Inspection on 25/07/06 for The Shrubbery Nursing Home

This inspection was carried out on 25th July 2006.

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

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

Other inspections for this house

The Shrubbery Nursing Home 21/06/07

The Shrubbery Nursing Home 17/01/07

The Shrubbery Nursing Home 22/12/05

The Shrubbery Nursing Home 05/09/05

The Shrubbery Nursing Home 08/02/05

The Shrubbery Nursing Home 18/07/04

The Shrubbery Nursing Home 03/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Shrubbery Nursing Home, The Birmingham Road Kidderminster Worcestershire DY10 2JZ Lead Inspector Chris Potter Unannounced Inspection 25th July 2006 10:00 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 Shrubbery Nursing Home, The DS0000004143.V304877.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. Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shrubbery Nursing Home, The Address Birmingham Road Kidderminster Worcestershire DY10 2JZ 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) 01562 822787 01562 68122 Minster Care Homes Limited Mr Nicholas Peake Care Home 33 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (33), of places Physical disability (33) Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd December 2005 Brief Description of the Service: The Shrubbery Nursing Home is a Grade II listed building set in large gardens and approximately half a mile from Kidderminster town centre. Care is provided for the physically and mentally disabled who require both nursing and personal care. Single and double rooms are available on the ground and first floor. The first floor is accessed via a passenger lift. The home has a secure rear garden, which residents can access, via a conservatory. The fees for this service range between £447.00 - £586.00, depending on the size of the rooms and the assessed needs of the resident. Chiropody, hairdressing and newspapers are additional to the fee. Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the homes unannounced key inspection. It was undertaken by 2 inspectors from the Worcester office of the CSCI and was carried out over two days. The inspection totalled 12 hours of inspector time. The last inspection of the shrubbery took place during December 2005. At the time of the visit the home was caring for 29 residents. The inspection assessed information from residents, relatives and staff to establish their views about the home. Some resident’s care was case tracked to identify that their assessed care needs were being met by the home. A tour of the environment was undertaken and relevant records and registers were reviewed. Since the last inspection the home has changed its registered manager. Mr N. Peake is now the Registered Manager for the home. As a result of this inspection a number serious concerns were identified. An Immediate Requirement Notice was issued as a result of this inspection. The inspectors were concerned with the homes failure to address requirements from the previous inspection. On the second day of the inspection the home had addressed the immediate requirement notices. The Registered Provider confirmed their commitment in addressing the issues and ensuring that the home meets the standards. The home is required to provide the CSCI with an improvement plan detailing how they are going to address the requirements. What the service does well: The home has exceeded the standard of providing 50 of care stuff with NVQ level 2 qualifications. The home has a training manager who arranges the training for the staff and monitors their progress through supervision meetings. Many of the residents bedrooms have been personalised this gives a more homely appearance. A comment from a relative stated “they were happy with the care provided. The staff are very friendly with visitors and relatives.” Shrubbery Nursing Home, The DS0000004143.V304877.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. Shrubbery Nursing Home, The DS0000004143.V304877.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 Shrubbery Nursing Home, The DS0000004143.V304877.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): 1,2,3,4 and 5 The quality outcome in this area is adequate. This judgement has been made using available evidence including visits to this service. Residents’ individual needs are assessed prior to them moving into the home in order to establish the home’s ability to meet those needs, and to help ensure appropriate care is provided. EVIDENCE: The home provides prospective residents and relatives with a copy of the homes Service User’s Guide and a copy of this is available in the resident’s bedrooms for reference. Relatives spoken to during the inspection confirmed they had been provided with the appropriate information to assist them in choosing the home. It was confirmed they had also been invited to visit the home and a record of this is included on the proposed residents pre-admission assessment. One relative stated, “The home was very welcoming and helpful when I first approached them.” Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 9 The home provides all residents with a contract of terms and conditions on admission to the home. Copies of these are available in the home for reference. Three new residents care records were reviewed to assess that the resident had been appropriately risk assessed, to ensure that the home could meet there needs. The manager usually undertakes the risk assessment, and a record of the assessment is recorded on the assessment. The assessment was very brief and for one resident the pre-admission assessment had not been completed. It appeared from the homes documentation that the resident was admitted on the 18th of July, however risk assessments had not been completed until the 23rd July and these were not fully completed. The resident had been admitted for terminal care and no appropriate care plan had been developed to evidence how the home was going to meet those needs. The second pre-admission record was brief and assessed needs had not been developed appropriately. The third residents care documentation had not been completed appropriately, and failed to demonstrate the residents care needs fully. It was also discussed at the time of the inspection that the home must ensure that the residents admitted are within their category of registration. It was evident from notifications and care records that the home had admitted a resident with severe Alzheimer’s who had been challenging in their behaviour. Other residents have incidents reporting challenging behaviour, which the staff are, not trained to manage. Shrubbery Nursing Home, The DS0000004143.V304877.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): 7,8,9,10 and 11 The outcome for this area is poor. This judgement has been made using available evidence including visits to this service. Care plans and risk assessments were insufficient and inconsistent in that they did not give the necessary detail regarding residents care needs to ensure that care staff are able to provide the level of input required. This shortfall can leave residents at potential risk. In addition the systems for the administering and recording of medication are poor and potentially place residents at risk. EVIDENCE: A random selection of six residents’ care files was examined during the inspection of the home. Serious concerns were raised about the poor care documentation and the need for improvement. The care plans must demonstrate accurately each resident’s care needs fully. Given the home was issued with an immediate requirement notice in December 2005 to improve the care documentation, the CSCI are disappointed with the homes progress. Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 11 The care documentation for a resident admitted for terminal care, failed to record their physical and psychological care needs. Appropriate risk assessments had not been completed. The only care plan in place was for “End of Life” with syringe driver recorded by it no signature had been recorded. Another residents care records reviewed and the nurses’ were recording “care as plan” however a care plan had not been completed. For other residents risk assessments had not been updated monthly as required i.e. 20/04/06 – 07/07/06. Wound care documentation provided insufficient detail about the management of the resident’s wounds. For other residents identified as being aggressive, no detailed plan of care had been provided to assist staff in meeting their care needs. The social needs of the residents had not been included into the residents care documentation. Staff advised that another resident had improved with their mobility following admission to the home. This was not evidenced in their moving and handling risk assessment staff had recorded “no change in care plan”. The management and organisation of medication was reviewed and an immediate requirement notice was issued for the home to address the shortfalls. • Inappropriate storage for the controlled medication, and controlled drugs not being discarded in an appropriate time following the discharge of the resident. • The medication trolley was left unattended during the medication round. • Some gaps were evident on resident’s medication administration record so it could not be assessed whether or not the resident had been given their medication. • On another record a resident prescribed for a variable dose the amount given had not been recorded. • The oxygen cylinder should be secured. • The medication administration record failed to record if the resident had any known allergies. • On handwritten medication administration record charts they had not been signed by two members of staff. • Boxed or bottled of medication must record the date of opening. • Creams in bedrooms were observed with no date of opening. The home should review the use of portable screens in shared rooms to ensure the resident’s privacy is maintained. Shrubbery Nursing Home, The DS0000004143.V304877.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 The outcome for these standards was poor. This judgement has been made using available evidence including visits to this service. The opportunities for residents to partake in activities are limited by the availability of staff and are therefore in need of improvement. The dietary needs of residents are met; residents are however not offered a choice of meals. EVIDENCE: The activities for residents are limited and only suitable for few of the residents. On the first day of the inspection residents in the lounge were participating with a mobility to music session, which they appeared to enjoy. Given the high dependency of residents many are nursed in bed and no stimulation was available for them. Care plans failed to record the social needs of the residents. The home is in the process of arranging an outing for some of the residents to the local pub. A summer BBQ is also being arranged for the residents and relatives. Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 13 Some residents spoken to confirmed they did not participate in the homes activities, as they preferred to stay in their bedrooms. Relatives confirmed from feedback that they are allowed to visit at any time and the staff always appeared welcoming and friendly. The inspectors also observed the lack of staff supervision in the lounge during the inspection. This was further emphasised by the number of accidents reported. Several residents had fallen in the lounge and assistance was summoned by another resident. Another resident had received a cigarette burn smoking in the conservatory, from not being supervised. Residents were complimentary about the quality of food provided at the home. They stated that they were not provided with a choice of meals. A relative spoken with during the visit confirmed that the home assessed the resident’s likes and dislikes on admission to the home. Another relative stated “That they visit the home frequently during the lunch time. If the residents refuse anything rarely is something else offered.” Staff were observed assisting residents who required help with feeding appropriately. The home should review how the meals are kept heated whilst the residents are waiting for assistance to be fed. Shrubbery Nursing Home, The DS0000004143.V304877.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 The outcome for these standards is poor. This judgement has been made using available evidence including visits to this service. There is a complaints procedure in place to fully safeguard the residents. However, the complaints procedure must be adhered to. EVIDENCE: The homes complaints records were reviewed at the time of the inspection. From the register it was unable to identify how many complaints the home had received since the last inspection in December 2005. The home must ensure they maintain an accurate record of any complaint made and an outcome of the investigation is available. Complaints were identified from feedback gathered from relatives, and they had not been included in the residents care documentation or the complaint register. One relative commented, “They had repeatedly mentioned that their mother should be provided with rugs and cushions, but this is not followed by all staff. Also problems waiting to be hoisted from the wheelchair to a more comfortable chair.” Another comment included that complaints are received sympathetically, but not sure that any response is lasting. Feedback received from relatives commented that they were not kept up to date, and felt communication could be improved, not all staff aware of day-to-day incidents occurring at the home. A District nurse raised a concern to the CSCI about the care of a resident requiring a syringe driver. They felt that staff were not experienced to manage the equipment and they had to provide the medication or else the resident Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 15 would have been left without pain relief. This was discussed with the deputy manager and the registered provider and it was requested that they investigate the concern and assess that the nurses are competent to manage the equipment. The home had reported several incidents to the CSCI involving one resident whose behaviour was affecting other residents. The CSCI was concerned that the home had not referred this resident to the vulnerable adults team. This was advised by the CSCI to do. From accident records the resident had been challenging and causing injuries to both staff and residents. From the initial assessment it was queried whether this resident should have been admitted to the home. During the inspection three residents advised the inspector that not all staff spoke kindly to them some were “sharp”. This needs to be addressed all residents should be treated with the dignity and respect at all times. All staff should be provided with training to ensure that they understand abuse and their responsibility to report any concerns they may have. Shrubbery Nursing Home, The DS0000004143.V304877.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): 19,20,21,22,23,24,25 and 26 The outcome for this area is adequate. This judgement has been made using available evidence including visits to this service. Although many areas of the home are acceptable other areas are in need of replacement or repair in order to provide an environment that is homely and safe to live in. Shortfalls were noted in relation to some record keeping regarding bath temperatures; this can potentially leave residents at risk. EVIDENCE: The home is conveniently located in a residential area of Kidderminster, which provides easy access for relatives and staff. It is a large home providing accommodation for 33 residents. The decoration and carpets are appearing dated and the homes appearance would benefit from a redecoration program and refurbishment in some areas. The registered provider confirmed that they were in the process of reviewing some Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 17 replacement carpets. It was noted that the carpet along one corridor as tape in place this was reported on the last inspection. Many of the carpets are stained and badly worn and some odours of incontinence were evident. It was concerning to find many of the residents fire doors were wedged open with a portable wedge. This is a potential fire risk for residents and staff. An immediate requirement notice was issued for the home to address this. Resident’s doors can be open providing an approved device is used. It was concerning to see that the home was still using the bath temps between 35.5ºC –37.7ºC which is too low. The bathing water temperature should be between 37ºC - 43ºC. Staff were also failing to record the bath temperatures the last bath temperature recorded was May 2006. Towels were observed being stored in the bathrooms on the shelves. This is not recommended given the steam and hygiene issues. Many parts of the home were cluttered with black bags of provisions, this adds to making the homes appearance poor. The downstairs bedpan washer was out of use at the time of the inspection. A disposable razor was observed in a shared bedroom not identified to an individual. Resident’s bedrooms were generally in good decorative order and majority seen had been personalised by the resident to reflect their personality. Feedback from relatives and residents confirmed that they were pleased with their bedrooms. The home was generally clean albeit cluttered, and given the size of the home and dependency of residents the management of odours was good. Shrubbery Nursing Home, The DS0000004143.V304877.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 outcome for this area is poor. This judgement has been made using available evidence including visits to this service. Staffing competencies should be reviewed to ensure that residents’ safety is maintained. The recruitment procedure should be followed to ensure the protection of the residents. EVIDENCE: Further to the last inspection and the follow up requirements, the inspectors were concerned with the lack of progress in ensuring the residents care needs were clearly identified in the care documentation. Whilst staff spoken to stated that they felt that the staffing levels were adequate, it was evident that care records, and other records were not up to date. The homes duty rota’s evidence that the staffing levels are within the minimal recommendations required. The staffing levels should be calculated on the assessed needs of the residents and to meet their needs fully. In addition to the care hours the home provides laundry staff covering six hours a day. Catering staff and domestic cover, it was recommended that the domestic hours are reviewed given the size of the home, for 6 days only one domestic covers for 6 hours. Maintenance and administration cover are also provided. Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 19 The home currently is fully staffed with no vacancies. Comments received from some residents and a relative stated that there was not enough staff on duty. Residents have to wait in their perception a long time for the toilet and to be transferred from wheelchairs to chairs. The training manager advised the inspector of the development with the training program developing for the staff. The need to record the length of training and the course content was required. Training records had improved since the last inspection. However some staff were not up to date with mandatory training, the manager explained the difficulties in getting staff to attend training. The home is trying to provide the majority of training at the home to assist staff. The home must ensure that all staff are up to date with mandatory training. The home must also ensure that a first aider is rostered on duty for the 24 hours. There was no evidence to support that the nurses were receiving clinical update. The home must ensure that the nurses have the skills and competencies to meet the needs of the residents. The home is commended on the number of staff with the NVQ level 2 qualification or are in the process of completing this. A random selection of three staff personal files were reviewed at the time of the inspection. These evidenced that the home had not followed their recruitment procedure fully issues highlighted from these included: • • • • • Poor employment history The gaps in employment not explained One reference in some cases not the most recent or current employer. There appeared a delay for one member of staff in obtaining the CRB result. No evidence of the training or qualifications prior to starting work at the Shrubbery. Shrubbery Nursing Home, The DS0000004143.V304877.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): 31,32,33,34,35,36,37 and 38 The outcome for this area is adequate. This judgement has been made using available evidence including visits to this service. Improvements are necessary to the overall management of the home to ensure positive health and safety practices are promoted and accurate records are kept. EVIDENCE: Since the last inspection the deputy Manager has been appointed to manager. The manager is required to complete the Registered manager’s Award by September 2007 as a requirement of registration. The manager has many years experience of working with older people, and has worked at The Shrubbery for 3 years. Feedback from staff confirmed that the manager was always approachable and helpful. Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 21 The home hold regular monthly staff meetings, the training manager advised that these are poorly attended by the staff with the same ones attending. Comments received from other professionals about the staff was generally good, and stated that they have a good working relationship with the home. One comment received stated they felt the home was a first class establishment, with a high level of care, but some staff required some training. The home has service and maintenance contracts for all the equipment in the home. The records were available for the inspection, and a copy of renewal dates provided for the CSCI file. Residents finances are not managed by the home, their relatives tend to manage them on their behalf. The home keep small amounts of money for hairdressing, newspapers and this is being appropriately managed. The home completed a quality audit in March 2006 and the results of this were good. A couple of negative comments had been made and it was difficult to establish whether these issues had been followed up by the home. The training manager has commenced some staff supervision and the records of these were available. Not all staff are receiving regular supervision sessions at the moment. Shrubbery Nursing Home, The DS0000004143.V304877.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 1 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 2 2 3 3 3 3 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 3 3 2 2 2 Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 (1) Requirement The home must ensure all residents admitted to the home are assessed appropriately and are within the homes category of registration. Remains outstanding from previous inspection. Timescale for action 10/08/06 2. OP4 12 (1) 3 OP7 15 The home must provide staff with the relevant competencies to meet the care needs of the residents admitted to the home. The registered manager must ensure that care plans are reviewed on at least a monthly basis and any changes in the resident’s condition must be included. Remains outstanding immediate notice issued. 10/08/06 01/09/06 4. OP7 15 Wound and pressure sore documentation must be up to date and reflect the wound care needs of the resident Remains outstanding from previous inspection 01/09/06 5. OP7 15 The home must ensure that a plan of care is developed to accurately reflect the residents risk assessments and care DS0000004143.V304877.R01.S.doc 01/09/06 Shrubbery Nursing Home, The Version 5.2 Page 24 needs. 6. OP8 12 (1) Remains outstanding from previous inspection. Residents care plans must cover all aspects of health care needs and identified risks must be assessed and acted upon. Remains outstanding from the last inspection. 01/09/06 7. OP9 13 (2) The registered manager must ensure that Medication Administration Record (MAR) sheets are completed adequately and at the time of administration. The registered manager must ensure that when a variable dosage is prescribed the actual dose given is recorded. The registered manager must ensure that any handwritten amendments to the medication administration record (MAR) sheets are checked dated and counter signed by a second member of staff. The home must ensure that the date of opening is recorded on boxes of medication to assist with auditing. The home should be able to account for all medication held in the home for residents. The Medication Administration Record must show all known allergies. In the event of none known this should be recorded. All creams in use should be dated on opening and discarded after 28 days to reduce the risk of contamination. The home must ensure that the residents are afforded privacy and dignity at all times. The use of portable screens in shared bedrooms should be reviewed. DS0000004143.V304877.R01.S.doc 26/07/06 8. OP9 13 (2) 26/07/06 9. OP9 13 (2) 26/07/06 10. OP9 13 (2) 26/07/06 11. OP9 13 (2) 26/07/06 12. OP9 13 (2) 10/08/06 13. OP10 12 (4) (a) 30/10/06 Shrubbery Nursing Home, The Version 5.2 Page 25 14. OP11 12 (1) 15. OP12 16 (2) 16 17. OP15 OP16 15 (7) 16 (3) 18 OP18 12 (1) 19 OP19 23 (1) 20 21 22 OP20 OP21 OP22 16 (1) 23 (2) 23 23 OP24 23 The home must ensure that residents admitted for terminal care, are provided with the care to reflect their care needs, and the families are included. Care plans and risk assessments should be completed to evidence and direct staff to deliver that care. Residents’ interests must be recorded and they must be given opportunities for stimulation through leisure and recreation, which suit their needs, preferences and capabilities. The home must ensure that the residents are provided with a choice of food at meal times. The home must maintain a record of all complaints received and details of the investigation and any action taken. The home must ensure staff are appropriately trained in protecting vulnerable adults, and all allegations and incidents of abuse are followed up promptly, and records are available of the action taken. The home must provide the CSCI with a plan to identify how the home is to be upgraded and provide appropriate timescales for this. The home should review the furnishings to further enhance the homes appearance. The home must ensure that bathrooms are appropriate for the residents assessed needs. The registered manager must ensure that appropriate storage is available for items such as towels and equipment to prevent the bathrooms being used. The registered manager must ensure that residents have the opportunity (unless a risk DS0000004143.V304877.R01.S.doc 01/09/06 30/10/06 01/09/06 26/07/06 26/07/06 30/10/06 30/10/06 30/10/06 10/08/06 30/10/06 Shrubbery Nursing Home, The Version 5.2 Page 26 assessment suggests otherwise) a key to their bedroom. Locks provided must be in line with those approved by the fire authority. 24 25 OP26 OP27 13 (3) 18 1 a The home must repair the bedpan washer to reduce the potential risk of cross infection. The home must ensure that at all times suitably qualified competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of residents. The home must ensure that they adhere to their recruitment policy. Including obtaining two written references, a full employment history is provided and any gaps explained. Evidence of previous qualifications are provided. Staff records must contain an up to date photograph of the person employed The home must ensure that accurate records regarding bath water temperatures are maintained Bath temperatures must be suitable to residents needs while remaining within safety limits. The home must ensure all staff receive mandatory training and are updated annually. The home must also ensure that a member of staff is trained in first aid available on duty for the 24-hour period. The manager must complete the Registered Manager’s Award by September 2007. DS0000004143.V304877.R01.S.doc 10/09/06 26/07/06 26 OP29 18 1 a 26/07/06 27 OP29 7,9,19 26/07/06 28 OP25 13 (4) 26/07/06 29 OP30 18 (1) 30/10/06 30. OP31 9 30/09/07 Shrubbery Nursing Home, The Version 5.2 Page 27 31 OP32 21 (1) 32 OP33 10 (1) 33 OP36 18 34 OP37 17 35 OP38 23 The registered manager must conduct the care home so far as it may affect the health or welfare of the residents. This should be done through auditing the systems in place. The home makes progress with the requirements identified by the CSCI inspection. A system to review the action taken to address negative feedback should be addressed. The home must ensure that the staff supervision program is extended for all staff employed at the home. This should cover all aspects of practise, philosophy of care and career development needs. The home must ensure that accident records are available and accurate for any accident that occurs in the home. All staff should understand the accident policy. All Staff must receive fire training every three months The nominated member of staff must have specific health and safety training The home must not wedge the fire doors open, unless an approved device is used. The home was issued with an immediate requirement notice. 30/10/06 31/12/06 31/12/06 26/07/06 26/07/06 36 OP38 13 30/10/06 37 OP38 13 26/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000004143.V304877.R01.S.doc Version 5.2 Page 28 Shrubbery Nursing Home, The Standard Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Shrubbery Nursing Home, The DS0000004143.V304877.R01.S.doc Version 5.2 Page 30 - 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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