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Inspection on 24/01/07 for Shoreline Nursing Home

Also see our care home review for Shoreline Nursing Home for more information

This inspection was carried out on 24th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

Shoreline is a modern, purpose built facility situated on the sea front in Redcar, a number of the bedrooms in the home environment benefit from having a sea view. The home in general is well run and residents residing at the home are happy. One resident spoken to during the visits said, "The staff are great", another said, "I`m contented and happy, I feel safe here", another said, "Staff are polite and respectful". Robust recruitment procedures are followed and there is a regular programme of mandatory training provided to staff.

What has improved since the last inspection?

This was a first inspection visit to the home for the Inspector. Requirements identified at the lat inspection had been addressed. A programme of refurbishment has commenced at the home. Corridors in the home environment have benefited from re-decoration and new carpets. Lounge, dining and bedroom areas are also to benefit from refurbishment.

What the care home could do better:

Some of the care plans in the home need to be reviewed/updated to ensure that they contain all important information about the resident and how care is to be delivered. Risk assessments also need further development. Care plans and risk assessments must be updated on a monthly basis or more often if required. This inspection identified that a resident had not been given medication as prescribed and as such the Manager must conduct an investigation into the incident. This will be addressed as a separate issue to the inspection. The Registered Person must ensure that all medication that is prescribed to residents is administered. The Registered Person must continue with the programme of refurbishment, woodwork in lounge areas needs painting and carpets need deep cleaning or replacing. The laundry floors need to be impermeable which will help to reduce the spread of infection. Staff files need to be updated to include a recent photograph and the homes induction needs updating to include all of the required elements. The Manager needs to complete her NVQ level 4 in Management.

CARE HOMES FOR OLDER PEOPLE Shoreline Nursing Home Park Avenue Redcar TS10 3JZ Lead Inspector Katherine Acheson Key Unannounced Inspection 11:15 24 and 25th January 2007 th 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 Shoreline Nursing Home DS0000000137.V327972.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. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shoreline Nursing Home Address Park Avenue Redcar TS10 3JZ 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) 01642 494582 F/P 01642 494582 Dr Lal Dr Dave, Dr Puri Mrs Helen Pasco Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home can admit 20 service users age 55 . The home can admit 10 service users with a physical disability aged from 55 . The home can admit three named service users under 55 years of age, until such a time that the placements are no longer required. The home can admit one named individual under the age of 40 years. Date of last inspection 21st November 2005 Brief Description of the Service: Shoreline Nursing Home is registered to provide personal and nursing care to a maximum number of 44 service users. The home is situated on the sea front as is close to Redcar town centre where there are pubs, shops and other local amenities. The home is two storey, modern and purpose built. The ground floor of the home accommodates twenty service users, there are eighteen single rooms and one double room. The first floor of the home accommodates twenty-four service users; there are twenty single rooms and two double rooms. Thirty five of the bedrooms have ensuite facilities which comprises of a toilet and hand washbasin, the remainder have a sink. All bedrooms meet the required amount of space. The ground floor of the home has a combined lounge/diner; the first floor of the home has both a lounge and dining room. Toilet and bathing facilities are on each floor. The cost of care at the time of the inspection visit ranged from £360 to £498 per week depending on the category of care. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection of the home was carried out over two days the 24th and 25th of January 2007. On the first day of the inspection the Inspector arrived unannounced. The Manager of the home was aware of the second day of the inspection. On the 24th January 2007 the Inspector arrived at 11:15 and left at 16:45. On the 25th January 2007 the Inspector arrived at 09:25 and left at 13:05. Seven residents were spoken to during the visit, five at length and two briefly, one relative was also spoken to. Discussions took place with two care staff, one trained nurse, the Office Administrator, the Cook and Manager. Numerous records including care plans, menus, complaints and staff recruitment and training records were examined. A tour of the premises was carried out. Requirements identified at the last inspection in November 2005 were revisited. The details of any issues identified at this inspection requiring action are to be found at the back of this report. What the service does well: What has improved since the last inspection? Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 6 This was a first inspection visit to the home for the Inspector. Requirements identified at the lat inspection had been addressed. A programme of refurbishment has commenced at the home. Corridors in the home environment have benefited from re-decoration and new carpets. Lounge, dining and bedroom areas are also to benefit from refurbishment. 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. Shoreline Nursing Home DS0000000137.V327972.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 Shoreline Nursing Home DS0000000137.V327972.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): 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: The Manager said that prospective residents receive an assessment that is carried out by a social worker or other health care professional. A copy of this assessment is forwarded to the home before admission and reviewed by the Manager and staff to ensure that the home can meet their needs. The Manager said that for those residents who are self finding she would carry out a pre-admission assessment visiting the person in hospital or their home. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 9 Records were available on resident files examined during the inspection to confirm that this is the case. The home does not provide intermediate care. Shoreline Nursing Home DS0000000137.V327972.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 adequate. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of care, however some resident plans of care do not contain enough detail as such could compromise care required. Residents are treated with respect and their right to privacy is upheld. In general good procedures are in place to ensure safe practice in respect of the handling of medication, however improvement is needed to ensure that all medication prescribed to residents is administered. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three plans of care were examined at random during this inspection. Signatures were evident within care plans examined to confirm that residents and their representatives had been involved in drawing up the plan of care. The Manager said that care plans are stored in resident’s bedrooms so that they can read them at anytime. All three plans of care contained a detailed assessment of needs. The assessment showed clear evidence of involving the resident, likes and dislikes were documented as well as the time they would like to get up and go to bed. Two of the three care plans examined contained specific, detailed individual plans of care for problems highlighted one did not. One resident had angina yet there was no plan of care as to how the condition should be managed. Of the three care plans examined two were reviewed on a monthly basis, the other was not. Residents files examined contained a nutritional assessment that is reviewed and updated at regular intervals. The Manager said that the home weigh residents on a monthly basis, however, records examined showed that residents had been weighed in July 06 and then not again until November/December 2006. All residents’ weights were recorded on one sheet, which made it difficult to determine weight lost or gained and also did not ensure confidentiality. It was also noticed that for one of the three residents care plans examined at random they had lost weight, however nothing was recorded within plan of care of action/intervention required or care plan developed for this. A discussion took place with the Manager in respect of this who said that she would take immediate action to address the situation. On returning to the home the next day the Manager said that she had asked the GP of the resident who had lost weight to refer to a dietician. New weight charts had also been introduced. Each resident had been allocated their own weight chart which included a column for action taken when weight lost or gained. Risk assessments were evident on files examined during the inspection, however were too basic. Risk assessments did not include detailed specific action required to minimise/prevent the identified risk. Risk assessments must be updated/evaluated on a regular basis to confirm effectiveness. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 12 Seven residents were spoken to during the visit five and at length and two briefly. Comments made included: “I have been in the home along time, the staff are all very kind, we grumble but that is human nature” “It’s very nice really, comfortable and the beds are nice. The staff are really good” “The staff are great and the view is nice” “I’m quite happy here, they are gentle with you when they wash you”. Residents spoken to confirmed that their dignity and privacy was respected. During the inspection arrangements for receiving, storing, administering, recording and disposing of resident’s medication were observed and examined. The Manager said that it is the responsibility of trained nurses to administer medication to residents. The home has a medication policy, which was updated in January 2006. The Manager said that this requires further updating following the change in procedure for returning medication to the licensing company for destruction. During the visit a medication audit of two of the three residents files sampled at random during the inspection was carried out. Medication administration charts had been completed correctly and the stock balance of medication belonging to the residents was correct, matching up with medication ordered, received, administered and remaining in the home. It was observed that the home do not keep a record of medication returned to the licensing company for destruction. Examination of the homes register of controlled medication highlighted a discrepancy. One resident had been prescribed medication every seventy-two hours, however the controlled register on two occasions highlighted that the resident had gone longer than seventy-two hours. This was pointed out to the Manager at the time of the visit for an investigation to be undertaken. This will be followed up as a separate issue. Shoreline Nursing Home DS0000000137.V327972.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 adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide sufficient activities and outings for those residents who want to participate and as such some residents are not stimulated. Residents are able to exercise choice and control. Visitors are encouraged and made to feel welcome at anytime. Food provided is varied, appetizing and enjoyed by residents. EVIDENCE: At present the home are looking to recruit an Activity Co-ordinator to spend eight hours a week planning/providing activities, entertainment and outings for residents at the home. The Manager said that in the interim care staff working at the home are taking on the role until an Activity Co-ordinator is appointed. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 14 Daily activities mentioned included bingo, dominoes, quizzes and walks along the sea front. The Manager said that the Fisherman’s Choir had come into the home last week to sing to residents. A number of residents spoken to during the inspection said that they did not feel that there were enough activities and outings. One resident said, “There’s not much going on, there used to be. I would like to go out more. I go out with my sister but not with the home”, another resident said, “We had the Fisherman’s Choir last week but there is not much else, I would like to go out”. One relative spoken to during the inspection said, “The home needs more activities, I visit at different times and never see anything going on. There are no trips out”. One resident spoken to during the inspection said that they preferred their own company and chose not to join in activities, “I like to read and I have my memories”. Other than walks along the sea front and shopping in Redcar, the home has not planned any trips out for residents. The Manager said that trips out are difficult due to the physical disability of many of the residents at the home. A discussion took place regarding accessing transport for residents with poor mobility, or who require a wheelchair. A discussion took place with the Manager regarding the lack of activities and outings provided by the home. The Manager acknowledged and agreed with comments made by residents. She said that she would take action to address the situation. The home supports residents to practice their religion and that visits from clergy are available to the home, residents spoken to confirmed that this was the case. Residents interviewed spoke of flexibility in routine and freedom of choice. Residents spoken to during the inspection said that contact with family and friends is encouraged and that visitors are made to feel welcome at any time. The home has a four-week menu plan with a choice available at each mealtime. Residents spoken to said that they enjoyed the food that is provided. One resident said, “The food that I get is very good”, another said, “The food is very good I am having pork chop today and they cut the bone off for me”, another said, “The food is great, I have my main meal at tea time”. Shoreline Nursing Home DS0000000137.V327972.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives are encouraged and supported to make any complaints they feel necessary, however the complaint policy/procedure could be strengthened to include information of residents/relatives rights to complain to commissioning agencies such as Social Services and Primary Care Trusts. Residents residing at the home said that they felt safe. Adult protection procedures are in place, however do not give clear procedures for staff to follow if abuse is suspected and lack of staff training leaves residents vulnerable. EVIDENCE: The home has a complaints policy/procedure. This policy/procedure should be updated to inform residents/relatives of their right to complain to any commissioning authorities such as the Primary Care Trust or Social Services. The complaint procedure within the statement of purpose/service user guide should also to be updated to include such information. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 16 Residents spoken to during the inspection said that they would feel comfortable in raising and concern or making a complaint to the staff or management of the home. The home keeps a record of complaints. There have not been any complaints made to the home or the Commission for Social Care Inspection in the last twelve months. The home has an adult protection policy and a copy of the Teeswide Guidance regarding the protection of vulnerable adults. The homes adult protection policy/procedure is confusing and does not give clear procedures for staff to follow if abuse is suspected. Residents spoken to during the visit said that thy felt safe. The Manager said that Adult Protection training is provided to staff on commencement of their employment, however not on a regular basis thereafter. One adult protection referral has been made in the last twelve months. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 17 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, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained providing residents with a comfortable place to live. The laundry floors are not impermeable and as such raise concerns for infection control. EVIDENCE: The Manager accompanied the Inspector on a tour of the home and informed the Inspector that a programme of refurbishment had commenced. Corridors on the ground and first floor of the home have been re-decorated and benefited from new carpets. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 18 Communal lounge/dining areas were generally pleasant with appropriate furnishings throughout. Some of the carpets were marked and in need of deep cleaning and woodwork needed painting. The Manager said that communal lounge and dining areas are to benefit from re-decoration and replacement carpets within the next six months. On the first floor of the home there is an allocated area at the top of the stairs for residents who wish to smoke. This leads out onto an open top balcony. The smoking area contained a worn table and basic wooden chairs. This area was neither comfortable nor pleasing to the eye. There is also a concern that if there were a number of residents using the smoking area then this would block the staircase, which is a designated escape route if there was to be a fire. In light of concerns a telephone call was made to Fire Safety who are to look at this as a separate issue. The Manager said that in the summer residents can go out onto the open top balcony and enjoy the views. The Manager must ensure that she carries out individual risk assessments on those residents who go out onto the open top balcony area to determine if they are safe to do so or if measures need to be put in place to maintain safety. Bedrooms visited on the day of the inspection visits were personalized with a number benefiting from re-decoration and new carpets, however bedroom eighteen required a new carpet. Appropriate laundry facilities were in place, however the flooring in this area was not impermeable. Skirting had come away from where the washers were raised and the lyno flooring did not go into the area were clothing was stored. Flooring must be impermeable to allow cleaning to reduce/prevent the spread of infection. On the day of the inspection visits the home was observed to be clean and odour free. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 19 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. Good recruitment procedures are followed which helps to protect residents residing at the home. Staff receive regular mandatory training, however induction training does not meet the required standard and as such could compromise care residents receive. Appropriate numbers of staff are on duty to meet the needs of residents. EVIDENCE: On the day of the inspection visits there were thirty-nine residents residing at the home. Staffing rotas examined informed the inspector that there were six care staff on duty on a morning, five on an afternoon, five on an evening and four on night duty, in addition to two trained nurses being on duty morning, afternoon and evening and one trained nurse on night duty. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 20 Residents spoken to said that they felt that there was sufficient staff on duty to meet their needs. The Manager of the home works five days supernumerary a week. The Manager said that the home has worked extremely hard to assist care staff to achieve an NVQ level 2 in care. 57 of care staff working at the home have now achieved an NVQ level 2 in care. Two staff files were examined at random during the inspection. Files examined contained two references, appropriate Criminal Record Bureau checks and proof of identity, however this did not include a recent photograph of the staff member. The Manager said that all newly appointed staff receive induction training. Staff files examined during the inspection confirmed this, however this induction did not meet the required standard. A discussion took place with the Manager in respect of required induction standards. Records were available to confirm that moving and handling, fire training and other training relevant to the job that staff do is undertaken on a regular basis. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is a First Level Registered Nurse who runs the home well, however she needs to achieve and NVQ level 4 in Management to be appropriately qualified. In general the health Safety of welfare of residents is promoted, however shower temperatures need to be taken and recorded on a regular basis to ensure safety of all. The home seeks the views of residents to ensure that it is managed with their best interest. Results of the survey need to be published to inform everyone of the findings. Systems are in place to ensure resident’s money is managed appropriately. Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Manager, Helen Pasco, is a first level Registered Nurse who has worked in the nursing and social care environment for many years. The Manager commenced her NVQ level 4 in Management, however did not complete. The Manager advised that she is to re commence this course and will complete by 30th September 2007. Quality assurance and quality monitoring practices are in place. Surveys are sent out to residents on a six monthly basis to see if they are happy with the home and care that is provided, however the results are not published and made available. The Manager said that she would take action to address the situation. The home looks after the personal allowance of a number of residents written records of all transactions are maintained. The home operates a rolling programme of servicing appliances and equipment. Records examined at random confirmed that the home’s hard wiring and gas boilers are serviced on a regular basis. The home had a new fire alarm system fitted in December 2006. Water temperatures in resident bedrooms and communal bathrooms are taken on a regular basis, however records examined highlighted that shower water temperatures were not checked. On return to the home 25th January 2007 the Manager had implemented a new weekly template for water temperatures this included showers. Shoreline Nursing Home DS0000000137.V327972.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 2 2 X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 13, 14, 15 • Requirement Care plans require further development to ensure that they are individual to the resident. Care plans must include limitations, preferences and assistance required to meet the needs Risk assessments must be developed further to ensure that they include detailed specific action to minimise/prevent the identified risk Risk assessments must be evaluated on a regular basis to confirm effectiveness Care plans must be evaluated on a monthly basis A care plan must be developed if a medical condition is highlighted and specific care is required A care plan must be Version 5.2 Page 25 Timescale for action 28/02/07 • • • • • Shoreline Nursing Home DS0000000137.V327972.R01.S.doc 2 OP9 13 • developed if a resident is nutritionally at risk or losing weight The Medication policy/procedure must be updated to include procedures to follow for destruction of controlled medication and returning unused medication to the licensing company for destruction 28/02/07 3 OP9 13 4 OP12 16 5 OP18 13 6 7 OP19 OP20 OP19 OP20 16, 23 13 The home must keep a record of medication returned to the licensing company for destruction The Registered Person must ensure that all medication prescribed to residents is administered as directed The Registered Person must consult with residents and plan/provide appropriate activities and outings • The Registered person must develop the homes adult protection policy/procedure to include action that staff should take if abuse is suspected • Adult protection training must be provided to staff on a regular basis The Registered Person must continue with their plan of refurbishment The Manager must carry out individual risk assessments on those residents who go out onto the open top balcony area to determine if they are safe to do so or if measures need to be put in place to maintain safety. The Registered Person must replace the carpet in bedroom eighteen DS0000000137.V327972.R01.S.doc • 24/01/07 15/03/07 15/03/07 24/01/07 24/01/07 8 OP24 16, 23 30/03/07 Shoreline Nursing Home Version 5.2 Page 26 9 OP26 16 10 11 OP29 OP30 9 18 The Registered Person must ensure that the laundry flooring is impermeable and readily cleanable to reduce/prevent the spread of infection Staff files must be updated to include a recent photograph The Registered Person must review the homes induction and ensure it includes all common induction standards as set by Skills for Care. 30/03/07 30/03/07 30/03/07 12 13 OP31 OP33 9 24 14 OP38 13 The Manager must achieve her 30/09/07 th NVQ 4 in Management by 30 September 2007 The Registered Person must 30/04/07 ensure that the results of the residents and relatives surveys are published and made available to all The Registered person must 24/01/07 ensure that the home takes and records the water temperature of showers on a regular basis 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 OP16 Good Practice Recommendations The Complaints policy/procedure should be updated to include information of resident’s rights to complain to commissioning agencies such as Social Services and the Primary Care Trust. The homes statement of purpose and service user guide should also be updated to reflect such information Shoreline Nursing Home DS0000000137.V327972.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Shoreline Nursing Home DS0000000137.V327972.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. 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!