Inspection on 24/01/06 for The Conifers Nursing Home

This inspection was carried out on 24th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Conifers Nursing Home 11/12/06

The Conifers Nursing Home 02/08/05

The Conifers Nursing Home 11/11/04

The Conifers Nursing Home 28/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Conifers Nursing Home, 18 Johns Lane Great Wyrley Walsall West Midlands WS6 6BY Lead Inspector Lynne Gammon Announced Inspection 24 January 2006 9:30 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 The Conifers Nursing Home, DS0000038253.V274798.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. 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. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Conifers Nursing Home, Address 18 Johns Lane Great Wyrley Walsall West Midlands WS6 6BY 01922 415473 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) Sovereign Healthcare Associates Limited Fabienne Harris Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability over 65 years of age of places (34) The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: The Conifers is currently registered to admit 34 elderly persons, and elderly with physical disabilities. A 34-bedded nursing home situated in Great Wyrley, close to Cannock and Walsall, all major road and rail networks, and a regular bus service, making access easy for visitors and staff. The home is a twostorey building, purpose-built in 1986 and located in a built-up housing estate with adjacent parking. Work is almost complete to convert and extend the home to increase beds to 40. The provider and care manager have been working with the CSCI in implementing the building and commissioning process. The current proprietor Mrs Kandola has run the home since April 2003. Once the work is completed, the home will have 36 single and 2 double bedrooms, most of which will have en-suite facilities. There will be two lounges and two dining areas, plus a quiet room. Other services include a hairdressing room, and garden/patio facilities. All areas of the home have access via stairs and passenger lift. There is also an annex housing a training and office suite, extensively used as a nationally accredited staff training school. All staff receive formal training and are qualified to, or training towards NMC or BTEC standards. The Conifers is a member of the Investors In People Award. The management of the Conifers Nursing Home is committed to maintaining quality systems that support the care of the service users. Teams of trained staff led by Registered Nurses deliver care. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out on the 24th January 2006 at 9.30am using the National Minimum Standards for Older People as the basis for the The total time spent for the inspection, including pre and inspection. fieldwork, amounted to 9 hours. The inspection included a tour of the home, inspection of records, observation and discussions with service users and staff. Since the last inspection on 2nd August 2005, no complaints nor any incidents or reports of abuse of any kind had been received and no requirements or recommendations, against the regulations or the minimum standards, were outstanding from the last inspection report. What the service does well: What has improved since the last inspection? The home had been completely renovated and had a new extension. The quality of the work was excellent, the furniture and furnishings in the communal areas were particularly of a high standard. Colour co-ordinated accessories complemented these and the home appeared much more inviting and homely. A welcoming reception area with drink making facilities had been created for relatives and visitors. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 6 Also 2 new Malibu baths had been purchased and there were 2 new shower rooms, 1 disabled toilet, a new dining room, new quiet room, new kitchen with new equipment, all bedrooms had been redecorated and new carpets purchased, 2 double bedrooms had been changed to 3 single en-suite rooms and 1 single bedroom, new sluice facilities, new fire alarm system, new nurse call system, new heating system etc. The combination of all of the above had created a very pleasant, enjoyable and safe environment for the service users to live in and was a credit to the provider and staff of the home. 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 Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. The information provided by the home ensured that service users could make an informed decision. Contracts were in place for each service user and they received confirmation that the home could meet their needs prior to moving in. EVIDENCE: The Statement of Purpose had been updated in December 2005 and was seen to contain all required elements to provide service users with a clear understanding of the aims and objectives of the service, the philosophy of care, details of the facilities and services provided at the Conifers Care Home, plus a range of other useful information. The Statement of Terms and Conditions was seen to include details regarding: a trial period, fee structure, services covered by the fees, those items/services not covered by the fees, health, medication, bedroom and furnishings, personal possessions and finances, complaints, termination etc. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 9 The registered manager stated that verbal confirmation was given to prospective service users that the home could meet their needs prior to moving in, however, it is a requirement of this report that written confirmation be provided. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. There was a clear and consistent care planning system in place to provide staff with the information they needed to meet service user’s needs satisfactorily. The health needs of service users were well met with evidence of good multidisciplinary working taking place on a regular basis. The systems for the administration of medication were good with clear and comprehensive arrangements being in place to ensure service user’s medication needs were met. EVIDENCE: A sample of service user’s care plans were examined and found to be of a very good standard. Daily records, reviews and risk assessments were completed well and were individualised to evidence ongoing consultation with service users, families and other healthcare professionals where appropriate. The health care section of the care plan showed needs were closely monitored and medical professionals contacted when necessary. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 11 Medication administration, storage and disposal processes were robust to ensure the on-going protection of the service users. The registered manager undertook a regular medication audit to ensure correct recording and management was in place at all times. A contract was seen for the safe disposal of surplus medication in the home using a registered waste carrier. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14. All of the key standards were reported upon satisfactorily in the report of the previous inspection of 2/08/05 and the home continued to provide a range of activities to meet the needs of the service users. The home had a relaxed and welcoming atmosphere where people were encouraged to continue with their individualised lifestyle. EVIDENCE: Records of the range of activities provided for the service users were held in the activity folder which outlined group activities and one-to-one sessions for those who were bed bound. This was considered to be a good foundation to build on but it is recommendation of this report that this is further developed to provide evidence of linking with the social care needs identified in the individual care plans. Examples of a document called ‘This is my Life’, was seen and evidenced that this was also an excellent record for detailing specific important events in a service user’s life and could also be used to link the social care needs of the service user as set out in the care plan. The Commission for Social Care Inspection had received a large amount of completed questionnaires from service users and relatives regarding the service provided at the Conifers Care Home. One service user stated ‘Care needs are attended to, standards are high. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 13 Food is very good’. A relative commented as follows: ‘The view of the Conifers in my 18 months seeing my Mother is more than satisfactory – Home from Home’. A few service users stated that they did not feel that the home provided suitable activities and it is anticipated that this issue will be resolved once the activities are linked with the social care needs in the care plans as above. Standard 15 was examined at the previous inspection on 2nd August 2005, however it was noted that the menus had been changed in consultation with the service users and evidence of feedback from service users about each meal was seen. In addition to this, minutes from the service users and relatives meeting in December 2005 evidenced that a variety of issues had been raised and dealt with, including individual requests from service users for specific food items which were actioned. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. A satisfactory complaints procedure was in place and service users felt that they were listened to and action was taken to resolve their issues. Service users were supported and enabled to participate in the electoral process and were protected from abuse by the home’s Adult Protection procedure and training on abuse awareness. EVIDENCE: Both the Commission and the home had not received any formal complaints during the last twelve months. Service users confirmed that they did not have any complaints but if any complaints were raised, the Matron and staff would make every attempt to resolve them as far as possible. The registered care manager and Matron of the home confirmed local Councillors visited the home during election time and service users were supported to take part in the electoral process by postal vote if they so wished. There had been no incidents or allegations of abuse received by the home or the Commission for Social Care Inspection. The home had an Adult Protection procedure and all staff received training in abuse awareness. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 22, 23, 25 and 26. Satisfactory toilet and washing facilities were available for the service users and a range of specialist equipment was provided to support independence. Rooms were suitable to meet needs and the home had recently been refurbished and extended to provide a safe, comfortable and clean environment for the benefit of the service users. EVIDENCE: There were adequate toilets and washing facilities within the home including 2 showers and 2 bathrooms. Specialist equipment was provided and included manual handling equipment e.g. hoists, slings etc, 2 electric Malibu baths, pressure cushions and mattresses and 18 hospital beds were also in place. The home had recently undergone an extensive refurbishment and a large extension to increase the number of beds from 34 to 40. The work was seen to be of a high standard and significant effort had been made to provide quality furnishings and fittings – to create a homely and comfortable environment for the service users. The home was immaculately clean and considering the amount of building work that had taken place, the domestic staff were to be commended for maintaining such a high level of cleanliness. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 16 Almost all bedrooms had en-suite facilities and all rooms had low surface temperature radiators, smoke alarms, emergency lighting and were well decorated, bright and individually personalised. The corridors were found to be free from obstruction and well lit and the home provided a safe environment for those who lived there. The laundry facilities were inspected and found to be well organised, clean and hygienic. Soiled linen was contained and held separately from other laundry. Foul laundry was washed appropriately to ensure it was thoroughly clean and to control the risk of infection. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30. Service users were well cared for by the numbers of qualified staff that were competent and trained to carry out their jobs. All other standards were examined at the previous inspection and were found to be satisfactory. EVIDENCE: Staffing levels were examined and on the day of the inspection, Matron was on duty all day plus 1 Registered nurse with 1 senior carer and 5 care assistants in the morning, 3 full time care assistants and one part time carer in the afternoon and 1 registered nurse plus 2 carers on night duty. In addition to this, there was: a cook, a kitchen assistant, 2 administrators, 1 activities coordinator and 1 maintenance person. These staffing levels were found to be satisfactory to meet the needs of the 28 service users living in the home at that time. The inspector examined the records of the type and frequency of training undertaken by the staff within the home. Training records included the following mandatory training: Health and Safety including COSHH May 05 and October 05, First Aid November 05, Manual Handling November 05, Fire Safety on numerous occasions throughout 2005, and managing fire safety on 5th and 6th January 06. In addition to this, there was abuse awareness training in May, June and August 05, palliative care June 05 and a further palliative care workshop in January 05 and food hygiene in June 05. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34, 35, 36, 37 and 38. The registered care manager was fit to be in charge, responsible and of good character. Financial procedures were robust to protect service user’s financial interests. Staff were provided with regular formal supervision sessions. Records held were accurate and secure and the health, safety and welfare of service users and staff were upheld and protected. EVIDENCE: The Matron was the registered care manager for the home and had qualified as a registered nurse in 1984. She had worked at a number of care homes before commencing work at the Conifers Care Home in January 2005. She had completed the Registered Manager’s Award and NVQ Level 4 in Care and achieved BTEC NVQ Assessor in 1997, Diploma in Palliative Care in 2003 and had undertaken a range of other training to ensure that she kept up-to-date with current practice and procedures. She was very experienced in managing her responsibilities and staff to meet the needs of the service users in the home and service users benefited from her open approach. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 19 Records of service user’s personal allowances were examined and found to balance with monies held. Receipts were seen for every financial transaction undertaken in the home and financial processes were robust to protect service users and staff. Staff supervision records were examined and seen to be extremely well documented and interactive. Staff were encouraged to participate and contribute to the formal sessions. Records for the protection of service users, individual records and home records were seen to be secure, up to date and in good order. Policy and procedural documentation was inspected and the inspector was impressed with the quality and range of these and noted they were reviewed regularly. The inspector examined a range of records and documentation, which evidenced that the health, safety and welfare of service users and staff were protected. Fire safety records showed that the fire alarm system was checked on 14/11/05 and testing took place on 12/01/06, a certificate of maintenance for the fire extinguishers was issued in June 2005 and a fire drill took place on 20/01/06. Other records included: a 10 year electrical installation inspection undertaken on 14/10/03, hoists checked on 28/11/05, nurse call system checked and tested 15/10/05 and water testing was carried out on 17/01/06. The gas system was checked on 29/09/04, the lift had a routine service on 16/12/05 and the Malibu bath was installed and checked on 30/12/05. Following completion of the building work, new commissioning certificates for extensions to existing main services will be required. The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 20 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 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 4 X X 4 3 3 X 4 4 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X 3 3 4 3 3 The Conifers Nursing Home, DS0000038253.V274798.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NONE 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 OP4 Regulation 14(1)(d) Requirement To provide written confirmation to service users that their needs can be met prior to moving in. Timescale for action 24/01/06 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 OP12 Good Practice Recommendations To further develop the activities record to provide evidence of linking with the social care needs identified in the individual care plans. 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