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Inspection on 29/11/05 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 29th November 2005.

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 provides excellent care to a number of residents who have complex nursing needs. The home is warm, friendly and cosy and there is emphasis on choice for residents in all activities of daily living, this is reflected in the care plans. There is currently a full complement of staff and the work force is stable; a number of the staff have worked at the home for a number of years; and have therefore built up good relationships with residents and families.

What has improved since the last inspection?

Care plans are continuing to be developed and there is clearer evidence of care needs, reviews and risk assessments. Refurbishment is ongoing and rooms have been decorated. Staff receive updated fire training regularly and all staff are required to answer a questionnaire on fire equipment and its use every three months.

What the care home could do better:

A number of environmental issues which posed a risk to the health and safety of staff and residents were identified during a tour of the premises, these were discussed with the registered manager and have become requirements of this report.A foundation programme and some core training needs of staff have not been addressed; the new owners of Dove Care are in consultation with the registered manager to develop a training programme for all staff.

CARE HOMES FOR OLDER PEOPLE Shrubbery Nursing Home, The 27 Shrubbery Avenue Worcester Worcestershire WR1 1QN Lead Inspector C Presley Unannounced Inspection 10.45 29 November 2005 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 Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 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.V258407.R01.S.doc Version 5.0 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 41 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (41), of places Physical disability over 65 years of age (41), Terminally ill (2) Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 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 Tything and Barbourne Road. The home has three floors serviced by two lifts and provides single and double accommodation. The Home accommodates 36 residents. The Home is registered to provide twenty-four hours nursing and personal care. The registration certificate does not reflect the homes true status; the home can accommodate a maximum of 36 service users and not 41 as stated on the certificate. The registered manager Mrs Sandra Mayne is a first level nurse and oversees the day-to-day running of the home. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the late morning and early afternoon, this inspection focused on standards not inspected at the last inspection and requirements from the last report. A number of residents and staff were spoken to during the course of the inspection and time was spent with the registered manager and the administrator, both have worked in the home for a number of years and know the residents well What the service does well: What has improved since the last inspection? What they could do better: A number of environmental issues which posed a risk to the health and safety of staff and residents were identified during a tour of the premises, these were discussed with the registered manager and have become requirements of this report. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 6 A foundation programme and some core training needs of staff have not been addressed; the new owners of Dove Care are in consultation with the registered manager to develop a training programme for all staff. 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.V258407.R01.S.doc Version 5.0 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.V258407.R01.S.doc Version 5.0 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): None of the standards in this section of the report were inspected during this visit; for further information please refer to previous inspection report. EVIDENCE: Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 9 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): 9 Medication policies and procedures are robust and medication is handled and administered safely to residents. EVIDENCE: Medication policies and procedures have been reviewed and updated to reflect current practice. The home did not have in place a disposal of medication contract with a waste supplier (under new legislation nursing homes must dispose of medication using a waste supplier, as chemists no longer take medication returns from nursing homes). There were no residents currently self-medicating due to their frailty. Records of medication were inspected and there were no signature gaps medication charts, which were hand written, were signed and dated by the registered nurse. The registered manager who is a first level nurse undertook audits of medication periodically. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 10 Homely remedies are given in accordance as per GP instructions, and these were clearly documented in the medication folder seen. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 11 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): Residents are enabled within their disabilities to live as full a life as possible and retain their own autonomy. EVIDENCE: Residents made positive choices about their lives with regard to getting up and going to bed, mealtimes and where they choose to take their meals. Bedrooms were personalised and care plans contained information about furnishings belonging to residents. The home did not have any facilities to hold monies on resident’s behalf. Some residents did not have lockable space in their bedrooms. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 12 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): None of the standards in this section of the report were inspected during this visit; for further information please refer to previous inspection report. EVIDENCE: There has been one complaint to the Commission since the last inspection this is ongoing. The home has responded to the complaint using their complaints procedure and has co-operated with the Commission throughout the investigation. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 13 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): The home is warm, cosy and homely; there are some areas of the home, which risk the health, and safety of residents. EVIDENCE: Staff have fire training regularly and have written assessments three monthly on the use of fire fighting equipment. A number of bedrooms have been fitted with door guards (the fire door closes automatically if the fire alarm is sounded) however the laundry room door was wedged open, unattended and the roller iron was left on. One fire door did not close on its rebate; this was dealt with before the inspector left the home. One of the passenger lifts in the home was not working on the day of the inspection; the home was waiting for parts and said the lift should be operational within six weeks. The home is able to manage with one lift during this period. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 14 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): None of the standards in this section of the report were inspected during this visit; for further information please refer to previous inspection report. EVIDENCE: Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 15 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): 33 & 35 There was no quality assurance audit programme in place; the home did not have any facilities for the safekeeping of resident’s monies. EVIDENCE: The new owners of the home are working towards developing a quality assurance programme with the registered manager that complies with current legislation and requirements. The home does not have any facilities for safekeeping of resident’s monies, extras are charged either to the resident or their next of kin by invoice. The registered manager and her staff are aware of their responsibilities to safeguard residents from financial abuse. Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 16 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 3 3 3 3 2 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 x x x Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 17 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 OP18 Regulation 18 Requirement Staff must receive training in the Protection of the Vulnerable Adult; ongoing new time scale set of 31/03/06 Residents must be provided with lockable storage space for medication, money and valuables and a key which he or she can retain (unless the reason for not doing so is explained in the care plan) ongoing new time scale set of 30/06/05 All members of staff must receive foundation training to National Training Organisation specification within 6 months of appointment ongoing new time scale set of 30/06/05 The home must have in place a disposal of medication contract with a recognised company in order to comply with new legislation regarding the disposal of medication Fire doors must not be wedged open and must close on rebates The laundry door must be kept locked at all times when no one is in attendance and must not be DS0000004142.V258407.R01.S.doc Timescale for action 31/12/05 2. OP24 12,13 31/12/05 3. OP30 12,18 31/12/05 4 OP9 13(2) 31/12/05 5 6 OP19 OP19 23 13 29/11/05 29/11/05 Shrubbery Nursing Home, The Version 5.0 Page 18 7 8 9 10 11 12 13 14 15 16 OP19 OP21 OP24 OP25 OP24 OP24 OP26 OP19 OP26 OP30 23 13 &23 16 16 &23 12 16 &23 13 13 13 18 16 OP33 24 wedged open; a keypad lock must be fitted The lift must be in working order as soon as possible Toiletries belonging to residents must not be left in bathrooms. All residents must have a lockable bedside cabinet or similar facility in their bedrooms Bedrooms must be kept warm Screening on the door of the bedroom identified must be addressed The carpet on the top floor landing must be replaced and in the meantime risk assessed Bath temperatures must be taken when residents are bathed Keys must not be left in locks where signage clearly indicates keep locked at all times Laundry including foul laundry must not be placed on the floor outside bedrooms. The home must have a training programme in place which ensures all staff are adequately trained to perform their duties this includes; all core training such as manual handling, infection control, food hygiene, first aid, fire training and the protection of the vulnerable adult A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. 31/12/05 29/11/05 30/06/06 29/11/05 31/12/05 30/06/06 29/11/05 29/11/05 29/11/05 31/03/06 30/06/05 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 DS0000004142.V258407.R01.S.doc Version 5.0 Page 19 Shrubbery Nursing Home, The 1. Standard OP19 It is recommended sluice doors are fitted with a key pad lock Shrubbery Nursing Home, The DS0000004142.V258407.R01.S.doc Version 5.0 Page 20 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.V258407.R01.S.doc Version 5.0 Page 21 - 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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