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Inspection on 28/07/06 for Selena House Nursing & Residential Home

Also see our care home review for Selena House Nursing & Residential Home for more information

This inspection was carried out on 28th July 2006.

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

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

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

What the care home does well

There is a genuine commitment to meet the medical and personal care needs of the residents at Selena House and there were good comments from residents about the attitude of the staff and the acting manager. Staff endeavour to respect residents privacy and dignity and to give them control and choice where possible. Residents were happy about the quality of the meals. Appropriate equipment to support residents is available and the home is well maintained. Staffing levels appear appropriate and recruitment arrangements are good and protect the residents.

What has improved since the last inspection?

There were twelve statutory requirements set at the previous inspection of which nine were found to be met during this visit. Efforts have been made to improve the level of social activity in the home, although the comments of some residents indicated that further work is needed in this area. Comments indicated that the quality and choice of evening meal had improved. There has been some further decoration throughout the home and the level of cleanliness has improved. The laundry has been retiled.

What the care home could do better:

Care plans were generally good, however plans that that reflect residents` wishes regarding end of life decisions were not in place for those residents who were very frail and dying. Plans also need to be in place for all residents who are at risk from developing pressure damage. As stated previously, efforts have been made to improve the level of social activity, but it remains inconsistent and not always based on residents needs. There is a commitment to staff training, although induction and mandatory training needs to be standardised and the number of care staff with an NVQ increased. Staff could also benefit from some training relating to protection of vulnerable people. Health and safety issues that need improvement include safe storage of cleaning substances, fire safety checks and consistency in food safety measures. The registered person needs to ensure that any outstanding requirements from the previous inspection are met within the stated timescales.

CARE HOMES FOR OLDER PEOPLE Selena House Nursing & Residential Home 192 Oxford Road Stratton St Margaret Swindon Wiltshire SN3 4HA Lead Inspector Steve Cousins Unannounced Inspection 09:30 28th July – 1 August 2006 st 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 Selena House Nursing & Residential Home DS0000015943.V303699.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. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selena House Nursing & Residential Home Address 192 Oxford Road Stratton St Margaret Swindon Wiltshire SN3 4HA 01793 822982 F/P01793 822982 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) Mr Yogindrananth Abhee Vacant Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability (2), Terminally ill (2) of places Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 2 physically disabled persons at any one time No more than 2 persons in receipt of terminal care at any one time No more than 20 service users in receipt of nursing care at anyone time. 29th September 2005 Date of last inspection Brief Description of the Service: Selena House is registered to provide personal care and nursing care, and can accommodate up to 28 persons over the age of 65. A registered nurse is on duty at all times supported by care assistants. Support services include catering, domestic, laundry and maintenance staff. Fees currently range between £340 to £580 per week. Accommodation is provided on two floors. Residents’ rooms do not have ensuite facilities, but all rooms have wash hand basins. The main sitting room and adjoining dining room are situated on the ground floor of the building. Selena House is located in a residential area of Stratton St Margaret, on the outskirts of Swindon. All local amenities are a short drive away. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the 28th and 31st July and the 1st August 2006 in order to inspect all of the key minimum standards relating to care homes for elderly people. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The findings from this inspection are based on a tour of the premises, speaking to residents, relatives and staff, and visiting frail residents. A number of records were inspected, including care plans, medication records and staff records. Comment cards were sent to GP’s. Comment cards were also received from residents and relatives following the inspection. The findings of the visit to the home were discussed with Mrs Cain, the acting manager, at the end of the third day of the inspection. The findings from the comment cards received from residents and relatives following the inspection are incorporated in this report. What the service does well: What has improved since the last inspection? There were twelve statutory requirements set at the previous inspection of which nine were found to be met during this visit. Efforts have been made to improve the level of social activity in the home, although the comments of some residents indicated that further work is needed in this area. Comments indicated that the quality and choice of evening meal had improved. There has been some further decoration throughout the home and the level of cleanliness has improved. The laundry has been retiled. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Selena House Nursing & Residential Home DS0000015943.V303699.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 Selena House Nursing & Residential Home DS0000015943.V303699.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Standard 6 does not apply to this home. The home has the capacity to meet the needs of elderly people requiring nursing and residential care and residents’ needs are assessed before they move in. The quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: A review of residents care plans indicated that pre admission assessments had been carried out by the acting manager, who is a registered nurse and that she had visited the potential resident to carry out the assessment. Where appropriate, supporting information from social services care managers and relatives was available. Information used from pre admission assessment contributed to the development of residents care plans. A new resident confirmed that the pre admission assessment had taken place. Selena House is registered to provide nursing and personal (residential) care. The environment is suitable and the adaptations and equipment appropriate. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 9 The positive comments of the residents and the inspectors observations indicate that the home has the capacity to meet the needs of the client group. In one case, where the home has not been able to meet a resident’s changing needs, appropriate action has been taken to find a more suitable placement for them. Although national Minimum Standard 1 was not fully assessed during this inspection, two comment cards received indicated that not all relatives were aware of or had access to the homes inspection report, however a copy was available and was put on display in the entrance foyer of the home before the end of the inspection. Selena House Nursing & Residential Home DS0000015943.V303699.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The residents’ health and personal care needs are being met but the standard of care planning could be improved in some areas. The procedures for dealing with medicines protect the residents and they appear to be treated respectfully and their right to privacy is upheld. The quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The inspector chose six residents to case track, four females and two males between the ages of 69 and 95. They were a mixture of active and frail residents with varying physical and social needs, four were receiving nursing care and two were unable to verbally communicate. A review of the residents care plans indicated that they were generally an accurate reflection of assessed needs and regularly reviewed. Assessments for tissue viability and nutrition were in place in all cases. The inspector did find some examples where care planning and assessment procedure required improvement. In one case a resident who had been assessed as at risk from developing pressure damage did not have a related care plan to record and Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 11 direct care, however pressure relief equipment had been provided and was in use. Care plans that reflected residents’ wishes regarding end of life decisions were not in place for those residents who were very frail and dying, to ensure that they receive the care they would wish. As found at the previous inspection, not all care plan assessments had been signed and dated by the person completing them. Some files contained care plans that were no longer relevant and should be removed to make plans easier to read for staff. The inspector visited the residents who were being case tracked and found that interventions were in place to meet their assessed needs, such as pressure relief equipment, fluid intake charts, continence aids and manual handling equipment. Their personal hygiene needs were being met and residents appeared clean and comfortable. Those who were able to communicate indicated satisfaction with the care given as did the relative of one resident who was unable to communicate. Other residents spoken to throughout the inspection were happy with the support from the staff, one stating “the staff are very helpful” and another “they are kind here”’. Care records and residents comments indicated that they were able to see their GP when needed and that staff reacted promptly to any change in their health. A relative commented that “care is good” and comment cards received from relatives and GP’s all stated that they were satisfied with the overall care provided. All the residents spoken to felt that they had enough to eat and drink during the day. Where possible, residents are weighed monthly and the result recorded. It was noted that, where as resident had sustained weight loss, GP referral had been arranged. Registered nurses are responsible for the administration of medicines in the home. Due to their condition, there were no residents who self-administered medication. Medicines are stored securely and records of receipts, administration and disposals maintained. Evidence of checks on new residents’ medication was available. There is limited use of sedatives in the home. The inspectors observations and the residents’ comments indicated that they were being treated respectfully and staff endeavoured to respect their dignity and privacy. Personal care was carried out behind closed doors and staff knocked before entering residents rooms. GP’s confirmed that they were able to see their patients in private. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Social activity is provided but is somewhat inconsistent and does not always meet residents’ individual needs. Residents are able to maintain contact with family and friends and there is a commitment to help them exercise control and choice over their lives. The home provides the residents with nutritious meals in a suitable environment. The quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Residents spoken to were generally positive about the home, one stating “I like it here, very good, the food is good, no problems”. Some residents felt that there was a lack of social activity in the home, one saying, “I just sit here for the day” and another “It’s a bit quiet, we have things occasionally, but there’s not much to do really’. One resident stated that they were happy with the activity provided and that they attended a locally run club but another said “There is just the TV or the garden if it’s nice”. A requirement of the previous inspection was that residents be consulted about what social activities are provided in the home. Mrs Cain said that this had been done and responses were recorded, but she felt it was proving difficult to implement activities due to some residents’ lack of interest. An activity Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 13 organiser had been employed but had little impact and had now left. It was recommended that the manager research how activities are organised in other homes. The inspector recognises that some action has been taken to try to meet residents social needs, however their comments would indicate that further improvement is required. Comment cards received from three relatives indicated that they were made welcome in the home, were able to visit in private and were kept informed of important matters. Visitors were in the home during the inspection and some residents confirmed that they had contact with friends and relatives. Visitors could be received in residents’ rooms or in the communal areas. Residents’ comments during the inspection indicated that they had some control over how they lived their lives, one resident saying “I am able to go to bed when I want, I like to get up about 7o’clock and the staff help me”. Residents are able to bring in personal items and furniture if required and residents are able to voice their opinions during meetings. Details of advocacy services were available. Comments from residents were generally positive about the food available in the home. The meals provided at lunchtime over the three days of the inspection appeared well cooked and nutritious and were served hot. A choice of meal is offered and hot and cold drinks were available throughout the day. Special dietary needs are catered for and a list of suitable foods specifically for a resident with a particular medical condition was displayed in the kitchen. Comments indicated that the quality and choice of evening meal had improved. Residents were observed eating in their own rooms or in the dining room or lounge if preferred and staff were observed assisting some residents to eat sensitively and giving them sufficient time. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A complaint procedure is available and on display however none have been made directly to the home since the last inspection to enable a judgement to be made on how they are handled. Staff require further training in respect of the protection of vulnerable adults to ensure residents are further protected from abuse. The quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Review of the complaints book indicated that none had been received by the home since the previous inspection in September 2005. Two complaints had been received by CSCI since the homes last inspection, one in December 2005 and one in January 2006. Two unannounced visits were undertaken to investigate these complaints. The first, regarding care provision, cleanliness of the home, hygiene practice and meals found that the complaints about meal provision and cleanliness of the home were upheld. The second, regarding the care of a person admitted for a respite stay, was not upheld. Comment cards received from three relatives indicated that they were aware of the homes complaint procedure and the procedure was on display in the home and is contained in the service users guide. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 15 The manager demonstrated an awareness of local Adult Protection Procedures however some staff spoken to were unsure. Training records indicated that not all staff had received training in abuse issues. Review of recruitment records confirmed that POVA checks and references are obtained on staff prior to starting work and that enhanced CRB checks are undertaken. Selena House Nursing & Residential Home DS0000015943.V303699.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 and 26 Apart from some minor redecoration and repairs that are required, the premises are well maintained and the overall standard of cleanliness has improved, although some areas could be improved further still. Residents have access to internal and external communal areas. The quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: A tour of the building indicated that there had been an overall improvement in the cleanliness and decoration of the home. Review of the maintenance records indicated that the building and essential services and equipment were regularly serviced and maintained. External areas of the home were in good order. A large storage cupboard on the first floor presents a potential risk, as the sliding doors are unstable. There is a large communal lounge on the ground floor of the home with an adjacent dining room. Furnishing is of a domestic nature and the lounge Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 17 benefits from a good level of natural lighting. Wheelchair access is available from the lounge to the rear garden, which is well kept. Redecoration of the lobby between the lounge and dining room is recommended as the paintwork is heavily marked. There are 22 single and three double bedrooms, washbasins are provided in each room but there are no en-suite toilets. Some bedroom doors required repainting. Some areas that required improvement with regard to cleanliness were brought to the attention of the manager and action was taken during the three days of the inspection. Bedroom doors were particularly marked due to the residue left from the powdered gloves worn by staff and some toilets and a sluice required additional cleaning. It was recommended that the manager undertake regular audits of the cleaning in order to maintain standards. The laundry had been retiled and was clean and functional, infection control measures were in place. There was an unpleasant odour confined to one area of the home that the staff are making every effort to resolve. Selena House Nursing & Residential Home DS0000015943.V303699.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. The numbers and skill mix of care staff available appears to meet the residents’ needs and recruitment procedure supports and protects the residents. There is a commitment to staff training although induction training needs to be standardised and the number of care staff with an NVQ increased. The quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The inspector’s observations, allied to the comments of the residents and staff, indicated that the care staffing levels were generally sufficient to meet the needs of the current residents. A review of the duty rota indicated that the agreed number and skill mix of staff were on duty in relation to the homes staffing notice. Call bells were answered promptly throughout the inspection and those residents spoken to report no delays. Care staff members spoken to felt that staffing levels were generally sufficient. The efficiency of the kitchen, laundry and maintenance service would indicate that the number support staff is appropriate. Of the four comment cards received from relatives, two felt that there were not always sufficient numbers of staff on duty, although they did not specify times. It is recommended that the manager and owner discuss these issues with relatives during residents and relatives meetings. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 19 The recruitment records of four staff members were reviewed, two of who had been recently recruited. All were found to contain the required documentation. Training records indicated that some induction training had taken place however not all induction training was based on TOPPS guidelines or had been completed within the current timescales. The inspector discussed the planned changes regarding induction training and forwarded further information following the inspection. As the timescales for completion of induction training are due to change in September 2006, a statutory requirement has not been issued at this inspection. Mrs Cain stated that there had been a concerted effort to increase the number of care staff with an NVQ, however four had left after obtaining the qualification. One care staff member had obtained NVQ level 2; four were currently undertaking it and three more would be commencing NVQ level 2 in the future. The inspector spoke with staff members who confirmed the training they had received. Some staff recruited from overseas felt that communication with residents could sometimes be difficult due to their (the staff’s) level of spoken English, although only one resident stated this to be the case. The manager stated that some staff are attending the local college to improve their standard of written and spoken English. Selena House Nursing & Residential Home DS0000015943.V303699.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 The home does not currently have a manager who is registered with the Commission but satisfactory interim arrangements are in place and evidence suggests Mrs Cain has performed well in her role as acting manager. Systems are in place to ensure that the home is run in the residents’ best interests and residents’ financial interests are safeguarded. Health and safety arrangements generally protect residents and staff although issues regarding training, food hygiene, COSHH storage and fire safety have the potential to compromise residents and staff. The quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The deputy matron, Lynatte Cain, a registered nurse, is currently acting manager and has applied to CSCI for registration. Mrs Cain has worked in the Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 21 home since 2004. The owner, Mr Abhee, visits the home weekly and supports her in her role. Comment cards received from visiting professionals indicate that there has been an improvement in the management of the home, one stating ‘ ---the current matron seems to have things working well at the moment’. A relative also commented that “things had improved” since Mrs Cain had taken on the management role. Current quality assurance measures include monthly resident and relative meetings, annual satisfaction questionnaires and weekly visits to the service by the provider. Mr Abhee also carries out monthly regulation 26 visits and reports are forwarded to CSCI. Comment forms for relatives are also available in the foyer. The introduction of audits of clinical practice may enhance the current quality assurance systems. The inspector reviewed the procedures in place to safeguard residents financial interests. Small amounts of money are held on behalf of residents. Money is held individually and records and receipts are kept and regularly audited. Four ‘accounts’ checked were accurate. The manager stated that staff members were not appointees for any resident’s finances or benefit payments. A statutory requirement of the previous inspection was that all hazardous substances (COSHH) be stored safely. The downstairs sluice contained some hazardous cleaning solutions and a storage cupboard containing solutions in a bathroom was unlocked. This was brought to the manager’s attention during the inspection. Radiators are covered and hot water temperatures are controlled and checked. The water supply had been checked for Legionella. General environmental risk assessments (including fire) are in place and records indicated that they are reviewed six monthly. The accident book was reviewed. Accidents are recorded and there was evidence that action was taken to reduce risks. In one instance a resident who frequently ‘fell’ had been referred to the GP for assessment and staff increased monitoring. Review of the fire log indicated that the fire alarms were checked weekly and that two fire drills had been undertaken so far this year. Monthly checks of means of escape, emergency lighting and visual check of fire extinguishers were not recorded and the manager was unable to verify that they are completed. An occupied bedroom had the fire door propped open on the request of the resident. This presents a risk in the event of a fire. Self-closing mechanisms linked to the alarm system should be fitted to fire doors in instances where residents’ wish to stay in their rooms with the door open. There are some rooms in the home where these have been fitted. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 22 Food safety procedures are in place in the kitchen however catering staff need to ensure that that the core temperature of cooked foods is checked and recorded at all times, as there were some gaps in records when the main cook was away. Mandatory training had been provided by a training provider and included manual handling, food hygiene, health and safety and infection control. The home currently only provides mandatory training on a three yearly basis. The frequency of training updates stated for infection control by the Health Protection Agency is on induction and annually thereafter. The Health and Safety Executive (HSE) advocate annual refresher training for staff that frequently move and handle people. Updates for food hygiene and health and safety training should be based on an assessment of the staff member’s knowledge, the potential risk to the home and the advice of the HSE or training agency. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 X 17 X 18 2 2 3 X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 24 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 (1) Requirement The registered person is required to ensure that care plans are in place for all service users assessed as being at risk of developing pressure damage. The registered person is required to ensure that, where appropriate, service users wishes concerning terminal care are set out in a care plan. The registered person is required to ensure that service users have the opportunity to exercise their choice in relation to social activity. The registered person is required to ensure that the sliding doors to the first floor storage cupboard be repaired or replaced. The registered person is required to ensure that a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved. Unmet requirement of the inspection held 29/9/05. Previous timescale for action 31/12/05 DS0000015943.V303699.R01.S.doc Timescale for action 07/08/06 2. OP7 15 (1) 12 (2,3) 01/09/06 3. OP12 16 (2,m,n) 01/09/06 4. OP19 13 (4,a) 01/10/06 5. OP28 18(1,a,b,c ,i) 01/01/07 Selena House Nursing & Residential Home Version 5.2 Page 25 6 OP38 13(4) 7 OP38 23(4a) 8 OP38 13 (3) (4,c) The registered person is required 01/08/06 to ensure that all hazardous substances (COSHH) are stored safely. Unmet requirement of the inspection held 29/9/05. Previous timescale for action 29/9/05 The registered person is required 01/08/06 to ensure that all fire safety checks are undertaken at the intervals recommended by the local fire authority. Unmet requirement of the inspection held 29/9/05.Previous timescale for action 29/9/05 The registered person is required 01/08/06 to ensure that the core temperature of cooked foods is checked and recorded at all times. Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 26 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. 3 4 5 6 7 8 Refer to Standard OP7 OP7 OP18 OP19 OP19 OP26 OP33 OP38 Good Practice Recommendations It is recommended that assessments contained in care plans be signed and dated by the person completing them. It is recommended that plans that are no longer current be removed from care plans and stored separately. It is recommended that staff receive further training regarding the protection of vulnerable adults. It is recommended that the lobby between the lounge and dining room be redecorated. It is recommended that the bedroom doors indicated to the manager during the inspection be repainted. It is recommended that the manager undertake a regular audit of the standard of cleaning in the home. It is recommended that audits of clinical practice be introduced to enhance the current quality assurance systems. It is recommended that self-closing mechanisms linked to the alarm system should be fitted to fire doors in instances where residents’ wish to stay in their rooms with the door open. It is recommended that the current frequency of mandatory training be changed to meet the recommendations of the HPA and HSE. 8 OP38 Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Selena House Nursing & Residential Home DS0000015943.V303699.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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