Inspection on 29/06/05 for Nightingale Lodge

This inspection was carried out on 29th June 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 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 Lodge 19/03/06

Nightingale Lodge 04/10/05

Nightingale Lodge 28/02/05

Nightingale Lodge 14/12/04

Nightingale Lodge 25/11/03

Similar services:

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

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

CARE HOMES FOR OLDER PEOPLE Nightingale Lodge 6-8 Austin Street Hunstanton Norfolk PE36 6AL Lead Inspector Chris Handley Announced 29 June 2005 9.30am 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. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Nightingale Lodge Address 6-8 Austin Street Hunstanton Norfolk PE36 6AL 01485 533590 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) Black Swan International Limited Mrs Sandra Rowe Care Home 22 Category(ies) of Dementia - over 65 (1) registration, with number Old age (21) of places Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to twenty-one (21) Older People may be accommodated. 2. One (1) person with dementia over 65 years of age may be accommodated. 3. The total number of persons accommodated shall not exceed twenty-two (22). Date of last inspection 28 February 2005 Brief Description of the Service: Nightingale Lodge is a registered home for 22 older people situated in the seaside resort of Hunstanton. It offers personal care, but not nursing care. It sits in a quiet road with access to the main shops within walking distance. There is a Methodist church next door and the sea front is at the end of the road. The house was originally two homes which have been converted into one. The majority of bedrooms are on the first floor with access by a shaft lift. There are three double rooms and 16 single rooms all with toilets and hand wash basin facilities. On the ground floor there are two lounge areas and a dining room. The home has had a new roof in 2004 and further upgrading of the windows is planned for the front of the house in 2005. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, and carried was out as part of the annual inspection programme. Preparatory work was undertaken beforehand. A total of 15 comments cards were received, 9 from residents, and 6 from visitors. On the morning of the inspection there were 20 residents in the home, 6 of whom were interviewed by the Inspector. There were a total of 7 staff on duty, 5 of whom were interviewed. A wide range of records, policies, and care plans, were seen and examined. The Manager, Mrs Sandra Rowe, and Mr Clive Hill, Director, were present during the Inspection, and accompanied the Inspector on a tour of the home. . What the service does well: *Provides detailed information to prospective residents and relatives, which gives them with a comprehensive picture of the home, and the services provided. *A preadmission assessment is undertaken on prospective residents, to ensure that the home can meet their needs. *Prospective residents and relatives are positively encouraged to visit the home prior to admission. * All residents have an individual care plan, and residents are part of the care planning process. *The medication system in the home is safe and effective. *The health care needs of residents are met from a variety of sources which ensures that their on going health is maintained. *Relatives are seen as important to the welfare of residents and are positively welcomed to the home. *Privacy, Choice, and Dignity, are part of the daily care provided to residents in this home. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 6 *The environment of the home is well maintained and residents speak very highly of their rooms. *The home provides a high standard of catering which the residents spoke well of. 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. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,&5 The home provides prospective residents with a full range of information about the home, prior to them coming into the home. All residents are provided with a detailed contract/terms and conditions, which describes the services provided. Prospective residents and their relatives are positively encouraged to visit the home prior to admission. EVIDENCE: The Inspector was shown a Statement of Purpose and Services Users Guide, which he briefly read. These documents are supplied to all prospective residents, it is detailed, and well set out. The Inspector recommends that the print size of these documents be increased as some of the people who read this document may have poor sight. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 9 The contract/terms of residence, it is detailed and comprehensive. The Inspector was shown and read a copy of this document. The Manager has the good practice of going through this document with the residents/and relative, to ensure their understanding of this important document. A copy of the document is retained by the residents, and the home keeps a signed copy. If the resident is subject to Power of Attorney a copy is sent to the appropriate solicitor, the Manager said. Two residents told the inspector that they had contracts, which were “kept safe”. The Inspector recommends that the print size in this document be increased as some people who read the document may have poor sight. The Manager said that she undertakes pre admission assessments to ensure that the home can meet the need of the prospective resident. The Manager stressed the importance to the residents of providing “a face” for the prospective residents. A comprehensive document is use to record these assessments, which was seen by the Inspector. When completed this document will provide the information the Manager needs to make a decision as to whether the home can meet the prospective residents needs, and thus admit them to the home. Because of the likely content of this document when completed it is recommended that it be headed “ Confidential Information,” and that the Manager carry identification with her when carrying out these assessments. Two residents told the Inspector that the Manager had seen them, prior to coming to the home. The Manager positively encourages prospective residents and relatives to visit the home prior to admission. She realises that admission to a home is a very big change in their life, and for some traumatic, and that if they see where they may be living, feels that this can help to allay some of their worries. Such visitors are taken on a tour of the home, and are shown the room that they will use. They meet staff and residents and refreshment is provided. A question and answer session take place. One resident told the Inspector that she had seen her room prior to coming into the home, and that had been a decisive element in her decision to come to the home. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 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 standard(s) 7,8, 9,& 10 All residents have an individual care plan. The residents health care needs are met The homes medication system is safe and effective. Residents are treated with respect, and their privacy is upheld. EVIDENCE: Care plans are in an A4 folder, four of which were read. The Management of these documents is good, there are named dividers in place which assists in finding information. The documents are of a good quality and the writing is neat, and legible, in some cases the content is printed. There is a clearly written Assessed needs, Agreed Action, Objective and Reviews. Residents are involved in reviews of care and sign to that effect. Two residents informed the Inspector that they were aware that records are kept about their health, and told the Inspector so. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 11 There is a detailed risk assessment, weight chart and Medical/District Nursing Notes. A Daily Record is maintained this is neatly written. The home has the Key Worker system in place. The Manager is recommended to review the mental health assessment element of the care planning system in order to make it more comprehensive. At present it does not include Depression which is a common feature of old age and the home needs to know if an individual has a past history of this. It is recommended that the folders are labelled “Confidential Information”. At present the care notes are kept in the office and a positive discussion took place with regard to the security of these documents. The Inspector recommends that the security of these important documents be improved. All residents have a G.P. The District Nurse calls to the home to undertake any nursing care required, and the Inspector was informed that the home gets a very good service from them. Additional health care services are obtained via referral from the G.P. Optical services are obtained locally, as are Audiology and Chiropody services were described as very good by the Manager. The Dietician visits on request. A member of the Blind Association attends the home every six weeks, as there are a number of residents who have poor sight. The home’s medicine system was inspected. The home has a Monitored Dosage System. Medicines are kept in a locked metal cupboard, and only staff who have received training in the administration of medicines hold the keys, and administer medicines. Medicine records were seen, they are neatly completed with the initials of the person administering the medicines. There are no Controlled Drugs in the home at present. The home has a Controlled Drug cupboard, and a dedicated Controlled Drug register. There is a small refrigerator, which was ice-free. The home has detailed medicine policy, which was seen and briefly read by the Inspector. Training in Medicines is provided by the Isles College and it is certificated. There is one resident who self medicates and this is discreetly monitored, the Manager said, so as to ensure that it works effectively. The home has a sound working relationship with the supplying pharmacist. If staff had any concerns about the effects of medicine on a resident, they would contact the prescribing G.P. Medicines are reviewed on a regular basis and this is recorded. This therapeutic practice ensures that there is effective prescribing and monitoring of medicines. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 12 The Manager said that when staff commence working at the home they shadow a more experienced member of staff and see the practices, which the home has in regard to privacy and dignity. Any personal care or examinations are conducted in private, the Manager said. Knocking prior to entering, is one of the established practices of the home, and the Inspector observed this on numerous occasions during the process of the inspection. Residents wear their own clothes at all times, and the Inspector observed that they were all smartly and individually dressed. Residents are called by their preferred name, the Manager said. There are privacy curtains in place, in double rooms, which the Inspector saw. The residents told the inspector that the staff provided privacy for them, “ They always knock on the door” was a comment made. The comments cards from the residents all said, “Yes” to the question “ Is your privacy respected” . Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 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 residents enjoy a life style in which their choices, likes, and preferences are met. Families are seen as an important to residents welfare, and are positively welcomed to the home. The home provides wholesome, nutritious and varied meals. EVIDENCE: The Manager said that residents may stay in their room if they wish to do so, and have breakfast in their room or come down into the lounge, and have their meal in the dining room. Residents have a choice in their daily routines of life, do they want a news paper? what meal would they like? what time do they wish to go to bed? Representatives of religious organisations call to the home on a regular basis. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 14 There is wide range of activities provided for residents and these include Music, Singing, Reminiscence, and Movement to Music. Entertainers, Arts and Crafts, Mobile Library, TV with Videos. There is a notice of the activities provided which is posted up in the home and the record of what the residents enjoyed is kept. It is clear that there is a well established activities programme, and this can be built on and further expanded. The Inspector recommends that a small number of staff undertake training in providing activities for older people. Residents may have visitors at any reasonable time the Manager said, this was confirmed by some of the residents interviewed by the Inspector. Relatives and friends are received in the privacy of the resident’s room. Residents are able to choose whom they see and don’t see. Residents frequently go out into Hunstanton, shopping, or to a café for coffee. Some go out to church, or the Blind Club, Theatre/Pantomime and there are various trips out. Children of relatives are positively welcomed to the home and their presence in very much enjoyed by the residents, the Manager said. The Menus were seen by the Inspector, they are nutritious, interesting, and varied. The Inspector was informed that no special Diets are required at present. Menus are discussed at residents meetings The comment cards all said “yes” when asked “Do you like the food.” Residents who were interviewed by the Inspector, spoke very well of the catering service .The Manager and the cook are fully aware of the importance of a good catering service and ensure that there is a good choice and variety of meals provided. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 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) 16,17,&18. The home has effective practices and procedures for dealing with complaints. The Manager takes steps to ensure that the legal rights of residents are protected. Staff are aware of the importance of preventing abuse in the home. EVIDENCE: The home has not had any complaints since the last inspection, the Manager said. The homes complaints policy is displayed in the front entrance of the home. The Inspector recommends that it be put in a bigger print. Residents interviewed knew whom to see if they were unhappy with their care. Visitors to the home who had completed the comment cards, said that they were aware of the homes complaint procedure. The legal rights of residents are protected. The Manager said the residents would either go out to vote or use a postal vote. There are 5 residents who are subject of Power of Attorney, the Manager said, and that she would facilitate legal advise if it were needed. Any meeting between the residents and their solicitor would take place in private, the Manager said. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 16 The home has an Adult Abuse Protection policy and all staff have been provided with training in this matter, the Manager said. The training took the form of a Video Presentation followed by a question and answer session. Some of the staff interviewed by the Inspector were asked about this matter, and they knew what action they would take in the event of them suspecting that there was abuse going on in the home. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 17 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) 19,24, & 26 The residents live in a safe, well maintained home which is suitable for its stated purpose. Residents’ rooms are furnished and well equipped and provide comfort and privacy. The home is neat, clean and tidy, and is free from offensive odours. EVIDENCE: The home is suitably located and is adjacent to the town centre of Hunstanton, which means that residents can visit shops, cafes, of just go for a walk to the sea front, often with relatives. Originally two private homes it was converted into one large one, it is suitable for its stated purpose. There is a plan of routine maintenance with records kept. The Inspector was shown a neatly typed out plan of maintenance. Both the Manager and Director are aware of the need to keep ahead of maintenance in this building. The grounds are kept neat and tidy and the garden at the rear of the home, which is lawned, provides a very nice quiet sitting out area. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 18 The building complies with the requirements of the local fire service and the environmental health, the Manager said. The Inspector visited eight of the rooms during the day. The rooms were neat, tidy, and odour free. There were a wide range of ornaments pictures and photographs seen. With residents explaining who was in the various photographs. All the rooms are carpeted and this is in good condition. There are locks on doors which if needed could be opened from the outside. The residents spoke very highly of their rooms and one said that was what had attracted her to this home. There are privacy curtains in double rooms, of which there are two. The central heating can be adjusted by the resident. The home has its own laundry, which was visited by the Inspector accompanied by the Manager. The laundry was neat and tidy, and there were no offensive smells. Soiled or infected linen is not taken through food store areas. There are hand-washing facilities in place. The laundry floor is impermeable. The Home has polices for the control of infection. The machines used are of an industrial nature and have sluicing facility. The washing machines have specified programming ability to meet disinfection standards. The manager is unsure as to whether the facilities comply with the Water supply (Water fittings) Regulations 1999, the Director is of the opinion that they may do, but the Inspector recommends that the manager take steps to find out for certain. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 19 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) 28 29 & 30 The home has a programme of NVQ training, which needs to continue. The home’s recruitment programme ensures the welfare and protection of residents. There is training provided to staff to ensure that they can carry out their jobs effectively and safely. EVIDENCE: The Manager provided the figures for the NVQ training. At present there is 1 member of staff who has NVQ II, and 1 member of staff with NVQ3, making a total of 2 members of staff who have NVQ, this is a very low figure and represents 0.15 of the care assistant work force. How ever there are currently 6 members of staff who are taking NVQ level II the Inspector was informed. This is to be commended. It is recommended that the training programme continue. It can be difficult for staff to undertake this training and the Manager and Director are advised to encourage and support staff in this matter. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 20 The home has a detailed recruitment procedure, which was outlined by the Manager. Posts are advertised, applications forms are provided, short listing takes place, and references are sought. Interviews, which are carefully prepared for, take place. There are two people involved in the interviews. Police and POVA checks are carried out. The successful candidate is provided with a contract and a Job Description. Both the Manager and the Director are fully aware of the importance of appointing good staff. The home has an Induction training programme which is recognised by TOPSS, and is currently developing a foundation which it is intended will also be recognised by TOPPS. The home has a very clearly set out Core Training programme which was supplied to the Inspector, this shows that First Aid Training, Basic food Hygiene, Manual Handling, Fire Safety training, Health and Safety , Training in Medication, Training in Adult Abuse Awareness, Vulnerable Adults, Diabetes, Infection Control, Communication & Confidentiality, Dementia Training, Oral Healthcare, Certificate in Care Skills, Loss and Bereavement, Blind Awareness, and Management Skills/Supervision in the Care home have been provided. This represent a considerable amount of training and the Company are commended for this. To further develop the knowledge of staff, the Inspector recommends that a small number of senior staff undertake specific training in Caring for the Elderly. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 21 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) 31,33,36,37,38, The Manager is an effective manager for this home. The home has a Quality Assurance system in place. The home has effective supervision practice, which is recorded. Most records are held securely but the security of care plans needs to be improved. The home does not have all the Health and Safety documentation required. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 22 EVIDENCE: The Manager has been in post for 6 years and during that time has undertaken a wide range of training, including First Aid, Fire Safety, Administration of Medicines, Manual Handling, Health and Safety, Protection Of Vulnerable Adults Awareness of diabetes, Manual Handling, Supervision Management, Care Skills, Loss and Bereavement, Blind Awareness and Management Skills and it is her intention to undertake NVQ level 4. The Manager and the senior staff are familiar with the conditions/diseases of old age. She is responsible for this home only. The Manager has a job description, which outlines her responsibilities and duties There are clear lines of responsibility within the home and her responsibilities to the company. The home has a Quality Assurance system in place, which was demonstrated to the Inspector. Basically this system operates on resident’s choice, which is ascertained on a regular basis, and the information is then sent to the Headquarters and then a monthly audit is then carried out. Supervision is well established in this home and the Inspector was shown detailed records which are kept in this matter. Supervision covers all aspects of practice, the philosophy of care in the home, and career development. The home does not have volunteers. The home keeps a wide range of records required by regulation and residents may have access to their records. The records, many of which have been developed by the company are of a high quality. How ever there is some doubt about the degree of security of care notes which are kept in the office and the Manager and Director undertook to resolve the dilemma of having good access to the office, whilst having security of records. The Inspector went carefully through all the elements of Standard 38 with the Manager and Director. The home complies with all the elements of Standard 38 except 38.4 the Health and Safety Documentation. It is required that the home has all this documentation and the Inspector advises that once the home has obtained this information it be kept in a box file clearly marked “ Health and Safety” file so that all will know where this information is. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x x 3 x 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 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 2 STAFFING Standard No Score 27 x 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 x 3 x x 3 2 2 Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 38 Regulation 38 Requirement It is required that the Manager obtains all the Health and Safety information required by Standard 38 ,38.3. Timescale for action 1/9/05 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. Refer to Standard 1 2 3 Good Practice Recommendations It is recommended that the print size of the Service Users Guide, and the Statement of Purpose, be increased. It is recommended that the print size of the Terms and Conditions be increased. It is recommended that: 1. The Pre admission Assessment document be headed Confidential Information. 2. The Manager carry identification with her when undertaking these visits. It is that: 1. The mental health assessment of the care planning system be made more comprehensive. 2. That the Care Plan Folders are marked Confidential Information. 3. The security of the care plans is improved. It is recommended that training in providing Activities be provided to a number of staff.. I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 25 4. 7 5. 12 Nightingale Lodge 6. 7. 8. 30 26 28 It is recommended that a number of senior staff undertake a recogised course in Care of The Elderly. It is recommended that the Manager take steps to find out if the services and facilities of the laundry comply with the Water supply ( Water Fittings ) Regulations 1999. It is recommended that the NVQ II training programme continue. Nightingale Lodge I55 S27482 Nightingale Lodge V232378 290605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 1YF 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 Lodge I55 S27482 Nightingale Lodge V232378 290605 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. 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