Inspection on 14/04/08 for Tapton Court Nursing Home

This inspection was carried out on 14th April 2008.

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

Tapton Court Nursing Home 24/02/10

Tapton Court Nursing Home 12/02/10

Tapton Court Nursing Home 06/04/09

Tapton Court Nursing Home 18/04/07

Tapton Court Nursing Home 26/04/06

Tapton Court Nursing Home 01/11/05

Tapton Court Nursing Home 26/04/05

Tapton Court Nursing Home 02/11/04

Tapton Court Nursing Home 20/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Tapton Court Nursing Home 63 Tapton Crescent Road Crosspool Sheffield South Yorkshire S10 5DB Lead Inspector Mrs Janis Robinson Key Unannounced Inspection 14th April 2008 09:00 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 Tapton Court Nursing Home DS0000021812.V362057.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. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tapton Court Nursing Home Address 63 Tapton Crescent Road Crosspool Sheffield South Yorkshire S10 5DB 0114 266 0648 0114 266 1345 care@amocura.co.uk 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) Amocura Limited Miss Evangelista Jana Care Home 69 Category(ies) of Dementia - over 65 years of age (69) registration, with number of places Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service can admit service users between the age of 60-65 years provided that their care needs can be met. 18th April 2007 Date of last inspection Brief Description of the Service: Tapton Court is a purpose built home situated in the Crosspool area of Sheffield, which was first registered in 1996. Nursing and residential care is provided for up to 69 older people of both sexes with mental health problems. The home is a two-storey building with a passenger lift, and is fully accessible to service users. Communal lounges and dining rooms are situated on each floor. All of the bedrooms are single, and all are provided with en-suite toilet facilities. Sufficient bathing facilities are in place. A central commercial type kitchen and laundry serve the home. A car park is available. There is easy access to local facilities, such as shopping centres, public houses and bus routes. Current fees range from £368 to £513. Additional charges are made for hairdressing, toiletries and chiropody. Information about the home is provided to people. Copies of the most recent inspection report, and statement of purpose, are available from the home. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Janis Robinson, regulation inspector. The site visits took place between the hours of 09:00 am and 12:30 pm on the 14th of April, and 09:00 am and 01:30pm on the 22nd April. The registered manager, Evangelista Jana, was not present during these visits. The regional manager, Maureen French, was present during both site visits. Prior to the visit the registered manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires regarding the quality of the care and support provided were given to people living in the home, their relatives, staff and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received five questionnaires from people using the service, six from relatives and two from staff. Comments and feedback from these have been included in this report. On the days of the site visits staff were observed interacting with people that live in the home. A partial tour of the premises was made and records relating to care and the running of the home were checked. . Five people that lived at the home were spoken with, three of whom were able to share their views of living at the home. The majority of the staff on duty, including, qualified nursing staff, care staff, the deputy, the administrator, the cook and domestic staff were spoken with about aspects of their jobs. Two care staff and one qualified were formally interviewed about their jobs. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in April 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 6 What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “Staff are lovely”. “Staff are kind and caring”. “Everything is smashing”. “They look after us, don’t know what I would do without them”. “They’re all very kind”. Comments received from questionnaires and from talking to relatives were positive and included: “The care home keeps mother clean at all times and does not smell, that is important to me”. “I am very pleased with the care home and have no worries”. “It means a lot to know she (my Mother) is safe and clean”. “Take care of their needs very well”. “I always find the staff extremely helpful and very pleasant” “We have no complaints. Support is always there when we need it” “Lots of tender loving care when needed” The interactions observed and overheard between staff and residents appeared respectful and caring. Each person living at the home had a written care plan. People’s health care was monitored and access to health specialists was available. Relatives could visit the home at any time, to maintain contact. People said that they had a choice of food and that the quality of food served was “good”, and “smashing”. There was a complaints procedure and adult protection procedure in place, to promote peoples safety. People said that they felt safe living at the home. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 7 There was a maintenance programme to keep the home clean and well decorated. Some training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? What they could do better: Requirements made at the last inspection in relation to care plans, recruitment procedures and staff training have been carried forward as further improvement was required to meet standards. Care plans needed more detailed information on the specific actions required of staff to meet people’s individual personal care needs. Some staff did not routinely look at plans for information or advice. Written agreement to the practice of locking bedroom doors during the day should be obtained to show that people had been consulted. Further activities should be offered to improve people’s choice. Bathrooms and shower rooms should be considered for refurbishment to maintain the good standards of decoration. The damaged sink surround in the hairdressing room should be repaired to minimise risk. Recruitment records should consistently record dates of employment history, to enable full and safe procedures to be followed. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 8 The rolling programme of staff training should be provided to make sure staffs’ skills remain up to date. All staff should be provided with adult protection training to equip them with the essential skills to keep people safe. Staff should be provided with supervision regularly, for development and support. Some staff reported poor communication from the manager and felt that some issues and concerns were not responded to. 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. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 9 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 Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3 and 5. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A statement of purpose and service user guide were available, to give people information about the home. Assessments of needs were undertaken prior to admission, to make sure all needs were identified and could be met. People were able to visit the home prior to admission, to help them make a decision about moving in. EVIDENCE: A statement of purpose and service user guide, in the form of a ‘Commitment Booklet’ was available at the home. The staff spoken with confirmed that each person living at the home and their representative had been provided with a Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 11 copy of the booklet, to inform them about the home, their rights and choices. A copy was seen on display in the entrance area so that visitors could read this, if they wished. It contained a range of information and was available in large print if required. The regional manager confirmed that the manager carried out detailed needs assessments with people and their representatives to ensure identified needs could be met. Copies of social workers full needs assessments were obtained, where available, to provide the home with all relevant information. The manager, alongside a senior carer if available, visited the people and their representatives in their own home or hospital to meet them and gather information. The regional manager confirmed that people were only admitted to the home once they were sure that they could meet their needs. Copies of needs assessments were in place in the three care plans checked. Information gathered on assessment was used to write the care plan. People were able to visit the home and have a look around before choosing to move in. In surveys, all six people living at the home and four of five relatives said that they had been given enough information about the home to help them to decide to move in. One relative said “The home was clean and staff were very friendly, this helped me make a decision about my (relative) moving in” Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person had a plan of care to record their needs. Further detail was required to ensure all relevant information was recorded. People’s health care was monitored and access to health professionals was provided to maintain health. The recording and administration of medication was well managed, to promote people’s health and safety. People said their privacy and dignity was respected. EVIDENCE: Three care plans were checked. Whilst some sections of the plans contained sufficient detail, other sections contained insufficient detail to inform staff of the actions required to meet people’s needs. Sections on personal care Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 13 contained generic statements such as ‘full assistance required’, and did not specify how this assistance was to be given. Further training on writing care plans was being planned. The inspector spoke with the training officer, who was able to show an example plan that contained comprehensive detail for use in staff training to improve care plans. All of the care plans were reviewed regularly to keep them up to date. Whilst the staff spoken with were aware of peoples needs, this information was gained verbally. Some staff said that they rarely looked at people’s plans, and were not involved in writing them. It is important that all staff feel involved and keep up to date with written plans so that they remain aware of peoples changing needs. It is hoped that the planned training will address this issue to improve knowledge and minimise risk. People’s health care was monitored to keep them as healthy as possible. Care plans contained records of health assessments, such as moving and handling, pressure sores and nutrition to make sure individuals needs were identified and responded to. Contact with health care professionals was maintained and recorded, to ensure up to date information was available. People said that their health care needs were met, and they could see health professionals in private, to respect their privacy. Accidents were recorded and monitored. One person said “They (staff) are good. They keep an eye on us and send for a doctor if we need it”. There was a policy and procedure in place on medication systems, to identify safe procedures and inform staff. Qualified staff and trained senior carers administered medication. Part of a medication administration round was observed; medication appeared to be administered correctly and safely. Medication was stored securely, to keep people safe. Three medication administration records were checked and were fully recorded and up to date. The details recorded corresponded with the medication stored. Staff were seen to treat service users respectfully. The interactions observed between staff and people living at the home appeared caring and positive. One domestic staff was seen hugging some people, who said “She is lovely and always comes to say hello, she brightens our day”. Care staff spoke to people in a patient and reassuring way. Staff were observed to respect service users privacy by closing bathroom and bedroom doors. Staff were seen to knock on doors before entering. It was practice to keep peoples bedroom doors locked during the day so that their personal belongings were safe from people who ‘wandered’. Staff confirmed that this had been agreed with the person living at the home or their relative. They said that any person wishing to spend time in their room could do so. It would be good practice to obtain written consent to evidence that people had been consulted. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A limited range of activities was on offer, further activities would promote choice and maintain peoples interests. Meals served at the home offered choice and ensured people received a healthy balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was made to feel comfortable whilst visiting his or her loved one. Carers at the home had the responsibility of carrying out activities, which although they enjoyed, added to their tasks. Staff rotas were sometimes difficult to cover due to sickness, staff said that this resulted in activities Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 15 sometimes being difficult to organise. The inspector discussed with the regional manager the need for an activities worker, to enhance people’s social life and reduce the burden on carers. The inspector acknowledges that the company have been advertising for an activities worker for some time. People said: “We sometimes play noughts and crosses, but most of the time we just sit here”. “My Mum really enjoys the sing-a-longs organised by care staff”. Staff supported people’s choices, and were overheard to offer individuals choice of breakfast and lunch. The homes menu was varied and choices were offered. One person spoken with said the food was “smashing”’. Staff sat with people that required assistance with eating, and this support was given patiently and respectfully. The cook was aware of individuals’ special dietary requirements. There were plentiful stocks of food, which staff had access to, to provide snacks and drinks during the evening and night, if required. One relative said “When I visit at mealtimes the food always looks appetising” Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clear and accessible complaints procedure was in place, to ensure any concerns listened and responded to. An adult protection procedure was in operation, to keep people safe. Some staff had not been provided with training in adult protection to promote safe practices. EVIDENCE: The complaints procedure was seen on display in a communal area of the home. This contained relevant information and provided the reader with details of who to contact outside of the home, to ensure any complaints were taken seriously. A record of complaints was kept, which was seen to record the actions taken and outcome of any complaint. The staff spoken with were clear about the homes complaints procedure. A relative said “We have been informed how to make a complaint but have never had reason to” Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 17 All of the people that returned surveys said that they had been told how to complain. Staff training in abuse was planned within the homes training plan, to ensure staff were able to protect people effectively. However, whilst this training had been identified as needed at the last inspection of April 2007, some staff had still not been provided with this training. It is important that training in protection be given priority so that all staff have a basic understanding of the types of abuse and the action to take if an allegation was made, so that people are safe. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and generally well maintained, to provide a pleasant environment for people EVIDENCE: The inspector carried out a partial tour of the environment. The home was mostly well decorated and well-maintained, homely touches were provided to create a comfortable environment for people. A handy person was employed to help maintain the environment. A rolling programme of redecoration and replacement was in place. The homes gardens appeared well maintained. The corridor carpet on the ground floor had been repaired to avoid a tripping hazard. New dining furniture, some new electric beds and new lounge carpets had been provided since the last inspection to maintain a pleasant living space. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 19 However, some bathrooms and shower rooms appeared in need of redecoration. It is recommended that they be given priority within the homes maintenance plan to maintain good standards. The hairdressing room on the first floor had a damaged sink surround that exposed pipe work and uneven ledges. This must be replaced as a priority to minimise risk of accidents. All of the bedrooms seen were well decorated and personalised with peoples own belongings to create a homely space. Control of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were provided to meet people’s needs. The home had recruitment systems in place to protect people, however, not all of the required information had been obtained to uphold safe procedures and ensure applicants were suitable for the post. Induction and training was provided to staff so they were competent to do their jobs. EVIDENCE: Two weeks rota was checked. This showed that sufficient staff were provided to meet the needs of people. One qualified staff was provided on each floor at all times. The staff spoken to said that agency staff were sometimes used when permanent staff rang in sick. Activities did not always take place as planned if this happened. When asked about staff numbers, one person said “There is always somebody here” Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 21 One relative said in their survey that more staff would improve the service offered. Some staff had undertaken National Vocational Qualifications (NVQ) training, to enhance their skills. Recommended levels of NVQ trained staff had not been achieved. The aqaa recorded that of the 23 permanent care staff, 5 had achieved NVQ level 2 in care. No further staff were undertaking the award. However, staff had expressed an interest in furthering NVQ training and the aqaa stated a commitment to provide this to staff. A recruitment procedure was in operation to keep people safe. Three staff recruitment files were checked. Two contained all of the required information and evidenced that safe and thorough procedures had been adhered to. However, one file did not include any dates of previous employment. The application form had not requested these so that any gaps in employment could be explored. It is important that this information is obtained so that suitable checks are carried out and people’s safety is promoted. A range of training was provided to staff, to improve their skills and enable them to support people effectively. The three staff files checked and the staff spoken with confirmed that all new staff had induction training within the first twelve weeks of employment to equip them with the skills needed to meet people’s needs. The training matrix checked showed that additional training provided included Dementia, Diabetes and Dealing with Challenging Behaviour to enhance staff skills. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36 and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improved communication would benefit the manager’s leadership, staff and people living at the home. A quality assurance system was in operation, to obtain and act upon peoples views. Systems were in place to ensure people’s monies were safely managed. A rolling programme of staff supervision was in place to develop and support staff. Some staff had not been provided with supervision at appropriate frequencies to ensure levels of support were maintained. Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 23 Health and safety systems were, in the main, maintained, to ensure people were safe. Some mandatory refresher training was required to ensure staff skills remained up to date. Not all staff had participated in a fire drill at an appropriate frequency to maintain their skills and keep people safe. EVIDENCE: Since the last inspection the manager had registered with the CSCI and completed the registered managers award. In addition, she had also been provided with external training in management to enhance her skills. The manager was a qualified nurse. One staff spoken with said the manager was approachable and supportive. However, several staff said that whilst the manager was approachable they felt that they were not always listened to and action was not taken to address some issues brought to her. Staff said that communication was sometimes poor, the manager would put up notices with information instead of taking to them. Some staff said that the manager was rarely seen in communal areas of the home and spent most of her time in the office. This impacted on staff morale and confidence in the way the home was managed. No relatives expressed any concerns in their surveys. Annual surveys were undertaken with people to monitor the service provided and obtain views and suggestions for improvement. The results of surveys were published and on display in a communal area of the home. The surveys examined all made positive comments about the home. People’s monies were stored securely to keep them safe. Two finance records were examined, the amounts kept tallied with the records held. Two signatures were recorded for each transaction to uphold safe procedures. Informal supervision took place on a daily basis. However, records checked showed that formal staff supervision, to support and develop staff, did not take place at the recommended frequency. Annual appraisals took place. It is acknowledged that the homes new deputy had worked hard to complete supervisions for some staff to commence the rolling programme. The equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. Fire drill training took place on a regular basis. However, the training matrix showed that some staff required refresher training in food hygiene and infection control. Some staff had not participated in a fire drill for several months. A proportion of staff had undertaken training in first aid. Tapton Court Nursing Home DS0000021812.V362057.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 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 2 X 2 Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must contain specific detail on the staff action required to meet individual personal care needs so that staff are fully informed. (Previous timescale of 01/06/07 not met) 2 OP7 12 All care staff must read and remain aware of peoples written care plans to make sure they know how to meet people’s needs. All staff must be provided with adult protection training to keep people safe. (Previous timescale of 01/08/07 not met) 4 OP19 23 The damaged sink surround in the first floor hair dressing room must be repaired to minimise risk of accidents. 01/07/08 30/06/08 Timescale for action 30/06/08 3 OP18 13 01/08/08 Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 26 5 OP29 19 Records must evidence that gaps in employment history have been explored to ensure safe procedures have been followed. (Previous timescale of 01/06/07 not met). Application forms must detail the dates of previous employment so that any gaps can be checked. (Previous timescale of 01/08/07 not met) 01/08/08 6 OP29 19 01/08/08 7 OP31 OP32 9 Ways to improve communication with the manager and staff must be explored. The planned programme of training must be provided at frequencies that maintain staff skills. All staff must be provided with food hygiene refresher training to maintain their skills. (Previous timescales of 01/08/07not met) All staff must be provided with infection control training 01/08/08 8 OP38 13,18 01/08/08 9 OP38 13,18 01/07/08 10 OP38 23(4) (e) All staff must be provided with fire drill training at appropriate intervals so that people are kept safe. (Previous timescale of 01/06/07 not met) 30/06/08 Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 27 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 OP10 Good Practice Recommendations Written agreement to keeping peoples bedroom doors locked during the day should be obtained to evidence that consultation had taken place. A fuller programme of activities should be developed to include a wider and more frequent range of activities. People should be consulted on their preferences, and activities provided should be recorded and monitored. An activities worker should be recruited so that the programme of outings and activities is enhanced. Bathrooms and Shower rooms should be given priority within the homes redecoration programme to maintain the good standards. 50 of the care staff should be trained to NVQ level 2 in care. All staff should be provided with supervision at an appropriate frequency for development and support. 2. OP12 3. 4 OP12 OP19 5 6 OP28 OP36 Tapton Court Nursing Home DS0000021812.V362057.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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