CARE HOMES FOR OLDER PEOPLE
Ruislip Nursing Home 173 West End Road Ruislip Middlesex HA4 6LB Lead Inspector
Mrs Clare Henderson Roe Key Unannounced Inspection 10:40 3rd January 2007 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 Ruislip Nursing Home DS0000068138.V322504.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. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ruislip Nursing Home Address 173 West End Road Ruislip Middlesex HA4 6LB 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) 01895 674 267 01895 623 412 Hassam Cader Mrs Raziya Banu Cader, Hannah Cader, Javed Zulficar Ali Cader Mrs Raziya Banu Cader Care Home 24 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0), of places Physical disability over 65 years of age (0) Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Minimum staffing notice As agreed on 10th July 2006, 7 named service users with a diagnosis of dementia can be accommodated, as agreed by the Commission for Social Care Inspection, for as long as there is no deterioration, which affects the well being of other service users. The rooms used for each service user will revert to listed categories for the home once the service user no longer resides at the home. The home must advise CSCI when a service user no longer resides at the home. 15/05/06 Date of last inspection Brief Description of the Service: Ruislip Nursing Home is a converted detached house situated in a residential area of Ruislip. There is an enclosed garden to the rear of the premises. The accommodation consists of fourteen single bedrooms and five double bedrooms. There is a large communal room and a conservatory for service users to utilise. Local transport facilities are available in the form of buses and Ruislip Gardens and South Ruislip underground stations. Clergy from the Roman Catholic and Church of England Churches make weekly visits to the home, and arrangements to meet other religious and cultural needs can be made. The home offers accommodation to male and female service users over the age of 65 years of age and can accommodate those with physical disability associated with old age. The home is not designed to offer care to those with significant physical disabilities. The fees charged are between £650-£700 per week. The home does offer respite care at £94.95 per day. The home is under new ownership and this is the first inspection since the change of ownership. The Registered Manager, who is also one of the new Registered Providers, was in post for the last inspection. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 10 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff records, financial records and maintenance & servicing records were viewed. 6 service users, 6 staff and 4 visitors were spoken with as part of the inspection process. The pre-inspection questionnaire and comment cards from service users, representatives/visitors and healthcare professionals have also been used to inform this report. Since the last inspection the home has had two additional visits, and the requirements and recommendations from these visits have also been reviewed at this inspection. What the service does well:
The home is being effectively managed and the Registered Manager has the qualifications and experience to fulfil her role. Service users and their representatives are provided with information about the home and encouraged to visit prior to admission, allowing them to make an informed choice. Written contracts of terms & conditions are in place. Prospective service users are fully assessed prior to admission to ensure the home is able to meet their needs. Specialist care needs to include cultural and religious needs are being met. Information in respect of the service users care needs is well documented and kept up to date. Medications are being robustly managed at the home. Staff care for service users in a courteous, gentle and professional manner, respecting their privacy and dignity. Service users spoken with plus those who completed CSCI comment cards expressed their satisfaction with the care they receive at the home. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said they are made welcome at the home. Information regarding advocacy services is available in the home. The food provision is good, offering variety and choice and catering for individual dietary needs. Robust procedures are in place for the management of complaints and POVA. The home is being well maintained, providing service users with a well presented, homely environment to live in. The home has endeavoured to create more space in the communal areas, for seating to be better spaced. The home is clean and fresh and there are good systems in place for infection control. The home is appropriately staffed to meet the service users needs, and this is kept under review. Robust systems are in place and being adhered to for staff recruitment. Overall the training provision in the home is good, to include NVQ in care and induction training, plus topics relevant to the diagnoses and needs of the service users. There are good systems in place for quality assurance and for the management of any service users monies. The home has a business plan in place, evidencing budgeting and the financial viability of the home. Health & safety is being well managed in the home. Ruislip Nursing Home DS0000068138.V322504.R01.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 be made available in other formats on request. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 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 Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information about the service, thus allowing them to make an informed choice about the home. Written contracts are in place, thus ensuring information regarding the homes terms and conditions are understood and agreed. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Staff have the skills to care for service users, to include those with specific specialist care needs. Service users and their representatives are encouraged to visit the home prior to admission, thus giving them the opportunity to make an informed choice. EVIDENCE: The Statement of Purpose and Service User Guide have been updated to reflect the new owners information and to ensure all required information is included, and are available by the visitors signing in book, along with other publications of relevant interest. Copies of the Service User Guide are available in each
Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 9 service users bedroom. Representatives spoken with said that they were provided with information prior to the admission of their relative to the home. For service users who are being funded by Social Services or a Primary Care Trust, contracts between the home and each funding body are drawn up. The service user or their representative signs copies of the homes terms and conditions. For privately funded service users the service user or their representative signs a contract plus terms and conditions. Pre-admission assessments carried out by the Registered Manager were viewed as part of the inspection process. These were comprehensive and provided a clear picture of the service user and their needs. Since the last inspection the home has applied for a variation in respect of continuing to accommodate existing service users with a diagnosis of dementia. Staff had received training in dementia care and at the time of inspection there was a good atmosphere within the home. For one service user with specific religious and cultural care needs, there was evidence that these were being met. A member of staff who speaks the service users language is always on duty, special meals and a radio channel as enjoyed by the service user to meet their needs are also provided. Representatives from the Roman Catholic and Church of England Churches make weekly visits to the home. The home encourages prospective service users and their representatives to visit the home prior to admission. Representatives spoken with said that they had been able to visit the home to view it prior to their relative being admitted. It is acknowledged that it is sometimes not possible for service users who are unwell or in hospital to visit the home prior to admission. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans are well completed and maintained up to date, thus giving a good picture of the service users needs and how these are to be met. Medications are being well managed at the home, thus safeguarding service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: Three service user plans were viewed. These were comprehensive and gave a good picture of each service users needs and how these are to be met. Risk assessments for falls were in place. The service user plans had been reviewed monthly and whenever there had been a change in the service users condition. Where new needs had been identified, care plans had been formulated to address this. The Registered Manager has a list of service user plan review dates and there was evidence of service users representatives being involved with these reviews, plus of action being taken to address any feedback
Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 11 received. The involvement of service users who are able to partake in the formulation and review of their own service user plans was discussed. Wound care documentation was in place. The Registered Manager has formulated a ‘Dressing Chart File’ that contains separate dressing records for each service user. These include a full assessment of the wound, dressing regime, dressing renewal dates, body maps and wound grade information and evidence of input from the Tissue Viability Nurse. Pain assessments had also been completed where a need had been identified, and all service users had a pressure sore risk assessment completed. The specific pressure relieving equipment in use had not always been identified in the service user plan and the Inspector recommended that this be recorded for all service users. This information was available in a separate document, together with the correct settings for the pumps in use and evidenced regular checks to ensure the equipment is in full working condition. Nutritional assessments had been carried out and care plans for nutrition formulated. If there are any nutritional or weight concerns service users are weighed weekly and also referred to the GP. This was evidenced in one service user plan viewed and the records showed a steady weight gain. Moving & handling assessments had been carried out. The specific moving & handling equipment to be used for each service user had not always been identified and the importance of ensuring that this information is recorded was discussed. Continence assessments had been carried out and care plans formulated for service users with continence care needs, to include management regimes. For service users for whom bedrails were in use, bedrail assessments had been carried out to clearly identify the appropriateness of their use and signed consents were also in place. It was clear that the home has worked very hard to improve the service user plans and bring them up to a good standard. Medication records were viewed. All receipts, administration and disposal of medications had been signed for. For some service users having medication on an ‘as required’ basis, a coding had been used without an explanation having been recorded. This was discussed and the Registered Manager said that she would discuss this with the registered nurses and decide on a system for clearly recording such medications. It was noted that some of the medications in regular use had been hand-written onto the medication administration record (MAR). It was explained that if a medication is not ordered for any reason, for example, the home already holds a stock, it is not printed onto the chart. The Inspector strongly recommended that this be discussed with the dispensing pharmacist to ensure all regular medications are printed on the MAR until they are discontinued. Liquid medications had been dated when opened. Eye drops management is good, with secondary records being kept as well as the administration records. The minimum/maximum/actual fridge temperatures are recorded daily and were within accepted safe range. The management of the controlled drugs is good, with a stock check being carried out at every registered nurse shift change. The administration records had been completed in full and were accurate. The medication policy was reviewed
Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 12 and had been updated to reflect changes in legislation and guidance. The system for blood glucose monitoring in the home was discussed, and following the inspection the Registered Manager has confirmed that a new system has been ordered in line with current best practice. The Registered Manager said that she would update the medication policy to reflect this. The dispensing pharmacist carries out a medication audit every 3 months and provides a written report. They have also provided medication training updates for the registered nurses. In addition the dispensing pharmacist has also carried out individual medication reviews for some service users, and any recommendations have been followed up with the GP. Medications are being well managed at the home. Staff were seen conversing with and caring for service users in a gentle, courteous and professional manner. Service users spoken with expressed their satisfaction with the care they receive. Staff address service users using their preferred term of address. Service users personal clothing is labelled, and service users were well dressed, showing individuality. Screening is provided in the double rooms, to maintain service users privacy. Service users can bring in personal possessions in line with fire safety. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an activities programme and is doing work in this area to ensure service users individual wishes are catered for and respected. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the service users rights and opinions are heard and respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: Care plans and activity programme sheets are in place for each service users social and leisure interests. The Registered Manager is also introducing a ‘map of life’ document that will record each service users life and social history, thus providing staff with a good picture of the service users past and their interests. In addition a ‘likes and dislikes’ form is being introduced to record these specifically in relation to activities. The home has a folder of events with photographs and documentation showing how the home has celebrated festive and other significant days in the year. A list of all such days for 2007 had been compiled and events will be planned to celebrate each of these days. The home
Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 14 does have an activities programme for each day, however it was clear from entries in the activities diary that this was not being fully implemented. Some feedback was received by the Inspector regarding the wish for more activities to be provided, and the importance of having an activities programme to meet the service users needs, plus the carrying out of activities as planned, was discussed. The home has an open visiting policy, and asks that visitors ring through to the home if they are visiting after 8pm, for security purposes. Visitors spoken with said that they are made welcome at the home and are always asked to sign in the ‘visitors book’. Details of advocacy services to include Age Concern, the Hillingdon residents and relatives support group plus contact details for Hillingdon Social Services and Primary Care Trust are on display in the home. The kitchen was clean and tidy. There is a 4 week menu and a clear record of service users meal choices is kept, plus a separate list with each individuals breakfast choice has been drawn up. The records evidenced that specific cultural nutritional needs for one service user were being met. Temperatures for fridges, freezers and food temperature after cooking are done daily. Food safety information and records of any menu/meal changes are kept. Service users spoken with expressed their satisfaction with the food provision at the home. The Inspector sampled the lunchtime meal and this was well presented and tasty. Staff were available to assist service users with their meals in a gentle and discreet manner. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any complaints raised by service users and their visitors. There are robust systems in place for the safeguarding of service users from abuse. EVIDENCE: The home has a clear complaints procedure. Since the last inspection the home has received 2 complaints and there was comprehensive documentation to show how these had been addressed. In June 2006 CSCI received 2 complaints that resulted in 2 additional visits to the home. The requirements and recommendations made in those reports have been fully addressed by the home and no further complaints have been received. Service users said that any concerns raised are promptly addressed. The home has an Adult Protection procedure and also a copy of the Hillingdon Safeguarding Adults documentation. POVA training took place in September 2006 for the majority of staff, with a follow up session being planned for staff that have not yet received this training. Staff spoken with were very clear to report any concerns and understood the ‘Whistle Blowing’ procedure. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, thus providing a clean and homely environment for service users to live in. Infection control within the home is good, thus safeguarding service users. EVIDENCE: The Inspector carried out a tour of the home. The home was clean and tidy and was being maintained to a good standard. An environmental audit had taken place and there was evidence of redecoration, refurbishment and maintenance taking place, with records and completion dates being kept. The rear garden is well maintained. The front area of the building is a car park and the demarcation lines for the parking had recently been renewed, with the area being tidy and smart. The home had recently had an Environmental Health Office Inspection and the cook stated that there had been no issues identified. The Fire Safety Officer had inspected the home in December 2006 and was satisfied with the fire safety management within the home.
Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 17 The Registered Manager said that following a relatives meeting, action had been taken to clear any unused furniture from the communal room to allow more space between service users chairs. Also the conservatory had been cleared of unused furniture to allow more space for visitors to sit with service users. There is a large plasma screen television in the communal room, and television is alternated with music that the service users enjoy. The home does not have a separate dining room, although a table is available in the conservatory should service users wish to use it. Each service user has their own table in the communal room. The bathrooms were clean, tidy and uncluttered. Assisted bath and shower facilities are available to ensure the service users needs are met. Toilet facilities are available throughout the home, and in close proximity to the communal room. The sluice room is combined with the laundry and an electronic disinfector is in place. Bedrooms viewed were personalised and homely. Screens are provided in double bedrooms. The rooms were appropriately furnished. All the beds are adjustable for moving & handling purposes. Bedroom doors are fitted with locks that can be accessed by staff in an emergency and service users are offered a key unless there is an assessed reason why this is not suitable. There is also a lockable space in each bedroom for valuables. The home was pleasantly warm, clean and tidy and smelled fresh throughout. The laundry/sluice room was clean and uncluttered, and strict attention is paid to maintaining clear definition and good infection control between the two areas. The home has an industrial washing and an industrial drying machines. Good practice notices and a cleaning schedule were on display in the laundry. Protective clothing to include disposable aprons and gloves were available. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the service users can be met, and this is kept under review. Systems for vetting and recruitment practices are in place and protect service users. There is an ongoing training programme, providing staff with the knowledge and skills to meet the needs of service users. EVIDENCE: The home was being appropriately staffed to meet the needs of the service users. The Registered Manager said that staffing is based on the service users dependencies and that this is kept under review. The current staffing is 1 registered nurse and 5 care staff in the morning, 1 registered nurse and 4 care staff in the afternoon and 1 registered nurse and 2 care staff at night, with the Registered Manager on call. Clear rosters are kept to evidence the staff on duty at all times. The Registered Manager reported that 65 of the care staff are qualified to NVQ level 2 in care or the equivalent. Several of the care staff from overseas are trained nurses in their own countries. The home has also had an assessment for training carried out and have identified several staff for funded training, to include NVQ level 4 in management and NVQ in care training. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 19 Three sets of staff employment records were viewed. These contained all the information required under the Care Home Regulations 2001. New staff undergo an induction programme based on the Skills for Care common induction standards. The staff files viewed also evidenced training being undertaken in topics relevant to the service users diagnoses and needs. The kitchen staff are all undertaking NVQ 2 in ‘food processing and cooking’. The Inspector met with the trainer who said that the staff are keen and very receptive, and the kitchen environment is being maintained to a high standard. Since the last inspection there has been good training input for staff. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 and aspects of 34. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home, and does so effectively. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. The home has a clear business plan, thus evidencing the home is financially viable. Service users monies are well managed and securely stored. Overall systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with general nursing and mental health qualifications. She has attained the Registered Managers Award, NVQ level 4. She is also an NVQ in care assessor and undertook a postgraduate qualification in teaching and assessing. In addition the Registered
Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 21 Manager has undertaking periodic training in topics relevant to the service users diagnoses and her management role. There is a quality management system calendar in place, which has daily, weekly, two monthly, quarterly and annual tasks to be completed listed. An action plan for quality assurance is also in place. An environmental audit and action plan have been carried out. Satisfaction surveys had been carried out with service users and with representatives in September 2006 and there was evidence of action being taken to address any issues raised. The results of the surveys had been collated and copies were given to the Inspector. CSCI comment cards had been completed by representatives, service users and healthcare professionals. Overall the feedback received was very positive and any comments were fed back to the Registered Manager in a general manner. Relatives meetings and staff meetings take place every 2-3 months and minutes are taken, with responses being made to any issues raised. The Registered Manager carries out audits of various areas of care to include pressure sores, medications, falls, bedrail use, healthcare professional input and also for service user deaths. The home had formulated a business plan, which is very clear, with an annual budget to include a breakdown of expenditure. The home holds small amounts of money for service users. This is used for any hairdressing payments, and a full record and receipts are kept. Any other expenditure is dealt with directly by the service users representatives. The Registered Manager said she would ensure this information is contained within the Statement of Purpose and Service User Guide. The home has a safe facility. Staff had received health & safety training to include fire safety, however some staff were still to undergo moving & handling training and updates and the Registered Manager said that this would be arranged. Servicing and maintenance records were sampled and those viewed were up to date. The information provided on the pre-inspection questionnaire indicated that all servicing of equipment and systems was up to date. A clear record of maintenance is kept for each room with the weekly and monthly checks being carried out and recorded. Any repairs identified are carried out promptly. Risk assessments for equipment and safe working practices were in place and were up to date. The fire risk assessment was completed for 20/10/06. The Fire Safety Officer carried out an inspection on 07/12/06 and was satisfied with the fire safety for the home. The record of fire drills did not evidence that all staff had attended drills at the required intervals, plus the Inspector recommended that the information recorded following any fire drills include the response of staff and any additional training needs identified. Information regarding staff training has been received following the inspection. Overall health & safety is being well managed at the home. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X X 2 Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP8 Regulation 17 Requirement The specific moving & handling equipment being used for each individual must be identified in the service user plan. The home must ensure that the activities programme meets the needs of the service users and is being fully implemented. All staff must undergo health & safety training, to include moving & handling training and fire drill practices, at the required intervals. Timescale for action 19/01/07 2. OP12 16(2)(n) 19/01/07 3. OP38 13, 18 01/02/07 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 OP7 OP9 Good Practice Recommendations It is strongly recommended that, where able, service users are involved with the formulation and review of the service user plans. It is strongly recommended that discussion take place with the dispensing pharmacist to ensure all medications in use
DS0000068138.V322504.R01.S.doc Version 5.2 Page 24 Ruislip Nursing Home 3. OP38 for each service user are printed on the MAR, regardless of whether a supply is ordered for the month. It is strongly recommended that the outcome of any fire drills be recorded, to include an action plan to address any shortfalls identified. Ruislip Nursing Home DS0000068138.V322504.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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
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