Inspection on 25/07/05 for Tapton Grove Nursing Home

This inspection was carried out on 25th July 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tapton Grove Nursing Home 20/06/07

Tapton Grove Nursing Home 09/05/06

Tapton Grove Nursing Home 13/02/06

Tapton Grove Nursing Home 16/03/05

Tapton Grove Nursing Home 13/10/04

Tapton Grove Nursing Home 22/03/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Tapton Grove Nursing Home Grove Road Brimington Chesterfield Derbyshire. S43 1QH Lead Inspector Bridgette Hill Unannounced 25 July 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. 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 Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tapton Grove Nursing Home Address Grove Road, Brimington, Chesterfield, Derbyshire, S43 1QH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01246 274178 Sun Healthcare Limited Mrs Patricia Willey Care Home 47 Category(ies) of Dementia (10), Mental disorder, excluding registration, with number learning disability or dementia (37) of places Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Compliance with the identified programme of works (repair/upgrade) and refurbishment of the building as confirmed and detailed in writing - letter dated 28.09.04, serious concerns - extended timescale agreement. All works to be completed in accordance with this agreement, with total completion timescale: by 31.03.05. Date of last inspection 16th March 2005 Brief Description of the Service: Tapton Grove provides nursing and personal care for up to 47 persons of both sexes, which includes up to 10 persons with dementia and 37 persons with mental disorder (excluding dementia and learning disabilities).There are separate nursing and care staff groups for each category with centralised hotel services (with satellite kitchens provided to each unit) and an overall registered manager. Service users with dementia are accommodated separately to those with a mental disorder. The home is located approximately 1.5 miles from Chesterfield town centre with a secluded setting approximately a half-mile from the nearest bus route. The older part of the building has a large double to single ratio of bedrooms. Details of room sizes are given in the statement of purpose for the home. There is level access to garden areas for service users. Good relationships and networks are establishing with outside health care professionals with regard to the specialist health care needs of those service users accommodated. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place over 5 hours. During the inspection 4 staff members and 7 residents were spoken with. Various records including care planning records were examined the findings are recorded in the body of this report. The scoring of outcomes page has not completed due to technical difficulties. Where standards have not been met requirements and recommendations are listed. What the service does well: What has improved since the last inspection? What they could do better: The condition of registration for works to be completed by 31st March 2005 has not been met in full. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 6 Parts of the building particularly bedrooms and bedrooms furniture are in need of upgrading. 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. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Standards Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitablity of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) OP 1 YA 1,5 It was considered that service users could be given improved access to information regarding the home in order to make informed choices. EVIDENCE: Forms were in files signed by service users to say that they had read the Service User Guide however the Statement of purpose and Service User Guide were not made readily available to service users or their families as they were located in the office. The content of the Service User Guide and Statement of purpose was not inspected as this has met requirements at previous visits. Terms and conditions of residency contracts were evident in service user files and had been signed by the service user. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) OP 7 YA 6,9 Care plans were in place for all service users and were generally sufficiently detailed in order that staff were able to be aware of service users assessed needs. EVIDENCE: A sample of care plans from a range of service users on each unit was examined to assess how standards were being met. Care plans were in place for each service user and contained a number of risk assessments including tissue viability, falls and moving and handling. Photographs of service users were available and preferred form of address was recorded. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 10 It was found that one care plan did contain service delivery instructions for a diagnosed medical condition which required on going monitoring (older persons unit). There were care plans that had been signed by the service user which indicated that service users had seen their plan of care. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experiencd in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 OP 12,13 YA There were satisfactory arrangements in place to enable service users to access education and training and take part in/pursue occupation and social activities. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 12 EVIDENCE: Service users spoke of being able to go on holiday accompanied by staff. It was evident from one service user that appropriate support was given was given to help maintain family links. A list of activities that were on offered was available. Service users spoke of playing bingo and games. One service user said that there was ‘too much television’. Some individual sessions of leisure time were recorded. For younger adults in the home the provision of community contact was more informal due to the independence of the service user. Some in house activities such as a Women’s group was organised regularly. Some of the younger adults attended local colleges. The home had transport and as the home was situated some way off of the bus route this was invaluable. Service users spoke of being able to go away on holidays accompanied by staff. Some outings were planned to Mablethorpe, the zoo, and Matlock. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) OP 8 YA19 It was assessed that there was adequate provision in place to ensure the healthcare needs of service users were met. EVIDENCE: It was evident that service users were supported by a range of external professionals including psychiatrists, social workers and community psychiatric nurses. Care files contained details of optician and chiropodist’s visits. Positive relationships with Community Mental Health Teams and Psychiatrists were reported by the Manager. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 14 The storage and administration of medicines was not assessed at this visit and requirements remain listed, as compliance was not checked. The Manager did state that a dedicated medications fridge was on order. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are sageguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) YA 22 &23 ,OP 16 & 18 Procedures were in place to ensure that staff had information available in order that any allegations of abuse or complaints would be handled appropriately though not all staff had received the required training. Service users access to the complaints procedure requires improvement. EVIDENCE: Suitable procedures were in place for complaints and the Protection of vulnerable adults. There was a copy of the complaints procedure displayed for service users to access. No complaints had been received by the home or Commission for Social Care Inspection since the last inspection. One Protection of vulnerable adults strategy had been held since the last inspection, this is ongoing. As part of this staff training had been identified as a need. This was planned to be held on the 29th July 2005. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 16 Some staff had completed Protection of vulnerable adults training facilitated by Derbyshire County Council in the past year but not all staff had received training. This is an outstanding requirement from previous inspections. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) OP 19,20,21,2,23,24,25,26 YA 24,25,26,27,28,29,30 There is not adequate investment and maintenance of the building to ensure service users are being cared for in an environment which is comfortable and meets National Minimum Standards. EVIDENCE: Tapton Grove is an old building which whilst retaining some of its original features giving it character requires significant investment and upkeep to ensure standards are maintained. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 18 An agreed schedule of works is a condition of the homes registration; this was to have been completed by 31st March 2005. It was evident that at this visit that whilst some works have been completed for example windows have been repaired some works have not been completed. Ten sets of bedroom furniture have been purchased but this is not sufficient to ensure that all service users have furniture which is of a good standard and basic items such as headboards available. Some bedrooms were not fitted with appropriate locks. One bathroom was in the process of refurbishment at the time of the inspection. Some vanity units were in need of replacement. Not all radiators have been guarded as is included in the schedule of works that was a agreed as a condition of registration. One recently fitted carpet had split at a joint the Manager was going to approach the company from whom the carpet was purchased about his. A monthly audit of the environment on the Younger Adults unit is undertaken. The audit completed on 2nd July 2005 indicated there was significant works required. The audit indicated that there were items of broken furniture, areas that required redecorating and poor hot water supply in some rooms. A handyman was employed at the home but the time available does not appear to be sufficient to ensure adequate upkeep of the building. The Environmental Health Officer last visited on 4th July 2005 and the report had not yet been received. Service users were found to be personalised though more so in the younger adults unit. The home has extensive grounds with mature woodland and a lake. A new seating area had been developed since the last visit. Outdoor access was limited for some service user in the Older Persons unit as a small area only was accessible from this. Loose bark chippings were on the floor here and risk assessments had not been completed regarding the risk of falls on this type of surface. The lounge in the older persons unit was also dark as some light bulbs required replacement. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 34 and 35 (Adults 18-65) and Standards 27,29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) OP 27 YA 33 Staffing levels were found to be variable and on one unit were not adequate to care for two different groups of service users being cared for on two floors. EVIDENCE: The staffing for the home is arranged into two groups. One staff group is dedicated to the care of 27 Younger adults, the levels on this unit were found to be satisfactory. The staffing for 20 further service user (10 older adults and 10 younger adults) arranged over two floors with separate communal accommodation for each group was found to be low. The staff group on this unit were responsible for the care needs of two differing groups of service users. It was acknowledged Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 20 by the Manager that staffing in this unit was low with some staff form the adjacent unit providing support on occasions. This was not formally documented. Recruitment was underway with staff being appointed subject to appropriate checks being received back satisfactorily. Whilst training was not formally examined at this visit one staff member said they had little understanding of the mental health conditions service users had. Staff had not yet received training in equal opportunities as identified on the previous report. This is an outstanding requirement from previous inspections At least 50 of care staff throughout the home held at least NVQ(National Vocational Qualification) level 2 in care. There were 3 staff who worked on a bank basis that were completing nurse-training qualifications. There were no volunteers used at the home. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 39 and 42 (Adults 18-65) and Standards 33,35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) OP 31,33,38 YA 37,39, 42 There appears to be good management of the home internally but restrictions on how to improve the environment and ensure that actions identified in internal audits of the environment are evident. This directly affects service users adversely. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 22 EVIDENCE: The Manager of the home was spoken of positively by service users and a rapport with service users was evident. The manager had recently completed a relevant managerial qualification. Information regarding service records was taken from the pre inspection questionnaire completed by the Manager. These indicated that hoists were serviced on 10.1.05. The five yearly electrical wiring check is due having been last completed on 28.7.00. The following quality assurances systems were in place: • • • A service user survey was completed in March 2005, 6 forms were returned these were followed up with discussions by the Manager. The Manager undertook audits of care files on a 3 monthly basis with written feedback given to key worker responsible for the care files. A buildings audit is completed monthly. It has been identified on previous visits that this action has not been taken to the findings of this and this remains so. There was no evidence of consultation with families/representatives/outside stakeholders as was required at the last inspection. This is an outstanding requirement from previous inspections for which the timescale has not yet passed. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 2 Score ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x x x x x x x x Standard No 24 25 26 27 28 29 30 STAFFING x x x x x x x Score 11 12 13 14 15 16 17 Standard No 31 32 33 34 35 36 x x x x x x x x x x x x x Version 1.40 Page 24 CONDUCT & MANAGEMENT PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tapton Grove Nursing Home Score x x x x 37 38 39 40 41 42 43 C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP 1 YA 1 OP 7 Regulation 4&5 15 Requirement Service users must be given access to the Statement of Purpose and Service User Guide Care plans must be in place for all assessed needs and detail how care is to be delivered to the service user A refrigerator to be used only for the storage of medicines must be provided (and medicines which require storage in a refrigerator must be stored there). This was said to be on order 31.01.04 Medication that is no longer required or out of date must be returned to pharmacy for disposal. Staff must only administer medication that has a printed label from the pharmacy attached to the container. Loose strips of medication or unlabelled containers must not be used. A documented risk assessment must be undertaken in relation to the use of loose tree bark chips as a covering for the patio area and the potential for increased risk of falls for older Timescale for action 30.9.05 30.9.05 3. OP9 YA20 13,23 Old timescale 31.05.05 4. OP9 YA20 13 Old timescale 31.05.05 Old timescale 31.4.05 5. OP9 YA20 13 6. OP19 13 Old timescale 31.4.04 new timescale 30.9.05 Page 25 Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 7. OP18 YA23 13 18 service users/those with dementia.Action must be taken in accordance with the risk assessment and to ensure the safety of those service users who may access this area. There must be regular training updates in relation to the protection of vulnerable adults and associated procedures. Completion of a programme of repairs, upgrading and renewal to the home. (NB Completion of this is a condition of the home’s registration by 31.03.05 – items remain outstanding) The lighting in the lounge of the older oersons unit must be improved (bulbs replaced) There must be a programme in place to ensure that where deficits are identified in the environment these are actioned Staffing levels must be provided in sufficient numbers giving consideration to the needs of the service users and the structure of the units Staff must undertaken equal opportunities training. 8. OP19 YA 24 13,16,23 9. 10. OP19 OP19 YA24 23 23 Old timescale 30.6.05 new timescale 30.10.05 Old timescale 31.3.05 new timescale 30.9.05 30.8.05 30.10.05 11. OP27 YA 33 18 30.8.05 12. YA 32 12 13. YA39 24 14. OP38 YA42 23 The quality assurance system in the home must be developed to include the view of service users families/representatives/outside stakeholders . The Provider must ensure that the electrical installation is checked, safe, fit for purpose and any identified works are completed C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Old timescale 31.3.05 new timescale 30.10.05 30.8.05 30.9.05 Tapton Grove Nursing Home Version 1.40 Page 26 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 YA28 Good Practice Recommendations The registered person should consider providing a separate laundry facility from the main laundry, where service users who are able may wash and iron their own clothes. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby. DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Tapton Grove Nursing Home C52 C02 S2079 Tapton Grove V239286 250705 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!