Inspection on 03/11/05 for The Conifers Nursing Home

This inspection was carried out on 3rd November 2005.

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

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

Other inspections for this house

The Conifers Nursing Home 03/02/09

The Conifers Nursing Home 14/03/08

The Conifers Nursing Home 02/11/06

The Conifers Nursing Home 31/05/05

The Conifers Nursing Home 15/03/05

The Conifers Nursing Home 05/10/04

The Conifers Nursing Home 23/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 Brampton Road Wombwell Barnsley South Yorkshire S73 0SS Lead Inspector Mr Steven Vessey Unannounced Inspection 3rd November 2005 09:35 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 DS0000006477.V261199.R01.S.doc Version 5.0 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 DS0000006477.V261199.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Conifers Nursing Home Address Brampton Road Wombwell Barnsley South Yorkshire S73 0SS 01226 751007 01226 751007 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) Mr John Dominic Manfredi Mr Anthony Constantine Manfredi, Mr Anthony John Manfredi, Mr Ian Hyde Mrs Carole Law Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above. Two specified service users under the age of 60 may live at the home. Date of last inspection 31st May 2005 Brief Description of the Service: The Conifers offers accommodation for a maximum of 33 residents, requiring nursing or personal care. The home is situated within access to local amenities and is very close to a bus stop. It is sited between Rotherham and Barnsley. Resident’s accommodation is on two floors; the upper floor can be accessed using the lift. The building is modern in appearance and has a patio area for residents. There is ample car parking facilities. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There had been two complaints made to the Commission for Social Care Inspection relating to the home, the provider was asked to investigate these complaints. Part of this process included the provider asking for the views of residents and relatives via questionnaires; comments from the questionnaires have been included in this report. This unannounced inspection took place over approximately seven and a half hours from 09:35 to 16:50. The inspection process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to eight staff, seven residents and relatives in some detail. What the service does well: Residents were able to make choices about daily routines. Residents were pleased with the environment acknowledging in particular the standard of cleanliness within the home and that their rooms were comfortable. In the main the home smelled pleasant and was cleaned to a high standard and had a homely atmosphere. Residents received a good standard of care, comments included “staff are good at their jobs”, “they could not do any more for me”, “and staff come quickly if I pull the buzzer in my bedroom”. In the main residents felt that they were treated with respect, comments included “staff are kind to me”. Residents were happy with the food provided, comments included “If I want something different to eat they will get it for me”. Medication was well managed and stored securely. Residents and relatives spoken to were very satisfied with the quality of the service, comments included, “I don’t think they could do anything better” and “You can’t improve on things which are good”. In the main residents and relatives were aware of how to complain and felt that their complaints would be listened to and sorted out. Staff had received some induction training and had opportunities to attend other training; some staff were NVQ level 2 trained. Residents stated that they were asked their views about the home and stated that they had just completed a questionnaire. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 DS0000006477.V261199.R01.S.doc Version 5.0 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 DS0000006477.V261199.R01.S.doc Version 5.0 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 and 3, standard 6 is not applicable at the home. Prospective residents do not receive up to date information to help them choose where they want to live. Residents’ records included a detailed assessment of their needs. EVIDENCE: The administration manager stated that the statement of purpose had not been updated, this did not give prospective residents up to date information to make a fully informed choice of where to live. Two care plans included an assessment of residents’ needs and some residents spoken to stated that they had been visited by staff from the home before their admission. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 9 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): 9 and 10. Medication was managed safely and stored securely. In the main residents felt that they were treated with respect by staff, however some relatives stated that this did not always happen. EVIDENCE: Records were kept of medication coming into and leaving the home and medication administration records for residents were completed appropriately. A qualified nurse administered medication to residents, when observed administering medication the nurse was sensitive to the needs of the residents by assisting them to take their medication where needed and asking residents if they wanted pain relief. Medication, including controlled drugs was stored securely, promoting the health safety and welfare of residents. Care staff were able to describe how they promoted privacy and dignity when providing care for residents, nursing and senior staff described how they monitored care delivery to ensure the privacy and dignity of residents was maintained. Staff stated that lunch was now served in two sittings; this The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 10 enabled them to help residents who needed assistance to eat in a more sensitive and discreet way, preserving their dignity. Residents spoken to stated that staff looked after them well and were kind. Residents stated that they were able to spend time in their room and were able to see their visitors in private if they wanted to. Staff were observed assisting and communicating with residents in an appropriate way, treating residents with respect, however some relatives stated that on some occasions staff did not treat residents with respect and dignity. Notices relating to care needs were displayed on the wall in a communal lounge. The manager stated that this was done to promote the health safety and welfare of the resident. Relatives stated that they were happy that the notice was displayed as it ensured the safety of the resident. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 11 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): 14 and 15 Residents were helped to make choices about their lives. Residents received a choice of food, which was of good quality and could eat in the dining room or their room. EVIDENCE: Residents stated that they had been able to bring personal items into to furnish their bedrooms. Residents spoken to stated that they were happy that their relatives handled their financial affairs. Residents stated that they received a choice of food and that the food served was of good quality. Residents spoken to stated that if they requested a particular food that they liked this would be provided, comments included “If I want something different to eat they will get it for me”. The cook stated that she was aware of the nutritional needs of the residents requiring special diets. The cook and the manager stated that a dietician had visited the home to reassess the catering service for an award, which the home has achieved for a number of years. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 12 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 and 18. Residents and relatives were aware how to complain and thought that their complaints would be listened to and dealt with. Policies and procedures were in place to protect residents from abuse, however all staff need to complete adult protection training. EVIDENCE: Residents spoken to stated that they would speak to the administration manager or manager if they had any complaints, they thought that their complaints would be listened to and sorted out. There was a complaints log and no recent complaints had been recorded, however two complaints had been made directly to the Commission for Social Care Inspection. Staff had commenced some adult protection training and staff spoken to were aware of the policies and procedures relating to the recognising and reporting of abuse. Residents spoken to all stated that they felt safe at the home and that staff were kind to them. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 13 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): 19, 21, 24 and 26 The environment would be improved if there was a programme of routine maintenance, which should include the redecoration of the dining room and the replacement of the dining furniture. Most areas of the home were accessible, however one bathroom was being used for inappropriate storage. Residents were happy and comfortable in their rooms, however some bedroom furniture was showing signs of age. The home was in the main clean, pleasant and hygienic, however there was an unpleasant odour in one area on the ground floor. EVIDENCE: In the main the home was well decorated and maintained, however there was some damage to the walls in the dining area and some of the dining furniture had damage on the legs. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 14 The manager stated that there had been no major redecoration of replacement of furniture since the last inspection and there was no programmed of routine maintenance and renewal of fabric and decoration of the home. The damaged bath panel in the bathroom on the first floor had not been repaired, however this does not directly affect the service received by residents, therefore the requirement has been removed. There were two pressure mattresses, a mattress for a divan bed and some boxes stored in a first floor bedroom used by residents. Residents spoken to stated that they were happy and comfortable in their bedrooms and that they had everything that they needed. They stated that their bedrooms were kept clean. The furniture in some bedrooms was showing signs of wear. In the main the home was clean and free from unpleasant odours, however an unpleasant odour was evident on the ground floor around the communal toilet area adjacent to the lift. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 15 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, 28 and 30 Sufficient staff was on duty to meet the needs of residents. The home needs to continue with the NVQ training programme to ensure adequate numbers of care staff are trained. Staff had received induction training. EVIDENCE: On the morning of the inspection there was a nurse and three care staff on duty, there was also one cleaner, two staff working in the kitchen and one member of staff working in the laundry. The administration manager and the manager were in the home later in the day. Staff stated that in the main there was enough staff to meet the needs of residents most of the time. Most residents spoken to stated that there were enough staff on duty to look after them and stated that if they used the call buzzer to request assistance staff responded quickly. However some relatives thought that at times there were not enough staff. The manager stated that four out of eleven care staff had completed NVQ training in care to at least level 2 and another member of staff was working towards this. Care staff stated that they received a booklet to complete as part of their induction training and that this was discussed with them to ensure that they understood their roles and responsibilities. Staff stated that they had opportunities for other training and nursing staff had attended training to update their clinical practice. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 16 The administration manager stated that a senior member of staff was attending a management course. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 17 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, 33, 35, 37 and 38. The manager should continue to work towards the level 4 NVQ in management. The quality monitoring of the home would be improved if the findings from the recent questionnaires were published and made available to residents and their representatives and the owners provided a written report following their visits to the home. Residents’ financial interests were not fully safeguarded, as financial records were not fully completed. Residents and relatives felt that the home was safe, however health and safety practices and records need improving to increase the level of safety for staff and residents. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 18 EVIDENCE: The manager stated that she was continuing to work towards the NVQ 4 in management and care. Residents stated that they were regularly asked what they thought about the home and that they had recently completed a questionnaire, the administration manager stated that the manager had reviewed the responses and had the information required to enable the results to be made available to interested parties. Some staff stated that they had seen the owners visit the home and that during these visits they talked to staff and residents. However no written records of these visits had been forwarded to the Commission for Social Care Inspection and they were not available at the home. A business plan was still not available, however as this does not directly affect the outcomes for residents this requirement has been removed. Residents spoken to were happy with the current arrangements for the management of their finances. Records checked relating to money held on behalf of residents included the date, the reason for any debit or credit, the balance and two signatures for every transaction. Residents were not protected as there were no recent entries in the records and the administration manager stated that the records were not up to date. She stated that she had some records in another book which needed transferring, however this book was unavailable on the day of the inspection. The administration manager stated that a float of money was left at the home outside office hours in case a resident needed some money in an emergency. She stated that this was stored securely and only the nurse in charge had access to it and recorded if a resident had been given any money. The registration certificate on display was not the latest issued by the Commission for Social Care Inspection. Staff stated that they had received fire and moving and handling training and that fire drills took place regularly. Records confirmed that fire drills take place at various times during the day and night. Staff stated that they had adequate equipment to assist them with moving and handling and were observed moving residents using safe and appropriate techniques. The health safety and welfare of residents and staff were not fully protected as the lounge doors were still being wedged open, records of weekly fire alarm checks were not available and the servicing of gas appliances still had not taken place. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 19 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X 2 2 The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 4 Requirement The statement of purpose must include the environmental information highlighted in standard 1 (Previous timescale of 15/05/05 not met). In the future notices giving information relating to individual residents must not be displayed in communal areas. Staff must treat residents with dignity and respect at all times. All staff must receive adult protection training. A programme of routine maintenance and the renewal of the fabric and decoration must be implemented with records kept. The dining room must be redecorated (Previous timescale of 31/08/05 not met). The dining room furniture must be replaced. The equipment stored in the first floor bathroom must be removed and stored in a suitable place. All parts of the home must be kept free from offensive odours A written report of the owner’s DS0000006477.V261199.R01.S.doc Timescale for action 03/02/06 2 OP10 12 03/02/06 3. 4. 5. OP10 OP18 OP19 12 13 13 03/12/05 03/02/06 03/02/06 6. 7. 8. 9. 10. OP19 OP19 OP21 OP26 OP33 23 23 23 16 26 03/02/06 03/02/06 03/01/06 03/12/05 03/12/05 Page 21 The Conifers Nursing Home Version 5.0 11. OP33 24 12. OP35 16 13. 14. OP37 OP38 12 13 15. OP38 13 16. OP38 13 monthly visit must be completed and forwarded to the Commission for Social Care Inspection (CSCI) (Previous timescale of 30/06/05 not met). The results of resident’s surveys must be published and made available to current and prospective resident, their representatives and other interested parties (Previous timescale of 31/05/05 not met). Resident’s financial records must be fully completed, up to date, and available for inspection and a copy supplied to the Commission for Social Care Inspection. The current certificate of registration must be displayed. A competent person must service gas appliances and the CSCI must be informed when this has been completed. Previous timescale of 15/03/05 not met). The fire alarm must be tested weekly and records must be kept. (Previous timescale of 31/05/05 not met). The practice of wedging fire doors open must cease (Previous timescale of 15/03/05 not met). 03/01/06 03/12/05 03/12/05 03/01/06 03/12/05 03/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP24 OP28 Good Practice Recommendations A plan to replace some bedroom furniture should be made within the next six months. The home should continue with its training programme to DS0000006477.V261199.R01.S.doc Version 5.0 Page 22 The Conifers Nursing Home 3. OP31 ensure that 50 of staff are qualified to NVQ level 2 or equivalent by 2005. Preparations should be made to ensure that the registered manager has a level 4 NVQ in management or equivalent by 2005. The Conifers Nursing Home DS0000006477.V261199.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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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