Inspection on 09/05/06 for Tapton Grove Nursing Home

This inspection was carried out on 9th May 2006.

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 13 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 13/02/06

Tapton Grove Nursing Home 25/07/05

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 Inspection 9th May 2006 09:45 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 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 Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 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 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 DS0000002079.V293598.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tapton Grove Nursing Home Address Grove Road Brimington Chesterfield Derbyshire S43 1QH 01246 274178 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.sunhealthcare.co.uk 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 DS0000002079.V293598.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 13th February 2006 Date of last inspection 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. The range of fees charged at the home are for the older persons unit £469.80 – £657.93 and for the younger adults unit £469.80 – £1467.88. Local authorities funded the majority of service users in the home. Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place on the 9th & 10th May 2006 over 10 hours. The purpose of this inspection was to assess all key standards and compliance to previously listed requirements. Various records including care planning records were examined the findings are recorded in the body of this report. The Manager Pat Willey was on during the inspection. 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: It was not possible to establish from the poor record keeping and planning what training staff had completed this included statutory training updates such as moving and handling and twice annual fire safety training for staff. Action to address shortfalls identified in staff personnel files has not been taken and recruitment procedures were not being fully implemented. The home is a large one and being a converted building requires significant upkeep. Whilst this is ongoing there is an incomplete approach to the tasks being undertaken for example radiator covers and partition walls only partly decorated. Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 6 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 DS0000002079.V293598.R01.S.doc Version 5.1 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 Outcomes 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 DS0000002079.V293598.R01.S.doc Version 5.1 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 suitability 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 the following standard(s): See below Systems were in place to ensure there was adequate knowledge of service users in place and service users were given opportunity to visit the home prior to admissions being agreed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: Shared Information All care files included a copy of the Terms and conditions of residency contracts which had been issued to service users. Service users or their representatives had signed these. Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 9 The Manager said that all service users had allocated Care Mangers and assessments from Care Managers and Free Nursing Care assessors were evident in files. Whilst there had not been any new service users since the last inspection systems were in place to give service users opportunities to visit the unit (one prospective service user was visiting during the inspection) and trial visits were offered. One service user was having a period of trail stays at the unit prior to full time placement. OP standards assessed 1, 3, 6 This home does not offer intermediate care as defined by this standard. YA standards assessed 2, 4 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 10 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 the following standard(s): See below The quality of care plans in place varied with some potential existing for staff to be placed at risk or have inadequate information to care for service users. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service EVIDENCE: A sample of four care plans from service users of a range of ages and assessed needs were examined. Older Persons (and Younger adults combined unit) Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 11 One care plan examined did not contain any detail of the service users assessed mental health needs. As has been highlighted at previous visits there was little detail on care plans to describe care needs and how staff were to deliver these. An example of this is that on a personal hygiene care plan the actions were to ensure needs were met but this did not detail for example the service users abilities, choices, or individual circumstances for example did they have own teeth/dentures. Staff would need this information to ensure appropriate care delivery. Care plans were also not always professionally written for example one recorded a ‘history of mental health problems’ but did not detail how staff were to identify potential future problems if they occurred. Younger Adults One service user spoken to knew that they had the right of access to the records held about them and a number of service users said they were involved in the care planning process. Care plans were found to be signed and service users spoken to said they did see their care plans. A number of service users spoke of future plans they had and how staff were helping with these. Where restrictions were in place for example limiting cigarettes/ monies service users knew of these. Whilst it was evident that in some care plans there were details on assessed risk both for the service user and other sin the home this was not consistent in all plans viewed. Some risks identified on one risk assessment was not supported by a plan of care. Care plans were found to be reviewed and had documented individual logs, activities logs and general daily logs. Positively all service users appeared to have some allocated individual staff time. General discussions with staff demonstrated a good knowledge of the service users. The Manager spoke of a new risk assessment format which was currently being piloted which was to be completed at multi disciplinary reviews. Some service users spoke of have limitations on the provision of money or cigarette but where this was in place service users appeared to be well informed of the limitations and described the reasons clearly why this was so. OP standards assessed 7,14 YA standards assessed 6,7,9 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 12 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 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 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 the following standard(s): See below Service users at the home appear to be offered choice and flexibility of lifestyle in and out of the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 13 EVIDENCE: Older Persons (and Younger adults combined unit) A record of activities participated in was kept in each service users file. Typical activities included bingo, trips out for lunch and a visiting entertainer. There was little documented in a care plans to demonstrate that service users had been assessed regarding social needs. One service user spoken said they enjoyed spending time in their room listening to the preferred radio. They said they could go to bed whenever they chose. Younger Adults Some service users spoken to said they attended local colleges. Some group activities were planned regularly such as a Men’s and Women’s group. A schedule of activities was pinned on a notice board. Two service users spoke of attending a course on small animal care and said they enjoyed this very much. Some service user attended groups organised by the mental health organisation Rethink. Service users said they participated in some cleaning and laundry tasks in the home and these were supported by assessment forms documenting abilities in areas such as budgeting, cooking and laundry. Shared information There was a car available for both units to use. This was seen to be well used partly due to the remote location of the home which was not near to any bus routes. There is one kitchen supplying the food for both units. All service users spoken knew what was planned for the next meal and said they had a choice offered to them. The main meal of the day is served at teatime. The meal served on the first day at teatime appeared to be well presented with a good choice of vegetables. Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 14 A kitchenette area was available on the younger adults unit where some service users shopped and prepared meals for themselves. Service users religion was recorded and one local clergyman visited 4 service users on a regular basis. It was evident that on both units service users were encouraged, supported and if need be taken to see family and friends. OP standards assessed 10,12,13,15 YA standards assessed 12,13,15,16,17 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 15 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 the following standard(s): See below An established network of external professionals met Service users healthcare needs. Observations proved that staff regarded service users positively and respectfully. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: Medications One shared room is used for the storage of medications for both units. Medication administration records were examined. On a number of these Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 16 handwritten entries had not been verified and signed by a second staff member. Some overstocking of medicines was found with some items being dated as received in August 2005 and subsequent stocks being evident. Topical preparations were found to be undated with part of the pharmacy label not being legible. There some gaps evident of medication administration records with no further records to demonstrate a reason why administration had not happened. Some of this may appear to relate to poor practice as a pattern of the omissions on the same medication round was evident. The storage and administration of controlled drugs was found to be in good order. There was not an appropriate disposal vessel in the home to ensure controlled drugs were disposed of as per recent protocols. Some staff were signing administration records where service users were self administering. Shared information On the first day of the inspection a Consultant Psychiatrist was visiting the younger adults unit to undertake planned reviews. A Social Worker was also in the home for the day and said they spent regular time in the home to see service users. It was apparent from speaking to service users they knew when their reviews were planned and participated in these. All care files contained a range of risk assessment tools. These included nutrition, tissue viability and service users weights were recorded on a monthly basis. Reviews of risk assessment tools were documented. One service user who care was tracked did have the pressure relieving equipment in place which was documented in their plan of care. All files had a section dedicated to recording post death wishes. The majority of these found to be completed. Where the service user had not wished to discuss this records reflected this. All care files examined contained details of when service users had accessed dentists and opticians. A private chiropodist visited the home regularly and saw service users in both units. Service users were assisted to attend outpatient appointments. Where service users shared a room a form for service users to sign agreeing to this was in files. One service user spoken to had mixed feelings about sharing a room as there had been some difficulties. Screening in shared rooms had recently been fitted as fixed partitions. This did improve the sense of space being allocated to each service user but the position of the screening did not afford privacy when using the wash basins. Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 17 General observations of staff/service user interactions were that these were frequently jovial with some leg pulling. Staff were respectful and respected service users privacy knocking on doors before entering. OP standards assessed 8,9,10,11 YA standards assessed 18,19,20,21 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 18 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 safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) 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 the following standard(s): See below Whilst systems and procedures were in place to ensure that complaints and any allegations of abuse were handled this was not supported by the staff training programme. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service EVIDENCE: The complaints procedure was displayed on both units and contained all relevant information. One service user spoken said they would feel able to approach staff if they had concerns. No complaints had been received since the last inspection on either unit. Two potential allegations of abuse had been referred through local Protection of vulnerable adults procedures and subsequent meetings held. None of these were substantiated. Training records did not include any details that staff had attended any Protection of vulnerable adults training. This was discussed with the Manager who said that 3 places had been for staff to attend in September 2006. It was Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 19 then planned that these staff cascade training to other staff in the home. This is an outstanding requirement from previous inspections. Some monies were stored safely on behalf of service users. Records examined confirmed that balances correlated with the records in all samples checked except one where there was a 10p discrepancy. Not all transactions were verified by two separate signatures as is recommended. Some service users had signed records for some transactions. Receipts for purchases made were retained. A range of policies were in place including whistle blowing, equal opportunities, racial harassment and bullying. OP standards assessed 16,18,35 YA standards assessed 22,23 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 20 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 the following standard(s): See below There is a lack of attention to detail in the completion and maintenance of the environment in some areas. Ongoing investment is required to ensure the home meets standards. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service EVIDENCE: Tapton Grove is a home converted from a large period property set in its own extensive grounds. Service users said they enjoyed the views and peaceful Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 21 location of the home but sometimes did find the distance to local bus routes difficult. The home is split into two units one accommodating 10 older persons and 10 younger adults. The second unit accommodates 27 younger adults 18 – 65 Tapton Grove is a large home and whist there was some redecoration completed since the last inspection this is an ongoing process and some areas required completion such as radiator covers and part of the new screening. Older Persons (and Younger adults combined unit) This unit is arranged on two floors with a lounge/dining area on each floor. The ground floor unit had an outdoor area for service users to use. This had been paved since the last inspection and service users were observed to be enjoying this area. Whilst covers were fitted on all radiators some of these had not been painted as was found at the last inspection. It was observed that some of these were becoming damaged where they were near water in bathroom/toilet areas. Some bedrooms had furniture which was relatively new others had older style furniture which was missing some handles. One bedroom had an unpleasant odour. Younger Adults The younger adults unit has two lounges (one allocated as a smoking area) and one dining room. It was apparent from observations that the smokers lounge was essentially the hub of the home and was used by most service users. The carpet and furniture in this room were found to be in a poor state due to numerous cigarette burns. Ashtrays were provided but these did not appear to always be used. The Manager said the carpet had only been fitted in January 2006 but was badly burned throughout. The alternative lounge was quieter and better maintained. A sample of service user bedrooms were examined. Service user said generally they liked there bedrooms and some were found to be well personalised, others less so. Some fixed partitions had been fitted in shared rooms to try to improve privacy for service users. This was generally appreciated by service users. Some of the woodwork on the partitions were not decorated. All Service users seen had the key to their bedroom. Shared areas Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 22 A new cooker had been delivered and was waiting to be fitted. The kitchen was found to be clean and tidy with all records in good order. Gloves and protective clothing was available. The laundry area was fitted with one washer and dryer and an additional domestic type washer which service users on the younger adults used to do their own washing. One service user spoken said they had an allocated day to do their washing. Each service user had an individual laundry basket. OP standards assessed 19,26 YA standards assessed 24,30 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 23 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 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 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 the following standard(s): See below Staffing levels were being maintained in the home but there was poor evidence of training, regular supervisions and recruitment processes being implemented. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service EVIDENCE: The home is arranged into two units for staffing purposes one for 27 younger adults and the second unit has a staff group caring for 10 older persons and 10 younger adults. Each unit had a designated Deputy Manager. Qualified nurses were on duty for all shifts on both units of the home. It was noted that there are positively all the nurses employed were mental health nurses. The Manager of the home worked on a supernumerary basis. Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 24 Older Persons (and Younger adults combined unit) Staffing levels were typically one nurse for all shifts with 4 care staff each morning, 3 in the afternoon and two at night. Younger Adults Staffing levels were typically one nurse for all shifts with an additional nurse working on a 9 – 5 shift with 3 care staff working day shifts and 2 care staff on nights. Shared Information There was 33 care staff employed at the home. Of these 15 hold at least NVQ (National Vocational Qualification) level 2 in care, 2 staff are currently completing nurse-training courses. A sample of recruitment files were examined. It was established that some records that were required had not been obtained. This included some records which had been identified as missing at the last inspection. The range of records missing included Criminal Records Bureau checks, photographs and references. Some application forms examined also had significant gaps such as schooling and employment histories. This is an outstanding requirement from previous inspections. Training records were poorly completed and basically contained only the date of the last fire safety training, one session of confidentiality training. The Manager said that the training records had gone missing and could not be located. It was there fore not possible to establish what training had been received at all. There was no planner in place to demonstrate what had taken place and what was planned. This is an outstanding requirement from previous inspections. Staff supervisions were allocated to a named staff member. Records viewed revealed an inconsistent pattern to frequency of supervision sessions. Some gaps were as long as 9 months between supervisions being held. Some planning is required to ensure all staff receive regular supervision. Staff appraisals had been completed with a form available to record these which included a section for the supervisees comments. Some self-appraisals had been completed which had yet to be followed up by discussions and action plans. OP standards assessed 27,28,29,30,36 YA standards assessed 32,34,35,36 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 25 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 37, 39 and 42 (Adults 18-65) and Standards 31, 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 the following standard(s): See below There are generally well established management systems in the home although it was evident that some areas require improvement for example staff training implantation and recording. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 26 EVIDENCE: The Manager of the home is a qualified Mental Health Nurse and has been in post for 20 Years and has achieved a relevant managerial qualification. Service users spoke positively of the Manager. All service user and staff spoke positively of the Manager. There were forms available to give out to service users, relatives and visiting professionals to establish views regarding the service offered at the home. There appeared to be samples of these sent out on a randomised basis. Some had been posted out to relatives but few of these had been returned. Where service users did not want their relatives to be involved this was recorded and respected. Feedback on all forms viewed was generally good. A space was also on the forms to discuss and follow up any areas of concern. Monthly monitoring visits made on behalf of the Provider had been completed. The policy file was well managed with policies being organised in sections relating to the National Minimum Standards. Service records for the home were examined. These were generally found to be in good order with the exception of the 5yrly periodic electrical report which has been outstanding for some time. Confirmation that this has been completed was faxed through to Commission for Social Care Inspection after the inspection. A weekly ‘safe practices’ audit was completed by the handyman this included checks of the fire system. Accident records were kept however these were held in the administration office and not with the service users file. This had the potential for staff coming on duty to be unaware of any accidents that had occurred. OP standards assessed 31,33,35,38 YA standards assessed 37,39,42 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 27 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 Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT Standard No Score 37 x 38 x 39 x 40 x 41 x 42 x 43 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tapton Grove Nursing Home Score x x x x DS0000002079.V293598.R01.S.doc Version 5.1 Page 28 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 be in place for all assessed needs and detail how care is to be delivered to the service user Previous timescale 30/09/05 & 31/03/06 2 YA9 15 Where assessed risks and needs are identified these must be supported by a plan of care to describe how needs are to be met Previous timescale 31/03/06 3 YA20 13,17, Schedule 3 Where medication administration records are hand written these must be signed, checked and counter signed by a second staff member Previous timescale 31/03/06 4 YA20 13,17, Schedule 3 A denaturing kit for the disposal of controlled drugs must be obtained DS0000002079.V293598.R01.S.doc Timescale for action 31/07/06 31/07/06 30/06/06 30/06/06 Tapton Grove Nursing Home Version 5.1 Page 29 5 YA20 13,17, Schedule 3 This requirement also applies to the Older Persons unit Topical preparations must be dated on opening and discarded according to manufacturers guidelines This requirement also applies to the Older Persons unit Where medications are prescribed on a regular basis these must be administered or a record maintained of the reason for ommisions This requirement also applies to the Older Persons unit A bedroom redecoration programme must be drawn up and implemented Radiator covers throughout the home must be decorated There must be regular training updates in relation to the protection of vulnerable adults and associated procedures. Previous timescales 30/06/05 & 30/10/05 30/06/06 6 YA20 13,17, Schedule 3 30/06/06 7 OP24 23 30/06/06 8 9 YA24 YA23 23 13 18 30/07/06 30/06/06 10 YA23 13 All financial records made on service users behalf must be accurately maintained and recorded at all times Previous timescale 31/03/06 The missing ceiling tiles must be replaced in toilet /bathroom areas Previous timescale 30/04/06 30/06/06 11 OP19 23 30/07/06 12 YA34 18 The home must ensure robust recruitment procedures are DS0000002079.V293598.R01.S.doc 30/06/06 Tapton Grove Nursing Home Version 5.1 Page 30 adhered to which includes all the checks as required by Schedule 2 pre commencement of employment Previous timescale 31/03/06 13 OP30 18 Training records must be kept 30/06/06 and made available to demonstrate staff are adequately trained to undertake the role for which they are employed Timescale given not yet passed at this visit 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 3 4 5 Refer to Standard YA20 YA20 YA20 YA26 YA26 Good Practice Recommendations Maximum and minimum temperatures of the fridge used to store medication should be recorded daily. Existing stocks of mediations should be considered before orders for further stocks are placed Staff should not medication administration record to confirm administration where the service user has self administered medicines The home must be kept free from offensive odours There should be ongoing investment into a furniture replacement programme to ensure standards are maintained Accidents forms should be accessible to staff who are providing care for the service users to ensure they have all relevant information available to them This recommendation also applies to the Older Persons unit 6 YA42 Tapton Grove Nursing Home DS0000002079.V293598.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Derbyshire Area Office 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. 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