Inspection on 24/05/06 for Somerset Nursing Home

This inspection was carried out on 24th May 2006.

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

Somerset Nursing Home 22/05/07

Somerset Nursing Home 18/12/06

Somerset Nursing Home 17/02/06

Somerset Nursing Home 13/07/05

Somerset Nursing Home 09/03/05

Somerset Nursing Home 15/06/04

Similar services:

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Somerset Nursing Home Somerset Nursing Home 1 Church Lane Wheldrake York North Yorkshire YO19 6AW Lead Inspector Denise Rouse Key Unannounced Inspection 24th May 2006 09:10 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 Somerset Nursing Home DS0000045154.V297305.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. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Somerset Nursing Home Address Somerset Nursing Home 1 Church Lane Wheldrake York North Yorkshire YO19 6AW 01904 448313 01904 448022 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) Roche Healthcare Limited Care Home 46 Category(ies) of Dementia (46), Dementia - over 65 years of age registration, with number (46), Old age, not falling within any other of places category (46), Physical disability (46), Physical disability over 65 years of age (46), Terminally ill (4) Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users in the category DE and PD must: (i) Be aged 50 and over and (ii) Require nursing care 13th July 2005 Date of last inspection Brief Description of the Service: Somerset Nursing home is a care home for older people providing personal & nursing care for up to 46 service users. The home is situated in the village of Wheldrake, approximately 8 miles from the centre of York, there are 14 elderly persons bungalows within the grounds of the home. The business is owned by Roche Healthcare Limited. The home provides both single and shared accommodation on two storeys and has a passenger lift. Fees range from social services rates to private rates of £525 per week for residential care and £625 for nursing. Fees include all services apart from hairdressing, dry cleaning, aromatherapy, newspapers, chiropody and private taxi hire. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit was carried out by one Inspector, from 09.10 am to 6.00pm following 2 days preparation. Evidence was gained by direct observation, talking with service users and staff, examination of policies procedures and documentation. A tour of the building was also undertaken. The pre site visit information requested from the home prior to the visit was not received by the deadline, and therefore could not be used in preparation for the site visit. The acting manager and deputy were available to assist on the day of the site visit. Surveys were left for service users, relatives and visiting professionals to be completed and sent to the Commission of Social Care Inspection. Six surveys were returned, two from service users, two from relatives, one from the General Practitioner and one from a Care Manager, all were satisfied with the home. What the service does well: What has improved since the last inspection? What they could do better: Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 6 The statement of purpose and service user guide must include information relating to service users who have dementia, and service users views about the home, to allow an informed choice to be made by potential and existing service users. Care plans and risk assessments need to be more detailed, they must be updated and reviewed, to ensure that service users needs are identified and met. Activities must be planned and provided to meet the individual social needs of all service users, including those with dementia. Staff remain committed and worked hard to care for service users, however there continues to be identified shortfalls which must be addressed. Training in dementia had not been undertaken for care staff as yet. Fire training and Appointed Persons First Aid training has not been adequately provided to ensure staff and service users safety. Managerial cover remains inadequate, this is because the acting manager works part time hours. A number of problems identified within the home were associated with the lack of monitoring of the service provided and remedial action to correct issues not being adequately implemented. The proprietor must ensure that effective managerial cover is in place, each day of the week, to ensure that the service does not continue to be adversely affected. 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. Somerset Nursing Home DS0000045154.V297305.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 Somerset Nursing Home DS0000045154.V297305.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): Standard 1 3 6 Quality in this outcome area was adequate. Service users had their needs assessed prior to moving into the care home, however there were some shortfalls relating to the information provided to help service users to make an informed choice about the home. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Intermediate care is not undertaken. The service user guide and statement of purpose had been improved and updated to include more information to enable service users and visitors to make an informed choice about the home. However some information was not included, the Statement of purpose states “ We accommodate ladies and gentlemen 60 years plus, requiring general nursing” There was no evidence within these document relating to the fact that the home provides care for service users with dementia. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 9 Service users views about the home were also not included in this documentation. This information must be included to ensure that prospective service users can make an informed choice about this service. Three service users were case tracked, there was evidence contained within their care profiles of an assessment undertaken prior to their admission. Somerset Nursing Home DS0000045154.V297305.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): Standard 7, 8, 9, 10 Quality in this outcome area was poor. While staff treated service users with respect and basic health and social care needs were met, staff were under pressure to meet service users needs, Medication systems were of poor quality, placing them at risk of harm. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Service users were seen to be treated with dignity and respect by the staff, and were seen to be addressed by their preferred names. Service users see their General Practitioners within their own rooms. Mail was delivered to service users unopened. A mobile phone and pay phone were available to service users who did not have their own phone line. The acting manager had held a staff meeting and carried out further training with the qualified and care staff regarding the completion and maintenance of documentation within the care profiles since the last Inspection. It appears that some staff have implemented this training but more training was required. Management must implement a recorded auditing system for all care profiles. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 11 This must be regularly monitored to ensure that all care profiles are completed timely, and all identified shortfalls rectified. Three service users care profiles were inspected; one had been admitted within the last 2 weeks .A pre admission assessment had taken place but no care plans had been created for two key areas, risk of falls and anxiety. This means this service users needs were not effectively transferred into action to meet there identified needs. Some nutritional and risk assessments were not dated and reviewed at least monthly or as the service users needs changed. Risk assessments were present for the three service users, but two risk assessments relating to maintaining safety and being unable to utilize the nurse call system were not dated. One-risk assessments had not been reviewed or re assessed during a 5 and a half-year period. Again this was discussed with the acting manager who stated, “ If the documentation was not there it had not been done”. Staff including the acting manager stated that they felt that the service users dependency had increased which placed care staff under pressure, basic care was being delivered, but it was stated that “ a further member of staff was required on each shift, above the current staffing notice, to allow care staff to deliver care and complete care profiles to the required standard”. The medication systems were observed, the system in place appeared of poor quality, a monitored dosage system was not in use. Medication charts for three service users were inspected. Two of these service users did not have a photograph within the medication documentation to assist the staff to identify the service user. Some medications were written on to the treatment sheet by the nursing staff .The route of the medications, start date and completion date was not recorded. Only one entry had the prescribing GPs signature recorded. Balances of medications were not always present. The nurse stated that the missing balances were recorded elsewhere. There was a gap recorded on the treatment sheet for one service user for one day, the nurse could not confirm if the medication had been given or if it had been refused. There was no indication key recorded on the treatment sheet for staff to use to clarify the reason for gaps upon the treatment sheet. One service user was self-administering medication, but a Roche Healthcare medication risk assessment had not been undertaken. Staff must ensure that an assessment is undertaken urgently to ensure this service user could maintain independence within this area. The nurse stated that the medication round in the morning takes 3 hours: the lunchtime round takes an hour. This seems an excessive time and requires further internal assessment and auditing by Roche Healthcare. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 Quality in this outcome area was adequate. The social care needs of service users especially those with dementia were not met fully. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three Service users care profiles were examined these stated their preferred activities although one document had not been reviewed since October 2004 and this service users needs had changed. Social needs were not documented within an individualized care plan. General activities were provided these were recorded in the service user guide. The part time activities co-ordinator had commenced recording the activities undertaken with service users from February 2006. Discussion with the activities co-ordinator revealed that no formal training in dementia has been received. It is vital that activities are provided which are specific for service users who have dementia. The activities co-ordinator also assisted in giving out meals to service users and carried out the afternoon tea round, although this gives contact with all service users, it would be beneficial to service users to have this time spent on specific activities with service users. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 13 The home had a programme of visiting clergy. Local bus trips were arranged periodically for service users. Visiting was not restricted. Hairdressing and aromatherapy were also available. Gentle relaxing music was being played within one lounge; a library was available with normal and large print books. One service user stated “ I know of the activities but I am not awfully keen, I’m perfectly happy on my own, doing crosswords, I can stand up and look out of the window, I am happy since I have arrived and I have settled”. The three service users who were being case tracked had no personal allowance monies held at the home. One personal allowance balance was checked and found to be correct. Service users were seen to have brought in personal items for their rooms. Visitors could see service users within the communal areas or in the privacy of their own bedrooms. Service users received a wholesome well-presented and nutritious diet. The chef was aware of special diets required by service users. The refurbished dining room was being utilized by service users who were able to socializing with each other. Hand made menus were displayed on the 3 tables stating the choice of meals available. Service users were able to eat within the lounge areas and in their own rooms. Assistance with feeding was given by care staff to service users who required this. A service user stated, “ The food was good”. The kitchen was inspected, cooked meat temperature; fridge and freezer temperatures were recorded. Stock received was rotated. A three-week rolling menu was available with adequate choice. It was noted that the chef and kitchen assistant were not wearing protective head ware in the kitchen during the morning and at lunchtime. The cleaning schedule was observed, the tray stackers had not been cleaned the day before, but they looked to have a build up of spilt food upon them. This was pointed out to the kitchen staff, acting manager and deputy. A fly screen in the store cupboard required repair to the bottom netting which had come away from the wood frame. This frame was also not fitted tightly around the window, this could allow vermin to enter the storeroom, and this must be addressed. The door leading from the reception to the dining room was held open by means of a wooden wedge; the door guard battery had stopped working that morning and was awaiting replacement by the handyman. The wedge was removed. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16, 18 Quality in this outcome area was adequate Service users can be assured that their concerns would be listened to, and acted upon. Service users were protected from abuse; however further training for staff was required in this area. This judgment has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints received since the last Inspection. The home has a complaints procedure, which was displayed at reception and available within the service users guide. Complaints were resolved within a 28day time scale. The details to contact the Commission of Social Care Inspection were available within these documents. The home had a policy and procedure for the Protection of Vulnerable Adults. New staff is about to commence a new induction programme, which appears comprehensive and covers the Abuse Policy. The induction records of two new staff were asked for to evidence that induction training had been given; these could not be observed as the staff had taken them with them. This information was faxed to the Commission for Social Care Inspection. This did not include written evidence that protection of vulnerable adults had been covered. Two key workers for the case tracked service users had received protection of vulnerable adults training. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 15 Yearly training for staff relating to abuse takes place within the home and was about to be scheduled to occur. The home operates a whistle blowing policy, which helps to protect service users from abuse. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 26 Quality in this outcome area was adequate. Service users live in a safe environment, however there were some shortfalls, relating to water chlorination and the supply of personal protective clothing for some staff, which need to be addressed. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home had recently benefited from a refurbishment of the communal lounges, library conservatory and dining room. Service users stated that they liked the new décor and furnishings. The handyman also decorates bedrooms within the home, all rooms seen were pleasant and decoration was in good order. Six bedrooms upstairs had benefited from new furniture. Service users spoken with were very pleased with these items. A lockable draw was also incorporated into the new bedside chest of drawers, to allow service users to store personal items securely. The grounds were well maintained and looked inviting. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 17 Outer door security had been improved by fitting a door closure since the last Inspection. This helps protects staff and service users from unauthorized persons being able to gain access to the home. The conservatory did not have a nurse call bell available; a hand bell was being utilized for service users to attract attention. This must be rectified. A system must be put in place to ensure that service users have access to a call bell; this has been discussed with the Commercial Manager and will be rectified as soon as possible. A tour of the building was undertaken, all areas were clean, tidy and free from any malodour. The Laundry was observed and appeared to be operating effectively. One upstairs bedroom carpet had frayed near the door; the handyman was going to attend to this, to prevent it becoming a trip hazard to staff or the service user. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 28, 30 Quality in this outcome area was poor. Service users basic care needs were met, but insufficient numbers of qualified and care staff, and inadequate training regarding the needs of service users with dementia limit the level of care provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users basic care needs were met; service users were seen to be well treated by staff. One service user stated “ I think the staff are exceptionally pleasant, they all come in smiling, they treat me with respect and always knock on the door, once I said don’t bother knocking, just walk in, but the staff said we have to knock.” Staff were observed assisting service users, they were polite and attentive. However there was some question about the level of staffing provided to meet the needs of service users. Shortfalls existed relating to Health and Safety for staff and service users, in relation to fire, First Aid Appointed Persons and dementia training, which had not been provided to ensure the homes service users and staff could be adequately protected. Dementia training was due to commence shortly. Induction training was provided for new staff. This induction was very basic and did not include protection of vulnerable adults. A new training document Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 19 has been devised and was about to be implemented; training will be more detailed and including the abuse policy, and protection of vulnerable adults. Fire training was not provided in line with the North Yorkshire Fire Service requirements; this guidance must be implemented to help ensure fire safety. Moving and Handling training was being undertaken. Ten places have been reserved for care staff to attend a Dementia course, held by Selby Collage. Only 2 staff currently holds the appointed persons first aid qualification. This is inadequate and places service users and staff at risk. The Acting manager Stated “Roche Healthcare will only let one person go on this at once”. The highlighted knowledge and skills gaps make this a poor service. Roche Healthcare have indicated that an audit will take place and that shortfalls in training will be addressed. Eight care assistants hold the National Vocational Qualification in Care qualification at level 2 or 3. On the 28,31 of May and 3,4 8,10,13,17 and 18 June the Day Duty Rota indicated that there would be 1 qualified Nurse in charge of the home between 2.00 to 8.00pm for 39 residents. This ratio is inadequate and does not allow the nurse in charge adequate time to oversee the care being delivered. There were also 4 early shifts were 1 qualified nurse would be in charge of the home, in view of the morning medication round taking 3 hours to complete this would take the nurse away from the delivery of care for an excessive amount of time, and again not permit adequate supervision of staff. This practice places staff under pressure and does not allow quality time to be spent with service users or allow quality time for reviewing care profiles. This must be addressed. The acting manager and staff stated that “Service users needs had increased over the last 2 years, they were more highly dependant” both felt that an extra member of staff was required on each shift to meet the high service users needs, Above the staffing levels already deployed. Another qualified nurse stated, “ I’m generally frustrated at Roche Healthcares attitude, nurses have to give general care and don’t have adequate quality time to provide either good care or ensure up to date paperwork.” These areas of concern must be addressed by the management team. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 38 Quality in this outcome area was poor. Service users financial interests were safeguarded. Ineffective managerial auditing and lack of cover over a 7-day period may place service users at risk. There were shortfalls relating to health and safety for staff and service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ineffective managerial auditing and action means that the home is not run in the best interests of service users and their health and safety is not always protected. Managerial cover within the home was problematic with the acting manager working part time and the support arrangements not being clear. The acting manager has not completed the registration process with the Commission and Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 21 this must be addressed. Roche Healthcare must inform the Commission of their arrangements to provide adequate managerial cover in the acting managers absence. Internal managerial monitoring of the home was irregular and in some areas, inadequate. The acting manager had audited all care profiles in January 2006, but did not record her findings, shortfalls in monthly evaluations; gaps in monitoring care plans and risk assessments were still evident. One new service user had not been allocated a key worker on the care profile documentation. Other audits such as accident monitoring within the home and the running of the kitchen had also taken place. There were no regulation 26 reports available within the home, for a long period of time, to evidence that the registered provider was checking how the home was run. The acting manager stated that monitoring visits had been made but not recorded as required. Roche Healthcare have a Quality Assurance Manager who will review quality issues at the home, The acting manager stated that “the aim was to make sure all service users were treated with respect and dignity”,” Audits were carried out on an as and when basis”, with questionnaires sent out to new admissions. However as part of this process, the acting manager had not gained the views of social workers and local general practitioners by means of a questionnaire, which was due to be sent out shortly after the last Inspection. Resident and relatives meetings had not been commenced. Yearly screening of service users and relatives views relating to the care home does not appear to have been undertaken. The views of service users and other interested parties have not therefore been sought in order to improve the service provided within the home. Service users personal allowance accounts were checked, the balances were found to be correct. Receipts were kept with the balance statement for each service user. The acting manager does not act as appointee for any service user. Service users financial interests were safeguarded within the home. The health safety and welfare of service users was not always appropriately promoted and protected. The home had general risk assessments in place but some staff were not aware of these documents and did not have them for specific tasks they had to undertake. Some staff had also not been provided with appropriate protective clothing. General maintenance was undertaken and there was evidence that lifts and hoists were serviced and maintained. Safety certificates were available for gas and electrical appliances and fire systems had been tested and maintained. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 22 However the water chlorination certificate was not in date this chlorination procedure had expired in February. This was pointed out and must be rectified The hot water temperatures supplied to the visitors toilet was too high at 63.5 degrees centigrade, this must be rectified by fitting a valve to this supply within 7 days. A bolt was available on the door to prevent service users accessing this area. The kitchen hot water supply was also above 43.0 degrees centigrade; action must be taken to address this. A clinical waste disposal contract was in operation for the home. There was no evidence of a clinical waste contract for medications. The acting manager phoned the pharmacist who stated that they had a contract to dispose of medications; the home must have a copy of this certificate. Further discussions with Roche Healthcare management, clarified that this issue required further investigation. The disposal of medications must be conducted in line with current law and legislation. The Commission of Social Care Inspection must be advised of the outcome of this investigation and actions to be taken. Somerset Nursing Home DS0000045154.V297305.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 456 Requirement The registered person must ensure the Statement of Purpose and Service User Guide contains sufficient information to enable potential service users to make an informed choice about where they wish to stay. And must include information relating to Service users with dementia using the service. And service users views who reside in the home must be included. 2. OP7 15 (1) (2) The registered person must 17/07/06 ensure that service users Care profiles are completed in enough detail to ensure adequate care can be provided. All entry’s must be signed and dated. Care plans and risk assessments must be reviewed and updated at least monthly or when the service users need change. Care plans for new service users must be created within one week. Service users and/ or their representative must be invited to DS0000045154.V297305.R01.S.doc Version 5.2 Page 25 Timescale for action 01/07/06 Somerset Nursing Home be involved with this process. OUTSTANDING REQUIREMENT FROM THE LAST INSPECTION. 3. OP8 12 (1) (a) The registered person must ensure that nutritional screening is undertaken for all service users who have care needs in this area. This must be adequately reviewed Records must be maintained of weight, and all appropriate action taken. Weighing equipment must be provided, to allow this to be undertaken in a timely manner. 4. OP9 13 (2) Medication policies and procedures must be in line with the current Royal Pharmaceutical Society guidelines and Nursing and midwifery Council guidance. A copy of the medication waste disposal certificate must be available within the home, and a copy sent to the Commission for Social Care Inspection. Service users who wish to self medicate must have the necessary assessment undertaken and documented. To ensure they are safe to do so. The registered person must ensure that service users Social interests are recorded within a care plan. Activities must be provided which are suitable for individual service users assessed needs. Especially those with Dementia. Tray storage racks in the kitchen must be cleaned thoroughly. DS0000045154.V297305.R01.S.doc 30/07/06 17/07/06 5 OP9 12 (1) (b) 24/05/06 6 OP12 16 (n) 30/07/06 7 OP15 16 (g) 17/07/06 Page 26 Somerset Nursing Home Version 5.2 8 OP27 18 (1) (a) The fly guard in the food storeroom must be repaired, and refitted to ensure there is no gap between the wall and the wooden frame. The registered provider must 24/05/06 ensure enough suitably qualified nurses are deployed within the home at all times. Care staff must also be present in sufficient numbers to be able to meet the needs of all the service users. These issues must be maintained from the date of this inspection. OUTSTANDING REQUIREMENT FROM THE LAST INSPECTION. 9 OP30 12 (b) The registered person must ensure all care staff receive Training in dementia. Appointed Persons First Aid training must be provided to ensure that the home has adequate cover, over a 7-day period. Fire training must occur in line with the North Yorkshire Fire Service Guidelines. All training must be documented. 30/08/06 10 OP31 12 (a) The provider must ensure that 17/07/06 there is adequate managerial cover over a 7-day period. So that the quality of the service does not deteriorate in the acting managers absence. Details of this must be supplied in writing to the Commission for Social Care Inspection. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 27 11 OP38 13 (4.) (c) A valve must be fitted to the hot 01/06/06 water supply in the visitor’s toilet to prevent the risk of scalding. The hot water supply in the kitchen must have a caution hot water sign placed above the tap. Assessment of the water tanks must be carried out to assess if chlorination to prevent the risk of legionella, is required. Evidence of this procedure must be sent to the Commission of Social Care Inspection upon completion. 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 OP38 Good Practice Recommendations The handyman should be provided with work related protective clothing, steel toe capped boots. The chef and kitchen assistant should be provided with protective head ware. The Roche management team should undertake a full audit of the medication systems in place within the home, and correct any shortfalls found. Medication balances should all be recorded on the service users treatment sheet. The part time activities co-ordinator should be encouraged to spend one to one time with service users or provide group activities if requested, rather that undertake communal tea rounds. A list of local Advocacy providers should be available within the home. Information relating to the Roche management teams regulation 26 visits should be recorded. A copy should be retained within the home and one should be sent to the DS0000045154.V297305.R01.S.doc Version 5.2 Page 28 2 OP9 3 OP12 4 5 OP14 OP26 Somerset Nursing Home 6 7 OP38 OP35 Commission for Social Care Inspection for review. A risk assessment relating to the handyman cutting the lawn should be created with his input. Roche Healthcare management team should undertake and complete a full audit of all documentation and services within the home, commencing on 21/06/06. Evidence of the audit findings should be sent to the Commission for Social Care Inspection, all shortfalls found should be addressed. Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Somerset Nursing Home DS0000045154.V297305.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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