Inspection on 10/10/07 for Potton House Nursing Home

This inspection was carried out on 10th October 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

Potton House Nursing Home 20/02/08

Potton House Nursing Home 19/04/07

Potton House Nursing Home 11/05/06

Potton House Nursing Home 26/10/05

Potton House Nursing Home 04/07/05

Potton House Nursing Home 24/01/05

Potton House Nursing Home 08/06/04

Potton House Nursing Home 06/01/04

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

CARE HOMES FOR OLDER PEOPLE Potton House Nursing Home Potton Road Biggleswade Bedfordshire SG18 0EL Lead Inspector Mrs Louise Trainor Unannounced Inspection 10th October 2007 07:40 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 Potton House Nursing Home DS0000017688.V350105.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 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. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Potton House Nursing Home Address Potton Road Biggleswade Bedfordshire SG18 0EL 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) 01767 314782 01767 314862 potton.house@craegmoor.co.uk Health & Care Services (NW) Limited Vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24) Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate a maximum of 24 service users. The home can continue to accommodate the identified service user who is aged under 65 years. The home cannot admit any other service users aged under 65 years. Date of last inspection 19th April 2007 Brief Description of the Service: Potton House is a purpose built care home with nursing situated in the grounds of Biggleswade Hospital on the outskirts of Biggleswade, a rural village, in mid Bedfordshire. Biggleswade has good road access and there is a limited bus service with the nearest train station in Sandy. Potton House provides places for up to twenty-four older adults with mental health care needs. The home is single story with accommodation separated into three wings. Each wing has eight bedrooms and its own living areas. There is also some additional communal space. The home has a large fenced garden and there is ample parking area at the front. All the beds at Potton House are block purchased by the Primary Care Trust. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the second unannounced Key Inspection this year for Potton House and it took place between the hours of 07.40 and 15:00 hours on 10th of October 2007. The inspection was undertaken by Louise Trainor, lead inspector, and Sally Snelson. The acting manager Mr Tony Gabaza, who is from one of the Company’s sister homes, was present from throughout the inspection to assist. Feedback was given throughout the inspection. During the inspection the care of four people who used the service was case tracked. This involved reading their records and comparing what was documented to the care provided. Three staff files were also inspected. In addition to sampling files and care observations, people who lived at the home, staff and visitors were spoken to and their opinions sought. Any comments received from staff or service users about their views of the home plus all the information gathered on the day was used to form a judgement about the service. The inspectors would like to thank all those involved in the inspection for their input and support. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There was no evidence to indicate that people in this home are assessed by the home, prior to being offered a permanent placement. The Statement of Purpose and Service User Guide both included information that was inaccurate about the management of the home, and information relating to fees was not included in these documents. Care plans were in place for each person who lives in this home, however these were all on new documentation and no information written prior to these plans could be located for these people. Care practices observed did not always reflect that consideration was being given to the information in the care plans. Choices for people living in this home remain limited and restricted particularly around mealtimes. This home has recently appointed an activity worker. She has introduced a general activity programme, however she has not yet assessed the residents for suitable individual leisure activities. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 7 The complaints file indicated that complaints are being addressed, however insufficient documentation is being recorded to identify how matters have been resolved. The communal areas of this home were generally clean and tidy however there were some areas where hygiene and maintenance required attention to ensure the safety and the comfort of the people who live here. In general the staff in this home appeared competent in their roles, however morale is very low and some staff are working regular shifts in excess of seventy hours each week. This is putting both themselves and the people they care for at risk. Temporary Management cover is introducing new systems to improve this home, however staff are unsettled and morale is low, so that the care of the people who use this service may be compromised. 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. Potton House Nursing Home DS0000017688.V350105.R01.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 Potton House Nursing Home DS0000017688.V350105.R01.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, 4, 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was no evidence to indicate that people in this home are assessed by the home, prior to being offered a permanent placement. EVIDENCE: The registration certificates for this home were displayed in the entrance hall of the home. However these still displayed the name of the manager who has now left this post. The Statement of Purpose and Service User Guide both included information that was inaccurate about the management of the home, and information relating to fees was not included in these documents. The files of four people who use this service were examined during this inspection. None of them contained any evidence to indicate that someone from the home had assessed them prior to admission. The beds in this home Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 10 are block purchased by the local Primary Care Trust, and bed placements are decided through panel meetings. However the home must still carry out full assessments to ensure that each individual’s needs can be fully met within this establishment. The home was not offering intermediate care at the time of this inspection. Potton House Nursing Home DS0000017688.V350105.R01.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, 10, 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place for each person who lives in this home, however these were all on new documentation and no information written prior to these plans could be located for these people. Care practices observed did not always reflect that consideration was being given to the information in the care plans. EVIDENCE: The files of four people who live in this home were inspected. One person’s file identified his love of darts, wrestling and rugby. It also gave a clear picture of his life history so that staff would be able to talk to him about things that maybe familiar to him. It was disappointing when a qualified nurse came over Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 12 to the inspector and began talking about him and his personal needs, in front of him, as if he was not there. This showed a lack of understanding of his dementia and capacity to understand, and a general lack of respect for him. In contrast to this, the care staff on duty generally showed a greater understanding of the residents and appeared caring and compassionate about the people they care for. One carer, who came on duty at lunch- time, approached different residents individually to chat with them on their level. This was spontaneous and clearly an every day occurrence for her, and was encouraging to see. Wishes relating to death and dying were documented in the care plans, and the home is working with the ‘Liverpool Care Pathway’, however one person’s file identified that; in the event of death they were not for resuscitation. The next of kin had signed this documentation, but there was no evidence that there had been any consultation with any health professionals involved in the care. Any such documents must be signed by the GP and kept under review. Observation of care practices throughout the day did not always demonstrate that information in the plans was being acknowledged. For example one person’s plan clearly identified that the individual did not like male residents and should avoid loud noises. However she was placed in a lounge area with a male resident and another individual who proceeded to shout. This in turn upset the individual and provoked her to start shouting and swearing in response. This could have been avoided had the care plan and given information been considered in her daily care. This person who also had a chest condition and a productive cough, was put in a lounge area, opposite a room that was being painted, causing paint fumes that may have been responsible for aggravating the cough. Risk assessments were in place in all the files inspected, and these included, moving and handling assessments, nutritional assessments, pressure area care, falls and the use of bed rails. These had been updated regularly over the past few months, but unfortunately, information prior to the new care plans, that had been recently implemented, and the corresponding risk assessments, could not be located for inspection. It was clear that where plans or assessments required regular monitoring such as blood sugars or weights these were done and any deviations noted and acted upon. The Medication Administration Record (MAR) sheets for six of the people who live in this home were examined in detail. Generally these had been appropriately signed and completed with omission codes where necessary. There was no one on controlled drugs and no one self -medicating. Medication cupboards were tidy and appropriately stocked. We were concerned that the 8am medication round started at almost 9am and always would if breakfast was not served until residents were up. The last early morning medication was not administered until almost 11.00am, and the 13.00hrs round started at 12.40 hrs which could mean that the gap between Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 13 one medication and the next was not equally spaced during the 24hours of the day. Potton House Nursing Home DS0000017688.V350105.R01.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Choices for people living in this home remain limited and restricted particularly around mealtimes. EVIDENCE: The breakfast time was observed from approximately 08:40 hours. At this time there were six individuals sitting at the dining room tables, all had brown bread sandwiches or a banana in front of them. As more residents were brought into the dining area, they were given, sandwiches, porridge or bananas. These were not offered they were just put in front of individuals. One lady was given a bowl of porridge. She did not seem interested in it so the inspector enquired “Aren’t you hungry?” She replied. “Yes I am, but not for that”. There was no evidence to indicate that anyone was offered a choice of cereals, toast or a cooked breakfast. Residents were not observed by staff to ascertain what they had eaten. One person had four sandwiches on her plate at 08:50 hours. Another resident walked past and took one of these sandwiches without any staff witnessing it. At 11:30 hours this person still had three sandwiches on a plate in front of her. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 15 Staff were heard discussing the fact that at least she had eaten one. She had not actually eaten anything. A member of care staff later informed us that this resident does have a problem with nutrition, and had suffered with an eating disorder in her younger days. This lady allegedly did not like any ‘white food’, however she was served a plate of what appeared to be ‘white’ mashed potato or pureed spaghetti, with bolognaise sauce, on a white plate for her lunch. Another resident would not eat unaided off a plate, and staff said they were not allowed to give her a bowl, no one had looked at alternative aids such as a plate guard or specialist dish, instead, the staff just fed her. This was the same resident who we had observed eating and drinking from other resident’s plates and cups. This did not demonstrate any understanding of the need to promote independence. There was a choice of menu for the midday meal. We witnessed each member of staff being offered a choice of beef and onion pie, spaghetti bolognaise or sandwiches for their lunch. However the residents did not appear to be given the same choice. Anyone requiring a soft diet, was served a plate of spaghetti bolognaise without being given any options. There was no evidence of picture menus or visual choices being offered, despite this being a requirement following the last two inspections. Drinks were not offered during the course of the morning except for tea with breakfast, and this was given to everyone except one lady in plastic beakers without handles. Staff also told us they were used to serve the soup in the evening and quickly became very smelly. This home has recently appointed an activity worker. She has introduced a general activity programme, however she has not yet assessed the residents for suitable individual leisure activities. She stated that she had researched information on dementia herself, but was looking for some local training. She did not appear to be aware of the need to produce care plans to support the activities provided and how they were suitable for the particular resident. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints file indicated that complaints are being addressed, however insufficient documentation is being recorded to identify how matters have been resolved. EVIDENCE: There is a complaints policy in place for this home, however it is out of date and refers to an specific inspector who left the CSCI two years ago. The complaints file was examined during this inspection. There were two complaints recorded. One had clear record of responses written both by the Director of the company and also by the Area Manager. The second was regarding the clothing of someone who lives at the home. There was no documentation to identify the outcome of this complaint. This complaint was made in January 2007, but the outcome was not available at the last inspection. There was a safeguarding policy in place that had been reviewed in December 2006. Throughout interviews the staff in the home were able to demonstrate their understanding of the subject and understood the importance of reporting incidents correctly. However there was one recent incident (29/09/07) identified in an individual’s records. This identified that the person was found on the floor and stated she Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 17 had been pushed. This had not been reported appropriately, either to CSCI or to the safeguarding team. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The communal areas of this home were generally clean and tidy however there were some areas where hygiene and maintenance required attention to ensure the safety and the comfort of the people who live here. EVIDENCE: The main lounge areas of the home were generally clean and tidy on the day of the inspection, however some of the bedrooms had an offensive smell in them and one room in particular had an en suite toilet, which was dirty and unhygienic, and there was no toilet paper located in the room. The laminate flooring in this particular room was sticky and loose fitting, and moved under foot. There was no threshold bar in place between the en suite and the bedroom, where the flooring had been lifted and needed replacing. This was identified to the acting manager as a risk requiring urgent attention. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 19 The bathrooms are now free from the storage and clutter reported at the previous inspection. However staff informed the inspectors that the baths are not used in this home, as they are inappropriate for most of these clients, in that they will no accommodate hoists and/or are not assisted facilities. There is presently only one shower that is used in this home for all the residents. This is insufficient. Staff also reported that some residents had not had more than a bed bath for a number of weeks. At 13:30 hours the staff started to take some of the people living in this home to the toilet. Staff were clearly having problems locating wheelchairs, as there did not appear to be a dedicated area to store them. There is a maintenance man dedicated to this home, and he is working through a redecorating programme at present. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. In general the staff in this home appeared competent in their roles, however morale is very low and some staff are working regular shifts in excess of seventy hours each week. This is putting both themselves and the people they care for at risk. EVIDENCE: The files of three staff were examined during this inspection. All appropriate recruitment documentation was present in these files. This included fully completed application forms, appropriate references, and various forms of identification including birth certificates, passports and a current photograph. Criminal Record Bureau and POVA first checks were present in all files. Where appropriate Home Office paperwork was present and qualified staff had been checked with the Nursing Midwifery Council to confirm authenticity of registration. Five staff were interviewed during this inspection. Information received indicated that morale was generally quite low. One said, “Morale goes up and down as managers come and go”. The home is presently working with six staff in the morning, five in the afternoon and four at night, however we were informed that for the past four to six weeks there has rarely been cleaning and laundry staff, therefore one Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 21 carer has been allocated each day to undertake the ancillary work. The staff are very unhappy about this matter. Concerns were also raised by the team regarding recent staff appointments made within the home. Staff were advised these issues must be raised with the management in order to resolve them effectively and efficiently. We fear that if these matters are not addressed immediately, the home will loose some very competent and caring staff. The acting manager was made aware of this at the end of the inspection. Staff rotas for October 2007 were examined. Staff generally work twelve hour shifts which start at 07:00 and finish at 19:00 hours. There is presently only two regular qualified staff rostered on day duty. One is rostered to work the whole of October with only five days off throughout the month. This means that out of thirty-one days, she will work twenty- six twelve hour shifts. The second qualified nurse also has a similar shift pattern, however she does have one weeks allocated leave at the end of the month. Two of the care staff are also working in excess of sixty hours each week. Staff reported feeling tired as the work is heavy. This home is registered for Mental Disorder (MD), and has an agreement with the Commissioning Primary Care Trust (PCT) that a Registered Mental Nurse (RMN) should be on duty at all times. Presently there is only one regular member of staff with an RMN qualification and they work night duty. The acting manager is an RMN, and therefore provides the necessary cover Monday to Friday however this still means that there is considerable time when there is no RMN on duty. Staff employed in this home are attending mandatory training as required. They are also encouraged to attend specialist lectures on subjects such as Epilepsy and Diabetes. Many staff have attended an awareness session on Dementia, however, given that this home is registered as a specialist facility for Mental Disorder, including dementia, further in depth training in this subject should be addressed as a matter of urgency. It is also necessary for the activity co-ordinator to have a greater understanding of dementia and how to engage residents. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 22 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, 36, 37, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Temporary Management cover is introducing new systems to improve this home, however staff are unsettled and morale is low, so that the care of the people who use this service may be compromised. EVIDENCE: The manager for this home left her post in July this year, and the changes in the company’s overall management of the home appears to have had a very unsettling effect on the staff. The deputy manager from another of the company’s homes is presently managing this home, and has been doing so for the last three weeks. He appears confident and competent in this role and is Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 23 introducing systems to ensure processes such as staff supervision are implemented and maintained, however this remains in the early stages and records were not yet completed for inspection. Some staff that were interviewed talked positively about him stating that he was approachable and supportive, however they were aware that a new permanent manager is due to start later this month, and therefore they remain apprehensive and unsettled. There was a clear definition of the terms accident and incident on the wall in the office. However the policy did not go into detail about the recording of these incidents and as a consequence when a accident was recorded in to the accident book it was then reported to other organisation such as ourselves and the local authority correctly. During tracking it was noted that incidents reported in the daily log where not always reported in the accident book and then no other body were made aware. For example on 29th September in the care notes of one of the residents case tracked it was reported that an individual had been found on the floor and stated it was as a result of another resident pushing them. This had happened over the weekend and had not been recorded in the accident book, to us via a regulation 37 notification, or to the local authority safeguarding co-ordinator. We were concerned that since June the number of accidents reported in the accident book had reduced considerably. This may be due to the management changes within the home. The personal allowance records for two people who live in the home were checked. Both crediting and withdrawal of funds were correctly recorded, and receipts were present where appropriate. It was apparent that resident’s had few opportunities to use money. Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 24 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 1 X 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 1 2 2 2 2 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 2 X 3 1 2 2 Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4(1) 5(1)5(2) Requirement Statement of Purpose and the Service Users Guide must be reviewed to reflect the changes in the company’s management structure. These reviewed documents must be available to CSCI. This requirement is unmet 01/08/07 People wishing to use this service must be fully assessed by a suitable qualified person from the home prior to being offered a permanent placement. The people who live at this home must be treated with dignity and respect at all times. This requirement is unmet 31/05/07 The people who use this service must be offered activities that are appropriate to them as individuals, and are delivered competently in order to provide them with appropriate stimulation. The people who live in this home DS0000017688.V350105.R01.S.doc Timescale for action 30/11/07 2. OP3 14(1)(a) 31/10/07 3. OP10 12(4)(a) 31/10/07 4. OP12 16(2) 30/11/07 5. OP14 12(2) 31/10/07 Page 26 Potton House Nursing Home Version 5.2 6.. OP15 16(2) must be encouraged and assisted to make personal choices. This requirement is unmet 31/05/07 Service users who are unable to communicate verbally, should be offered a visual choice of meals at mealtime. This requirement is unmet 01/08/06 & 30/06/07 People who use this service must have access to appropriate bathing facilities at all time. Bathrooms and toilets must be kept clean and safe for the people who use this service. The people who live in this home must be cared for by sufficient staff who are able to focus their attention on the care of the residents. Staff in the home must be appropriately trained so that the specialist needs of the people who live in this home with dementia are appropriately met. This requirement is unmet 01/08/07 The registered persons must ensure that a quality assurance system is ongoing and that improvement plans are implemented. This requirement is unmet 01/08/07 Staff must be supervised six times a year. This requirement is unmet 01/08/06 & 01/08/07 All accidents and incidents that occur in this home must be appropriately reported. DS0000017688.V350105.R01.S.doc 31/10/07 7. 8. OP21 OP26 23(2)(j) 23(2) 30/11/07 30/11/07 9. OP27 18(1) 31/10/07 10. OP30 18(1)(a) 30/11/07 11. OP33 24 31/10/07 12. OP36 18 31/10/07 13. OP38 37(1) 31/10/07 Potton House Nursing Home Version 5.2 Page 27 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 OP12 Good Practice Recommendations Care plans should reflect service users reaction to the activities provided. Different methods of offering service users with dementia a choice of meal should be considered. 2. OP15 Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Potton House Nursing Home DS0000017688.V350105.R01.S.doc Version 5.2 Page 29 - 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!