Inspection on 19/11/07 for Pentlands Nursing Home

This inspection was carried out on 19th November 2007.

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

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

Other inspections for this house

Pentlands Nursing Home 10/10/06

Pentlands Nursing Home 07/02/06

Pentlands Nursing Home 26/01/05

Pentlands Nursing Home 03/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pentlands Nursing Home 42 Mill Road Worthing West Sussex BN11 5DU Lead Inspector Val Sevier Key Unannounced Inspection 19th November 2007 10:10 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 Pentlands Nursing Home DS0000024194.V349610.R02.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 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. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pentlands Nursing Home Address 42 Mill Road Worthing West Sussex BN11 5DU 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) 01903 247211 South Coast Nursing Homes Limited vacant post Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 people under the age of 65 years who may have a physical disability but are not independently mobile through the use of a wheel chair may be admitted. 10th October 2006 Date of last inspection Brief Description of the Service: Pentlands is a care home presently registered to provide nursing care for thirty- two residents in the category of Older People. South Coast Nursing Homes Ltd own the service. The home is situated in a residential area between Goring By Sea and Worthing West Sussex and is near to shops, a pub and cafes. Worthing town centre is a short drive away. The area is suitable for wheelchairs and the sea front is approximately half a mile away. Buses serve the area and pass the home and the railway station is about half a mile away. The home is a detached house that has been adapted for nursing care. All bedrooms except four on the mezzanine level are accessible by a lift and all have ensuite facilities. The fees for the home are available on asking. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: the Annual Quality Assurance Assessment (AQAA) completed by the home, and an unannounced visit to the home, which was carried out on the 19th November, during which we were able to have discussions with staff and have interaction with the residents at the home. On this occasion an expert by experience, someone who has had experience of nursing care, assisted us with the inspection. The expert walked about the home looking at the environment and spent time speaking with people who use the service and staff and observing interaction. We sampled staff and care records and policies and procedures that are related to the running of the home. A second inspector was also able to walk about the home speaking with staff and residents about what it is like to live and work at Pentlands. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. There were three areas at the time of the inspection where action had been required twice before. The commission is currently considering what if any further action to take. What the service does well: The home welcomes people who will use the service and their families or representatives, to visit the home and assess the facilities of the home. The manager actively seeks information from external healthcare professionals as part of the assessment where necessary, to ensure that the home is able to meet assessed needs. Health care was promoted through the use of tools that assist with monitoring the needs of individuals when that was necessary. The home has also developed good working relationships with healthcare specialists and outside professionals for example chiropodists and dentists. Some people who live at the home were positive about the food that the home provided and were pleased with the activities in which they could participate and the condition of the accommodation that they occupied. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 6 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 Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 7 be made available in other formats on request. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 (6 is not applicable to this home). People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering using the service are given appropriate information about the service to enable them to make an informed choice. People that use the service can feel assured that their needs will be assessed and that the home has an understanding of their needs using the assessment process. EVIDENCE: The home has a statement of purpose and service users guide that is given to those that are interested in moving to Pentlands. We were given two documents to see, one of them was out of date and had incorrect information regarding how to contact the commission. This was discussed with the manager at the time who undertook to ensure that all documents that were available were the most up to date. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 10 The statement of purpose and service users guide is in the form of a brochure and contains information about the home and its facilities; for example: the aims and objectives of the home, how to make comments complaints and suggestions, data and information protection and access to health records, fire safety and emergencies, a staff list, daily routines and organised activities and services available to the individual and their family. The guide also comments on the values of the home, on privacy and dignity, independence, civil rights, choice, fulfilment, ethnic and cultural diversity and security with statements such as: “…To value each individual who comes to Pentlands and enjoy the opportunity to share the richness and diversity of their experiences”. “The involvement of the client and their advocates in the building of their care is paramount to ensure the best possible outcomes”. After an enquiry an assessment visit is then arranged and carried out by the manager or one of the nurses. After the assessment and when a decision has been reached as to whether the home is able to meet the identified needs the home begins to develop the care plan and use it to assist with the admission to the home. The assessment includes the following areas: personal hygiene and dressing, safe environment, breathing, eating and drinking and swallowing, control of body temperature, working and leisure and aids to ability. The AQAA from the home stated that: “We encourage family friends and where possible potential clients to view the home and all its facilities. All potential clients are assessed prior to admission to ensure all their needs can be met”. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was an inconsistency in the records and systems within the home that support the personal and healthcare needs of people who use the service, which could potentially place people who use the service at risk. There was also inconsistency in the management and recording of medication, which could place people who use the service at risk. Some of the staff working practice helped to ensure that the privacy and dignity of people who use the service is promoted however views of residents must be taken into account. EVIDENCE: The four care plans we sampled were being used in conjunction with medication records and other health-monitoring tools that are used as part of the care planning for individuals. The AQAA from the home states that:” On admission we do a health assessment, linking with the activites of daily iving and risk assessments before devising a plan of care with the involvement of the client and their familly, if the client wishes. Emphasis is put on freedom of choice, privacy, dignity and independence. If risk assessments highlight Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 12 specific needs for equipment this is provided promptly”. It also mentions that “a person centred approach is adopted by all staff when caring for clients”. All the care plans seen were pre typed with a space for additional information regarding the individual and or their abilities. Giving staff information on for example: oral care, maintaining dignity – ‘whilst washing, the resident should be covered with a towel. Consent must always be gained from the resident before carrying out any procedures’. In two of the care plans it was seen that there was information regarding the individual needs and support that staff need to give; for example where an individual had a poor appetite, there was information on likes and dislikes with food. There was also a record of the exercises that staff encourage and support the individual with when they are in bed. Another individual had had several falls recently and there was information on the support given by the GP and dentist and what staff need to do to assist with mobility, which has become of concern recently. One of the other two care plans seen, did not give clear personalised information on what support was to be given by staff. Some of the plans of care for this individual were dated and signed for October 2007; others in the file did not have the resident’s name, and staff had not dated or signed them. This individual has difficulty in speaking following a stroke and the communication care plan did not explain how staff could communicate with the person or how the individual could be supported in making their wishes and needs known. One risk assessment drew the reader’s attention to another plan of care, which was not easily found and was one of those with no date or name on. This care plan was concerned with eating and drinking, which posed the individual certain problems. This was discussed with the manager at the time who stated that the care plans for that individual were being updated, however the previous plans of care were not available in the care plan file. On another care plan seen, a highlighter pen had been used in some of the plans of care to draw the staff’s attention to issues for that individual and in some areas the highlighter had been used to highlight action not to be taken. There were risk assessments in place, these included a range of potential risks to residents such as pressure sores, falls, moving and handling and malnutrition. Where a pressure sore assessment indicated that an individual was at risk it was noted that the corresponding plan of care for the person concerned referred to the use of a pressure relieving aid. It was seen in the care plans that physical health needs are also addressed with recent residents having moved to the home with information from health and other specialists. It was also seen that residents have access to opticians and dentists as needed. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 13 It was seen that individuals have been assessed regarding risks in their dally lives, and that support had been put in place to minimise the risk for the individual whilst also enabling them to participate in the activity, for example bathing. There had been concerns at the past two inspections regarding medication and requirements for action were made. It was seen that the home had written policies and procedures concerned with the management and administration of medication. Medication was kept in locked and secured medicine trolleys, cupboards and where required in a medical refrigerator. Controlled drugs were stored securely and appropriately. Nurses are the only staff who administer medication. The home administers all medication from blister packs. We looked at the Medication Administration Records (MAR) and noted that there were no gaps in the prescribed medication. It was seen for the ‘as required’ medication, for example Co Codamol and Paracetamol, that where there was a choice of dosage for example 1 or 2 tablets, there was not a consistent record by staff of what they had given. Staff had not recorded any where what had led them to give ‘as required’ medication and whether this had worked. These omissions were also noted on the homely remedies that had been given. There were two examples where the name of the medicine had been written, Movicol and Blistex, with no instruction on how to administer, when it should be given and the amount to be given/used. People had expressed to the expert by experience concerns about some staff being a “bit rough” when supporting them at night. Also an individual commented that they had not expected to be cared for by a male carer and so felt uncomfortable. The residents were not able to say who the staff were or when this had happened. Staff were observed speaking and assisting the residents with dignity and respect. Affection was given to those residents who sought it. It had been seen on care plans that the preferred choice of name had been recorded and staff were heard to speak to residents by the name they wished. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals have limited social activities that may not meet all their needs and wishes. Whilst nutritional needs may generally be met there is a need to ensure that meals are appealing for all individuals. EVIDENCE: The expert by experience was asked to look at the areas covered in these standards with the people who use the service and the observations and comments are noted here. The second inspector also looked about the home and spoke with several residents, as well as observing interaction between staff and residents. The expert by experience was able to speak with seven people who use the service and several members of staff. During the inspection it was observed that the majority of people were in their rooms, and were either in bed or sitting in wheelchairs. People were asked about activities and they said that there were activities, Bingo and finger painting and one resident said: “I have my nails done once a fortnight which is lovely”. Of the seven spoken with only one said that they take regular part in activities. One individual said that they use the hairdresser and a chiropodist. One individual likes to smoke and is Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 15 wheeled outside with a fire blanket and left. They have signed a disclosure not to claim if they set fire to themselves. Other activities that were noted from an activity file, with the last entry being the 7th November 2007, are quizzes, which noted that two or three individuals join in. When we spoke with the staff it seems that they feel people are frail and spend most if not the majority of their time in their rooms, staff prioritise one to one with individuals. There was no record of what individual activities staff support people with, either on the care plans or in the activity file. There had been a fete at the home since the last inspection and money was raised for a local charity. Those individuals who agreed to speak with the expert by experience were seen to be feeding themselves. At one open door a carer was feeding one individual over a period of 15 to 20 minutes. The carer was sitting adjacent to the resident both facing outwards towards the door. One resident was speaking with the expert by experience when the food tray was brought to them. It was observed that they were sitting on a reclining chair propped up by pillows and they had some difficulty raising themselves sufficiently to eat but this “was usual” they said and that they managed on their own. It was noted that no one came back to check on the individual. The residents spoken with said that they spend all or the majority of the time, in their rooms. Of the seven people spoken with two were happy with the service of the staff and response time but five said they take too long and it’s worse at night”. Two of the five people complained that “the night staff were very rude and offhand”; and both felt that quite a few of the staff “are young girls and what do they want with wiping bottoms”. One individual is assisted with nutrition by being fed through a tube. Two of the other people spoken with were generally happy although one has wheat intolerance and has said that they have oat cereal “sometimes like today they run out and I have wheat which upsets my stomach”. The individual also has Ryvita instead of bread, which they like, but it’s “rough and hurts the inside of my mouth”. Two people spoken with were indifferent saying that “I’m not hungry anyway”; and two were very unhappy. “It’s tasteless, no salt, no butter in the potatoes, no fresh fruit and it’s never warm. Supper is the worst, it’s served at 5.30 to 6.00pm, and it’s often soup which is tasteless and two pieces of bread and butter”. It was observed that day that two residents ate their lunch in the dining room, all others ate in their rooms. We observed that people are sat in different bedrooms (that are vacant) so that they can have a change of scenery. One individual was taken from this second room to the dining room / lounge for lunch. It was noted that there is a four-week menu in the hallway and the manager stated that people are asked daily what they would like. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 16 Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected through the open complaints process. However there is insufficient evidence that staff have all had training in safeguarding adults and recruitment practices leave people at risk. EVIDENCE: The homes complaints procedure was seen to be available in the information given to people who use the service. It was noted that in one of the statement of purpose documents that was given to us to look at, the address and contact details of the commission was incorrect. This was bought to the attention of the manager who undertook to ensure that no more incorrect documents were available. There have been no complaints received by the commission since the last inspection visit. The home has received two complaints in the last twelve months regarding monies and care. Both were investigated and actioned with all parties satisfied with the conclusion. The manager advised us that the home promotes an open door approach to relatives and people who use the service, to help resolve complaints and issues effectively. The home uses the West Sussex safeguarding adult policy, the AQAA from the home stated that: “There are traning records to show attendance at adult Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 18 protection sessions. Written policies and procedures and POVA and CRB checks.” Also that “Adult protection is dealt with by clear policies and procedures. Staff training which is annual. Induction workbooks inculde adult protection issues and trained staff and senior carer prompt climets rights and are role models for all staff. Support and supervision addresses any poor practices. Robust recruitment procedures.” However it was not clear from the training records seen which staff had undertaken training in safeguarding adults, although the training plan for the year stated that it had taken place. Evidence about recruitment practices is covered in staffing section of this report. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have a pleasant and homely environment to live in which also has had adaptations to meet individual needs. EVIDENCE: The home was seen to be maintained and it has had new blinds and carpets in some areas. The rooms at the home are spread over two floors with an annexe built onto the ground floor. All parts of the home were very clean and there were no malodours, even when lunch was being cooked. There is a lounge/dining room, which was bright although on the day it felt cold. We noted that in the dining area the tables were laid up with 11 table settings, and there was enough seating for 12 in the lounge. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 20 It was noted that there is new carpet in some areas and additional carpet rolls, which are to be put down, were stored in the corner of the lounge diner. People were asked whether they used the lounge / diner some were unable to due to physical frailty whilst others said it was ‘cold’ and uninviting’. Both floors were being cleaned very thoroughly on the day and staff spoken with felt the home was a friendly place to work with everyone being supportive. The upper floor appeared less bright than the ground floor. It was observed that the in some rooms the toilet and washbasin were separated by a curtain from the rest of the room. People spoken with commented on the Presto bath the home has and it seemed to be popular, enabling people to have their hair washed for example without having to lean over the sink. People spoken with said that they loved their laundry as it was returned in a timely fashion and it was nicely cleaned. One person said that they had their own belongings returned to them although occasionally they might find someone else’s things with their clothes. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels and training vary and do not fully meet the needs and wishes of individuals including social care. People who use the services are potentially at risk because of the current recruitment procedure. EVIDENCE: The staff rota was seen and was noted that there is one nurse and six or seven care staff in the morning and one nurse between three and five care staff on in the afternoon; at night there is one nurse and three care staff. There are also kitchen and housekeeping staff during the day. The manager works Monday to Friday usually 8 – 4pm and is often the second nurse on duty when she is there. The rotas indicated that agency staff had been occasionally used at night. There is a training coordinator for the home and annual training for 2007 included, fire, food hygiene, infection control, manual handling, first aid, COSHH and safeguarding adults. The training file did not list fully which staff had attended the training and who needed to be updated. It was noted that there was to be an hour’s lecture on Parkinsons Disease which staff would not be paid for and a comment about ‘rallying the troops’. It was noted that for training in adult protection staff would be paid. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 22 The manager stated that there is staff induction for the first six weeks with a booklet for staff to complete; there were none available on the day of the visit to see. The training record of one new member of staff said that her induction was completed 22.1.07. We sampled four staff files of staff that had been employed since the last inspection to the home. There had been concern on two previous occasions that recruitment checks to safeguard people who use the service had not been completed. In the files seen it was found that all had two references and all had CRB and POVA First checks, however the dates for these checks on all four files were after the date the employee had started work. In one instance it was five days and in another 29 days. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst there are some beneficial management systems medication and recruitment practice put people at risk. The home would benefit from having a Registered Manager to ensure all procedures are in place and followed. Quality assurance must include recorded visits by the Provider EVIDENCE: The manager has been a nurse for approximately 30 years and has worked in nursing homes for about 22 years. She has worked at the home for over 11 years being employed as the deputy matron. In January 2007 she was appointed as the manager of the home. She has begun the application to be registered with us; we spoke with the manager of the home about the Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 24 application process and timings. She is a mentor for student nurses and the local nursing college places first year student nurses at the home. The manager was able to show that regular audits are undertaken for example infection control and accident reports. Questionnaires are sent yearly to the people who live at the home and their representatives or family and these responses are collated into a report. The current report mentions for example social and community activities, staff training, catering, staff recruitment, the environment, complaints and health and safety. The quality reports states that “I am confident that all staff have up to date CRB’s and that all staff paperwork has been checked”. “The standard of food in the recent survey was considered excellent by 10 of respondents, good by 50 o found it unsatisfactory”. “All staff members receive regular support and supervision as well as annual appraisals”. We require that there is as a minimum, regular monthly visits undertaken at the home by the registered provider and that a report is provided for that visit for us to see. A requirement was made at the last inspection for this to take place. It was noted that there had been a visit in December 2006 and January to June 2007, and one in August 2007. There was no record of the other months. The AQAA for the home received at the commission states in response to: ‘we have made the following changes as a result of listening to people who use our services’: “An entertainment programme has been commenced and is evaluated regularly. Garden area has new seating provided. Pond area has been redesigned.” “Team building exercises and training sessions. The ethos of recruiting multicultural staff. A person centered approach is adopted by all staff when caring for clients therefore ensuring all their needs are met and their preferences are taking into account.” There were a range of written policies and procedures available for staff to refer to as guidance and to inform their practice. These included the following: • Admission, discharge and transfer of residents • Human Rights • Confidentiality and access to personal records • Abuse of the person • Drug administration • Self administration of medication • Infection control • Complaints procedure • Whistle-blowing • Health and safety at work Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 25 Any monies held by the home have full documentation. It was noted that the home’s equipment, plant and systems were checked and serviced or implemented at appropriate intervals for example the passenger lift and hoists, fire safety equipment, portable electrical equipment and the hot water system. There were contracts in place for the disposal of clinical and household waste. There was a fire risk assessment for the premises; tests of equipment and regular risk assessments of the premises and working practices were undertaken regularly. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 26 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Sch3 Requirement Timescale for action 19/02/08 2. OP9 13 (2) 3. OP15 16 (2) 4. OP29 19 Sch2 People who use the service must have clearer individual care plans describing the support that staff can give. This must be up to date and individuals names must be recorded. Individuals records must state 21/01/08 the amount of medication given where there is a choice of dose for “as required medication” The records must also state the reason medication was given and any effect it had. A repeat requirement from February 2006 People who use the service must 19/02/08 be asked about their meals, when they have them and where. They must also receive any support they need from staff. The home must carry out 19/11/07 thorough recruitment practices and ensure all documentation needed to protect people who use the service is in place before staff commence employment. Including receipt of POVA first checks and applications for CRB DS0000024194.V349610.R02.S.doc Version 5.2 Pentlands Nursing Home Page 28 5. OP33 26 must have been made before anyone starts work. This is an amended but repeat requirement as made about staff records in February 2006 and August 2005 The provider must ensure that a 19/11/07 monthly visit is carried out to the service and that a report is available at the home to be seen. This is a repeat requirement from February 2006 and August 2005 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. Refer to Standard OP12 OP30 Good Practice Recommendations Whilst there has been some improvements to the activities offered further thought should be given to social activity and stimulation based on individual needs and abilities. The record keeping would benefit from a clear record of training staff have received and when they next need to be updated. Pentlands Nursing Home DS0000024194.V349610.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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