Inspection on 08/08/05 for The Shrubbery Nursing Home

This inspection was carried out on 8th August 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.

Other inspections for this house

The Shrubbery Nursing Home 28/10/08

The Shrubbery Nursing Home 30/07/07

The Shrubbery Nursing Home 28/09/06

The Shrubbery Nursing Home 29/11/05

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 The Shrubbery Nursing Home 27 Shrubbery Avenue Worcester Worcestershire WR1 1QN Lead Inspector Chrissy Presley Unannounced 8 August 2005 12.50pm th 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 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. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Shrubbery Nursing Home Address 27 Shrubbery Avenue, Worcester, Worcestershire WR1 1QN Telephone number Fax number Email 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 with nursing 41 Category(ies) of DE(E) Dementia over 65 (3) registration, with number OP Old age (41) of places PD(E) Physical disability over 65 (41) TI Terminally ill (2) The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14 December 2004 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 services users.The Home is registered to provide twentyfour hours nursing and personal care.The registration certificate does not reflect the home’s true status; the home can accommodate a maximum of 36 service users and not 41 as stated on the certificate. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the lunchtime and afternoon period. Care plan documentation, some policies and procedures, recruitment and contract records were examined. The inspector spoke with five residents who were enjoying a session of Bingo with the activities co-ordinator, time was spent talking with the activities coordinator the registered manager and administrator. What the service does well: What has improved since the last inspection? The home had addressed some of the requirements from the last report and had an action plan for those that had not been fully addressed. The registered manager was committed to ensuring staff had access to training courses and had enough information about conditions of the frail elderly The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 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 standard(s) 3 All residents were assessed prior to admission; the documentation used ensured the home was able to meet the resident’s needs when they were admitted. EVIDENCE: Three care plans were inspected, the assessment of need document was seen and covered all aspects of daily living. Information gained at assessment ensured new resident’s needs could be met and equipment necessary to nurse residents was in place, on admission. All assessments were carried out in the residents own environment whenever possible by a registered nurse from the home. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 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 standard(s) 7,8 &10 Residents are well cared for by experienced staff and have their individual health care needs met. EVIDENCE: Residents spoken to during the inspection looked and said they were well cared for by staff. Staff were overheard talking to residents in a kindly and friendly manner. All residents had a care plan in place, documentation continued to improve further development of these documents was discussed with the registered manager. Risk assessments were in place for all residents and there was evidence of resident and family involvement in the drawing up and continual reviews of the care plans. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 10 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 standard(s) 12,13 &15 Residents were offered a stimulating programme of activities, together with a well balanced, nutritious and varied diet. EVIDENCE: Time was spent talking to the activities co-ordinator who works three afternoons a week, records of activities evidenced activities are offered to all residents in either groups or individually. Residents were enjoying a game of bingo on the afternoon of the inspection. A recent strawberry and cream tea had taken place and the home was planning an Autumn Bazaar. A number of residents require assistance at mealtimes and this was given in a dignified manner. Menus are on a four weekly rolling programme and offered residents choice at all mealtimes; menus are varied and offer a well balanced diet. Residents said they enjoyed the food on offer. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 11 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 standard(s) 16 &18 The policies and procedures for complaints and protection of the vulnerable adult were robust. Although staff had not received formal training in this field they were aware of their responsibilities in protection of residents. EVIDENCE: There has been one complaint to the Commission for Social Care Inspection since the last inspection. The compliant was investigated by the home using their complaints procedure and was found not to be upheld. The complaints procedure was available to residents and had recently been reviewed and updated. Policies and procedures regarding protection of the vulnerable adult were in place, further information and contact telephone numbers needed to be added to the document. Staff had received no formal training in this field and a requirement has been made in this report for this to be addressed. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 12 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 standard(s) None of the standards in this section of the report were inspected during this visit. EVIDENCE: The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 &30 There are enough staff on duty at all times to meet the needs of the residents and recruitment procedures are robust. EVIDENCE: The home had a committed and experienced staff group who are able to meet the complex needs of residents in the nursing home. There were catering, laundry and domestic staff on duty seven days a week, which meant care staff did not have to undertake these duties at weekends. The registered manager has just completed her NVQ in management and felt the course had been useful. A number of care staff had commenced and/or competed an NVQ in care. The home had a full induction programme but the foundation programme in place did not meet the required standard. Trained staff are given the opportunity to attend courses. Four staff files were inspected and evidenced robust recruitment procedures are in place. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The home is managed by the registered manger who has the experience and knowledge to ensure the needs of residents are met. EVIDENCE: The registered manager Mrs Mayne is a first level nurse with many years experience of caring for the frail elderly in a nursing home setting. She with the administrator acts as the health and safety officer. Trained staff are not all first aid trained but have signed a declaration to say they are competent to deal with emergencies, which may arise in the home. Records of service contracts were in order. Staff had received fire training; further evidence was required to ensure all staff received fire training every three months. All policies and procedures were currently being reviewed and updated. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 15 The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 17 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. Standard OP18 OP24 Regulation 18 12,13 Requirement Timescale for action 31/12/05 3. OP30 12,18 Staff must receive training in the Protection of the Vulnerable Adult Residents must be provided with 31/12/05 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) All members of staff must 31/12/05 receive foundation training to National Training Organisation specification within 6 months of appointment 4. 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 OP7 Good Practice Recommendations It is recommended individual problems are kept on separate sheets in care plans. The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 18 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 The Shrubbery Nursing Home E52 S4142 Shrubbery NH(Worcs) V239892 080805.doc Version 1.40 Page 19 - 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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