Inspection on 13/11/06 for Staplehurst Manor Nursing Home

This inspection was carried out on 13th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Staplehurst Manor Nursing Home 24/04/07

Staplehurst Manor Nursing Home 09/01/06

Staplehurst Manor Nursing Home 28/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Staplehurst Manor Nursing Home Staplehurst Manor Frittenden Road Staplehurst Tonbridge Kent TN12 0DG Lead Inspector Elizabeth Baker Key Unannounced Inspection 13th November 2006 10:00 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 Staplehurst Manor Nursing Home DS0000026207.V315242.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. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Staplehurst Manor Nursing Home Address Staplehurst Manor Frittenden Road Staplehurst Tonbridge Kent TN12 0DG 01580 891251 01580 890150 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) www.bupa.com BUPA Care Homes (BNH) Limited Louise Mary Foster Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 31 People aged 50 and above who require nursing care by reason of physical disability, terminal illness or older age. To include provision for 6 people aged 40 and over who are terminally ill. 9th January 2006 Date of last inspection Brief Description of the Service: Staplehurst Manor is a large converted house on three floors standing in its own grounds close to the village of Staplehurst. The home is owned and managed by BUPA. The grounds include a secluded garden and patio area accessible to residents. There is a main line station close by, as well as local shops, a Post Office, Library and Community centre. There is also a nearby herb and garden centre. There is ample car parking at the front of the home. All bedrooms are used for single occupancy. 20 bedrooms have ensuite WC facilities. There is a passenger lift giving access to all floors. There is also a stair lift for four rooms not accessed by the other lift. All rooms used by residents are connected to the call bell system. Current fee charges range from £850 to £1100 per week. Additional charges are payable for chiropody, physiotherapy, hairdressing, newspapers and beauty therapies. A copy of the latest inspection report is kept in the main reception room. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced key visit to the home for the inspection period 2006/07. Lead Inspector Elizabeth Baker and Regulatory Inspector Helen Martin carried out the visit on the 13 November 2006. As well as touring the home, the visit consisted of talking with some residents and staff and inspecting some records for case tracking purposes. Three residents, one visitor and two members of staff were interviewed in private. A number of other residents, staff and a healthcare professional were also spoken with. Feedback was provided to the home manager at the conclusion of the visit. At the time of compiling this report, in support of the visit, the Commission received comment cards abut the service from nine residents, eight relatives/visitors and two health and social care professionals. At the Commission’s request the home manager completed and returned a preinspection questionnaire. Some of the information gathered from these sources has been incorporated into the report. At the time of the visit 30 residents requiring nursing care were residing at the home. The Commission has not received any formal complaints about the home. What the service does well: Additional comments contained in comment cards received by the Commission in support of the visit from health and social care professionals included “In my opinion this is a very good nursing home. Always well staffed, both patients and staff always happy”. Positive comments from relatives/visitors included “the manager and assistant manager and all the staff are always approachable, friendly, helpful and polite”; “We are very pleased with the care”; “I am very pleased with the excellent care, no complaints, kept informed”; “Regular carers are most pleasant and hard working”. Positive comments made from residents during the visit included “It’s like a first class hotel, meals are 10 out of 10”; “manager is excellent and full understands my needs” and “staff are very good and helpful”. Before deciding on whether to move into the home on a permanent basis prospective residents are able to stay at the home on a trial basis. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. Staplehurst Manor Nursing Home DS0000026207.V315242.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 Staplehurst Manor Nursing Home DS0000026207.V315242.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose is inadequate and does not provide prospective residents with sufficient information for them to make an informed choice. All residents are aware of the home’s terms and conditions of residence. EVIDENCE: All residents are provided with a contract or terms and conditions of stay. In addition to this residents are supplied with a Welcome to Staplehurst Manor document incorporating the Statement of Purpose and Service User Guide. This provides useful information to prospective and existing residents. However a review of the document presented at the visit identifies that some of the information is out of date, including the name of the home manager. The document is undated. The review also identified that some of the information for prospective residents and or their advocates is not detailed enough, including the numbers and sizes or rooms. Guidance on the contents of Statement of Purpose is available on the Commission’s website Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 9 www.csci.org.uk. This may assist the home manager in expanding the document Registered Nurses assess prospective residents in their current environments prior to a decision of admission being made. Information is also obtained from care management where appropriate. Information gathered at these visits is recorded on pre admission forms. These documents are used to determine whether the home can meet the prospective resident’s needs. However not all the forms inspected were complete of all fields and may result in vital information being missed. Residents are able to stay at Staplehurst Manor on a trial basis. This is good practice as it helps prospective residents get a feel about the home before deciding on whether to move in on a permanent basis or not. The home is not registered for provide intermediate care. Standard 6 is not applicable. Staplehurst Manor Nursing Home DS0000026207.V315242.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are potentially at risk because care and medication records are not adequately maintained. EVIDENCE: Residents are provided with a care plan. To supplement the plans a range of clinical risk assessments are available to monitor the effectiveness of the plans. These cover subjects such as skin integrity (Waterlow model), moving and handling, risk of falls, nutrition and continence. However not all the care plans included such assessments, despite the plans indicating the residents had assessed needs. One care plan identified a significant weight loss. There was no recorded evidence the matter had been investigated. The nutritional assessment used to monitor the situation ‘ ‘Malnutrition Universal Screening Tool’ (MUST) was incomplete. A healthcare professional provides regular physiotherapy for the resident. The healthcare professional described how much the resident’s condition had improved. Sadly there was minimum information about the input provided or progress made in the resident’s Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 11 corresponding care records. Indeed the care plan was contradictory to the resident’s current mobility situation. The home manager said only one resident has a pressure sore and this was acquired in hospital. The home has a stock of pressure relief/preventative equipment, which is provided to residents on an assessed needs basis. For a resident whose condition makes them prone to falls, there was no accompanying falls risk assessment. This is despite the resident having had a recent fall. The resident’s care plan included a risk assessment relating to the room. However the assessment was incomplete of all the risks seen in the room at the time of the interview. It was difficult to establish from the plans inspected whether residents’ social aspirations were being met as they focused primarily on residents’ nursing needs. None of the care plans inspected had recorded evidence they had been composed with input from the residents and or advocates. Registered Nurses administer medications. Medication administration record charts are used to record details of medicines administered. However not all registered nurses are completing the charts as required by their Professional Body. For example recording doses of medicines and administration frequencies by the use of symbols and Latin abbreviations. Some registered nurses may not understand what the symbols and abbreviations mean, therefore presenting potential risks to residents. Where residents had been prescribed medicines on a administer when required basis, there was no care plan component to provide the specific administration details. This resulted in inaccurate analgesic information being maintained with the corresponding medicine administration record (MAR) chart in one case. In another case there appeared to be some confusion as to what the resident was actually supposed to have been taking with regard to a particular condition. Indeed the MAR chart contained four entries for the medication. Only one of the entries was cross-referenced to the corresponding care plan. The home manager was of the view that two of the entries may have been a duplicated. The resident is fully aware of their condition and dependency of the prescribed medication. The resident inferred they do not always get the medication at the most effective times and felt their condition would be better managed if they could self-administer the medication. The resident had no idea why they could not do this. Disappointedly there was no recorded evidence in the resident’s care records that an assessment for self-medicating had been carried out to support the home’s decision. Another resident mentioned they sometimes receive their medications a bit late. Where specialist advice had been provided to assist a resident in taking their medication this had been recorded in the daily records and not included in the care plan. As daily records are removed on a regular basis for storing separately, this vital information may be lost. It was recommended that the home manager obtain a copy of the Royal Pharmaceutical Society of Great Britain’s publication “The Administration and Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 12 Control of Medicines in Care Homes and Children’s Services” (June 2003). Contact details were provided at the conclusion of the visit. Comment card respondents indicated that communication could be a problem. A resident also mentioned this during the visit. Good communication, whether verbal or written, is vital in ensuring appropriate care is delivered to residents. Residents were complimentary of the laundry service, which is carried out inhouse. Residents and or their families are requested to ensure clothes are marked so they are returned to the rightful owners after laundering. Residents seen looked appropriately dressed for the time of day and season. A hairdresser is available at the home on a weekly basis. Residents spoken with indicated they valued this service. Staff were seen knocking and waiting for a response before entering residents’ bedrooms. This is good practice. However it was identified on this visit that certain underclothes and some hosiery items are not marked, resulting in these items being used on a shared basis. This is an institutional practice and should be discouraged. It was noted on this visit that care plans do not include details of residents’ spiritual wishes and preferences in respect of death and dying. This is an important aspect of care and needs to be addressed. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in exercising their lifestyle preferences with regards to occupation and activities. Residents are offered a choice of meals and where to eat them. EVIDENCE: A religious service had taken place at the home at the time of the visit. Visitors are welcomed into the home and offered refreshments. Residents spoken with indicated they more or less do as they please, including joining in group activities or receiving one to one input. The home employs three activities coordinators who in total provide 44 hours activity time every week. Residents are provided with activity programmes. Despite this comment card responses from residents indicated only two respondents felt they are always able to take part in the home’s arranged activities. The remaining seven respondents indicated they usually or sometimes can. As mentioned previously it was difficult to establish residents’ involvement in activities as social care records are maintained separately and care plans contained minimal social information. A physiotherapist facilitates music and movement sessions every Friday. About 15 residents attend this. Some residents were seen sitting in their rooms reading or listening to the radio. A number of Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 14 residents were seen in the lounge enjoying a pre lunch alcoholic drink. Soft drinks and teas/coffees were seen in residents’ rooms. Residents can choose to eat their meals in the dining room or in their own rooms. The dining room tables were nicely laid out in preparation of the lunchtime meal and an appetising smell was filtering around parts of the home. The chef endeavours to speak with residents regularly to obtain their views and opinions of the meals provided at the home. One resident said they rate the meals ten out of ten. Comment card responses from residents indicated two residents always like the home’s meals, six usually do and one sometimes does. Bedrooms vary in shape and sizes and residents are encouraged to individualise them with personal effects to make them homely. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place for residents and others to make a complaint. Arrangements to ensure care staff are appropriately trained with regard to the County’s adult protection procedures will increase residents’ protection against potential abuse. EVIDENCE: Following a recommendation made at the last visit complaints and comments are now kept separately. The complaints book is arranged so that residents wishing to access their records and or/information held on them may do so without compromising other residents’ confidentiality. The organisation’s complaints procedure was seen publicly displayed. This information is also contained in the Welcome to Staplehurst Manor pack, which each resident is provided with. Five of the nine returned comment cards from residents indicated they always knew how to make a complaint. It was of a concern to establish on this visit that staff have not yet received adult protection training reflecting the County’s multi-agency procedures. The home manager said she has been in contact with the County’s AP coordinator requesting training details so this can be arranged. Staff spoken with described appropriately the action they would take if they suspected abuse against a resident. Staplehurst Manor Nursing Home DS0000026207.V315242.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Continued refurbishment of the environment will enhance residents’ quality of life. EVIDENCE: On entering, the home provides a warm, cosy and welcoming atmosphere. Apart from one area, the home was clean, tidy and odour free. Eight of the nine returned comment cards from residents indicated the home is always fresh and clean. Residents spoken with indicated the standard of cleaning in their rooms is good. However other information received in support of this visit included a comment about the level of detail of bedroom cleaning not being as thorough as it had been. The home manager acknowledged there had been a housekeeping problem because of some unfilled vacancies. However two new housekeeping assistants have just been employed and applications are being processed for a third. The home sits within grounds covering 42 acres. The gardens directly surrounding the home are maintained Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 17 to a good standard. There are proposals to extend the home. This will include bedrooms, day rooms and a new lift. This is quite timely as a comment card respondent indicated that the lift had been out of order for two days. The pre inspection questionnaire indicates the home’s equipment, including the passenger lift, is regularly serviced. However the lift service engineers inferred that although the lift is satisfactory its continued workable use is dependent on full modernisation works being carried out. As 19 bedrooms are situated on the upper floors, it is essential that there is a reliable safe method of assisting residents to and from those rooms at all times. The home was first registered some years ago and acquired by BUPA in 1996. Since that time some refurbishment work has taken place. Indeed the carpets in the reception and garden room, as well as the corridors immediately in the vicinity have been replaced and look very effective. However the standard of carpets seen in other corridors on all floors was not of the same standard. Indeed in some areas the carpets looked stained and grubby. This situation detracts from the general ambiance of the home. A separate environmental health inspection of the home’s kitchen was carried out in June 2006. No problems were identified. Because of this the kitchen was not re-inspected on this occasion. The home is equipped with fire safety systems. It was of a concern to identify on this visit that a folded wheelchair had been “parked” in a narrow corridor, leading to a fire exit. Also, a beanbag was being used to prop a resident’s bedroom door open. As technology has moved on with regard to door props, beanbags are now deemed unacceptable and should no longer be used. Beanbags can also be trip hazards to staff and ambulant residents. Not all bedrooms have ensuite WC facilities but there are sufficient numbers of communal WCs and bathrooms around the home. However one WC could not be used because a commode chair had been left inside the room, preventing residents accessing the WC safely. The home has three sluice rooms. However only one of the sluice rooms is lockable. As sluice rooms contain body waste materials as well as chemicals, doors should be kept locked when not in use to prevent unauthorised access. The standard of cleaning in the two sluice visited was not of a level expected of a home providing nursing care. Some continence and toilet aids had been left on the floor, the towel dispenser in one room was empty, the lid of a pedal bin was broken, a dirty toilet brush was still in use for washing continence aids, tiles were missing off the walls and floors were sticky. This situation does not promote good infection control practices. The home is fitted with a nurse call system. However during the visit to the main lounge it was noted that not all residents were in easy access of the device currently in use. The home manager reported that some residents could not activate them. However where a decision to deny this provision to Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 18 particular residents is made, it has not been the home’s practice to carry out a risk assessment to determine how the decision has been arrived at or indeed whether there would be a more suitable device for particular residents’ needs. Radiators are fitted with guards and water temperatures are monitored. This helps to ensure residents do not scald or burn themselves. The home has recently been tested for legionella. Fortunately none was detected. The laundry is appropriately equipped for a home providing nursing care. Despite size and height constraints, staff endeavour to keep the room in a clean, tidy and hygienic state and should be complimented on this. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is now appropriately staffed, although availability is sometimes lacking. Residents could be potentially at risk because robust recruitment procedures are not always followed. EVIDENCE: The home currently employs 13 registered nurses and 21 healthcare assistants. In addition to care staff, staff are employed for catering, activities, reception, administration, cleaning, maintenance and gardening. A record of staff on duty is maintained and demonstrates that the home is staffed 24 hours a day. The levels generally follow those set by the former registering authority in July 2000. Five of the eight returned comment cards from relatives/advocates indicated in their opinion there are not always sufficient staff on duty. Comments added to residents comment cards included “staff are busy people and often I have to wait sometime” and “I feel we need more staff to help”. And a comment obtained from a resident during the visit included “can wait up to ten minutes for a response to the buzzer”. Not all care records contained a dependency assessment, to ensure that the staffing levels actually reflect the needs of the current residents. It has not been the home’s practice to include the status of staff on the duty rotas. This Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 20 could present a problem if an investigation was to be carried out. Other comments received referred to the regular use of agency staff. Indeed the off duties supplied to the Commission in support of this visit indicated that for the first two weeks of October 2006 agency care staff were used on 18 occasions. This situation does not promote continuity of care. The home manager said there had been a staffing problem but a number of registered nurses and healthcare assistants have recently been appointed, thus reducing the home’s reliance on agency staff. The returned pre inspection questionnaire indicates that 66.6 of unregistered care staff are now trained to NVQ level II or above in care. Systems are in place for recruiting and appointing staff. The maintenance of staff files did not allow for an easy audit. It was established that requisite vetting checks had been carried to ensure staff fitness. However in one case there was an unexplained employment gap of 14 years. The matter is not helped in that the Provider’s application form requires applicants to state just ten years employment. New regulations require full employment histories must be stated. Staff are expected to undergo induction training, which follows the Skills for Care programme. Details of staff training provided in support of the visit included manual handling, fire training, infection control, food hygiene, supervision, peritoneal dialysis, Parkinson’s disease and phlebotomy. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is satisfactory overall but not all records are well managed. This practice could potentially place residents at risk. EVIDENCE: The home manager is a registered nurse. The manager reported that she anticipates completing the Registered Managers Award course in April 2007. Other courses and training undertaken by the home manager since the last visit includes moving and handling trainers refresher course, Parkinson’s disease and dementia care. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 22 As part of the organisation’s quality assurance programme, BUPA has recently circulated survey questionnaires to all residents. The responses will be analysed externally and the findings reported back to the home manager. The home manager is then expected to circulate the information to all residents and other interested parties. Meetings are facilitated at the home for residents, relatives and staff to meet. Minutes of these meetings are then made available to attendees and others. Since the last visit a system has been introduced to obtain the views of residents, who for whatever reason, decline to attend residents meetings. This ensure their views are sought and included. A copy of the last inspection report was seen in the main reception room. The returned pre inspection questionnaire included details of policies and procedures. However there was evidence that these are not being annually reviewed. Indeed some policies had implementation dates of 1998, 2000, 2001, 2002, 2003 and 2004. This situation may prevent staff working in accordance with current good practice and indeed current legislation. The home is currently responsible for maintaining personal monies for a number of residents. Computer records are kept of transactions made and receipts obtained. Monies are held collectively in a separate residents’ interest bearing account. BUPA has devised a system which enables it to calculate and distribute interest accrued proportionately. The Commission has agreed this system. BUPA finance staff, as part of the provider’s quality assurance programme, regularly audit these records. It was established on this visit that current accessibility arrangements could prevent residents accessing their monies, if required, out of normal working hours and weekends/bank holidays. Including this restriction in the service user guide or welcome document would enhance the current provision. Systems are in place for the safe keeping of possessions handed over for the home’s safe keeping. The returned pre inspection questionnaire indicates 12 members of staff are booked to undertake the First Aid training on the 14 November 2006. The form also records that the home’s electrical fixed wiring survey was last carried out on 28 February 2002. However a review of the maintenance file identified a survey had been carried out on 26 May 2006. The home manager agreed to clarify the matter. The pre inspection questionnaire indicates that the home’s equipment is serviced regularly. Structured regular supervision has not been taking place. However the home manager said heads of units and senior carers have now received supervisory training and formal supervision of all care staff is about to be rolled out. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 23 As stated throughout the report, not all records relating to residents are maintained as is required. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 2 X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 2 2 2 Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 4 and 6 Requirement Timescale for action 28/02/07 2 OP9 13(2) 3 OP18 13(6) 4 OP19 23(4) The registered person shall compile in relation to the care home a written statement which shall consist of a statement of the aims and objectives of the care home, a statement as to the facilities and services which are to be provided by the registered person for services and a statement as to the matters list in Schedule 1. The person shall keep under review and, where appropriate, revise the statement of purpose and the service user guide. The registered person shall make 30/11/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall make 30/11/06 arrangements by training staff or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall after 30/11/06 consultation with the fire and DS0000026207.V315242.R01.S.doc Version 5.2 Staplehurst Manor Nursing Home Page 26 5 OP26 13(3) 6 OP29 19(1) Sch 2(3) rescue authority take adequate precautions against the risk of fire. The registered person shall make 31/12/06 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall not 31/12/06 employ a person to work at the care home unless the person is fit to work at the care home. 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 OP7 OP31 Good Practice Recommendations Work to provide more personalised care plans should be pursued. Not yet achieved. As planned, the manager should undertake the registered managers award as soon as possible. The home manager expects to complete this by April 2007. Care staff should receive formal supervision not less than 6 times a year. This is about to commence. Pre admission assessments should be completed in full. Care plans should contain full details of assessed needs and preferences and choices. Plans should demonstrate they have been compiled with the resident and or their advocate and are regularly updated to reflect the current situation. All residents should be provided with a falls risk assessment where there is an identified need. All clinical and health and safety risk assessments should be completed in full. The home should obtain a copy of the Royal DS0000026207.V315242.R01.S.doc Version 5.2 Page 27 3. OP36 4 5 OP3 OP7 6 7 8 OP7 OP8 OP9 Staplehurst Manor Nursing Home 9 10 11 12 13 14 15 16 17 18 19 20 OP9 OP9 OP10 OP10 OP11 OP12 OP19 OP22 OP26 OP27 OP33 OP35 21 22 OP37 OP38 Pharmaceutical Society of Great Britain’s publication “The Administration and Control of Medicines in Care Homes and Children’s Services. Registered Nurses should maintain care records and charts as per the requirements of Nursing and Midwifery Council. Details of the prescriber’s instructions for medicines administered on a “when required” basis should be clearly stated in the resident’s care plan. Verbal and written communication between staff, residents and visitors/advocates should be improved. Net knickers and hosiery should be washed and provided on an individual basis. Care plan must contain details of residents preferences, rites and choices with regard to death and dying. All care plans should have information on residents preferences with regard to activities and occupation. All stained and grubby carpets should be thoroughly cleaned or renewed. Non-provision of call aids to residents should only be done following a detailed risk assessment. The findings should be recorded. Sluice room doors should be kept locked when not in use. Dependency assessments should be used to assist in determining staffing levels. Policies and procedures should be regularly reviewed to ensure they conform to current good practice and legislation. Restrictive access by residents to their personal monies should be recorded. Expanding this information in prospective residents’ information would enhance the current system. All records relating to residents should be accurate and complete. Clarification as to the currency of the home’s fixed wiring survey should be sought. Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Staplehurst Manor Nursing Home DS0000026207.V315242.R01.S.doc Version 5.2 Page 29 - 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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