Inspection on 31/05/05 for The Conifers Nursing Home

This inspection was carried out on 31st May 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 03/11/05

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 S73 0SS Lead Inspector Steve Vessey Unannounced 31st May 2005 09:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service The Conifers Nursing Home Address Brampton Road Wombwell Barnsley S73 0SS 01226 751007 01226 751007 None Mr John Dominic Manfredi Mr Anthony Constantine Manfredi Mr Anthony John Manfredi and Mr Ian Hyde Carole Law N Care Home with Nursing 33 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of OP Old age (33) registration, with number of places The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons accommodated shall be aged 60 years and above. 2. Two specified service users under the age of 60 may live at the home. Date of last inspection 15 March 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. Residents 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 J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately seven and a half hours from 9:50 to 17:15. The inspection process included a partial tour of the premises, inspection of a sample of records and policies, discussions with the manager, the administration manager, 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 four staff, seven residents and relatives in detail. What the service does well: What has improved since the last inspection? The manager has now been registered with the Commission for Social Care Inspection. Recruitment procedures have improved; staff are now not employed until the required recruitment checks have been carried out. Staffing levels were discussed with staff and have improved, following the recent recruitment of more care staff, which enables staff to spend more time with residents. Fire extinguishers and the lift had been serviced. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 standard(s) 1 and 3, standard 6 was not applicable at the home. Prospective service users do not receive up to date information to help them choose where they want to live. All residents did not have a detailed assessment of their needs prior to admission to the home. EVIDENCE: The manager and the administration manager stated that the statement had not been updated, this does not give prospective residents up to date information to make a fully informed choice of where to live. Three out of four care plans included an assessment of residents needs carried out by the home prior to admission, giving staff the required information about residents. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 standard(s) 7, 8 and 9. Residents had a detailed up to date plan of care reflecting their identified assessed needs. Resident’s health care needs were met. Medication was managed safely and securely stored. EVIDENCE: Four care plans included detailed information as to the actions required from staff to meet the needs of the individual residents and were reviewed regularly by staff. Residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved. Risk assessments were in place for the development of pressure areas, moving and handling, falls, nutrition and the administration of medication, meeting the health care needs of residents. One resident stated that they had been able to get a new GP, maintaining their choice. Records were kept of medication being received into and leaving the home and medication administration records for residents were completed appropriately. Qualified nursing staff administer medication. All medication, including controlled drugs were stored appropriately and securely, maintaining the health safety and welfare of residents. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 10 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 standard(s) 12, 13 and 15 Residents are given choice in many aspects of their lives, allowing them to maintain their independence and were happy with the activities and outings on offer. Relatives and friends are encouraged to visit and participate in some aspects of resident care enhancing the quality of life for all concerned. Residents receive a choice of food, which is of good quality and can eat in a pleasant dining room or their room. EVIDENCE: Residents and staff stated that residents could choose when they get up and go to bed and could spend time in their room when they want to. Staff and residents stated that a choice of food was offered. Staff stated that residents enjoy sing-a-longs, sometimes play dominoes or bingo, people visit the home to do a keep fit session and manicures and entertainers visit the home regularly. Staff were observed spending time in lounge areas talking to residents. Events are held throughout the year, a poster was on display advertising a craft fayre. Residents stated that they receive visitors and that they go out with their relatives and friends if they wish. Relatives stated that they could visit when they want and that staff always welcome them. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 11 Time was spent observing in the dining room at lunchtime, lunch was served in two sittings, meals were served in an unhurried manner giving residents adequate time to eat, staff assisted resident to eat where required in an appropriate and sensitive way maintaining dignity. The dining room was pleasant and tables were appropriately set. The inspector had lunch; the main course was served hot and was of good quality, resident’s comments included “the food has improved” and “we never have a bad meal”. The manager stated that contact had been made with a dietician to try and arrange training with regard to special dietary needs for catering staff to enhance the quality of the catering service for residents. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 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 are in place to protect residents from abuse, however staff need to attend adult protection training. EVIDENCE: Residents and relatives spoken to stated that they would speak to the manager or the administration manager if they had anything to complain about and stated that they thought complaints would be listened to and sorted out. A detailed complaints log was available, there were no recent complaints recorded. Policies and procedures were in place regarding the recognising and reporting of abuse including whistle blowing procedures. Residents were not fully protected as some staff spoken to had not attended protection of vulnerable adults training, however they were aware of the policies and procedures of the home and stated that they would inform the manager if they suspected any abuse was taking place. A copy of the Barnsley local authority adult protection policies and procedures were available and accessible to staff. Residents and relatives spoken to stated that the home was safe. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 standard(s) 19, 21 and 26 Areas of the home accessible to residents were in the main well maintained, however some decoration in communal areas was looking a little worn and some furniture was showing signs of age. A bath panel was damaged. Residents were happy and comfortable in their rooms. The home was in the main clean, pleasant and hygienic. EVIDENCE: In the main the home was well decorated and well maintained, however the decoration in the dining area was beginning to look at little worn, dining furniture had damaged legs and some bedroom furniture was showing signs of age. The manager and administration manager stated that plans were in place to redecorate the dining room and replace some bedroom furniture to improve the quality of the environment. Bathrooms were clean, however the damaged bath panel in a first floor bathroom was still in need of repair or replacement. Residents stated that they were happy and comfortable in their rooms and that they were always kept clean. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 14 Residents and relatives stated that all areas of the home were kept clean, and residents stated that they were happy with the standard of the laundry service. The window in the laundry had not been re-glazed, however as this does not directly affect outcomes for residents and was not an issue for staff working in the laundry the previous requirement has been removed. Policies and procedures were in place for control of infection, some staff had received training and staff reported that they had sufficient provision of protective clothing, reducing the risk of infection. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Sufficient staff was on duty to meet the needs of residents. Recruitment policies and procedures have improved and now protect residents. Staff had received induction training. EVIDENCE: On the morning of the inspection there was the Manager, a nurse, three care staff, one laundry staff, one cleaner and two kitchen staff on duty. The manager stated that there was a member of staff on duty under the age of eighteen who did not carry out personal care tasks other staff confirmed this. Staff stated that there had been a recent improvement in staffing levels and because of this there was enough staff on duty to meet the needs of the residents. In the main residents and relatives stated that there were enough staff on duty, however a relative did say that sometimes staff do not appear to have as much time to spend with individual residents, as they would like and a resident stated that there should be more staff on duty. Resident’s comments included “staff are kind and patient”, “staff do their jobs well” and “the night staff are excellent”. Staff stated that staffing levels had been discussed with them and that the manager and owners had listened to their views. Three staff files contained appropriate recruitment information including two references and CRB disclosures. The manager and the administration manager confirmed that all staff employed now have a CRB disclosure and new employees do not commence employment until there disclosure is received to protect residents. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 16 Staff spoken to stated that they had received induction training, some staff stated that they had completed a TOPSS induction booklet. Nursing staff stated that they had opportunities to attend training to keep them updated in their clinical practice. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 37 and 38 The manager needs to undertake the level 4 NVQ in management. Residents are consulted about the running of the home; the owners recording their discussions following their monthly visit could improve this. Residents and relatives feel that the home is safe, however health and safe practices and records need improving to increase the level of safety for staff and residents. EVIDENCE: The manager has worked at the home for a number of years as a nurse and then as Deputy Manager, she has now been registered with the Commission for Social Care Inspection and has commenced the level 4 NVQ in management. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 18 Residents stated that the manager, the administration manager and the owners ask them what they think about the home. Staff stated that the owners visit regularly to look round the building, carry out work and attend social events. When they visit they also talk to staff and residents. The manager and administration manager confirmed this but stated that no record is made of the visits. Staff stated that they had received fire and moving and handling training and that they attended regular fire drills. Records confirmed this and showed that fire drills take place at various times during the day and at night. Servicing of electrical systems, portable appliances, the lift and hoists had taken place and the hot water temperature tested was around 43 degrees centigrade. Staff reported that the electric hoist had been waiting for repair for approximately two months; the manager confirmed that the contractor had been contacted and were awaiting a replacement part. Staff stated that they were currently able to meet the needs of residents using the hydraulic hoist. The health safety and welfare of residents in not fully protected as the lounge doors were still being wedged open, weekly checks of the fire alarm were not carried out, servicing of gas appliances had not taken place and the hot water temperatures were not monitored in all areas of the building. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 2 2 x x 2 2 The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 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 1 Regulation 4 Requirement The statement of purpose must include the environmental information highlighted in standard 1 (Previous timescale of 15/05/05 not met). All residents must have an assessment of their needs prior to admission to the home. The catering team must have training with regard to special dietary needs. All staff must receive adult protection training. The dining room must be redecorated The damaged bath panel must be repaired or replaced A written report of the owners monthly visit must be completed and forwarded to the Commission for Social Care Inspection (CSCI). The results of residents surveys must be published and made available to current and prospective resident, their representatives and other interested parties. A business plan must be produced which is accessible on request to the CSCI (Previous Timescale for action 31/07/05 2. 3. 4. 5. 6. 7. 3 15 18 19 21 33 14 12, 16 13 23 13, 23 26 31/07/05 31/08/05 31/08/05 31/08/05 31/08/05 30/06/05 8. 33 24 9. 34 25 31/08/05 The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 21 timescale of 15/05/05 not met) 10. 37 12 The home must keep records as required by the Care Home Regulations and National Minimum Standards. 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. The practice of wedging fire doors open must cease (Previous timescale of 15/03/05 not met). See individual timescales on standards not met. 31/05/05 11. 38 13 12. 13. 38 38 13 13 31/05/05 31/05/05 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. 3. Refer to Standard 19 31 38 Good Practice Recommendations A plan to replace some communal furniture and some bedroom furniture should be made within the next six months. Preparations should be made to ensure that the registered manager has a level 4 NVQ in management or equivalent by 2005. A system should be in place for the monitoring and recording of water temperatures throughout the building. The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI The Conifers Nursing Home J51 S6477 Conifers V218827 31.05.05 UI Stage 4.doc Version 1.20 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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