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Inspection on 28/09/06 for The Shrubbery Nursing Home

Also see our care home review for The Shrubbery Nursing Home for more information

This inspection was carried out on 28th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

The home is being effectively and competently managed, and staff were very caring and considerate to residents, who were complimentary about the staff team. The rights and interests of residents are clearly promoted by staff. The proprietor, manager and staff continue to work hard to maintain and improve standards within the home.

What has improved since the last inspection?

Nursing staff within the home have worked well to ensure that the standard of care recorded by the home has improved, thereby underpinning and supporting consistency in the care provided to residents.

What the care home could do better:

Opportunity needs to be taken to improve issues relating to health and safety through; (a) (b) The provision of a qualified first aider throughout the entire 24-hour period, The development of care documentation andDS0000004142.V309502.R01.S.doc Version 5.2 Page 6Shrubbery Nursing Home, The(c)The provision of a mechanical sluicing disinfector on the each floor of the home.

CARE HOMES FOR OLDER PEOPLE Shrubbery Nursing Home, The 27 Shrubbery Avenue Worcester Worcestershire WR1 1QN Lead Inspector N Richards Unannounced Inspection 28th September 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 DS0000004142.V309502.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 DS0000004142.V309502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shrubbery Nursing Home, The Address 27 Shrubbery Avenue Worcester Worcestershire WR1 1QN 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) 01905 28916 01905 610986 Dove Care Homes Limited Sandra Jane Mayne Care Home 36 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (36), of places Physical disability over 65 years of age (36), Terminally ill (2) Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Shrubbery Nursing Home occupies a prominent position in Shrubbery Avenue in central Worcester. The Home can be easily accessible from the city centre via The Tything and Barbourne Road. The home has three floors serviced by two lifts, and provides single and double accommodation. The Home can accommodate up to 36 residents. The Home is registered to provide twenty-four hour nursing and personal care. The registered manager, Mrs Sandra Mayne, is a first level registered nurse, and oversees the day-to-day running of the home. The home has been recently acquired by Minster Care, as part of its purchase of Dove Care. Fees range from £550 to £575 per week, and excludes hairdressing, newspapers and private healthcare – which all vary in price. Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection over the morning and afternoon period. The home’s manager and the organisation’s area manager made themselves available to provide some information during the inspection process, while other methods were employed to gather further information about the service provided by the home. This included briefly talking to residents and staff, observing care practice, a tour of the premises and an examination of care, staffing and health and safety records. 31 residents were living in the home at the time of the inspection, of which, a total of three were temporarily in hospital. The evidence from this inspection emphasises how the home continues to provide a good quality service for residents. What the service does well: What has improved since the last inspection? What they could do better: Opportunity needs to be taken to improve issues relating to health and safety through; (a) (b) The provision of a qualified first aider throughout the entire 24-hour period, The development of care documentation and DS0000004142.V309502.R01.S.doc Version 5.2 Page 6 Shrubbery Nursing Home, The (c) The provision of a mechanical sluicing disinfector on the each floor of the home. 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 DS0000004142.V309502.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 DS0000004142.V309502.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 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents with the information they need to make an informed choice about the home, and comprehensively assess the needs of prospective residents prior to their arrival at the home. This ensures that the home and the prospective resident are confident that needs can be met before moving into the home. The home does not provide intermediate care, so Standard 6 is not applicable. EVIDENCE: A comprehensive, written pre-admission assessment is undertaken for all prospective residents by a registered nurse (usually the registered manager) prior to their admission to the home. Where prospective residents are to be funded by the local authority, a community care assessment is completed and provided to the home. This demonstrates the care needs of the individual, and Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 9 enables the home to form a judgment about whether (or not) it can meet the person’s needs. All care files examined contained a written contract/statement of terms and conditions that clearly specified the rights and obligations of the resident and the home. A copy of the home’s statement of purpose and complaints procedure had been provided to each resident and/or their nominated representative. The provision of a contract and statement of purpose helps to provide clarity about the service for residents, and enables people to understand what they can expect from the service, and how to complain if the service falls short of their expectations. The home does not provide intermediate care. Shrubbery Nursing Home, The DS0000004142.V309502.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of care records within the home is adequate. Records are not sufficiently detailed to ensure that individual residents’ needs are met in a consistent manner. Care practice discussed and examined, along with feedback from residents confirms that appropriate action is taken to meet the clinical needs of residents. EVIDENCE: Four residents’ care files were examined during the inspection. Each resident had a care plan in place, which had been completed by a registered nurse, but the quality and content of care plans varied considerably. While some care documents effectively specified how care is to be delivered, some care plans failed to effectively specify how care is to be delivered. The following deficits were noted about care documentation; 1. Care plans had not been formally agreed with and counter-signed by the resident and/or their next-of-kin. This is necessary to ensure that the Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 11 2. 3. 4. 5. 6. home (a) works in participation with the individual (rather than working to preclude the individual from the care process), (b) engages the individual within the care process, and (c) ensures that the individual understands and consents to the care provided. Some care plans need to be more specific and directive. This is important if care staff are to understand the symptoms they are supposed to be monitoring. Care plans were not being reviewed in accordance with the frequency specified by the National Minimum Standards i.e. at least once a month. This is important to ensure that (a) any changes to a person’s condition are noted, and (b) the plan of care is amended in response to any change/s noted. Although each file contained a range of risk assessments and health care assessments, some required further development as; (a) one file failed to contain any weight record, (b) one file contained a “Waterlow” pressure ulcer risk assessment which cited the individual as being at “high risk” of pressure ulcer development. However, the risk assessment had not been regularly reviewed, (c) care files contained a risk assessment for the use of bedside rails which identified the individual as being at “high risk”. A consent form for their use had been countersigned by the resident’s next-of-kin, but the consent form did not specify the risks of using bed side rails, neither did it specify the benefits and risks of their use. Care plans for pressure ulcers did not effectively demonstrate the nursing care and nursing interventions necessary to address the problem/s identified. Residents care files contained physiotherapy notes. One record cited that an individual had expressed a wish to overdose rather than remaining in the home. No plan of care had been developed. A range of health care risk assessments had been undertaken (such as pressure ulcer development risk assessments). When risks had been identified through assessment, plans of care necessary to reduce or eliminate the identified risk had been completed. A member of the nursing team was observed administering medication to residents. Medication was administered safely, sensitively and diligently to ensure that the right medication was administered to the right person, at the right time and in the right dose – thereby promoting the safety and well-being of residents. Residents spoken to were happy to confirm that staff within the home was meeting their care needs in a dignified and respectful way. Staff were seen providing care sensitively and discretely to residents, and discussions with staff confirmed that they were aware of residents’ care needs. Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 12 Care records clearly evidenced the accessing of multi-disciplinary healthcare professionals such as general practitioners (GPs), speech and language therapists, chiropodists, dentists and opticians, in response to changes in healthcare need (reactive care), and as a preventative measure (proactive care). Shrubbery Nursing Home, The DS0000004142.V309502.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Social care within the home is satisfactory. Residents have opportunities to participate in leisure and recreational activities, but the level of structured activity input could be increased to promote social wellbeing. Contact with family and friends is supported, and opportunities for residents to exercise choice over their lives has been maintained to enable them to maximise personal autonomy. EVIDENCE: Individual residents who were spoken to stated that there was opportunity to engage in occupational activities. An activities co-ordinator works for 9 hours each week with residents, and was seen to be very enthusiastic about her role. She has started to record a diverse range of individual activities with residents – with activity provided on either a 1:1 or group basis. The individual preferences of residents have been sought, and the activities being undertaken reflect the preferences conveyed by the residents within the home. The activities co-ordinator currently works three 3-hour sessions each week (comprising of one session in the afternoon (2pm to 5pm) on Tuesdays, Wednesdays and Thursdays). Given the size of the home, and the needs of Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 14 residents, opportunity must be taken to review the level of social, occupational and recreational activities to ensure that residents’ social care needs are being effectively met – particularly as many residents benefit from 1:1 contact and intervention(s). Residents and staff interviewed confirmed that family and friends are made welcome, and visiting restrictions were kept to a minimum. Residents are able to receive visitors within the communal areas of the home, or in the comfort and privacy of their own rooms. If residents choose and are able, they manage their own financial affairs. The home actively operates to ensure minimal contact with residents’ finances occurs. Menus were inspected and found to be balanced and interesting, and mealtime arrangements are also flexible enough to accommodate individual preferences. Menus were based on a four-week rotational basis. The main meal served on the day of inspection comprised of a choice between shepherds pie, cauliflower cheese and green beans or chicken, chips and peas. Dessert consisted of either bread and butter pudding or spotted dick and custard. Residents could partake of up to three cooked meals a day if they so desired. Breakfast comprised of a choice between cereal, toast, a “full English” breakfast and scrambled, boiled or poached eggs. The evening meal on the day of inspection comprised of sardines on toast, sandwiches and salad, or soup, fruit juice, toast and/or sandwiches. Dessert was either semolina with jam, jelly and ice-cream or cheese and biscuits. Catering staff demonstrated a good knowledge and understanding of individual residents’ dietary preferences and requirements. Residents’ weight charts confirmed that residents were not losing weight unexpectedly, and that weights were stable. During the morning and afternoon periods, care staff were seen providing residents with drinks and snacks. Shrubbery Nursing Home, The DS0000004142.V309502.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaint management and adult protection within the home is appropriate to ensure resident safety is promoted. Complaints are handled objectively and residents are confident that their concerns will be listened to, taken seriously and acted upon. A vulnerable adults procedure is available to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a simple and clear complaints procedure, and the complaint records indicate that this is followed. Complaints records demonstrated a clear audit pathway, enabling people to see how the investigation was undertaken and the finding(s) and outcome(s) from the investigation process. A copy of the complaints procedure was available to all residents, visitors and relatives. Residents spoken to were confident that concerns could be raised with the home. The home manager responds to complaints at a grass-roots level, and this approach helps to ensure that concerns are addressed speedily and effectively. A procedure for responding to allegations of abuse is available, and mirrors Worcestershire’s multi-agency adult protection guidelines (which was available for reference purposes within the home). Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 16 All staff receive training in relation to the protection of vulnerable adults and the recognition of, and prevention of abuse. Shrubbery Nursing Home, The DS0000004142.V309502.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 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A rolling programme of investment within the home is required to ensure that a decent environmental standard is maintained. There are areas within the home that have been identified by the organisation as areas that require investment, and an improvement plan is currently being developed and implemented. EVIDENCE: The home comprises of five adjoining domestic properties, and blends in with the surrounding buildings. A full examination of the physical environment was undertaken at the time of the inspection. Accommodation is provided on all three floors of the home. Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 18 Bedrooms were spacious, and shared rooms provided ample floor space that enabled residents to comfortably enjoy their own personal space. Separate lounge and dining room facilities are provided within the home. Residents interviewed confirmed that the option of using the dining areas, lounge areas or their own bedrooms at mealtimes was suitable to their individual needs, tastes, requirements and preferences. Systems were in place for the management of infection control, and the home was clean, tidy and free from offensive odours. There was a mechanical disinfector located on the ground and first floor of the home, but the second floor area possessed a manual sluice. This is unacceptable from an infection control perspective, and a mechanical disinfector is required on the second floor area. Each bedroom seen had been furnished with residents’ personal possessions, thereby generating ownership and a sense of autonomy for individuals. Several bedrooms did possess locking devices that could be operated by residents, and these had been provided based on the assessed capabilities of individual residents. The standard of the environment within the home is positive, providing residents with a homely place to live. Residents confirmed that they appreciated the physical environment. It was noted that several areas within the home possessed floor-coverings that required replacement due to fatigue, or marking. The organisation was in the process of implementing a phased replacement programme to those areas identified as in need of new floor coverings. The provision of replacement floor-coverings to affected areas will help to enhance the appearance of the home. Hot water temperatures have been risk assessed and had been regulated to prevent people being accidentally scalded when they have a bath, and radiators had been guarded and restricted to prevent people being accidentally burnt through intentional or unintentional contact All the windows located at or above first floor level had been restricted to prevent people from being injured through falling out of the windows (accidentally or deliberately). There were sufficient toilet and bathing facilities throughout the home to effectively meet the needs of residents. One ground floor bathroom required decorative upgrade, and the access to the room was poor. Consideration must be given to the provision of suitable facilities to ensure that residents can use the room for bathing/washing purposes. The inspector was informed that the provision of a walk-in shower facility might be a potential option available to enhance the usability of the room. Shrubbery Nursing Home, The DS0000004142.V309502.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met, while the system for staff recruitment robustly protects the residents by ensuring (as far as is practicable) that applicants are effectively screened during the selection process. EVIDENCE: There were suitable nursing and care staff on duty to provide care and support for the people who were resident in the home at the time of inspection. Staffing levels within the home were (typically) one registered nurse and six carers during the morning period, one registered nurse and four carers during the afternoon period and one registered nurse and two carers during the night time period. In addition to nursing and care staff, there were also ancillary staff (catering, domestic and activity staff) on duty to support service provision. The home employed a total of nine registered nurses and 22 carers and, as part of an organisation, had the ability to draw on staff from other homes if the need arose. During the visit, call bells were activated, and staff responded speedily to them. Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 20 The duty rotas confirmed that the staffing levels were stable, with little evidence of staff being absent through short-term sickness. Training has been provided to staff, and includes infection control, food hygiene, fire safety and moving and handling. Training was identified as a result of the needs of residents, to ensure that care delivered was appropriate to and in response to the needs of residents. Nine carers had undertaken and completed National Vocational Qualification Level 2, while a further four carers were looking to start NVQ Level 2 shortly. Staff were seen interacting with residents in a relaxed, informal and compassionate way. Residents interviewed were very complimentary about the staff team, and provided comments such as; “staff are very good”, and “kind and caring”. Four staff files were randomly selected for examination. The home adopts robust procedures to ensure that prospective staff are effectively screened prior to taking up employment within the home. All staff had completed an application form, and had been interviewed. Two positive written references had been taken up and all staff had been subject to an enhanced CRB (Criminal Records Bureau) check. Contracts of employment had been provided to all staff. Shrubbery Nursing Home, The DS0000004142.V309502.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is clear leadership, guidance and direction to staff to ensure residents receive consistent care, resulting in practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The registered manager is competent and appropriately qualified and experienced to manage the service, and significant diligence and action has been undertaken to maintain and improve the quality of the service provided by the home since the time of the previous inspection. Residents clearly expressed their opinion that the home was being run in their best interests. Staff were being supervised in a positive manner. Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 22 The home is undertaking regular quality assurance exercises on various aspects of the homes functioning to ensure that (a) quality is maintained and (b) to improve standards whenever possible – thereby enhancing residents’ quality of life and well-being. A “Quality Management Audit” had been undertaken on 12th September 2006, and the summary concluded; “The Shrubbery appeared friendly, well managed and provides a care service that, according to questionnaire feedback, is well perceived by relatives of residents. It should be pointed out that a good audit score has been achieved by the home (79 )”. The registered manager effectively discharges her duty of care to ensure that the health and safety of residents and staff is maintained and maximised. It was noted that there was not always a qualified first-aider on duty throughout the 24-hour period. This was discussed with the registered manager, who stated that previous advice was given that, as the home was staffed by registered nurses, the need for a qualified first-aider to be on duty at all times was not applicable to the home. The inspector challenges this advice, as not all registered nurses are either trained or competent in the delivery of first aid. Standard 38.2 clearly specifies the provision of “a qualified first aider at all times” to provide suitable care should anybody within the home injure their self. Shrubbery Nursing Home, The DS0000004142.V309502.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 3 3 3 3 X N/A 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 3 17 X 18 3 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? 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. 2. 3. 4. Standard OP24 OP38 OP26 OP7 Regulation 16, 23 13, 18(1)(a) 13(3), 16(2) 15(1)(a) Requirement The carpet on the top floor landing must be replaced and in the meantime risk assessed. A qualified first-aider must be on duty at all times. A mechanical disinfector must be provided on the ground floor. Care plans must be developed in accordance with the specifications of Standard 7 and Regulation 15. Activity organiser hours must be reviewed to ensure that the provision of activities (including 1:1 time) is effective in meeting the social care needs of people within the home. The ground floor bathroom must be reviewed to ensure that residents with physical disabilities can be assisted to bathe and wash. Timescale for action 28/02/07 31/12/06 28/02/07 31/12/06 5. OP12 18(1)(a) 31/01/07 6. OP21 16 31/01/07 Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 25 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 Standard Good Practice Recommendations Shrubbery Nursing Home, The DS0000004142.V309502.R01.S.doc Version 5.2 Page 26 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 DS0000004142.V309502.R01.S.doc Version 5.2 Page 27 - 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!