Inspection on 08/11/06 for The Cottage Nursing Home

This inspection was carried out on 8th November 2006.

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 17/01/06

The Cottage Nursing Home 22/09/05

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 The Cottage Nursing Home 57/58 Blakenall Heath Bloxwich Walsall West Midlands WS3 1HS Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 08:00 8th November 2006 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 Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 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 Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cottage Nursing Home 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 The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 26 frail elderly requiring nursing care 26 frail elderly requiring social care conditions 1 and 2 not mutually exclusive of which 5 may be terminally ill The home to accommodate a maximum of one person in an intermediate care bed. 17th January 2006 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. The home no longer provides the intermediate care facility. 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 is 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. The home currently charges between £326.83 and £443.98 per week for residency, this fee does not include extra services for hairdressing, chiropody and dentistry. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the service conducted by two inspectors from the Commission for Social Care Inspection (CSCI). Judgements made throughout this report are based upon information supplied to the CSCI by the home manager, by touring the building and talking with the staff and service users. Other time was spent reviewing service user files as part of the case tracking process and examining staff files to ensure the home has safe and robust recruitment practices. Some of the service users also took part in a postal survey and their comments have been included in this report. The inspector would like to thank the manager, all of the service users and staff for their hospitality throughout. What the service does well: What has improved since the last inspection? The home is currently being extended once completed this will add extra bedrooms and also provide the home with a new lounge for service users to access. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 6 The quality assurance systems within the home have been much improved and the views of service users, their relatives and other interested parties are now being sought. Once the results from these surveys are collected the manager is then able to take steps to address any issues arising. The homes policies and procedures have been updated, in particular the adult protection policy which now offers staff with clear guidance on their roles and expectations if they suspect abuse is occurring. All of the staff have now received training in Safeguarding vulnerable adults which has given staff added knowledge and skills in identifying potential abuse. 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 summary of this inspection report can be made available in other formats on request. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 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 Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will receive enough information about the home to be able to make a choice about living there. Service users needs will be thoroughly assessed before they move into the home, staff will generally have the skills and knowledge to meet their needs. All service users are encouraged to spend a trial period at the home before admission. The home no longer offers the intermediate care facility EVIDENCE: The home provides each potential new service user with a statement of purpose and a service users guide. Both of these documents were seen and generally they contain enough information for service users to be able to make a choice about living in the home. All service users have their needs assessed prior to admission and the manager will visit them at home or in hospital to do this. Service users can be The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 9 assured that staff do have the skills and knowledge to meet their needs but further training will enhance their skills. The home has a few service users with dementia so it would be advantageous for the staff to complete some dementia care and person centred training. Admissions to the home will only take place if the manager feels that the home can meet their needs. where emergency admissions take place the manager secures a copy of the care management assessment. All service users are encouraged to spend a day or visit for lunch should they wish to do so. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users all have an individual plan but service users cannot be assured that all of their needs will be included in this plan. Service users can be assured that they will have all of their health needs met and have access to health professionals are needed. Medication is administered safely but improvements in practice are required to further safeguard service users. Service users will be treated with respect and dignity at all times, the home needs to develop its end of life care planning for service users. EVIDENCE: Service users say that their needs are met, with staff having a good awareness of their needs. This was also evident when talking to the staff about service users needs. The home use core care plans. Care records and risk assessments do not reflect all service users needs, are not always accurately completed or are reviewed at least monthly. Care instructions lacked important information such as the site(s) that sub cutaneous fluids were being administered, when dietary supplements should be and were being administered. Care records The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 11 lacked evaluation with entries not always dated and when appropriate timed (such as when drinks and fluids had been given or offered). All required risk assessments are not available or were not accurately completed or updated. There is no adequate risk assessment for the use of bed rails available, moving and handling risk assessments did not fully identify all moving difficulties – it was identified that one service user frequently slips down in their chair and although the home has an anti slip mat available which would address this, it was not being used and there was no inclusion of this within their plan of care. Nutritional risk assessment did not detail required actions when it was identified that the service user was at risk. Service users do have access to other health professionals such as GPs, chiropodists and dentists. “always get medical attention when I need it” Qualified nurses are responsible for the ordering of repeat prescriptions, the storage, administration and disposal of medicines. The home does not have all required medication policies with others requiring updating- such as the covert administration of medicines and homely remedies policy. There are gaps on the treatment sheet making it unclear whether medicines have or have not been given. Procedures for the ordering of medicines does not comply with the Royal Pharmaceutical Guidelines- prescriptions are not seen and checked by the home and go directly from the GP to the pharmacist. Staff do not confirm the receipt of medicines into the home. There are appropriate systems in place for the ordering, storage, administration and disposal of controlled drugs. Staff record the temperature that drugs are stored at although the drugs fridge temperature is lower than medicines should be safely stored at, a need to defrost the fridge may also affect this. The date of opening of short life items is not always recorded with a bottle of antibiotics having no date of opening recorded. Staff are advised to record the pulse rate of service users requiring digoxin to safeguard the service user form potential adverse effects of this medicine. In an other situation it was observed that medication is being covertly administered by nursing staff, the home does have a policy regarding this but there are insufficient safeguards in place to protect the service user. This was discussed with the manager at the time of this inspection. Throughout the inspection it was clear that staff were talking to service users in their preferred term of address and were seen to be knocking doors prior to entering. Service users have the choice about an extra telephone line being installed into their rooms should they wish to do so, although this is not covered by their weekly fee. Service users were mixed in their comments about staff “some staff listen some staff don’t”, “staff are golden to me”, “I think that some of the staff are wonderful but some are nuisances with dirty habits”, “I have the best care I could possibly wish for and I’m happy here”. The home has made some attempts to gather the wishes of service users regarding their end of life care. It was noted that some decisions about The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 12 resuscitation have been made but it is unclear how involved the service users have been in this process. These decisions must be clearly recorded. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be encouraged to take part in activities and that they will be further encouraged to maintain contact with their friends and family should they wish to do so. Meals are satisfactory and service users are encouraged to choose what they want to eat. EVIDENCE: The home encourages all of the service users to take part in activities they plan. More recently work has been undertaken to gather information about the likes and dislikes of the service users. The home does not employ an activity coordinator and therefore the responsibility falls upon the care staff to entertain service users. This can mean that at times activities get cancelled because staff can be too busy to do them. However, service users were very positive about the home and the efforts of the staff “I always enjoy the activities especially the bingo”, “always activities to take part in”. The manager also informed the inspectors that a pantomime has been organised for Christmas and service users have received this news positively. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 14 Some of the relatives commented “my moms looked after here and that all that counts for me”, “it’s a fabulous home never a fault” “the girls are great”. The home encourages visitors at any time but does ask them to be considerate later at night when service users are retiring to bed. Whilst touring the building it was pleasing to see that service users bedrooms had been decorated with a few of their favourite things from home to make their rooms feel more cosy. Mealtimes are an unhurried affair, it was observed that the tables didn’t get laid and food was bought to service users on a plate and their cutlery handed to them. Consideration should be given to preparing the tables for service users to make the experience a more positive one. The manager has recently consulted with the service users about the meal provision and the menu planning. following this survey several changes have been made to the menu to include more of the choices service users wanted. Generally the comments about the quality of the food offered were positive although some service users still expressed their distaste for some of the food. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that if they have concerns they will be listened to and their wishes will be acted upon. Following the development of an Adult Protection policy and staff training service users can be assured that they will be protected from abuse. EVIDENCE: The home has received no complaints since the last inspection, this is very positive. The inspector is not fully able to assess all of the standard as a result, the manager was however able to give an account of what she would do should a complaint be raised. The home has a complaints policy that is displayed in the entrance of the home and a brief summary is also in the service users guide. There needs to be some fine tuning to ensure that the policy meets National Minimum Standards and the home must consider providing the policy in different formats such as large print or audio. The home has dealt with one allegation of abuse since the last inspection, the manager demonstrated that the home is able to collaborate with external agencies during this time. The home conducted an internal investigation and identified areas for improvement as a result. The manager has worked hard to ensure that all staff have now received Adult Abuse Awareness training and the provision of a new policy means that service users are further safeguarded. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do live in a home that is generally well maintained but there are areas where cleanliness could be improved. EVIDENCE: The home is currently being refurbished with lounges and corridors recently redecorated and having had new carpets, flooring and curtains. The refurbishment will continue with replacement of floor covering and decoration of residents rooms. The new extension is due to be completed in mid December which will give residents additional communal space. The refurbishment has made the home welcoming, homely and comfortable. Some areas of the home do require thorough cleaning with staff struggling in some cases to maintain the cleanliness of the home with the current building work being undertaken, however there is a need to address the cleanliness of the The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 17 kitchen, laundry, and dining area floor. Bed linen and towels stored in the linen cupboard will require replacement shortly and arrangements need to made to do this. The home only has a small garden area which will be landscaped when the extension is completed. There is a considerable build up of dead leaves outside the laundry door which must be removed to reduce the current fire risk. The home has required gloves, coloured aprons and hand scrub freely available to minimise the risk of cross infection. The kitchen was found to be generally dirty the cooker, microwave, pantry, food storage containers and the doors and floor all require a deep clean. Opened food containers are not pest proof and pose a risk as they will attract pests, teabags are stored in a open plastic box on the floor and other large food bins also have no lids. COSHH materials are also stored in food store. There are no fly screens on the kitchen windows, which will enable insects to come into the kitchen when the windows are open. There is no laundry cleaning schedule or an adequate kitchen cleaning schedule. The kitchen mop was dirty, and mops are not stored inverted when not in use as recommended infection control guidance. The home is managing the changing environment well as service users commented “we can’t wait can we, we’ve got a pantomime booked for Christmas I hope it’s done by then”. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their needs will be met by suitably trained staff and that they will be in safe hands at all times. Staff are generally recruited in a safe manner that safeguards service users. EVIDENCE: Staff are supplied in appropriate numbers to meet the service users needs. on the morning of the inspection 1 trained nurse and 5 carers were on duty and the manager. Duty rotas are maintained and were seen to be an accurate reflection of staff actually working. The manager keeps the use of agency staff to a minimum and relies upon current staff working extra hours if the situation needed it. In addition to care staff the home employs an administrator to help with paperwork, kitchen staff to ensure that service users receive a balanced meal, and domestic and laundry staff to ensure that the home is clean and tidy at all times. This is particularly important at this present time due to the building work being undertaken. The home is further supported by a maintenance worker. The home has worked hard to improve its number of staff with an NVQ level2 qualification, it now has 70 of its workforce with a minimum of NVQ level 2 and some workers are now nearing the completion of their NVQ Level 3. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 19 Five staff files were examined to assess the homes compliance with recruitment requirements. It was pleasing to see that the required safety checks were in place, e.g. PoVA and CRB disclosures. The manager is now keeping records of all interviews that take place and keeping a copy in the staff file. On the whole all of the files contained two references but the manager must ensure that at least one of those references is from the most recent employer especially where the worker has left a care position. Staff training could be improved to ensure that all skills are updated as needed and knowledge doesn’t lapse. There was evidence that the home does complete an induction process with its new employees, three files contained different inductions the manager should consider streamlining these so that some continuity be maintained for all staff. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a person fit to be in charge, the home is run in the best interests of service users. Service users can be assured that their financial interests are protected by the home. The health, safety and welfare of service users and staff is promoted but could be improved with further training for staff. EVIDENCE: The manager of the home has been in post for over two years, she has all of the required qualifications and is registered with the Commission for Social Care Inspection. All of the service users spoken to were pleased with the way The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 21 the home is run and felt at anytime they could contact “Rose” is they had a problem. “she’s always there if we want anything”. The management of the home is generally satisfactory although it was felt to enable the home to go forward they would benefit from a management consultant who could advise them in the implementation of more effective care records and the drawing up of required policies and procedures. For the majority of the time Mrs Broadhurst’s hours are supernumery this means she is able to deal with the running of the home whilst entrusting the care of the service users to the nursing and care staff. The manager has worked hard to develop the quality assurance systems within the home. Surveys are conducted amongst the service users, their families and other interested parties such as visiting nurses and doctors. The results of these surveys have been studied and action has been taken to improve the service delivery as a result. One recent example is the review of the menu’s service users were asked about their preferences and dislikes and as a result the menu’s have now been updated. On another occasion the service users have been consulted about the way the home is redecorated once the building work has been completed on the extension. In addition to surveying service users the manager also conducts reviews of care plans and nursing notes to ensure that standards are being maintained. All service users monies within the home have recently been reviewed and the home has sought the advice of the Crime Prevention Officer in doing so. As a result there are more robust systems in place for dealing with service users money. The manager has also updated the homes policy to further safeguard service users. The home does not keep large amounts of money for service users, of those service users monies viewed all transactions could be accounted for and had receipts and were signed by two people. Safe working practices in the home are generally satisfactory, maintenance certificates were spot checked and found to be in order. Hot water temperatures are recorded regularly and are within safe temperatures for the service users, but work may be required to update the system shortly, once the building work is completed. Portable electrical appliance testing is carried out in the home however the inspectors were unable to establish whether the worker who completes the PAT testing has received appropriate training in this area. The manager is taking steps to rectify this after it was bought to her attention. Staff receive mandatory training although this could be improved, a number of staff are still to complete their infection control training, food hygiene and first aid training. Fire safety records were also seen and were generally completed The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 22 in a satisfactory manner although the manager must ensure that all staff, including night staff participate in fire drills at least twice a year. The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 24 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 4,5 Requirement Timescale for action 01/02/07 2 OP2 3 OP4 4 OP7 5 OP8 The registered manager must review the contents of the Statement of Purpose and Service Users guide to ensure that they are up to date and remove any reference to the National Care Standards Commission and replace it with the Commission for Social Care Inspection 5 (b) The registered person must ensure that terms and conditions/contracts are reviewed taking in to account the Office of Fair Trading Guidance 2003. 18 (1) (c ) The registered manager must ensure that staff receive training in dementia and person centred care, and behaviour that challenges. 15 The registered person must ensure that all of the residents needs identified in their assessment is reflected in their care plans (previous timescale of 01/04/06 not met) 17(2)sch4 The nutritional screening tool currently being used must be DS0000020790.V316173.R01.S.doc 01/02/07 01/02/07 01/12/06 01/12/06 The Cottage Nursing Home Version 5.2 Page 25 6 OP8 13 (4) (a), (6) 7 OP9 13 (2) reviewed so that risk can be identified and acted upon. There is currently a score but this does not indicate what level of risk it represents. All service users requiring bed rails must have a comprehensive assessment of the risk of using bed rails and bumpers and be regularly reviewed. Policies and procedures in relation to the ordering and receipt of medication reflect the Royal Pharmaceutical SocietyStaff check prescriptions for accuracy of medication ordered. Staff see sight of the prescription before it is sent to the pharmacy. A copy of prescription is retained in the home. Staff record the receipt of medicines. 01/12/06 01/12/06 8 OP11 12(3) 9 10 11 OP16 OP19 OP24 22 23 (o) 16(2)(c) The registered manager must address service users needs regarding end of life care and ensure that they are documented in individual service user plans. The complaints policy must include timescales for the resolution of complaints The accumulation of dead leaves outside the laundry door and the rest of the home are removed. The registered person and manager must provide adjustable beds for service users’ who require assistance with moving and handling. (Previous Timescale of 01/06/05 not met) DS0000020790.V316173.R01.S.doc 01/02/07 01/02/07 01/12/06 01/02/07 The Cottage Nursing Home Version 5.2 Page 26 12 OP26 13(3)18(1 ) The registered person and manager must ensure that all staff receive infection control training. Priority must firstly be given to nursing staff. The kitchen must be deep cleaned. A comprehensive kitchen cleaning schedule must be available. All opened food must be stored in pest proof containers. Mops must be inverted when not in use and there is a identified programme for the washing or replacement of mop heads. The opening date of jars and bottles is recorded. Fly screens must be fitted to the windows in the kitchen to prevent pests entering. Extraneous items must be removed i.e. tin of gloss and masking tape. COSHH materials stored with the food stuffs must be removed and stored securely. 01/02/07 13 OP26 23 (2) (d) 01/12/06 14 OP26 23 (2) (d) A laundry cleaning schedule must be available. The laundry floor must be impermeable and where the floor has begun to lift around the sink must be secured. 01/01/07 15 OP29 17,19 sch 2, sch The hand washing sink must be thoroughly cleaned. The registered manager must 01/01/07 complete an audit of all staff files DS0000020790.V316173.R01.S.doc Version 5.2 Page 27 The Cottage Nursing Home 4 (6) 16 OP33 26 to ensure files contain the required information. The registered persons must visit 01/12/06 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. (previous timescale of 01/11/06) All staff must complete training in Infection control Food hygiene First aid Fire safety 02/02/07 17 OP38 18 (1)(c ) (i) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3 4 5 6 7 Refer to Standard OP2 OP9 OP25 OP26 Good Practice Recommendations It is recommended that a copy of the Office of Fair Trading Guidance is obtained. “guidance on unfair terms in care home contracts” October 2003 It is recommended that a Service users pulse rate is recorded prior to the administration of digoxin. It is recommended that the effectiveness of the hot water pump is reviewed. It is recommended that the home obtain a copy of the Department of Health publication “Infection control guidance for care homes” June 2006 It is recommended that a programme of replacement of bed linen and towels is identified. It is recommended that a management consultant is employed to assist in the development of policies, procedures, care records and risk assessments It is recommended that staff have training in the drawing up and evaluation of care records. OP26 OP31 OP37 The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 28 8 9 10 OP37 OP38 OP38 It is recommended that all nursing staff are issued with NMC guidance on record keeping It is recommended that fire drills include night staff It is recommended that the maintenance worker completes an accredited course in PAT testing The Cottage Nursing Home DS0000020790.V316173.R01.S.doc Version 5.2 Page 29 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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