Inspection on 04/12/06 for Nottingham Neurodisability Service Hucknall - Fernwood

This inspection was carried out on 4th December 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nottingham Neurodisability... 08/12/08

Nottingham Neurodisability... 31/10/08

Nottingham Neurodisability... 24/10/05

Nottingham Neurodisability... 13/07/05

Nottingham Neurodisability... 19/11/04

Nottingham Neurodisability... 14/05/04

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

CARE HOME ADULTS 18-65 Nottingham Neurodisability Service Hucknall Fernwood Hankin Street Hucknall Nottingham Nottinghamshire NG15 7RR Lead Inspector Steve Keeling Key Unannounced Inspection 4th December 2006 09:00 Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 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 Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nottingham Neurodisability Service Hucknall Fernwood Hankin Street Hucknall Nottingham Nottinghamshire NG15 7RR 0115 968 0202 0115 964 2747 Address 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) Four Seasons Homes (Ilkeston) Ltd Kim Lesley Santon Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Named Service user may be admitted over the age of 64 Years Date of last inspection 24th October 2005 Brief Description of the Service: Nottingham Brain Injury Centre, Fernwood Unit is a two-storey, purpose-built care home, owned by Four Seasons Care Homes. It is situated at the corner of Hankin Street, between its two sister units. It provides full and rehabilitatory skilled nursing care for up to 20 service users with post-trauma and polyaetiological brain injuries. All service users bedrooms are individually decorated, many have en-suite toilet facilities. Some bedrooms have direct access via patio doors to a safe, very pleasant, enclosed garden at the rear of the property. The residents needs are well-supported, promoting independent living skills within a risk assessment framework, helping them to make active choices and to be as fulfilled as possible. The facilities within Fernwood House are conducive to achieving optimum independence for the service users. Wheelchairs can access all areas within the home, mobility aids are available such as hoists, transfer belts and strategically placed handrails and easily accessible shower and bath areas. A vertical lift is also accessible to allow easy access to the first floor of the home. The fees currently charged at the home range from £1.500 to £2890.32 per week, which does not include payments for toiletries, podiatry services, hairdressing, holidays and newspapers or magazines. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 5.5 hour period and involved one inspector. The main method of inspection was case note tracking, this is a method of selecting service users within the home and discussing with them if possible, their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two residents notes were case tracked. Also as part of the inspection process a staff member within the home was informally interviewed together with a visitor to the home to further evidence the quality of care afforded to the service users. A range if information was used to determine the outcome of this inspection and the report, these included the previous judgments and findings, information received from service users in response to the Commission for Social Care Inspection questionnaires and the pre-inspection information provided by the registered provider on the 10th August 2006. What the service does well: The pre-admittance assessments evidenced that the service users holistic needs were being assessed effectively and that care planning procedures within the home are effective in addressing the identified needs of the service users. Service users are encouraged to make independent decisions about their own life and are encouraged to take risks as part of an independent lifestyle. Service users benefit from the provision of a varied social activities programme at the home and within the local community and can maintain appropriate relationships within family and friends. Service users are offered a healthy, balanced and nutritious diet Service users receive personal support in a way they prefer and require and the physical and emotional needs of the service users are met. The home has a complaints procedure in place, which is effectively distributed throughout the home to ensure that concerns and complaints are identified and Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 6 acted upon thus ensuring service users are protected from abuse, neglect and self-harm. The home provides a comfortable and safe environment and the planning total refurbishment should address the shortfalls identified in relation to the poor decoration of corridors and bathrooms. An appropriate number and skill mix of staff were employed at the home to meet the service users needs and the recruitment process utilised at the home promotes the safety of service users. The service users live in a well run home and are supported by an effective management structure and staff receive appropriate mandatory training to promote the health and safety of service users. 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. The summary of this inspection report can be made available in other formats on request. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 2. This judgement has been made using available evidence including a visit to this service. The pre-admittance assessments examined on the day of the inspection evidenced that the service users holistic needs were being assessed effectively. EVIDENCE: The service users pre-inspection questionnaires asked “did you receive enough information about the home before you moved in so you could decide if it was the right place for you”, 85 of the responses received by the Commission for Social Care Inspection stated “yes”. Service users receive a copy of the homes Statement of Purpose which includes a mission statement and general information relating to the services and facilities at the home so as to fully inform potential service users and their family of the services available. An examination of the pre-admission assessment documentation evidenced that the home utilised a recognised assessment tool (Activities of Daily Living) together with additional information from National Health Service (NHS) and Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 9 Social Services Departments when available. The assessments were effective in identifying the specific needs of the service users to maintain optimum independence and wellbeing within the home. Trial periods of residency, of up to four weeks are also available so that a comprehensive assessment process can be performed by the multidisciplinary team to ensure that the service users requirements can be fully met within the home, and that the service user can be assured that the services and facilities at the home are appropriate to their needs. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 6, 7, 9. This judgement has been made using available evidence including a visit to this service. The care planning procedures within the home was effective in addressing the identified needs of the service users. Service users are encouraged to make independent decisions about their own life The service users ability to take risks as part of an independent lifestyle is promoted. EVIDENCE: The manager at the home is currently transferring information to recently formulated core care plans. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 11 The new care planning formats provide research based information to inform staff and also allow additional information pertinent to the individual service user needs to be included within the individual care plans. Two service users care-planning documentation was examined on the day of the inspection. Both care plans gave specific information to inform staff of the needs of the service users. An examination of the care planning documentation evidenced that service users are allocated two “key workers” whose responsibility is to review the care plans on a monthly basis or more frequently if required to ensure that any changes in the needs of the service users are identified and addressed effectively. An examination of the case tracked care plans evidenced that informed consent in relation to the content of the care plans is sought whenever possible, from service users or their advocates thus encouraging their independent decision making process. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 12, 13, 15, 16, 17. This judgement has been made using available evidence including a visit to this service. Service users benefit from the provision of a varied social activities programme at the home and within the local community. Service users are encouraged to interact within the local community. Service users can maintain appropriate relationships within family and friends. Service users rights and responsibilities are respected at the home Service users are offered a healthy, balanced and nutritious diet Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 13 EVIDENCE: The social activities coordinator employed at the home provides social activities such as painting, drawing, board games, quizzes, videos and DVDs. In promoting interactions within the community the home benefits from a newly purchased mini bus to take service users to areas of local interest such as parks, the coast, theatres, pubs and restaurants. For service users with impaired physical or cognitive abilities the social activities coordinator provided documentary evidence that service users are provided with sensory and stimulation therapies such as aromatherapy and massage. A service user and a visitor to the home stated that no restrictions are in place in relation to visiting times at the home and went on to say that the staff at the are always welcoming. The manager also confirmed that visitors to the home could utilise the independent living skills room, which has tea and coffee making facilities. A case tracked service user together with a visitor to the home confirmed that staff at the home always promote the principles of independent lifestyle whenever possible. The service user stated that she could spend the days as she pleases and that the homes routine is flexible and her choice is always respected in relation to daily routines at the home. The manager stated that to promote the service users safety should they develop in intimate relationship she would perform an assessment to ensure the service user could give informed consent in relation to intimate relationships. If informed consent were to be established issues in relation to contraception, sexually transmitted diseases and privacy and dignity would be discussed to ensure the safety of the service users. It was established through discussions with the manager that the home does not have any policies or procedures do not offer guidance to staff to ensure the safety of service users who develop intimate relationships. To promote the service users safety, the registered person should ensure that a policy is available to inform staff of appropriate actions to be taken should a service user develop an intimate relationship. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 14 Information received in the pre-inspection questionnaire evidenced that a four weekly menu is provided to the service users and that three meal options are available at lunchtime, which includes a vegetarian option so as to promote the service users choice in relation to meal provision. The service users and a visitor to the home stated that the meals at the home are very good. A service user stated that the food is excellent and plentiful. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 18, 19, 20. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in a way they prefer and require and the physical and emotional needs of the service users are met. Practices and procedures in relation to medicines management at the home had not been fully adhered to which could compromise the safety of service users. EVIDENCE: Service users benefit from a multidisciplinary team (MDT) approach to health promoting interventions. Specialist input is available from a neuro-specialist, consultant in rehabilitation medicine, psychologist, qualified nursing staff, social workers, physiotherapists and occupational therapists with the aim of providing an extensive rehabilitative service provision at the home. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 16 Service users can also benefit from a specialised Independent Living Skills area (ILS) area in which service users can enhance their independent. Personal support provision was discussed with a service user and a visitor to the home, each said that they were happy with the way in which the care was delivered by the care staff at the home. The service user stated that the homes routine is flexible and personal interventions are always performed in a way they prefer and in the privacy of the service users bedroom or in the bathrooms. An examination of the service users care plans specified specific equipment to aid mobility together with the staff compliments required to ensure the service users safety whilst performing personal care. At the time of the inspection no service users were responsible for the selfadministration of medicines. The manager stated that should a service user wish to be independent in the administration of medicines a risk assessment would be performed. If the service users were deemed as being safe, the service user would be supported to be independent in relation to the self-administration of medication. The Medication Administration Records (MAR) charts of the case tracked service users were examined; it was evident that the staff had utilised the “O” key on the MAR chart. This ‘O’ signifies reasons for omission other than those listed on the MAR charts. Usually the staff should enter the reason on the MAR sheet to signify the reasons for omission but this had not been done. The MAR charts also had two gaps present with no explanation as to why the service had not received the medication. MAR charts should not have gaps present, if medication cannot be administered an explanation must be documented and appropriate “key” must be used. The temperature within the medication fridge had been monitored on a sporadic basis rather than on a daily basis throughout October 2006 and the temperature within the medication fridge was outside the acceptable parameters of 2-8 degrees centigrade on several occasions in October 2006 To ensure the safety of service users at the home the registered person shall ensure that practices in relation the medication management at the home ensure the safety of service users at all times. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place, which is effectively distributed throughout the home to ensure that concerns and complaints are identified and acted upon. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The manager was not investigating any complaints at the time of the inspection and the Commission for Social Care Inspection had not received any complaints appertaining to the service provision at the home. The service users pre-inspection questionnaires asked “do you know how to make a complaint and do you know who to speak to if you are not happy?”, 85 of the responses received by the Commission for Social Care Inspection stated “yes”. The complaints procedure was evident within the “Statement of Purpose” which service users are given on admission to the home and was also on display in the foyer of the home. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 18 The service user and a visitor to the home stated that they felt confident that the manger at the home would deal with any concerns or complaints effectively. A visitor the home confirmed that she had made a complaint in the past in relation to catheter care, the complainant stated that she was satisfied with the management and outcome of the complaint. An examination of the complaints procedure within the statement of purpose evidenced that it is clearly written, and is easy to understand but did not evidence agreed timescales to respond to complaints. An examination of the staff-training matrix evidenced that staff receive appropriate training in relation to the Protection of Vulnerable Adults (POVA). A member of the nursing staff spoken with on the day of the inspection demonstrated an appropriate knowledge is issues relating to POVA and stated that if she suspected abuse was happening at the home she would liaise with her line manager and follow the homes policies and procedures appertaining to the protection of the vulnerable adult. An examination of the home documentation appertaining to the management of service users money evidenced that some service users money is currently pooled in a joint account (interest free) in which individual names and corresponding monies could be evidenced. Regulation 20. - (1) Subject to paragraph (2), states the registered person shall not pay money belonging to any service user into a bank account unless the account is in the name of the service user, or any of the service users, to which the money belongs; and the account is not used by the registered person in connection with the carrying on or management of the care home. Regulation 20. - (3) The registered person shall ensure so far as practicable that persons working at the care home do not act as the agent of a service user. The unit’s general manager said that the service users money is maintained within a joint account, as the service users do not have advocates who could manage the service uses money for them. To promote the financial wellbeing of the service users the registered person should liaise with the social services Adult Residential Services department to ensure that the money of service users with impaired cognitive abilities are managed by an effective advocate whenever possible. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 24, 30. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment and the planned total refurbishment should address the shortfalls identified in relation to the poor decoration of corridors and bathrooms. Service users benefit from a home, which is clean and hygienic. EVIDENCE: The service users pre-inspection questionnaires asked “ is the home fresh and clean”, 72 of the responses received by the Commission for Social Care Inspection stated, “yes” with 28 of the responses stating usually. The inspector performed a partial tour of the premises as part of the inspection process. The service users bedrooms were well decorated, warm and safe. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 20 Service users are encouraged to personalise their bedrooms with their personal possessions and all the service users bedrooms examined had audio and visual equipment for the service users enjoyment. Although Service users and a visitor to the home stated that they were very satisfied with the communal living areas within the home the inspection process evidenced that some communal areas such as the bathrooms and corridors were looking somewhat shoddy mainly due to wheelchairs scuffing the walls and door frames. The manager stated that a planned complete refurbishment of the home, which is due to commence in the New Year, would address the identified environmental shortfalls. A relative visiting the home also stated that she had been informed by the manager of the planned refurbishment. To ensure the safety of service users, the home has a security system on all the external doors so that all visitors to the home are required to gain consent from a member of staff before entering the building. The home also benefits from attractive gardens areas which are accessible to service users and their families in wheelchairs to utilise in the summer months. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 32, 34, 35. This judgement has been made using available evidence including a visit to this service. An appropriate number and skill mix of staff were employed at the home to meet the service users needs. Recruitment process utilised at the home promotes the safety of service users. Staff receive appropriate mandatory training to promote the health and safety of service users. EVIDENCE: Staff employed at the home is in sufficient numbers to meet the needs of the 17 service users accommodated at the home. An examination of the staff rota evidenced that six carers and four qualified nursing staff were on duty throughout the morning, throughout the afternoon period six carers and four qualified nurses were on duty and three carers plus three qualified nurses covered the night period. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 22 An examination of staff files and a discussion with the manager evidenced that the homes recruitment policies are followed thus ensuring the safety of the service users. The recruitment documentation of the last member of staff employed at the home was checked and found to be satisfactory as appropriate Protection of Vulnerable Adult checks together with Criminal Record Bureau (CRB) checks had been undertaken together with the acquisition of two written satisfactory references. The manager stated that all new staff members received an induction programme that normally takes six weeks to complete. A member of staff interviewed on the day of the inspection also confirmed that she had undertaken the induction process. An examination of the staff training documentation together with a discussion with the manager and a member of staff confirmed that the training provision at the home is appropriate in ensuring the safety of service users and staff. An examination of the training records evidenced that mandatory training is provided in relation to Moving and Handling, First Aid, Health and Safety, Infection Control and the Protection of the Vulnerable Adult. Additional training specific to the needs of the service users at the home is provided in relation to the management of artificial ventilation, tracheotomy care and Percutaneous Endoscopic Gastrostomy (PEG) feeding techniques. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 37, 39, 42. This judgement has been made using available evidence including a visit to this service. The service users live in a well run home and are supported by an effective management structure. A range of health and safety documentation was examined and demonstrated that the service users safety is protected and promoted EVIDENCE: The manager at the home is a qualified nurse and benefits from a wealth of experience within the National Health Service and the private sector. She also benefits from over 20 years experience in senior management posts. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 24 The manager strives to improve services to provide an increased quality of life for service users by ensuring that appropriate quality audits are undertaken on a monthly basis to ensure standards of care are maintained effectively within the homes environment. The home has easily accessible policies and procedures, which are updated on a yearly basis so that staff at the home have an effective resource to inform practice and promote service uses safety. To ensure that staff receive feedback on their work the manager ensures that staff receive yearly Personal Development Reviews (PDR) together with formal supervision sessions bi-monthly. The staff member spoken with stated that the manager supports and promotes a strong team and provides clear direction to all staff whilst being approachable and professional. A visitor to the also paid particular praise to he manager, stating that she is very knowledgeable and professional and that she felt confident and reassured that the care her relative was receiving at the home is of a high standard. In determining that the Health and Safety of service users is protected the inspector examined a range of Health and Safety information provided by the manager within the pre-inspection questionnaire and the documentation evidenced that the home is effectively maintained. It was evident through a discussion with the home maintenance technician that appropriate precautions are taken in relation to the control of Legionella contamination, the testing of fire fighting equipment and fire alarms and the maintenance of equipment designed of aid mobility such as wheelchairs, hoists and baths. The maintenance technician employed at the home also performs hot water outlet checks on a monthly basis so as to minimise the risk of scolds together with internal and external environmental checks to ensure the safety of the service users. The maintenance technician keeps excellent records appertaining to the all the aforementioned issues; the documentation was clear, concise and very well maintained. Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000059006.V316564.R01.S.doc 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Version 5.2 Page 26 Nottingham Neurodisability Service Hucknall Fernwood 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 YA20 Regulation 13 Timescale for action The registered person will ensure 15/01/07 that the management of medicines within the home is effective in ensuring the safety of residents. Requirement 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 YA15 Good Practice Recommendations The registered person should ensure that a policy is available to inform staff of appropriate actions to be taken should a service user develop an intimate relationship, so as to promote the service users safety. The registered person should liaise with the social services adult residential services department to ensure that the money of service users with impaired cognitive abilities are managed by effective advocacy services. 2 YA23 Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nottingham Neurodisability Service Hucknall Fernwood DS0000059006.V316564.R01.S.doc Version 5.2 Page 28 - 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!