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Inspection on 07/12/05 for Oldbury Grange Nursing Home

Also see our care home review for Oldbury Grange Nursing Home for more information

This inspection was carried out on 7th December 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Both the manager and the matron had an in-depth knowledge of the wants and needs of those under their care. The relationship between the residents and the management was seen to be good. All residents spoken to said that the food is good and that there is always plenty to eat. Some also said that if you do not like what is on offer the cook tries very hard to get you what you want. Residents said that staff are kind and try their best.

What has improved since the last inspection?

Work has commenced on the bathrooms regarding decoration and tiling. One or two areas still require attention due to missing tiles, exposed pipe work and stains on the floor. Some issues identified at the last inspection visit have been addressed, improvements have been made to the cleanliness in the kitchen, a new refrigerator has been purchased and infection control issues have been addressed. A member of staff spoken to confirmed that staffing levels have improved recently and there is always enough staff on duty to enable tasks to be completed.

What the care home could do better:

Improvements are required to the information recorded in care files. Standardised documentation in use did not always have sufficient information recorded to enable staff to complete tasks with full details of the actions required. Daily entries, although comprehensive are only recorded once per day. Daily entries did not give evidence of any night care or ongoing care throughout the day, particularly for those residents that require regular interventions such as turning or peg feeding. Residents spoken to said that there is nothing to do in the day apart from sitting and staring at the television. A number of residents spoken to said that they did not like the television as there was nothing of interest on in the daytime. There is no activity organiser in place and no regular programme of activities. During the inspection staff played a short game of bingo with a few of the residents in one lounge but no other mental or physical stimulation was available. Staff must ensure that they maintain the privacy and dignity of residents. Poor practice was noted, particularly relating to toileting. Staff were saying in a loud voice that everybody had to go to the toilet before lunch, they were also seen asking individuals "if they had been to the toilet or whether they needed to go". This does not respect the privacy and dignity of residents and a more discreet and tactful approach should be adopted. A number of issues raised at the last inspection visit remain outstanding.

CARE HOMES FOR OLDER PEOPLE Oldbury Grange Nursing Home Oldbury Road Hartshill Nuneaton Warwickshire CV10 0TJ Lead Inspector Deborah Shelton Unannounced Inspection 7th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oldbury Grange Nursing Home Address Oldbury Road Hartshill Nuneaton Warwickshire CV10 0TJ 02476 398889 02476 398881 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) Dr B Sidhu Mrs C Sidhu Charan Kanwal Sidhu Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Oldbury Grange Nursing Home is situated in the Warwickshire countryside a short distance from Hartshill. Dr and Mrs Sidhu currently own the home. The home is registered to provide nursing care for 44 elderly people. The accommodation is purpose built with service user accommodation provided on two floors. Access to each floor is possible via passenger lift or stairs. Garden and patio areas are easily accessible to service users, including those that use wheelchairs. The accommodation provides excellent views over the local countryside. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place between the hours of 10.00am and 7.20pm on 7 December 2005. During this inspection the Manager was on duty along with the Matron, a registered general nurse, a senior care and five care staff. Thirty-eight people were living at Oldbury Grange. Some of the documentation was looked at in the lounge, this enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. During the whole inspection process six residents were spoken to about their experiences of life at the Home. The inspection process also involved looking at paperwork, a tour of some areas of the building and discussions with the manager, matron and with the staff on duty. What the service does well: What has improved since the last inspection? Work has commenced on the bathrooms regarding decoration and tiling. One or two areas still require attention due to missing tiles, exposed pipe work and stains on the floor. Some issues identified at the last inspection visit have been addressed, improvements have been made to the cleanliness in the kitchen, a new refrigerator has been purchased and infection control issues have been addressed. A member of staff spoken to confirmed that staffing levels have improved recently and there is always enough staff on duty to enable tasks to be completed. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 6 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. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents’ needs are not suitably assessed prior to admission to the Home. Residents therefore cannot be assured that any needs would be met. EVIDENCE: The initial assessment of the resident most recently admitted to Oldbury Grange was reviewed. The admissions process includes obtaining a community care plan provided by the social worker (if applicable) as well as obtaining a specialist health assessment. These documents were seen within this care plan. Once this documentation has been received an assessment is undertaken by the manager of the Home. The layout of the Home’s assessment allows all relevant information to be collected, this then enables the manager to decide whether the resident’s needs can be met at Oldbury Grange. In the assessment seen some of the information had not been completed and some details were brief. Not all assessments seen were dated and signed and some did not provide sufficient information to enable staff to meet the health care needs of residents. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 Not all residents have information in place to enable staff to meet their health, personal and social care needs. Lack of updated documentary information could put residents at risk. Administration of medicine is good. The Home’s policies and procedures for dealing with medicines protect residents from risk of harm. Residents’ rights to be treated with privacy and dignity are not always upheld. EVIDENCE: Individual plans of care were available for all residents. These were generated from the initial assessment of needs. Four care plans were examined and found to identify the specific needs of each resident. However they only contained basic information about the action required to meet individual needs. Residents are at risk of not having their health and personal care needs met if plans do not contain enough detail. For example, one plan regarding elimination states “daily care of catheter and catheter site” but does not give any instructions as to what action is to be taken. This plan also records observe urine for colour but does not say what to look for. Another plan Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 10 records that staff are to care for dentures but does not say what staff are to do to care for dentures. Standardised documentation is contained in all files. Not all information had been routinely completed, for example in two files the life history was blank. In another file dental and chiropody charts were blank and financial information had not been completed. Each care plan has a heading “particular preference, particular dislike” these had not been completed in a majority of the care plans seen. Daily entries are only recorded once per shift, these give a great deal of information regarding how staff are meeting the resident’s care needs. The Matron reported that these are recorded early afternoon. Information is provided to staff via handover and according to Matron any incident or important information would be recorded in another daily entry. Recording only one daily entry does not demonstrate that staff are meeting the health care needs of those residents that require regular interventions. One daily entry regarding a resident’s pressure area recorded “dressing renewed, pressure sore worse”. The pressure sore chart in this care file had not been updated. The daily entry was not signed. There was no evidence in one file that the bi-annual check of a resident’s pacemaker had taken place. The last check was recorded in May 2005. Not all care plans had been updated following review, for example the mobility care plan for one resident had been updated to say that the resident is now being nursed in bed 24 hours. However, the eating and drinking care plan still gives details regarding taking the resident to the dining room in the wheelchair. In another care file a mobility assessment dated 23.9.04 states requires assistance of two to transfer from bed to chair. However, the moving and handling assessment states transfers with the assistance of one. Other information such as a moving and handling assessment and a blood pressure chart had not been regularly updated. The personal and social care needs of residents were not fully assessed and lacked suitable care plans. Care files are kept in resident’s bedrooms, they are able to review information held in files as required. Not all files had evidence of residents/relatives involvement in the care planning process. The systems in place for medication ordering, storage, administration and disposal were reviewed and found to be satisfactory. Medication Administration Records (MAR) were completed correctly and were all up to Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 11 date. Changes have been made to the disposal of medications as required at the last inspection. The interaction between staff and residents was observed throughout the inspection process. Staff were loudly asking residents in the lounge whether they had been to the toilet or whether they needed to go. On one occasion a member of staff said that she would help a resident to change her top once she had taken everybody to the toilet. This does not respect the privacy or dignity of residents. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Social/leisure activities do not meet the expectations of all residents. The systems for resident consultation in this Home are poor with little evidence that resident’s views are sought or acted upon. Residents are able to receive visits from family and friends and staff ensure that visitors are made welcome. This improves resident’s sense of wellbeing. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: The activity organiser employed prior to the last inspection visit has left and the Home are advertising for a person to fill this role. Activity sheets that were developed have not been completed. There is no programme of regular activities. On the day of the visit staff were playing bingo with some residents in the first floor lounge. Prior to the game of bingo starting residents were sitting in the lounge snoozing or staring into space and some of those spoken to said that there is nothing to do in the day. The television was on but one resident spoken to said that she does not like the television and prefers to listen to music. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 13 Residents meetings are not held. The matron reported that details regarding likes and dislikes are discussed with residents on their admission to the Home. Informal chats are held to discuss residents’ individual wants and needs. There was no documentary or other evidence to demonstrate that this takes place. Not all care files contained likes and dislikes regarding social and leisure activities or food. Residents said that they can receive visitors of their choice at any reasonable time and they have visitors on a fairly regular basis. The matron reported that meals would be provided for visitors if they have travelled a long way or if their relative was ill. Visitors do not need to make appointments to see residents and can meet with them in the lounge or in their bedroom if they prefer. The Home have regular contact with the local community. A local school and a church choir have visited recently and a vicar comes into perform services once per month and visits to chat to residents. None of the people living at Oldbury Grange handle their own financial affairs. Each resident is assisted by family or a representative such as a solicitor. Care files demonstrated that residents are able to bring personal possessions in to the Home. An inventory of personal belongings is kept. Bedrooms seen had been personalised with pictures and ornaments. During discussions with the manager it was noted that resident’s personal choices are acted upon as much as possible. The manager gave examples of how individual requests are met. Care files seen did not demonstrate that likes and dislikes or specific requests have been recorded or acted upon. There is a choice of two meals at lunchtime, the main meal or an alternative of salad and jacket potato. The cook speaks to all residents on a daily basis to find out what they want for lunch from the choices available. If a resident wanted an alternative from the two meals on offer the cook reported that they would try and accommodate this. Three residents spoken to said that the food is good and that there is always a lot to eat. Details of residents requiring special diets are kept in the kitchen and the cook was well aware of individual requirements. Six of the residents at this Home currently require assistance at meal times either having food cut up, staff assistance to feed or encouragement and prompts. One resident spoken to said that she eats more when staff feed her but they do not always have the time. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 14 Hygiene issues identified in the kitchen during the last inspection have been addressed. One of the issues related to the seal around the door of a small fridge. This fridge has been replaced with a new larger fridge. However staff are not monitoring the temperature of this fridge to ensure it remains within the required temperature range. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff are aware of the correct procedures of reporting any suspicion or allegation of abuse to ensure that residents are protected from harm. EVIDENCE: Staff have undertaken Adult Protection Training recently, another course is scheduled for next year and staff will be expected to attend. The Home have both a whistle blowing and an adult protection policy. The adult protection policy does not mention contacting the Commission for Social Care Inspection if abuse is suspected, this must be included. The policy was reviewed in 2003 but has not been reviewed since. A member of staff spoken to regarding abuse was fully aware of the Home’s procedure and were to find documentation if she had any concerns regarding abuse. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25 and 26 The standard of the environment within this Home is generally well maintained, comfortable, clean and hygienic providing a homely place to live therefore improving the quality of life for residents. Improvements have been made regarding bathing facilities. Further work is required to provide sufficient and suitable equipment and facilities which are in a good state of repair for all residents. Monitoring of health and safety issues would reduce risk of injury to residents. EVIDENCE: It was identified at the last inspection that some of the paving slabs on the patio outside the lower floor lounge were uneven and could cause a trip hazard. The requirement to ensure that this trip hazard is removed has not been addressed. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 17 Requirements made at the last inspection regarding the refurbishment of bathrooms have been mostly addressed. Bathrooms have been re-painted, however tiles were missing from the wall in one bathroom, pipe work was exposed in another as boarding around pipe work was missing. Damp patches were noted on the floor in another toilet and plaster was coming off the walls. The extractor fan in the first floor bathroom was extremely noisy. The toilet opposite the first floor lounge is not in use, this bathroom is being used to store wheelchairs. Minibus seats and a mattress were being stored at the end of a corridor. Radiators in some bedrooms were extremely hot to touch, radiator temperatures are not monitored. Temperatures above 430C present a risk of burning to a resident. The manager reported that a new central heating pump had been fitted during the inspection, which had resulted in an increased heat output. The manager turned down thermostats on individual radiators which reduced the temperature. Lighting levels in one bedroom were poor, the Matron reported that this is at the request of the resident. Documentary evidence to demonstrate this must be available in the individual care file. The Home was clean and hygienic on the day of inspection and no unpleasant odours were noted. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 The number and skill mix of the staff is sufficient to meet the needs of the residents. The procedures for the recruitment of staff are robust with appropriate pre employment checks being carried out. EVIDENCE: The manager works in a supernumerary capacity, a Matron is employed who is responsible for all nursing staff and nursing care. Each day shifts are worked as follows:Early 2 registered general nurses Late 2 registered general nurses Night 1 registered general nurse 1 senior care assistant 5 care assistants 1 senior care assistant 4 care assistants 1 senior care assistant 2 care assistants A cook, an assistant cook and a laundry assistant are also employed seven days per week. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 19 On the day of the inspection staffing levels were not in accordance with duty rotas, a member of staff have telephoned in sick at short notice and the matron was working in a hands on capacity to cover this shift. The issue noted at the previous inspection regarding missing information in staff files was discussed. These staff were completing an adaptation course and no longer work at the Home. Staff files reviewed at this inspection contained information required by standards such as criminal records bureau checks, references, passports and birth certificates. There are no staff contracts in place, according to the manager some staff have refused to sign a contract. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The quality management systems in place ensure that the home is run in the best interests of the residents. Procedures are in place to manage residents’ monies and valuables so their interests are safeguarded. Issues surrounding some aspects of health and safety need attention to safeguard the health, safety and well being of the residents. EVIDENCE: Quality assurance audits are undertaken at the Home on a regular basis. A policy has been devised which records the actions the Home are to take regarding quality assuring systems and practices. Resident satisfaction surveys are undertaken every six months. Various audits take place such as Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 21 housekeeping and cleaning, management, resident’s records and infection control. The last residents satisfaction survey was completed in June 2005, only a few responses were received. The “service user records audit” was reviewed, this audit had not been dated or signed by the person completing the information. Residents spending money records were reviewed. Records were kept in good order and were up to date. It was noted that neither the hairdresser nor the visiting private chiropodist issue a receipt for work completed. The manager records the names of those residents who have seen either the hairdresser or the chiropodist in a book. The manager was advised to ensure that either a receipt is obtained or that the hairdresser/chiropodist signs the book to confirm that they have received fees from the residents listed in the book. An issue was raised during the last inspection visit that the system for management of files was disorganised and confusing. This issue has now been addressed, all documentation seen was in good order and was easily accessible. Residents care files are kept in their bedrooms and they are able to access information as required. Various audits are undertaken to ensure that the health and safety of residents and staff is maintained. Records were checked and demonstrated that electrical installation checks have been undertaken and are up to date, A Landlord’s Gas Safety Certificate was available, Lifts are serviced regularly, emergency lighting and fire alarms and systems are tested on a regular basis. Records demonstrated that the last examination of slings and hoists was completed in January 2005, this is a six monthly requirement and had not been done in July 2005. Regulation 37 notices have not been sent to the Commission for Social Care Inspection on each occasion when a resident has been sent to hospital following an accident. Records are not available to demonstrate that the temperature of radiators are monitored to ensure that residents are not at risk of a burn from a radiator surface temperature of higher than 430C. The temperature of the new fridge must be monitored to ensure that it remains within the required limits. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X 2 X X X 2 3 STAFFING Standard No Score 27 3 28 X 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14(1) Requirement The registered manager must ensure that a comprehensive pre admission assessment is completed for each prospective resident. Records of this assessment must be maintained, dated and signed by the person completing the information. (Outstanding since 23 June 2005) 2. OP7 15(1) The manager must ensure that care plans include the social and personal care needs of each resident. The Registered Person must ensure care plans show clearly how each residents needs are to be met. They must contain sufficient detail to enable staff to complete the required action to meet the individual care needs of residents. Standardised documentation in care files should be completed or should contain an explanation as to why the information is not available. Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 24 Timescale for action 21/02/06 21/02/06 The practice of recording only one daily record does not sufficiently demonstrate that staff are taking the required actions at all times to deliver the prescribed care. Staff must date and sign daily records. Documentary evidence must be available to demonstrate that residents are involved in the care planning process. Care plans must be reviewed on a regular basis to ensure that all actions as recorded in documentation are acted upon, i.e. bi-annual pacemaker check. 3. OP10 12(4)(a) The manager must ensure that all staff treat residents in a way that respects their privacy and dignity at all times. The registered manager must ensure that the arrangements for social and leisure activities are flexible and varied. These should suit residents’ preferences and capacities. Records are to be maintained of this and of resident participation. 21/02/06 4. OP12 16 07/03/06 5. OP14 16(2)(m) (n) Documentary evidence must be 07/03/06 available to demonstrate choices made by residents i.e. Minutes of Residents meetings, discussions regarding activities, menu development. The registered manager must ensure that the uneven patio slabs to the rear of the property are attended to. The registered manager must ensure that the redecoration and refurbishment of bathing DS0000004403.V270098.R01.S.doc 6. OP19 23 07/03/06 7. OP21 23 21/02/06 Oldbury Grange Nursing Home Version 5.0 Page 25 facilities continues and those issues identified in the main body of this report are addressed. 8. OP25OP38 13 (3) (4) 23 (2)(p) The manager must ensure that the health and safety issues identified in the main body of this report are addressed, i.e. uneven paving slabs, servicing of slings and hoists, fridge temperatures, storage of items in corridors (minibus seats and mattress) and regulation 37 notices. The registered provider and manager must provide evidence that radiator temperatures are monitored and that temperatures do not exceed 430C. Where temperatures are in excess of this a plan is to be forwarded detailing the action to be taken to remove the risk of burns to residents from hot radiators 21/02/06 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 OP19 Good Practice Recommendations The inspector recommends that the small patio/garden area outside the dining room is cleared and replanted to make a more attractive area for residents to view from the dining room. The contact details of the Commission for Social Care Inspection should be included in the Home’s adult protection policy. This policy should be reviewed to ensure information recorded is up to date. 2. OP18 Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 26 3. OP29 The inspector recommends that the manager obtains advice from suitably qualified personnel with regards to employment law and staff contracts. The inspector recommends that the staff-training matrix be up dated to accurately identify training attended. The manager should ensure that quality assurance audits are dated and signed by the member of staff who has completed the information. 4. 5 OP30 OP33 Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Oldbury Grange Nursing Home DS0000004403.V270098.R01.S.doc Version 5.0 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. 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