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Inspection on 16/05/05 for South Hayes Care Home

Also see our care home review for South Hayes Care Home for more information

This inspection was carried out on 16th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Following two inspection visits and ongoing monitoring visits of the service the inspector at the time of writing this report was unable to make any comment on what the home did well.

What has improved since the last inspection?

Since the last inspection the home has not actioned any of the requirements from the last report. The general condition of the home has not improved and residents told the inspectors of a number of outcomes and expectations which have not been achieved to improve the quality of their life in the home.

What the care home could do better:

All aspects of care, health and safety, environment, training of staff and stability of staffing in the home needed addressing. The home needed to attend to a number of health and safety risk areas identified during the visits immediately. The employment of a stable management and workforce team was paramount.

CARE HOMES FOR OLDER PEOPLE South Hayes Nursing Home 101 London Road Worcester Worcestershire WR5 2DZ Lead Inspector Chrissy Presley Unannounced 16 & 26th May 2005 15.00 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. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service South Hayes Nursing Home Address 101 London Road Worcester WR5 2DZ 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 357429 01905 357429 Regal Care (Worcester) Limited Care Home with Nursing 48 Category(ies) of OP Old Age - 48 registration, with number PD(E) Physical Disabilities (over 65) - 48 of places South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 December 2004 Brief Description of the Service: South Hayes Nursing Home is a large, detached, three storey building, which attracts a listed status. Situated approximately half a mile from Worcester City Centre, it occupies an elevated position set back from the road, and is approached by a short drive leading to a car parking area. The home is registered to provde nursing care for up to 48 elderly residents, who may also have a physical disability. The home is not registered to provide care for residents with dementia or who suffer a mental health problem. The stated aim of the home is to provide the best quality life for residents in an environment which is clean, comfortable, safe and welcoming, and where people are treated as individuals with respect and sensitivity. The home has been owned by Regal Care (Worcester Ltd) since 1998. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a two-day period. Ten residents were spoken to during the course of the inspections together with a number of relatives and other visiting professionals. Due to concerns about the lack of management and concerns for the health and safety of residents a number of monitoring visits have continued following the inspection, and will do so for the foreseeable future. Information gained at these visits is also included in this report. Staff on duty were interviewed this included the cook, assistant cook and housekeeper. Care plans, records, policies and procedures were discussed during the inspection. The inspectors walked round the premises. The acting manager was leaving on Friday 20th May 2005 and to date the home does not have a replacement manager in post and is using staff from its other homes to carry out management tasks to ensure safety of residents. What the service does well: What has improved since the last inspection? Since the last inspection the home has not actioned any of the requirements from the last report. The general condition of the home has not improved and residents told the inspectors of a number of outcomes and expectations which have not been achieved to improve the quality of their life in the home. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 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. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 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 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 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 The assessment documentation used was comprehensive; the information contained in the assessments was not used to create a care plan. EVIDENCE: Four care plans were seen and contained an assessment of need, the acting manager carried out assessments prior to admission of all residents. The information contained in the documentation was comprehensive, but was not used to create a care plan and in one case this had not been completed, signed and dated. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 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) 7,8,9,10 The complex needs of residents were not being addressed and in some cases residents were at risk from poor practice techniques. EVIDENCE: During visits a number of residents’ care plans were looked at. Care records did not support the work being carried out by staff and on several occasions the inspectors observed staff inappropriately moving and handling residents and ignoring requests for assistance. Information regarding care needs was not specific and staff were not seen to be using the care plans to check care needs. The home used a high number of agency staff and from records seen care plans did not give enough information to these staff to ensure care could be carried out safely. This included care plans for residents who had diabetes, the care plans did not detail their normal range of blood sugar levels and did not accurately record the frequency in which blood sugar levels should be monitored and recorded. Monthly reviews did not reflect what had happened in the previous month and significant events were not noted. Residents who had been identified, as at high risk of developing pressure sores had not been placed on appropriate mattresses to reduce the risk. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 10 Records of pressure sores were seen, these had not been reviewed or updated consistently, the inspector asked the trained nurse on duty how many pressure sores the home had and her response was none, on checking the records there were found to be eight residents with varying degrees of pressures sores. The tissue viability nurse told the inspector poor moving and handling techniques and inappropriate mattresses on beds had caused many of these. The inspector was told that five pressure-relieving mattresses were being repaired. Residents spoken to said they had little to do during the day and were not left with means of calling for assistance this meant they had to re-sought to shouting ‘help’ to gain the attention of nurses. The pharmacy inspector from the Commission for Social Care Inspection paid a brief visit to the home and found a number of medication signature gaps; a recent anti-biotic prescribed for 14 days had taken 21 days because nurses forgot to give the medication. An agency-trained nurse spoken to by the inspector was still a little uncertain about how to use a ‘pen-type’ insulin administration of medication and was in charge of a shift over the weekend. One resident spoken to said he had been waiting for half an hour for painkillers. There was further evidence that nine residents did not have their lunchtime medication. Staff were observed interacting with residents and residents felt they did their best, residents said they had to wait to go to the toilet as staff were too busy, Two Romanian nurses had little command of the English language. A number of immediate requirements were left with the home and further requirements to ensure the safety of residents have been given to the home on monitoring visits, which are continuing. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 The food offered by the home is of poor quality and this is voiced by residents. There are no activities on a regular basis that ensure all residents have access to a stimulating programme of activities. EVIDENCE: Residents spoken to said they had little to do during the day. The home had employed an activities co-ordinator, but records kept did not ensure all residents were offered a meaningful and stimulating programme of activities. On the day of the inspection six residents had been taken for a ride in the home’s minibus, the minibus was not discreetly labelled and had South Hayes Nursing Home written in large letters on both sides of the vehicle. Food on the evening of the 16th May was fish fingers and a small spoonful of spaghetti; one resident was asked if she was enjoying this she said it was cold. The inspector asked for another meal, the kitchen assistant who was 17 years of age and managing the kitchen that evening had little understanding of the resident who was a diabetic nutritional needs. Menus seen did not evidence residents were offered a suitably nutritious diet; the home used offal such as faggots and sausages on a number of occasions each week rather than prime meat. On the 17th May lunch was observed to be bacon chops, these were overcooked and looked dry and were not suitable for the current resident group. There was fresh fruit in the pantry in the home the South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 12 cook said this was thrown away on many occasions, as residents were not offered fruit on a regular basis by staff. Care plans did not evidence specific nutritional needs for residents i.e. finger foods. There were only enough facilities for residents to be seated in the dining room therefore residents were given their meals at their chair in the lounge. A number of immediate requirements have been made, to ensure residents are not nutritionally compromised. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 13 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 Policies and procedures for complaints and the protection of the vulnerable adult had not been developed or implemented. Staff had no training in this field. EVIDENCE: There is currently an ongoing Vulnerable Adult Protection investigation, the outcome has not yet been decided, and related to the care of a resident. The complaints procedure was posted in the hallway of the home, the nurse in charge was asked for a number of key policies and procedures regarding complaints, whistle-blowing, protection of the vulnerable adult, residents monies and safekeeping, storage of valuables and staff involvement in gifts from residents, these could not be found. Residents did not have a facility whereby they could lock their door if they chose and not all residents had a lockable storage facility in their bedroom. Staff had not received training in protection of the vulnerable adult. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 14 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) 19,20,21,22,23,24,26 Environmental and health and safety issues identified during the visits risked the safety of residents in the home. EVIDENCE: The home had a stale odour in the entrance hall and sitting room of the home. The home employed a housekeeper who had been recently employed and was attempting to ensure rooms were kept clean and tidy. A number of environmental issues, which risked the health, and safety of residents were noted and immediate requirements were left with the home. • Service users were left without means of summoning help in bedrooms and other areas of the home • There was only one carpet-cleaning machine in the home and staff had difficulty maintaining hygiene in the home. • There was no on-going maintenance programme • The fire log book was not up to date and fire bells had not been tested regularly South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 15 Sash cords were broken on windows and some windows were not fitted with window restrictors. Some windows did not open at all • Carpets were noted to be threadbare in some bedrooms • Hoists seen were dirty and one was in need of a repair • Bolts were fitted to the outside of doors in the home, this caused a potential hazard to residents if they became accidentally locked in • Fire doors had been damaged by wheelchairs and did not close on rebates and one fire door had been sealed up • Door handles were broken • Wheelchairs did not have footrests, and the lift could not accommodate a wheelchair with footrests which meant staff had to take the footplates off and then replace them if they needed to move a resident upstairs by use of the lift. • A bedroom was currently being occupied by two care staff, the room did not have a lock or en-suite facility • Several wardrobes were not attached to the wall and were deemed unsafe. • Extractor fans around the home were not in working order • Some areas in the home were either too hot or too cool • Water temperatures had not been recorded and water in excess of 70 degrees centigrade were recorded • Clinical waste was not being dealt with appropriately and an immediate requirement had been left with the home to fit a mechanical sluice. • A number of bedrooms were small and could not accommodate a resident who required care from nurses either side of the bed. • Not all rooms had a suitable lock or lockable furniture in their bedroom • Not all rooms had basic minimum furnishings and there was no evidence in care plans of reasons why • The public address system seemed intrusive • The infection control policy and procedure could not be found and from observation of staff infection control protocols were being breached which risked the health of staff and residents • There was no evidence in care plans seen of furnishings belonging to residents • Bathrooms were noted to be out of use and a hoist in one bathroom was not working • A number of hot and cold taps were not working • Radiators in some rooms were cool even though they were turned up fully • Boilers did not deliver hot water to areas of the home at all times • There were no separate toilet facilities for residents on the second floor • Toilets were found not to be working Immediate requirements have been left with the home which have not been addressed. • South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 16 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 The staffing arrangements in the home is not sufficiently robust to provide safeguards for the residents living there. EVIDENCE: The acting manager left the home on 20th May 2005; the Responsible Individual has interviewed a number of potential managers however he has still not appointed a suitable candidate. There is currently no deputy manager in the home either. From duty rotas seen there were a high number of agency trained staff over lengthy periods and agency staff were working excessive hours. The Responsible Individual was invited into the Commission to discuss this; as a short-term arrangement a manager from one of the other homes in the group is currently seconded for two weeks. The Commission is continuing to monitor the situation closely. Staff spoken to said their training needs were not met a number of staff had not received up to date core training in moving and handling, first aid, fire training or food hygiene. This became clear when staff were observed moving and handling a resident. There were not enough kitchen staff to ensure residents received an adequate diet. Four staff files were seen and it was evident the home was not following rigid procedures as set out by the Care Homes Regulations 2001 to ensure the safety of the vulnerable adult. Criminal Record Checks had been transported South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 17 from other homes and POVA first checks had not been carried out on a number of trained staff. The home had had a large turnover of staff in the past six months; this included both trained staff and carers. There was no induction or foundation programme for staff in place and staff told the inspectors they had not received training. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 18 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) 33,35,38 The current management crisis within the home places residents and staff at risk. The Responsible Individual has not addressed any of the requirements or recommendations from the last report or immediate requirements left within the home during visits. EVIDENCE: There was no quality assurance system in place that evidence information had been collated into a report. There was no evidence that emergency lighting had been tested or fire bells for a number of months. The fire risk assessment was out of date. There was evidence of two recent fire drills the time of the drill was not noted on one and they were unsigned the inspector was therefore unsure who had instructed staff and if they were appropriately qualified. There was no named first aider on each shift. Wiring in the visitor’s toilet appeared to be crumbling and unsafe. A legionella risk assessment could not be produced. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 19 The environmental risk assessment was not in place. There was no overall record of health and safety and core training to be undertaken by staff and no plan in place for future training of staff. Further immediate requirements have been left with the home regarding electrical safety. South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 20 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 x 15 1 COMPLAINTS AND PROTECTION 1 1 1 1 1 1 1 1 STAFFING Standard No Score 27 1 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 1 x 1 x 1 x 1 1 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 21 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. Standard OP3 Regulation 14 Requirement The nurse who undertakes the assessment process must ensure that all aspects of the document are completed in full, are signed and dated and information gained at this time forms the basis of the care plan to ensure the home can meet the needs of the residents being admitted. Care plans for residents with diabetes must be updated to included normal blood sugar levels for each person and must accurately specify the frequency at which levels are to be monitored and recorded. Blood sugar levels of residents who have diabetes must be monitored and recorded at a minimum of twice daily or as required by the medical practitioner. Individual risk assessments in relation to developing pressure sores and sustaining falls must be reviewed and updated at least monthly. The five pressure relieving mattresses currently not working must be in working order Evaluations of care plans must Timescale for action immediate 2. OP7 13 (1) 15(1) immediate 3. OP7 13(2) 15(1) immediate 4. OP7 12(1) 13(4) immediate 5. 6. OP7 OP7 13 15 by 10th June 2005 immedaite Page 22 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 reflect the current situation 7. 8. 9. OP7 OP7 OP7 12 & 13(4) 15 15 Residents who require assistance to go to the toilet must be attended to immediately The residents care plans must cover all aspects of care as set out in standards 7.2 and 3.3 Unless it is impracticable residents or their representatives must be involved in drawing up their care plan. All medication must be administered and prescribed and records signed accordingly. All staff administering medication should do so in accordance with the homes policies and procedures for the safe administration of medication and action to be taken in the event of an error occuring. A record should be kept indicating when each member of staff is made aware of the procedures. Agency staff must be competent when giving insulin. Residents must have means of summoning help via a call bell system in all areas of the home There must be enough activities offered to residents which are stimulating and meaningful. A record of the activities must be kept. There must be enough seating facilities for all residents to sit if they wish at the dining table in the dining room. Records of food given to residents must be kept Care plan records must identify the types of food residents are able to manage to maintain their independence such as finger foods The complaints policy and procedure must be readily immediate by 31st May 2005 by 30th June 2005 immediate immediate 10. 11. OP9 OP9 13(2) 13(2) 12. 13. 14. OP9 OP10 OP12 13(2) 12, 16 & 23 16 immediate immediate by 30th June 2005 15. OP15 23 by 31st July 2005 immediate immediate 16. 17. OP15 OP15 17 17 18. OP16 22 by 15th June 2005 Page 23 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 19. OP18 12,13 20. 21. 22. OP18 OP18 OP18 & 24 12,13 18 12,13 23. OP18 & 24 12,13 24. 25. 26. 27. 28. 29. 30. 31. 32. OP21 OP21 OP24 OP19 OP19 OP19 OP19 OP19 OP19 23 13 17 13,16 23 23 13 23 13 & 23 available to residents and staff and open to inspection. Procedures for responding to suspicion or evidence of abuse or neglect (including whistleblowing) must be drawn up in accordance with the Public Interest Disclosure Act 1998 and the Department of Health Guidance No Secrets. A Whistle-blowing policy must be drawn up and implemented Staff must have training in protection of the vulnerable adult Residents must be provided with keys to their bedrooms unless a risk assessment suggests otherwise Residents must be provided with lockable storage space for medication, money and valuables and a key which he or she can retain unless the reason for not doing so is explained in the care plan. Bathrooms that have been agreed as part of the registration must be kept in working order Bath temperatures when residents are bathed must be recorded Records must be kept of furnishings belonging to residents Residents must have a call bell at all times The home must be kept odour free at all times The fire log-book must be brought up to date and equipment tested regularly Sash cords in bedrooms must be repaired Carpets that were noted as threadbear and worn must be replaced Mobile hoists must be cleaned by 30th June 2005 by 7th June 2005 by 30th June 2005 31st July 2005 by 31st July 2005 by 30th June 2005 immediate by 30th June 2005 Immediate immediate immediate by 30TH June 2005 by 31ST July 2005 immediate Page 24 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 33. 34. 35. 36. 37. OP19 OP19 OP19 OP19 OP19 13 23 13 & 23 13 13 38. 39. 40. OP19 OP19 OP19 13 13 13 41. 42. 43. OP19 OP26 OP26 13 13 13 44. 45. OP26 OP19 13 23 46. OP19 13 & 23 Bolts must be removed from the outside of all doors and keypad locks fitted Fire doors must not be wedged; and must close on rebates Door handles must be repaired and in working order Wheelchairs in constant use by residents must have foot rests on at all times A bedroom currently occupied by two staff must be fitted with a lock and an identified bathroom for their use must be provided Wardrobes must be attached to the wall for safety Extractor fans must be in working order Thermostatic control valves must be fitted throughout the home on all baths and sinks and records of water temperatures must be kept, in the meantime all areas where residents have access to hot water must be risk assessed A legionella risk assessment must be carried out TIMESCALE OF 31/01/05 NOT MET Clinical waste must be dealt with appropriately An infection control policy must be drawn up and implemented and an infection liason nurse must be identified within the nursing team A mechanical sluice must be fitted The laundry room door must not be wedged open and must be locked at all times when not in use The passenger lift must be replaced to ensure residents can be moved safely between floors with enough room to ensure footplates can be kept on Immediate Immediate Immediate Immediate Immediate Immediate by 7th June 2005 BY 30th August 2005 By 30th August 2005 Immediate By 7th June 2005 BY 31st July 2005 Immediate BY 30TH June 2006 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 25 wheelchairs at all time 47. 48. 49. 50. 51. OP19 OP19 OP19 OP19 OP19 23 13 13 &23 23 23 The bathroom hoist identified during the inspection must be in working order Windows must be able to be opened and window restricitors fitted There must be hot and cold water avaiilable in all rooms All toilets must be in working order Boilers in the home that are currently not working efficiently to deliver hot water at all times to the bedrooms and other areas of the home must be either replaced, or serviced and repaired The premises and facilities must be assessed by a suitably qualified person and specialist equipment provided as necessary to enable residents to maximise indepedence TIMESCALE OF 30/09/04 NOT MET Suitable qualified, competent and experienced staff must be employed to work at the home as are appropriate to the health and welfare of the residents TIMESCALE IMMEDIATE AND ONGOING FROM THE LAST INSPECTION NOT MET Suitable kitchen staff who have the training and knowledge of the resident group must be employed in enough numbers Staff must receive training in moving and handling, infection control, fire safety, first aid By 15th June 2005 Immediate By 7th June 2005 By 7th June 2005 By 31st August 2005 52. OP22 16 & 23 By 31st August 2005 53. OP27 18 Immediate and onging 54. OP27 18 Immediate and ongoing Immediate and ongoing but by 30th June 2005 Immediate 55. OP27 18 56. 57. OP27 OP29 18 19 Agency staff must not work excessive hours Recruitment procedures must be Immediate developed in accordance with the E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 26 South Hayes Nursing Home 58. OP29 19 59. OP30 12,18 60. OP30 12,18 61. OP30 18 62. OP31 8 63. OP31 18 64. OP32 10 & 12 requirments of Regulation 19 Schedule 2 and Standard 29 Disclosure checks from the Criminal Records Bureau and POVA first must be obtained before staff commence work All members of staff must receive induction training to National Training Organisation specification within 6 weeks of appointment of their posts.TIMESCALE OF IMMEDIATE AND ONGOING FROM THE LAST INSPECTION NOT MET All members of staff must receive foundation training to National Training Organisation specification within 6 months of appointment to their post. TIMESCALE OF IMMEDIATE AND ONGOING FROM THE LAST INSPECTION NOT MET All staff must receive a minimum of three days paid training per year (including in-house) training and have individual training and development assessments and files TIMESCALE OF IMMEDIATE AND ONGOING FROM THE LAST REPORT NOT MET Appropriate and suitable management arrangements must be made by the Responsible Individual in the home A member of staff must be identified on each shift as to who is taking management responsibility for that shift A clear sense of direction and leadership must be communicated to staff and residents which is understandable and related to the aims and purpose of the home TIMESCALE OF IMMEDIATE AND ONGOING FROM THE LAST Immediate immediate Immediate Immediate Immediate and ongoing Immediate and ongoing Immediate and ongoing South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 27 INSPECTION NOT MET 65. OP33 24 The quality assurance system must be further developed in accordance with the requirements of Regulation 24 and Standard 33 and the results of surveys published TIMESCALE OF 30/09/04 AND 31/03/05 NOT MET Visits to the home by the registered provider must take place at least once a month in accordance with the requirements of Regulation 26 TIMESCALE OF IMMEDIATE AND ONGOING FROM LAST INSPECTION NOT MET The person carrying out the monthly visit must prepare a written report on the conduct of the care home and supply copies to the Commission, the registered manager and the registered provider in accordance with the requirements of Regulation 26 TIMESCALE OF IMMEDIATE AND ONGOING FROM THE LAST INSECTION NOT MET There must be at least one member of staff on duty at all times day and night who is trained in first aid to at least the level of an appointed person A complete electical check of wiring in the home must be undertaken by a qualified electrician and that report submitted to the Commission The fire risk assessment must be updated A written statement of the policy, organisation and arrangements for safe working practices must be drawn up and implemented An environmental risk Immediate and ongoing 66. OP37 26 Immediate 67. OP37 26 Immediate 68. OP38 13 Immediate 69. OP38 13 Immediate Notice 70. 71. OP38 OP38 13 & 23 13 By 30th June 2005 Immediate and ongoing Immediate Page 28 72. OP38 13 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 assessment must be carried out 73. OP38 23 74. *RQN 75. PART 11 (SECTION 24) CARE STANDAR -DS ACT 2000 -- There must be evidence to support that all staff have received fire training at least three monthly by a suitably qualified instructor The home must not admit any Immediate resident into the home that breaches Registration categories. and ongoing Immediate 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. 2. Refer to Standard OP15 OP18 Good Practice Recommendations It is recommended the food trolley is replaced with a more appropriate style of trolley which would assist staff to deliver food to residents more safely. A policy should be developed and implemented regarding residents monies and financial affairs, ensuring residents access to their personal financial records, safe storage of money and valuables, consultation on finances in private, advice on personal insurance and preclude staff involvments in assisting in the making of or benefiting from residents wills. The need of the public address system throughout the homeshould be reviewed and the possiblity of deactivating the one used considered A programme of routine maintenace and renewal of the fabric and decoration of the home should be produced and implemented 3. 4. OP22 OP19 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 Page 29 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 South Hayes Nursing Home E52 S4144 South Hayes NH V223814 160505.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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