Inspection on 22/09/05 for The Cottage Nursing Home

This inspection was carried out on 22nd September 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 Cottage Nursing Home 08/11/06

The Cottage Nursing Home 17/01/06

The Cottage Nursing Home 22/02/05

The Cottage Nursing Home 04/11/04

The Cottage Nursing Home 01/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Cottage Nursing Home, The 57/58 Blakenall Heath Bloxwich Walsall West Midlands WS3 1HS Lead Inspector Mrs Cathy Moore Unannounced Inspection 22nd September 2005 07:45 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 Cottage Nursing Home, The DS0000020790.V250223.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. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cottage Nursing Home, The Address 57/58 Blakenall Heath Bloxwich Walsall West Midlands WS3 1HS 01922 712610 01922 712610 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) Acepay Limited Rosemary Elizabeth Broadhurst Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 26 frail elderly requiring social care conditions 1 and 2 not mutually exclusive of which 5 may be terminally ill 26 frail elderly requiring nursing care The home to accommodate a maximum of one person in an intermediate care bed. 22/02/05 Date of last inspection Brief Description of the Service: The Cottage Nursing Home as the name suggests is registered by the Commission to provide nursing care to a maximum 26 older people at any one time. One bed is funded on a contract basis for intermediate care. The home is located in a pleasant residential area. A bus stop is situated virtually outside of the home. The home was purpose built and first registered in 1992 by the present owners. The home comprises of 14 single and 6 double bedrooms. The intermediate room only, has en-suite facilities. The main lounge / dining room is located on the ground floor. A small lounge available on the first floor. A number of assisted and non-assisted bathing facilities and toilets are located on both floors throughout the home. Bedrooms are available on both floors. The kitchen, treatment room, and offices are on the ground floor, staff room and laundry in the lower ground floor. The garden whilst attractive with its mature shrubs has limited usable space, as the grassed area is sloped. Limited car parking spaces are available at the front of the home. The owners have applied for planning permission to add extra 7 beds to the home, improve facilities and have the garden levelled. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.45 and 16.15 hours. The inspection was the first of the homes two routine inspections for this year. Three residents’ were selected for case tracking purposes. Two were focussed on in more detail. The case tracking process involved the perusal of their assessment documentation, care plans, risk assessments and daily notes. Seven residents’, two relatives and three staff members were informally interviewed. One other relative declined the offer of speaking to the inspector. The premises were randomly assessed this included the lounges and dining area, garden, laundry a number of bedrooms, toilets and bathrooms. Records pertaining to health and safety, staff training, staff recruitment and equipment maintenance were also examined. The manager was instrumental to the inspection. What the service does well: The home has a stable staff team. The manager has been in post for three years. Two of the nurses for six plus years. Generally there is a low turn over of staff providing stability and continuity of care to the residents. Staffing levels overall appear to be good. The atmosphere of the home was found to be extremely positive, staff friendly and welcoming. Record keeping and nursing care in general is of a good standard. The home has very few past requirements. Positive comments from relatives included, “ What attracted me to the home was the fact that it is small. Staff have got the time to provide care. The staff are respectful and friendly, I have got no concerns at all”. Another said “ My Mother is well looked after I have got no complaints or concerns”. One resident commented “ I have thrived since I came in here. I like the home, I really do. There’s no one I don’t get on with”. Another resident commented” The staff are definitely respectful to the residents’. I have got a nice big room “. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 6 Three recent completed questionnaires by stakeholders included the following comments, “ Very friendly, staff are well informed about the residents’”.” Very pleasant odour of cooking”. “ Staff attentive dignity etc very much so”. One resident who has lived at the home for three years commented “ At first I did not want to come in here, now I would not like to leave. I have made so many friends with other residents’”. Over 50 of the care staff team have achieved N.V.Q level 2 or above in care. Others are working towards this qualification. A number of care staff have also or are working towards N.V.Q level 3. 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. Cottage Nursing Home, The DS0000020790.V250223.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 Cottage Nursing Home, The DS0000020790.V250223.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): 2,3,4,5. Terms and conditions documents require further development to ensure that each one issued is accurate, up to date and contains the required information. No resident moves into the home without having their needs assessed and being assured that these needs can be met. Prospective residents’ and/ or their relatives have the opportunity to visit and assess the service and its suitability before they are admitted. EVIDENCE: A terms and conditions document was on file for all residents’, these however, had not all been completed. The terms and conditions document did not all detail the current fee or the applicable room number. The manager did comment that terms and conditions documents had recently been revised. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 9 There was sufficient evidence available to demonstrate that an assessment of need had been carried out for all residents’ before they were offered a placement at the home. One assessment documentation had been signed and dated by the residents’ niece. The manager is fully aware of the homes registration categories and conditions. It was pleasing to see that a letter is in operation which confirms to prospective / new residents’ that their needs can be met. There was evidence available to demonstrate that prospective residents’ and their representatives are offered an introductory visit to the home prior to admission to assess its facilities and quality. Two prospective relatives were viewing the home during the inspection. One relative of a resident living at the home commented “ I came to look around the home, Mum was still in hospital at that time”. One resident said “ I came to see the home before I moved in”. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 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): 7,8,10 Residents’ health and personal care needs are set out in an individual plan. Generally, residents’ health care needs are fully met although fine tuning is needed in some areas. Residents’ feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: The home operates a core care planning system whereby a range of possible care plans are produced and selected according to need. Generally these were of an acceptable standard, although, evidence to demonstrate resident involvement was lacking with some. There was evidence of robust systems in place in respect of weight checking and overall weight monitoring. Pressure area care/ pressure sore treatments are documented to a good standard which includes photographing wounds to demonstrate when these were first identified, examples being on admission or return from hospital. The photographs also monitor progress in healing. Nutritional and tissue viability assessments are carried out on admission and regularly thereafter. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 11 It appears that the home has a good relationship with the local doctors they work with. The district nurse was on site giving flu vaccines during the inspection. There was evidence of referral to consultants and other professionals where needed. There was evidence of chiropody and optician visits, but not regular dental assessments for all. This may have been however, through lack of appropriate recording mechanisms. It was pleasing that mechanisms are in place to record personal care delivery. However, these records are not always completed with diligence or consistency. For example nail care recordings were frequently lacking and there were times when records had not been completed for residents’ for three days. One resident did comment that “ There is not enough encouragement given to make people walk”. That they are pushed in wheelchairs. This issue should be explored. Locks are provided on bathroom and toilet doors. Privacy screens provided in double bedrooms. Residents’ indicated that they are treated with respect by the staff one commented “The staff are respectful and friendly”. A visiting professional remarked when completing a questionnaire “ Staff attentive dignity etc very much so”. Staff who were asked about promoting dignity responded as follows; “ We call the residents’ by the name they choose”. “ When attending to personal care I make sure that doors and curtains are closed”. “ I ensure that as much of the residents’ body is kept covered as possible. I make sure that they do as much as they can for themselves”. There was positive staff/ resident interactions observed during the inspection. Residents were spoken to respectively, staff giving choices where possible on where the residents wanted to sit, what they wanted for meals and giving the opportunity for them to spend time alone. One resident commented “ I like my own company and do spend time alone in my room”. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 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): 12,13,14,15 Generally residents’ find the lifestyle experienced in the home matches their expectations and preferences. To enhance this further work should be undertaken to determine individual activity/ stimulation preferences /abilities and full preferences in terms of daily routines. Residents’ are encouraged to and do maintain contact with family and friends. Residents’ receive wholesome appealing food in acceptable surroundings. EVIDENCE: Preferred rising and retiring times for some residents’ have been determined and recorded but not for all. From observations however, it did appear that residents could get up when they want to. Times of rising were from 07.45 onwards. One resident said “ I have no preference what time I go to bed but I do like to get up around 08.30 and this is arranged”. Other preferred routines such as shower or baths times require further confirmation even if this is to determine if baths or showers are preferred am or pm. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 13 Information in relation to activity provision in the home was available. Records of activities provided revealed that residents had been offered 4 main activities since June 2004 including sing-a-longs, a performance by Sweet Assurance and a trip to Hollybush garden centre. Hobbies and interests are discussed on admission but there is no individual, regular, planning thereafter. One resident was seen reading a newspaper she commented “ I also enjoy knitting, I am knitting baby clothes at the moment for my daughter’s baby. Another said “ I like watching the television and talking to other residents’. Residents’ have the opportunity to receive communion on a regular basis. A hairdresser visits the home every Monday. The homes visiting times are open and flexible. Several relatives visited the home during the inspection. They all confirmed that they could visit the home when they want to. One relative said “ I visit most days”. Residents’ bedrooms viewed held a number of various personal processions ranging for ornaments, pictures, small pieces of furniture and televisions. A number of residents’ have their own chairs brought from home in the lounge. An inventory for each resident, confirmed belongings brought into the home. Information pertaining to advocacy services was on display in the front entrance hall. The home has a dining room with four tables which can accommodate four residents’ at each. Catering hours provided are positive, two cooks are provided daily one to cover the morning one the afternoon/ evening. Each day there is a period of three hours when two cooks are on site. The home has a set menu which details three meals a day breakfast. Lunch and tea but not supper. Staff ask residents’ on a daily basis what they would like for their lunch. A record is made of all food (and or fluids) consumed by each resident where a concern in respect of food intake or weight loss has been identified. The breakfast and lunch times were partially observed. Breakfast was available from early morning until well after 11am. Staff were heard giving food choices to residents at breakfast time. They could opt for cereals, toast and a cooked breakfast. One resident said “ I like and have bacon, eggs and tomatoes for my breakfast”. Lunch time was relaxed, staff were on hand to give assistance. The food was well presented with good sized portions. One resident had fish cakes for her lunch, she commented “ I like all the food. They give us plenty to eat. I’ve gained loads of weight since I have been in here”. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 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. Residents and their relatives can be confident that their complaints will be listened to and acted upon. Systems are in place to prevent abuse to residents’. EVIDENCE: The home has a complaints procedure on display in the front entrance hall. The print on this procedure slightly larger than average. The complaints procedure has not been produced in any other format which may appropriate to the needs of the residents’ accommodated. The home has received one complaint which was investigated well within 28 days. A written response was provided to the complainant to which no further verbal or written comments have been received. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 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): 19,20,21,24,26. The home whilst being pleasant leaves a lot to be desired in a number of rooms in relation to decoration and carpets. Communal areas are comfortable and homely but would benefit from new chairs and carpets. The home provides sufficient lavatories and toilets in terms of numbers, however these all require redecoration and new flooring. Residents’ bedrooms are safe. They have their own personal belongings around them. Many however are unacceptable in respect of the state of the carpets and décor. The home generally is clean and hygienic. EVIDENCE: The home employs a full time handyperson who is responsible for general maintenance, fire safety and the checking of equipment. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 16 The bottom half of the walls in the dining room and ground floor lounge are suffering from general wear and tear. Paintwork including door frames and skirting boards throughout is damaged. Toilets and bathrooms are in dire need of redecoration. The state of the laundry is very poor in terms of maintenance. The majority of bedrooms require redecoration. Carpets in the lounge, corridors and bedrooms (with the exception of the two that have had new carpets) need replacement. Whilst it is appreciated that a planning application has been made. It may take 18 months for this work to be completed. The home requires attention now. The rear garden is pleasant and attracts the sun. There is however, limited flat space that can be used. Bedrooms seen varied. Whilst they appeared safe, the majority require attention as stated. One double bedroom discussed during the inspection looks ‘sparse’ this added to by the vinyl type flooring. The home has a list of items provided in each bedroom. This does not however, indicate that residents are happy where certain items are not provided in their rooms. One adjustable height bed has been purchased, 5 more are needed. An infection control audit of the home was carried out. This involved the checking of bathrooms, toilets and the laundry. Toilets and bathrooms although in need of redecoration did not appear to be unclean. However, flooring around toilet bases in some rooms was not satisfactory secured or sealed possibly allowing bacteria to grow. The laundry is very poor in terms of décor, walls and flooring. It was difficult to distinguish if it was redecoration needed or a good clean as well. Liquid soap and paper towels were available in toilets and bathrooms. Gloves and aprons nearby. Not all toilets and bathrooms had ‘ hand wash’ signs displayed. To date only one nurse and one carer have received infection control training. It is positive that domestic and laundry staff are provided seven days per week. The home has two washing machines with disinfectant programmes and one dryer. The home has a separate ironing room. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 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): 27,28,29. Residents needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. Further development and diligence is needed in respect of staff recruitment to ensure that the residents’ are fully protected. EVIDENCE: The home is adequately staffed as follows: AM shift- Most days 2 RGN’s ( plus the manager during the week) - Minimum of 4 care staff sometimes 5 - One domestic and one laundry person - One or two catering staff - A handyperson during the week PM shift - 1 RGN - 4 care staff - 1 catering staff Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 18 Night shift – 1 RGN plus 2 carers Positive comments were received about the staff which included “ The girls are lovely”. “ The staff are alright we all get on well”. Staff during the inspection appeared to be friendly and caring. Over 50 of the care staff team have achieved N.V.Q level 2 or above a number also have achieved or are working towards level 3. All staff files viewed included a valid Criminal Records enhanced disclosure and a Protection Of Vulnerable Adults list check. All files included a completed application form. Documents lacking were a health declaration for one, photos for two and written references for one. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 19 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): 31,33,38 Residents’ live in a home which is run and managed by a person who is fit to be in charge. Further developments are needed to ensure that the home is run in the best interests of the residents’. Generally observance to health and safety is good. A few issues however, must be addressed. EVIDENCE: The manager has been in post for three years. She has been approved by the Commission as being fit to run and manage the home. She is a first level Registered General Nurse and has numerous years of caring for people both in a hospital and care home environment. The manager has recently completed her Registered Managers Award and is waiting for her certificate. The manager appears to be motivated and caring. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 20 The manager has developed a robust system for the monitoring of quality in the home which identifies non-conformance to policy and practices. Policies in the home are reviewed regularly. There was no evidence available to demonstrate that the registered persons compile a written report in accordance with Regulation 26 visits. Overall health and safety issues are observed. There were certificates available to demonstrate servicing of fire fighting and other equipment. Although there was evidence available to demonstrate staff training it was difficult to determine fully what mandatory training staff have received. It appeared however, that not all staff are receiving two fire training / fire drill sessions on an annual basis. Two slabs in the rear garden are uneven and could present as a tripping hazard. It was also observed that staff are not using the required footrests on wheelchairs. The kitchen was not assessed during this inspection. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 21 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 x 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 2 2 x x 2 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x x x 2 Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 22 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 OP2 Regulation 5(1) Requirement The registered person and manager must ensure that: Each residents’ terms and conditions document is signed and dated as soon as possible. The current fee is detailed on the terms and conditions document. The room number applicable to the resident is included in their terms and conditions document. The registered person and manager must ensure that all residents’ where possible sign and date their care plans to demonstrate that they are aware of them and have been involved in their compilation. The registered person and manager must be able to evidence that all residents are offered regular dentistry assessments and treatments. The registered person and manager must ensure that records pertaining to daily care delivery are completed diligently DS0000020790.V250223.R01.S.doc Timescale for action 10/10/05 2 OP7 15(1) 15(2)(a) 10/10/05 3 OP8 12(1)(a) (b) 13(1)(b) 12(1)(a) 01/11/05 4 OP8 05/10/05 Cottage Nursing Home, The Version 5.0 Page 23 5 OP12 12(2) 6 OP12 12(4)(b) 7 OP15 16(2)(i) 17(2) 23(2)(b) 8 OP19 and consistently. The registered person and manager must further explore with each resident their preferences in respect of rising and retiring times and preferences regarding bath or shower times. This must be done before or on admission for new residents’. The registered person and manager must ensure that plans are produced and implemented in respect of each residents’ stimulation/activity needs. This especially so for residents’ who have limited physical abilities/ complex needs. The registered person and manager must expand the homes menu to capture supper options. The registered person and manager must provide the CSCI with written timescales to inform when the following work will be carried out: The replacement of carpet in the lounge. The replacement of carpet in the ground and first floor corridors. The replacement of bedroom carpets. The refurbishment of the laundry. The refurbishment of all bathrooms and toilets. The redecorating of communal areas. The replacement of any threadbare easy chairs in the two 15/10/05 01/11/05 01/11/05 01/11/05 Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 24 lounges. The re-varnishing of chair legs in both lounges. The registered person and 01/11/05 manager must provide in writing, an up date on the proposed extension work. The registered person and manager must expand upon the list used to determine what is provided in each bedroom. 01/11/05 9 OP19 23(1)(a) 10 OP24 23(2)(e) 11 OP24 16(2)(c) 12 OP24 16(2)(c) Residents must be informed what must be provided (as per standard 24.2) and they or their relative make a decision if they want all these items. If not they must be asked to sign and date the form. The registered person and 01/11/05 manager must determine from each resident and or their chosen representative their preferred choice of floor covering in their bedroom and take this into account when re-carpeting the bed rooms (This also applies to the vinyl floor coverings) The registered person and 01/12/05 manager must provide adjustable beds for service users’ who require assistance with moving and handling. Timescale of 01/06/05 not met The registered person and manager must provide a mechanical sluicing disinfector to reduce the risk if potential infection to service users’ and staff. Sluicing disinfectors must be available on both floors. Timescale of 01/06/05 not met. 13 OP26 13(3) 01/12/05 Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 25 14 OP26 13(3) 18(1) 15 OP29 19(1) (19)(4) The registered person and manager must ensure that all staff receive infection control training. Priority must firstly be given to nursing staff. The registered person and manager must ensure that the following are obtained (and retained on file) before any staff member is allowed to commence employment; Two written references. A photograph. A health declaration. 01/12/05 22/09/05 16 OP33 24 17 OP33 26 18 OP38 13(3) Two official sources of identity. The registered person and 01/12/05 manager must formalise the results of feedback questionnaires. The results published and made available to current and prospective service users’ and other interested parties including the CSCI. The registered persons must visit 01/11/05 the home unannounced at least on a monthly basis and compile a written report of their findings as per regulation 26. A copy of which must be provided to the CSCI. The registered person and 05/10/05 manager must ensure that any uneven slabs in the rear garden are levelled and made safe. 19 OP38 23(4) The registered person and 01/02/06 manager must ensure that all staff receive two fire training and two fire drill training sessions in any 12 month period. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 26 20 OP38 13(4) 18(1)(a) The registered person and manager must produce a training matrix which must include as a minimum the dates staff have received the following mandatory training: Moving and handling plus hoist training. Fire safety and drills. Health and safety- risk assessment. Infection control. First aid. Food hygiene. A copy of which must be provided to the CSCI. The registered person and manager must ensure that footrests are used at all times on wheelchairs. 01/11/05 21 OP38 13(4) 23(2)(c) 22/09/05 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 Refer to Standard OP16 Good Practice Recommendations The registered person and manager should consider producing the complaints procedure which is appropriate to the residents’- for example a pictorial format. Cottage Nursing Home, The DS0000020790.V250223.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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