Inspection on 30/07/07 for The Shrubbery Nursing Home

This inspection was carried out on 30th July 2007.

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

The inspector 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 28/10/08

The Shrubbery Nursing Home 28/09/06

The Shrubbery Nursing Home 29/11/05

The Shrubbery Nursing Home 08/08/05

The Shrubbery Nursing Home 14/12/04

The Shrubbery Nursing Home 03/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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 27 Shrubbery Avenue Worcester Worcestershire WR1 1QN Lead Inspector Andrew Spearing-Brown Unannounced Inspection 02:30 30 and 31 July and 2 August 2007 th st nd 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.V338442.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.V338442.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.V338442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th September 2006 Brief Description of the Service: The Shrubbery Nursing Home occupies a prominent position in Shrubbery Avenue in central Worcester. The Home is easily accessible from the city centre via The Tything and Barbourne Road. The home can be reached by public transport. A large car park is situated behind the home. The home has three floors serviced by two lifts, and provides single and double accommodation. The Home can accommodate up to 36 residents. Communal facilities include a large lounge / dining area, another large lounge primarily used for activities and two smaller lounges. The Home is registered to provide twenty-four hour nursing and personal care. The registered manager, Mrs Sandra Mayne, who is a first level registered nurse, oversees the day-to-day running of the home. Fees range from £545 to £600 per week, and excludes hairdressing, newspapers and private healthcare such as chiropody - which all vary in price. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector based at the Worcester office of the Commission for Social Care Inspection (CSCI) undertook this unannounced key inspection. This inspection was conducted over a period of three visits to the home. This inspection takes into account information received by the CSCI in relation to the home since the previous inspection as well as the visits to the home. Prior to this inspection a Annual Quality Assurance Assessment (AQAA) document was requested. The AQAA is a self-assessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with the CSCI areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the commission within a given timescale. The manager completed this document and returned it the commission. Comments from the AQAA are included within this inspection report. As part of the inspection process a number of questionnaires were sent to a sample number of people using the service, their relatives as well as health and social care professionals. A number of completed questionnaires were returned to the commission from relatives and health professionals before the inspection and are taken into account as part of this inspection. The manager was present throughout this inspection. The homes area manager was present during the final visit. Discussions took place with some members of staff as well as a number of people using the service. No visitors were consulted during this inspection. A look around the home took place which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records and staffing records. What the service does well: Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 6 Information is available for people who may wish to move into the care home. The registered manager carries out an assessment of care needs before any new admission takes place to ensure that care needs can be met. Visiting professional voiced no concerns regarding the service provided. One professional was complementary regarding the homes ability to manage pressure care needs. Bedrails fitted with bumpers to prevent entrapment were in place. People using the service were appropriately dressed and appeared comfortable. A hairdresser visits the home regularly. Representatives from a local church also visit the home in order that spiritual care needs can be met. Catering staff are employed, people consulted spoke favourable about the food provided. The homes complaints procedure is sufficiently robust to ensuring that people have their rights protected and are protected against potential abuse. The home is generally well maintained and is a comfortable and clean place for people to live. Sufficient staffing levels are maintained; these need to be kept under view to ensure that care needs can be met. The area manager visits the home regularly and prepares a monthly report as required. What has improved since the last inspection? What they could do better: Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 7 The Shrubbery is able to care for a small number of people with a dementia type illness. Other people using the service may have a degree of memory loss. The registered manager is aware that training needs to be provided regarding dementia awareness. The care plans remain insufficient in detail and were not person centred. Care plans do not give the guidance to carers necessary to ensure that care needs are met consistently. A number of shortfalls were evident regarding the management of medication. Due to the level of the concerns an immediate requirement was issued. Assurance was given that the issues identified would be addressed and the registered manager has written to the commission detailing the actions taken. The practice of staff not always knocking on bedroom doors needs to be addressed. Although an activities coordinator is employed within the home the number of hours remains insufficient to provide suitable social stimulation. Systems within the home need to be sufficiently robust as to protect the health, safety and welfare of people using the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 8 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.V338442.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3, 4 and 5. Standard 6 is not applicable. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who may use the service have they needs assessed beforehand to ensure that care needs will be able to be met. Information is available to people to assist in their decision as to whether the home is suitable. EVIDENCE: A copy of the homes statement of purpose and service users guide was available in the hallway near to the front door. The registered manager confirmed that a copy of the service users guide was held within each bedroom. Contracts or statements of terms and conditions were not sought as part of this inspection. The AQAA completed by the registered manager prior to this inspection stated that people using the service have such a document and that they are explained to people by the business manager. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 10 The pre admission assessment regarding a recently admitted individual was viewed. The registered manager carried out the assessment before the admission took place. Information on the assessment form was basic however it was sufficiently detailed to commence a more detailed care plan. A professional who visits the home informed the inspector that the registered manager recently took appropriate action to enable the admission of a resident from another home and provide suitable pressure relieving equipment. The registered manager confirmed that representatives of any potential resident would be encouraged to visit the home before the admission. The registered manager spoke on a number of occasions about the need to ensure that the home has the ability to meet care needs and that a full pre admission assessment takes place. Under The Shrubbery’s registration categories the home is able to accommodate three persons who have as their primary care need a dementia type illness. The registered manager stated that due to the physical layout of The Shrubbery it would not be possible to accommodate individuals with a severe dementia illness. Caring for people with a dementia is a specialist service. Currently staff have not received any training regarding dementia awareness, however the registered manager hopes to be able to address this in the future. The Shrubbery does not provide intermediate care and has no plans to provide such a service in the foreseeable future. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Although some positive comments were made and staff were able to verbally evidence knowledge of care needs the documentation was insufficient in detail and could potentially result in people using the service not having their care needs fully met. Medication systems were found to be insufficient and needed urgent attention to safeguard people within the home. EVIDENCE: Individual care plans are in place for all people using the service. A representative sample of care plans were viewed and assessed as part of this inspection. The registered manager stated that she had spent considerable time since the last inspection working on the care plans to improve them following the deficits previously noted. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 12 Care plans were generic with each person having the same overall care plan for a range of care needs. Some additional information was added to the generic care plans but the detail was insufficient and did not give sufficient guidance to carers to enable them to carry out their task in a consistent manner. Fluid charts were in place however these were not always completed fully and did not give any guidance to the amount of fluid needed. Risk assessments were in place on the files seen included nutritional screening and pressure sore prevention. Bathing records were not sufficient and in a number of cases showed that people using the service had gone a considerable period of time without receiving a bath or shower. Some concern was raised on a questionnaire regarding the infrequency of a relative having a bath. Bedrails were seen to be in use in a number of bedrooms to prevent accidental falling to the floor. Bumpers were in place to prevent entrapment between the bars. It was reported that some new bedrails are due to be delivered. The response to the question ‘Do you feel that the care home meets the needs of your friend / relative?’ on the surveys sent to a sample number of relatives the responses were as follows: Always Usually Sometimes 4 3 1 No concerns were raised within the questionnaires returned to the commission from health care professionals. A professional who visits the home was complementary regarding the pressure care within the home. In discussions with care staff they were able to give a satisfactory account of the care needs of people using the service. As part of the first visit to the service the management of medication was assessed. A significant sample of MAR (Medication Administration Record) sheets where viewed as part of the inspection covering a four-week period concluding on the 29th July 2007. In addition a small sample of the MAR sheets commencing 30th July and some of the MDS (Monitored Dosage System) cassettes were also viewed. A number of shortfalls were identified and as a result an immediate requirement was issued. The recording of medication was insufficient and could of potentially placed people using the service at risk. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 13 A number of gaps were evident on the MAR sheets whereby qualified nurses had failed to either sign for medication as given or enter a code to explain why medication was omitted. The date of opening was not recorded upon boxed medication and some bottled medicine. This would make a full drugs audit difficult. Staff had failed on a number of occasions to book medication into the home correctly. A second signature was not in place regarding handwritten entries on the MAR sheets to show that the original entry was checked. On one occasion nobody had signed the handwritten entry at all. A box of water tablets were not booked into the home and the MAR sheet was not amended, the previous dosage remained within the trolley therefore it was potentially possible that the wrong dose could have been given by mistake. It was evident that staff had signed the MAR sheets prior to administration as on occasions staff had over signed their signature with the code ‘R’ (refused). Both the registered manager and the area manager assured the inspector that the identified shortfalls would be addressed. As part of the second visit to the home a small number of matters regarding medication management were assessed. The controlled drugs register was audited against a number of items held and found to be in order. A dedicated fridge is located within the clinic to store items requiring such a facility such as eye drops. The fridge was locked as required and temperature records maintained. The temperatures recorded were on occasions slightly above the required temperature. Prior to the completion of this inspection the registered manager responded in writing to the immediate requirement issued during the inspection. The response detailed the action taken and demonstrated that nurses were informed that disciplinary action could happen in the event of future noncompliance. Screens are available within the home to be used in double bedrooms. On checking 3 bedrooms it was discovered that the screens were not available in 2 of them. These were later found and returned to the bedrooms. One resident commented that staff do not knock on bedroom doors before entering. While in a bedroom with one person using the service a member of staff opened the bedroom door without knocking. A pay phone is available which can be used in any bedroom. Nobody living within the home had a telephone of their own. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 14 Individuals preferred term of address was included within their care plan. Staff were seen to be addressing people using the service appropriately and respectfully. People using the service appeared to be appropriately dressed taking into account gender and the weather conditions. A number of people were in bed all of whom appeared to be comfortable. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Some social activities are provided on a number of days each week therefore providing limited stimulation and opportunities. The level of stimulation needs increasing in order to fully promote wellbeing. People using the service generally spoke favourably of the food provided. EVIDENCE: Although no visitors were consulted as part of this inspection there are no concerns regarding any restrictions placed on visitors. An activities coordinator is employed nine hours per week within the home working between 2.00pm and 5.00pm on Tuesday, Wednesday and Thursdays. As part of this inspection the coordinator was consulted and found to be very enthusiastic about her job and keen to seek new ideas regarding ways of encouraging participation in a range of activities. The number of hours whereby activities are provided is however the same as reported within the Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 16 previous inspection report (September 2006). The report following the last inspection stated: ‘Given the size of the home, and the needs of 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.’ The activities coordinator made reference to her desire to ensure she was able to see people using the service who remain in their bedrooms on a 1:1 basis. This however takes time and therefore the number of hours available remains insufficient. The AQAA completed by the registered manager prior to the inspection stated that the home has a ‘structured programme of leisure activities’ and ‘we display activities in the communal areas’ A programme is in place and a notice was displayed in the main lounge / dining room however due to the activities coordinator taking some time off the only event planned for an entire week was bingo. Although the game of bingo did not happen (people using the service choose not to partake) it was reported that usually 6 – 7 people take part in a game. Entertainers were reported to visit the home on about a monthly basis. Concerted efforts need to be made to increase the availability of activities and social recreation within the home. The AQAA highlights the provision of a monthly newsletter. This is primarily a means of communicating with people who use the service and their relatives regarding what is happening or has happened within the home. A copy of the most recent newsletter was on display within the home. The activities coordinator is also wanting to set up a ‘Friends of The Shrubbery’ group. Representatives from a local church visit the home regularly in order to meet the spiritual needs of people using the service. Other links with the community are limited although books are available via the mobile library. A hairdresser visits the home once per week. The home does not have a dedicate room for hairdressing therefore a top floor corridor is used. Catering staff are employed to prepare all meals. Menus are available on the tables within the dining room. A relatively small number of people using the service take meals sat in the dining room. The vast majority of people took their meals in their own bedroom. Supper on the first day of this inspection was due to be faggots and peas with potatoes and gravy or soup or sandwiches. Lunchtime was observed during one visit. The meal consisted of braising steak, mashed potato, sprouts and carrots an alternative of sausage with the above vegetables was available. A number of people using the Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 17 service commented that they had enjoyed the meal. A number of people have a soft diet option. A smaller number of people require their meal to be purified; one meal was seen before it was taken to the individual concerned. The purified meal was well presented with each item separated on the plate. It was reported that mainly fresh vegetables are used. People sat in the dining room had either a glass of sherry or beer with their meal. During the afternoon a number of people using the service were having a cup of tea and a slice of cake sat in the garden Some concerns were raised by relatives regarding the availability of drinks stating that they are at times left by people’s bedsides not drunk. This was not evidenced during this visit however the comment is drawn to the attention of the registered manager. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service have access to a robust complaints procedure and can be assured that any concerns they may have will be dealt with effectively and therefore have their rights protected. EVIDENCE: The manager stated within the AQAA that the home has a ‘robust complaints procedure which is accessible to staff and residents’. The complaints procedure is included within the homes statement of purpose. The procedure states that complaints can be referred to the commission for social care inspection and gives the address of the local office. In response to a question on the survey sent to a sample number of relatives all eight people who responded answered yes to the question: ‘Do you know how to make a complaint about the care provided by the home if you need to?’ One relative stated ‘I would voice my concerns to Sister in Charge have not had any reason to take matters further.’ Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 19 Over the past 12 months the home has received three complaints. Out of the three complaints two were not upheld. The third complaint was in relation to a stained feeding beaker. Records regarding these complaints are maintained. Other than some concerns included within some surveys the commission have not received any complaints regarding the service provided at the home. The concerns within the surveys were taken into account throughout this inspection. Following an incident within the home the registered manager involved the police as necessary. The commission knows of no other safeguarding or adult protection matters. As part of this inspection a number of carers were asked about the action they would take in the event of actual or potential abuse, the answers given were satisfactory. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23 24 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is generally well maintained to provide people using the service with a homely, clean and comfortable place to live. EVIDENCE: The Shrubbery nursing home comprises of five adjoining domestic properties. The home blends in well with the surrounding area. A large car park is located at the rear of the building therefore staff and visitors do not have to park in front of private properties. As part of this inspection a tour of the property was undertaken. The lighting in communal areas of the home was domestic in style. The carpet in the main Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 21 lounge / dining room has some ridges within it, these need to be closely monitored due to the potential trip hazard these ridges could present. Bedrooms are located on three floors. The bedrooms seen were pleasant with evidence that people are able to bring into the home their own personal belongings. One bedroom had a vase of dead flowers in it. Toilet and bathing facilities are adequate; some paintwork needs attention due to wheelchair damage. The toilet close to the main lounge has no privacy lock on the door. The water supply is disconnected to the bath near to the activities room. Another bath near to the front of the home was reported to not be used. Other bathrooms and a shower room were seen and reported to be in use. On one survey a relative stated ‘spotless clothing bedding room’ while another stated ‘clean bedding’. Two passenger lifts are provided to afford access to all parts of the home. Some concern was voiced regarding the location of the sensor beam and a possible hazard as a result of this. It was stated that nobody using the service would use the lift on their own however the senor should be risk assessed. Hoisting equipment was available within the home. The registered manager was aware that the date for a service had expired and was making every effort to get the required service done. Prior to the completion of this inspection a engineer had visited. The reports seen showed the equipment was safe to use however some defects were noted needing attention. An emergency call system is fitted within the home. Due to the design of the panel it is potentially possible that the call is reset without attending the place of activation. Freestanding wardrobes in bedrooms are not secured to the wall to prevent accidental toppling over. It was reported that an Environmental Health Officer from Worcester City Council visited the home recently and that no concerns were voiced. The garden at the rear of the home was well kept. Some parts of the patio could be potentially unsafe to people with limited mobility, as the slabs are not ideal. Liquid soap and paper towels were available within each of the toilets viewed. Some offensive odour was detected during the first visit to the home in the downstairs bathroom. It was likely that the unpleasant odour was as a result of carers placing foul items in the yellow bag within that room. Staff consulted Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 22 confirmed that personal protective equipment such as disposable gloves and aprons are available. The laundry was adequately equipped. The laundry is staffed between 10.00 am and 3.00pm seven days per week. Due to the fact that the home is located in a residential area of the city the laundry can only be used until 3.00pm each day to avoid unnecessary noise in the area. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Staff in the home are training and usually in sufficient numbers to support people using the service. Robust recruitment procedures provide a safeguard against potential abuse. EVIDENCE: At the time of this inspection 33 people were residing within the home. It was noted during the morning shift six carers are on duty while four are on duty during the afternoon / evening shift. Two wakeful carers are on duty throughout the night. One qualified nurse is on duty at all times in addition to the registered manager. It was reported that the home infrequently uses agency staff. In addition to the above staff are catering and domestic staff. During one visit to the home it was reported that three people were working within the kitchen during the morning and two during the afternoon. A total of five domestic staff were working during the morning shift, no domestic staff work during the afternoon. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 24 At the time of this inspection the home did not employee any male carers or male nurses. The following comments were made within some of the questionnaires returned to the commission: ‘ Staff are very helpful and friendly’ ‘ Care for residents very well ’ ‘ The nurses are very caring ’ Although a high percentage of people using the service were, at the time of this inspection, nursed in bed and required more than one carer both the registered manager and staff consulted believed the staffing levels to be sufficient. The number of staff to care for the needs of people using the service needs to be kept under review. Currently thirteen carers out of the twenty-two carers employed have a National Vocational Qualification (NVQ) level 2. Therefore the percentage of staff with a NVQ is just over 50 which is the National Minimum Standard. Staff are given a copy of a booklet issued by the General Social Care Council regarding code of practice. The file of a recently appointed member of staff evidenced that PoVA first (Protection of Vulnerable Adult) checks and satisfactory references are obtained prior to the person commencing work. The PoVA first is followed up by an enhanced CRB (Criminal Records Bureau) disclosure. The majority of mandatory training has taken place. Some staff need to undertake moving and handling training. The registered manager is a trained trainer regarding moving and handling. In addition a physiotherapist visits twice per week. Staff consulted stated that moving and handling training takes place in small groups lasting 45 minutes. The majority of staff undertook fire awareness training during May 2007. Staff consulted stated that they would know what to do in the event of a fire. Most of the responses to a question on the survey sent to relatives stated that people believe that staff either ‘always’ or ‘usually’ have the skills and experience to look after people properly. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A qualified manager manages the home. Some improvement is needed to ensure that safe systems are in place to protect the health, safety and welfare of people using the service. EVIDENCE: The registered manager has both the necessary experience and qualifications to manager the home. Assurance was given that shortfalls identified, as part of the inspection would be addressed. Some other matters noted during the inspection process were suitably actioned at the time of the inspection. It was Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 26 noted that the manager had a good knowledge of individuals care needs. People living within the home spoke highly of the manager. A number of quality assurance systems are in place within the home. The homes area manager visits and prepares written reports upon the conduct of the home on a monthly basis as required under Regulation 26. The written reports were available for inspection within the home. A quality assurance audit was undertaken during September 2006. The last meeting with nursing staff took place during September 2006. Full staff meetings do not take place relying on handovers to discuss matters. Documentary evidence as well as discussions with carers evidenced that formal supervision in line with standard 36 of the National Minimum Standards takes place. The home does not hold money on behalf of people using the service. Therefore expenditure such as hairdressing is invoiced to the individual’s representative. A gas safety check was carried out during July 2007. Equipment was found to be satisfactory and safe to use however some ventilation needs to be increased. This matters is currently with head office. The testing of portable electrical equipment was last carried out during February 2006. It was acknowledged that this was over 16 months ago it was stated that quotes were awaited to have these checks redone. At the time of the last inspection it was noted that although a registered nurse was on duty at all times there was not always a qualified first aider on duty. A first aider is now on duty at all times following staff training. Window restrictors were in place on bedroom windows to prevent accidental or deliberate falling to the ground. The suitability of restrictors needs to be kept under review. The use of a wooden devise on some windows was of some concern, the registered manager asked the maintenance operative to change these to a more secure restrictor. The fire log showed that the alarm is tested on a regular basis. Some gaps in the records were evident which suggested that the testing does not take place when the maintenance operative is on annual leave. Records regarding the visual checking of fire fighting equipment do not exist therefore the home was unable to evidence that this check takes place. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 27 Items such as rings with stones or bracelets and necklaces can be hazardous to both residents and staff members in certain circumstances such as the potential to damage skin tissue as well as the risk of harbouring germs. Reference to training including matters relating to health and safety are included elsewhere within this report. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 3 3 X 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 2 Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(a) Requirement A full and comprehensive care plan must be developed regarding each person using the service. The care plan must be updated to reflect all aspects of care need. Ensure that records and other recording regarding medication and its administration are clear, accurate and up to date to ensure that residents received items as prescribed therefore ensuring the health, safety and welfare of residents. 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. Previous timescale to ensure suitable provision of activities with a timescale of 31/01/07 is unmet. A revised timescale is given Timescale for action 31/10/07 2 OP9 13 (2) 31/07/07 3 OP12 18(1)(a) 31/10/07 Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 30 4 OP21 16 Suitable and sufficient bathing facilities must be available within the home. This requirement replaces a similar one in the previous report, which is not met. A new timescale is given. 30/11/07 5 OP38 13 Systems must be in place to protect the health, safety and welfare of people using the service. 07/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations It is recommended that a mechanical disinfector is provided on the ground floor. Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Worcester Local Office The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shrubbery Nursing Home, The DS0000004142.V338442.R01.S.doc Version 5.2 Page 32 - 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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