Inspection on 18/04/07 for Tapton Court Nursing Home

This inspection was carried out on 18th April 2007.

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

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

Other inspections for this house

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 14/04/08

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 09/07/2008.

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 18th April 2007 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.V331577.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.V331577.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 none None Amocura Limited 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) Vacant Care Home 69 Category(ies) of Dementia - over 65 years of age (69) registration, with number of places Tapton Court Nursing Home DS0000021812.V331577.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. 26th April 2006 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 £438 to £488. Additional charges are made for hairdressing, toiletries and chiropody. Information about the home is provided to current and prospective residents and their representatives. Copies of the most recent inspection report, and statement of purpose, are available from the home. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The inspector visited the home for 7 hours from 8:30 am to 3:30 pm on the 18th April 2007. Parts of the building were inspected, including communal and individual rooms. A selection of records was examined, including; assessments, care plans, residents’ finances, complaints, quality assurance, staff training, recruitment and supervision. Ten residents were spoken with, three of who 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 cook and domestic staff were spoken with about aspects of their jobs. Two care staff were formally interviewed. Interactions were observed between staff and residents. The registered managers post was vacant. The deputy was acting up to the manager’s post to cover this vacancy. A permanent manager had been recruited and was due to commence employment in May 2007. Discussions with the acting manager and area manager took place about the organisation and running of the home. In addition to the visit to the home, the acting manager completed a preinspection questionnaire to provide further information. Surveys were sent to a sample of residents, relatives, staff and health professionals for their comments on the home. Three residents, five staff, and three health professionals returned their surveys. Information gathered from these is reflected throughout this report. The inspector would like to thank the residents and the staff at the home for their openness and support of the inspection process. What the service does well: The acting manager has managed the home well, and provided continuity and some improvements to the running of the home. All of the comments made to the inspector were positive. Residents said ‘the staff are lovely’, ‘I am looked after very well’ and ‘very good’. The interactions observed and overheard between staff and residents appeared respectful and caring. Staff responded promptly to reassure anxious residents, and spent time chatting to individuals. A statement of purpose and service user guide were in place, to provide information about the home to prospective and existing residents. Needs assessments were carried out prior to admission; to ensure identified needs Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 6 could be met. Relatives and staff confirmed that prospective residents had been able to look around the home and meet other residents and staff before choosing to move in. Staff displayed an understanding of the needs of the resident group, both in interactions observed and during discussions. Care plans were in place for all residents, these set out in some detail the staff action required to ensure all aspects of care were met. Health care was monitored and access to health care professionals was provided, to maintain health. Systems were in place to ensure the safe storage and administration of medication. The interactions observed between staff and service users appeared respectful. Choices were offered and the routines at the home were flexible. Residents were free to walk around the home. Visitors were welcomed at any time. The homes menu was varied, and choices were offered. Special dietary needs were catered for. The home had a complaints procedure, to ensure any complaint was taken seriously. The staff spoken with were clear about adult protection procedures. The home was well decorated and well maintained, to provide a pleasant environment. Sufficient staff were provided to care for residents. Staff undertook periodic training to keep them up to date. Systems were in place to ensure the safe storage and administration of resident’s monies. All of the people spoken with had confidence in the homes acting manager. What has improved since the last inspection? Care plans contained information on resident’s wishes regarding dying and death, to make sure these could be carried out. Care plan recordings had been developed to contain more detail on the staff action required to respond to specific behaviours. A rolling programme of training on dementia and dealing with challenging behaviour was being provided to staff to improve their skills. The acting manager had attended adult protection training and was planning this training for all nursing and care staff to update their knowledge. A programme of staff supervision had commenced to support and develop staff. Some improvements to records had been made. The training records were more detailed to enable staff training to be monitored and planned efficiently. Accident records recorded more detail to enable the acting manager to audit them thoroughly. Records of incidents of challenging behaviour were audited Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 7 and monitored to assist in care planning. A communications book had been developed to identify staff roles on each shift. Some trees and shrubs had been cleared from the grounds to create more light in residents bedrooms. 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. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 8 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.V331577.R01.S.doc Version 5.2 Page 9 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): 1,3 and 5. 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 the home. A statement of purpose and service user guide were available, to give residents and their representatives information about the home. Assessments of needs were undertaken prior to admission, to make sure all needs were identified and could be met. Prospective residents and/or their representatives 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 resident and their representative had been provided with a copy of the booklet, to inform them about the home, their rights and choices. A copy was seen on Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 10 display in the entrance area of the home to let visitors to read this, if they wished. It contained a range of information and was available in large print if required by the resident. The acting manager carried out detailed needs assessments with all prospective residents 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 acting manager, alongside a senior carer if available, visited the prospective resident and their representatives in their own home or hospital to meet them and gather information. The manager confirmed that residents 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 five care plans inspected. Information gathered on assessment was used to write the care plan. Prospective residents and their representatives were able to visit the home, have a look around and meet other residents and staff before choosing to move in. One relative spoken with said that this was very helpful in deciding which was the right home for their loved one. One relative stated that the staff and managers had been very welcoming and supportive, which helped in their decision. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 11 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 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 the home. Each resident had a plan of care to record all relevant information, identify needs and inform staff of the actions required to meet individual needs. Further detail was required to ensure all relevant information was recorded. Records evidenced that residents’ health care was monitored, to maintain health. The recording and administration of medication was, on the whole, well managed, to promote residents safety. However, additional information on administration records would improve safe practices. Interactions observed between residents and staff evidenced that resident’s privacy and dignity was respected. Written policies and procedures were in place regarding dying and death, to ensure residents and their relatives were supported sensitively. Any wishes regarding dying and death had been sought and recorded, to ensure any specific requests were carried out. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector examined five care plans. Care plan recordings had been developed to contain specific detail on the staff action required to respond to specific behaviours. Some sections of the care plans were comprehensive and contained detail of the staff action required to ensure needs were met, for example, methods of communication and mental health. Other sections of the plans contained insufficient detail to inform staff how to meet need. Sections on personal care contained generic statements such as ‘full assistance required’, and did not specify how this assistance was to be given. Resident’s photographs were in place in the plans checked. Care plans were reviewed regularly to keep them up to date. Residents’ health care was maintained and 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. Residents 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. Records had been improved to enable them to be audited more thoroughly. 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 residents safe. Medication administration records were up to date. The details recorded corresponded with the medication stored. Some records relating to PRN (as and when needed) medication had not been fully completed. Staff were not consistently recording when a medication had not been required, or was refused. This practice was not in line with safe procedures. Staff were observed to respect service users privacy by closing bathroom and bedroom doors. Staff were seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Residents preferred form of address was respected. Staff were seen to treat service users respectfully. Staff promptly responded to residents that became anxious in a kindly, reassuring and patient manner. One resident said that staff were ‘always lovely and kind’. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 13 A policy and procedure were in place regarding dying and death. Relatives spoken with confirmed that they were kept informed of their loved ones health. Discussions with the acting manager and staff evidenced that residents and their families were treated with dignity at this sensitive time. Records had been undertaken regarding residents’ wishes in relation to dying and death, to ensure these were carried out. Tapton Court Nursing Home DS0000021812.V331577.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): 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 the home. Activities were provided to residents by care staff, to improve choice and quality of life. The routines at the home were flexible and residents were able to choose how to spend their time, in line with health and safety and assessed risk, to respect preferences. An open visiting policy was in operation, in order to develop and maintain good relationships with resident’s representatives. Contact with relatives and friends were supported. The homes menu was varied, and special diets were catered for, to meet residents’ needs and maintain health. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 15 EVIDENCE: Care staff provided activities, and a programme of weekly activities was on display around the home to inform residents and their relatives. Photographs of recent events were on display for residents’ enjoyment and to personalise space. Activities included music, chair aerobics, bingo and some trips out. The residents and staff spoken with said that enough activities were provided. Residents were seen to walk freely around the home, staff respected their choice and when able joined them in walking around, to provide company. A visitor spoken with said ‘I am always made to feel welcome, and have no concerns about the care of my relative, I am very happy with the care provided’. Staff supported residents choices, and were overheard to offer individuals choice of breakfast. The homes menu was varied and choices were offered. One resident spoken with said the food was ‘lovely’. Staff sat with the residents that required assistance with eating, and this support was given patiently and respectfully. The cook was aware of individual residents 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. Tapton Court Nursing Home DS0000021812.V331577.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): 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 the home. A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened and responded to. An adult protection procedure was in operation, to ensure residents safety was promoted. Staff had not been provided with training in adult protection to ensure they were aware of the procedures to follow if an allegation was made. EVIDENCE: The complaints procedure was 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 had been improved since the last inspection to ensure relatives and residents had a confidential way to report any concerns. No complaints had been received since the last inspection. The staff spoken with were clear about the homes complaints procedure. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 17 Staff training in abuse had been identified within the homes training plan, to ensure staff were able to protect residents effectively. The acting manager had attended training in adult protection and was planning to cascade this training with the staff team. Any allegations of abuse were responded to promptly. The staff, visitors and residents spoken with all stated that they had confidence in the homes acting manager to listen and respond to any concerns raised. Tapton Court Nursing Home DS0000021812.V331577.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): 19,22 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 the home. The home was clean and generally well maintained, to provide a pleasant environment for residents. Equipment to meet the moving and handling needs of residents was provided. Control of infection procedures were in place, to promote residents health and safety. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 19 EVIDENCE: The inspector carried out an inspection of a proportion of the environment. The home was well decorated and well-maintained, homely touches were provided to create a comfortable environment to residents. 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, several trees and shrubs had been cut back to improve the light in residents bedrooms. The corridor carpet on the ground floor was worn in one very small area. Whilst this did not deter from the overall appearance, there was the potential to pose a future tripping hazard if this was not repaired. Whilst the home had hoists in place, staff reported that they did not appear to lift very heavy residents easily. This was discussed with the acting manager, who confirmed that all residents were within the weight limit of the hoists available. It may be beneficial to explore the availability of alternative hoists to better meet the needs of individuals. 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.V331577.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): 27,28,29 and 30 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 the home. Sufficient staff were provided to meet the needs of residents. However, at the time of this inspection the registered managers and administrators post was vacant. The inspector acknowledges that systems had been put into place to cover these vacancies. Some staff undertook NVQ training, to enhance their skills. Recommended levels of NVQ trained staff had not been achieved. The home had recruitment systems in place to protect residents, however, records did not evidence dates of previous employment, or that all gaps in employment history had been explored, to uphold safe procedures and ensure applicants were suitable for the post. A range of training was provided to staff, to improve their skills and enable them to support residents effectively. However, the area manager reported a reluctance of some care staff to attend the training provided. Whilst a rolling programme of training was in operation, not all staff had been provided with all of the training available to enhance their skills and knowledge. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 21 EVIDENCE: The rota evidenced that agreed levels of staff were being maintained. One resident spoken with said that enough staff were provided. One visitor spoken with said they were happy with the levels of staff. The deputy manager was covering the registered managers post. A senior carer was covering the administrators post on a part time basis. Of the thirty-one care staff, five had achieved NVQ level 2 or 3 in care. This did not meet the recommended minimum of 50 of the staff team trained to NVQ level 2 in care. Induction and ongoing training were provided to staff. The acting manager had worked hard to improve training records and ensure appropriate training was available to staff. A training matrix and individual training records were maintained, to assist in monitoring the training provided. Whilst relevant training events had been organised, for example in dementia, diabetes, and dealing with challenging behaviour, few care staff had attended these events. This had resulted in gaps in the training provided to all staff, and staff knowledge. This clearly did not meet the needs of residents. Every effort must be made to ensure staff attend the training organised to equip them with the skills needed to provide residents with a good quality of life. Discussions with the acting manager evidenced a recruitment procedure was in place. Three staff files were inspected. These contained all of the required documentation. However, gaps in employment history were unable to be identified, as the updated application form did not request dates of previous employment. This meant that any gaps in employment had not been identified or explored, in line with safe procedures. Tapton Court Nursing Home DS0000021812.V331577.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): 31,33,35,36,37 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 the home. The acting manager’s leadership approach benefited staff and residents. A quality assurance system was in operation, to obtain and act upon the views of residents, relatives and professional visitors. Systems were in place to ensure resident’s monies were safely managed. A rolling programme of staff supervision was in place to develop and support staff. Whilst this was being introduced some staff had not been provided with supervision at appropriate frequencies to ensure levels of support were maintained. Appropriate policies and procedures were in place to inform good practice. Records were stored securely to protect confidentiality. Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 23 Health and safety systems were, in the main, maintained, to ensure residents 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. EVIDENCE: All of the staff and residents spoken with said that the acting manager was approachable, supportive and a good listener. The acting manager evidenced that she had identified and prioritised areas for improvement, and had implemented these to enhance the service provided. Annual surveys were undertaken with residents and/or their representatives, and professional visitors 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. Resident’s monies were stored securely to keep them safe. The inspector examined two finance records, the amounts kept tallied with the records held. Informal supervision took place on a daily basis. However, formal staff supervision, to support and enhance staff skills, did not take place at the required frequency. Annual appraisals took place. The acting manager had introduced a rolling programme of supervisions for staff, which was the responsibility of the senior team. Whilst this was in the early stages, some staff had not been provided with supervisions at appropriate levels to maintain safe practices. A range of policies and procedures were in place to promote good practice and ensure resident’s needs were met. Staff had access to all of the homes policies. Records were securely stored. 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. A training matrix had been developed. This evidenced that some staff required refresher training in food hygiene and moving and handling and fire. A proportion of staff had undertaken training in first aid. Tapton Court Nursing Home DS0000021812.V331577.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Tapton Court Nursing Home DS0000021812.V331577.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. Medication administration records must detail when a medication is not required or has been refused. All staff must be provided with adult protection training 50 of the care staff should be trained to NVQ level 2 in care. Records must evidence that gaps in employment history have been explored. (Previous timescale of 31/01/06 and 01/08/06 not met). Application forms must detail the dates of previous employment. 6 OP30 18(1) (c) Identified gaps in training must be scheduled in the rolling programme. All staff must be provided with all aspects of training relevant to Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 26 Timescale for action 01/06/07 2 OP9 13(2) 01/06/07 3 4 5 OP18 OP28 OP29 13(6) 18(1) (c) 18(1) (c) 19 01/08/07 01/08/07 01/06/07 01/08/07 their role. 7 OP38 18(1) (c) 13(5) All staff must be provided with food hygiene refresher training. (Previous timescales of 01/01/06 and 01/08/06 not met) All staff must be provided with moving and handling refresher training. 8 OP38 23(4) (e) All staff must be provided with fire drill training at appropriate intervals. 01/06/07 01/08/07 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 OP19 OP22 Good Practice Recommendations The condition of the ground floor corridor carpet should be monitored to make sure potential tripping hazards are identified and dealt with. Discussions should take place with the staff team regarding the hoist equipment available. The responsible person should ensure that the most suitable and up to date hoists are available. Efforts should be made to recruit to the administrators vacancy. Discussions should take place with the staff team to ensure they are fully aware of their responsibility to participate in all of the training provided. All staff should be provided with supervision at an appropriate frequency 3 4 5 OP27 OP30 OP36 Tapton Court Nursing Home DS0000021812.V331577.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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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