three storeys, which can be reached by lift. Residents are able to bring personal items with them on admission and bedrooms indicated individual tastes and preferences. All bedrooms have a telephone point, enabling residents to install private telephone lines should they wish. A payphone is situated on the ground floor. The owner has begun to implement a programme of refurbishment and a number of improvements had been made since the last inspection. Repainting of the internal and external paintwork was complete and some areas of the home had been recarpeted. These developments are encouraging, and demonstrate a commitment to improving the fabric and décor of the home. However, a number of issues required attention. The last inspection report made a requirement regarding the storage of potentially dangerous products in one of the home’s ground floor bathrooms. This inspection found that the bathroom continues to be used for this purpose. An immediate requirement was made regarding the storage of potentially dangerous chemicals in the home. See Requirement 7. (See also Standard 38). The bath and bathroom flooring must be replaced in one second floor bathroom. See Requirement 8. A privacy screen for one of the home’s shared bedrooms had been delivered but not yet installed. See Requirement 9. One resident’s room had a newly fitted window. A window restrictor had yet to be installed to ensure the resident’s safety. See Requirement 10. Previous inspection reports have identified unpleasant odours as a problem in the home. This inspection found that unpleasant odours were less apparent but were still noticeable in some areas. Improvements in this area must continue to be made. See Requirement 11. One first floor bathroom had no soap, whilst another had no hand drying facilities. See Requirement 12. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 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 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 The number and skill mix of staff was appropriate at the time of inspection. Recruitment practices must improve to provide adequate protection for residents from the risk of abuse. Contracts that accurately reflect working terms and conditions must be issued to all staff. EVIDENCE: The owner reported that four members of staff had been employed since the last inspection and that there were no vacancies on the staff team. Staff were available in sufficient numbers and interacted positively with residents and relatives throughout the visit. Residents spoke highly of staff and the care they provide. Three staff files were examined. All contained Criminal Records Bureau disclosures and evidence of identity check against an official document such as a passport. All staff files contained application forms but the home must improve the references taken up for new employees. One staff file had no references, another contained one, whilst the third contained two references addressed ‘To whom it may concern’. See Requirement 13. The owner was able to demonstrate that job descriptions are now in place for all staff except the manager. A job description for the manager must be developed for the manager’s post. See Requirement 14. A standard staff 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 19 contract has been developed since the last inspection. However the current contract classifies all permanent members of the staff team as ‘casual/bank’ workers. The contract must be amended to reflect each member of staff’s individual terms and conditions. See Requirement 15. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 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 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, 32, 36, 37, 38 The appointment of a new manager to work alongside the owner should benefit the home. The manager provides a positive role model for staff in her interaction with residents. The induction and supervision of staff needs to improve. Staff meetings must be held more regularly. The home must inform the CSCI of incidents affecting the welfare of residents. Standards of food storage need to improve. EVIDENCE: 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 21 The owner has managed service the since acquiring the home in 1998. The owner recently decided to delegate the management of the home and had just appointed a new manager at the time of inspection. The new manager was due to start work the week after the inspection. The owner advised that the new manager has experience of managing older peoples’ homes and will concentrate mainly on issues relating to residents and staff. The owner added that she intends to continue working at the home most days to support the manager and to assist with administration. The owner provided a positive role model for staff in her interaction with residents. Staff communicated well amongst one another and worked well as a team. The owner reported that a standard induction package has been identified by the home, although staff files did not provide evidence that new starters undertake a formal induction when they begin work. See Requirement 16. Staff files also contained little evidence of individual supervision. See Requirement 17. The last inspection report required the owner to introduce regular team meetings to improve internal communication and to ensure that all staff are well briefed on developments within the home. There was no evidence that staff meetings have been introduced since the last inspection. This requirement is reinstated. See Requirement 18. The Certificate of Registration was displayed in the Home. The Home has valid Employers Liability Insurance. A Visitors’ book is maintained. The Home’s Complaints procedure was prominently displayed. The Care Homes Regulations (2001) require providers of registered services to notify the CSCI of any event in the home which adversely affects the well-being or safety of any resident. Inspection of records indicated that the Home has failed to notify the CSCI of such incidents. See Requirement 19. The Fire Officer last visited the home in May 2004. The home’s fire extinguishers were checked in September 2004. Staff advised that fire drills are carried out on a monthly basis. The last inspection report required the home to arrange testing of portable appliances to ensure their safety. The owner advised that an appropriate electrical contractor was due to visit on the 9th June 2005 to carry out this work. See Requirement 20. A cooked meat product was stored unlabelled in the fridge. See Requirement 21. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 1 x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 1 x 2 x x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 3 3 x x x 1 2 2 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 23 Yes 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 2 Regulation 5(b)(c) Requirement Residents must be issued with a written agreement that accurately sets out the terms and conditions of their placement. The agreement must specify the room to be occupied. The statement of terms and conditions must reflect that the home has a duty of care to residents at all times. Creams and similar applications must be stored in residents bedrooms. Improve the range of activities and outings available to residents. All food must be served with appropriate utensils. All staff appointments must include checks against the Protection of Vulnerable Adults list. All potentially dangerous substances must be stored safely. This Requirement is reinstated from the last inspection. The timescale for compliance was 30.01.05. Replace the bath and bathroom Timescale for action 30.06.05 2. 2 5(b)(c) 30.06.05 3. 4. 5. 6. 10 12 15 18 & 29 12(4)(a) 16(m)(n) 12(4)(a) 13(4)(c) 19(1) 15.06.05 30.06.05 12.05.05 30.06.05 7. 19 & 38 12(1) 13(4) 12.05.05 8. 21 23(2)(b) 30.07.05 Page 24 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 9. 10. 11. 24 24 26 12(4) 13(4) 16(2)(k) flooring in one second floor bathroom. Privacy screens must be installed 30.06.05 in shared bedrooms. Window restrictors must be 15.06.05 installed on all windows accessible to residents. Keep the home free of 30.06.05 unpleasant odours. This Requirement is reinstated from the last inspection. The timescale for compliance was 28.02.05 Ensure that all bathrooms and toilets contain hand washing/drying facilities. This Requirement is reinstated from the last inspection. The timescale for compliance was 30.01.05. Obtain two references for all staff and ensure that the references are from a suitable source. Develop a written job description for the role of manager. Staff contracts must accurately reflect each member of staff’s terms and conditions of employment. Ensure all new members of staff have a formal induction. Ensure all staff have supervision at least six times each year. Ensure that staff meetings are held on a monthly basis. Notes of these meetings must be recorded and held on file. This Requirement is reinstated from the last inspection. The timescale for compliance was 30.01.05. Notify the CSCI of any incidents affecting the health or well-being 12. 26 13(3)(4) 12.05.05 13. 29 19(1) Schedule 2 12(5)(a) 12(5)(a) 30.06.05 14. 15. 29 29 15.06.05 30.06.05 16. 17. 18. 36 36 36 18(1) 12(5) 12(5) 15.07.05 15.07.05 15.07.05 19. 37 37 30.06.05 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 25 of service users. 20. 21. 38 38 13(4) 16(2)(i) Provide evidence that portable 30.06.05 appliances in the home have been tested. Label and date all refridgerated 30.06.05 pre-packaged food after opening. 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 12 Good Practice Recommendations Allocate dedicated staffing hours to the development of a programme of leisure activities and occasional outings for residents. 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road Wimbledon `` 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 23e6780i-5512aZ G54-G04 S17384 Nightingale House V227892 120505 Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!