Inspection on 06/12/05 for The Ellenborough Nursing and Residential Home

This inspection was carried out on 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Ellenborough Nursing and... 08/08/07

The Ellenborough Nursing and... 27/07/06

The Ellenborough Nursing and... 27/07/05

The Ellenborough Nursing and... 16/02/05

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

CARE HOMES FOR OLDER PEOPLE The Ellenborough Nursing and Residential Home 9-11 Neva Road Weston Super Mare North Somerset BS23 1YD Lead Inspector Carolle Wise Scanlan Announced Inspection 6th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Ellenborough Nursing and Residential Home Address 9-11 Neva Road Weston Super Mare North Somerset BS23 1YD 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) 01934 621006 01934 621006 Ellenborough Care Limited Ms Susan Jane Welsh Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. May accommodate up to 31 people aged 65 and over requiring nursing care May accommodate two named persons under the age of 65 years. Home will revert when named persons leave. Staffing Notice dated 04/04/2001 applies. Manager must be a RN on part 1 or 12 of the NMC register Mrs Welsh to attend POVA training by 28th February 2008. Mrs Welsh to attend person centred planning training by 30th March 2005. 27th July 2005 Date of last inspection Brief Description of the Service: The Ellenborough Nursing and Residential care home is owned by Mr and Mrs Yilmaz since November 2004, operating under the name of Ellenborough Care Limited. The home accomodates residents of 65 yesrs or older who require personal care.The home is an attractive Victorian building conversion of two detached properties.The accomodation is arranged over two floors with a passenger lift or chair-lift for access.The majority of the rooms offer ensuite facilities with 15 en-suite single rooms and 5 ensuite doubles. There are two seperate lounge areas one of which has recently been refurbished to a high standard. There are two seperate dining areas. The home accomodates residents who smoke with a designated smoking area overlooking the rear garden. It is close to local amenties, and public transport, bus and rail are within easy reach. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 10 hours. The inspector met with eight residents and staff on duty. The commission received four very positive comment feedback cards from relatives/visitors to the home. One stating that “I cannot praise the home highly enough”. During the inspection it was noted that historically four residents accommodated had learning disability and two residents had mental health concerns. Their needs are regularly monitored involving other health and social care professionals. The registered manager, Sue Welsh, is aware of the homes registration category. One focus of the inspection was upon the homes maintenance. The inspector sampled and reviewed documentation in this regard. The inspector looked at and reviewed a number of records that need to be kept in the home. What the service does well: What has improved since the last inspection? Medication administration and recording on the Medication Administration Records had improved with appropriate storage of medications noted. The kitchen procedures and environment had improved to meet the recommendations made by the Development and Environment office. Enhanced Criminal Record Bureau checks are undertaken on all care staff. The resident’s involvement in the care planning process is now a more integral part of the process. The registered managers office is now lockable further protecting the documentation held regarding the residents. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 6 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 Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Ellenborough Nursing and Residential Home DS0000062713.V260024.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 Resident’s needs are assessed prior to moving into the home to ensure that the home can safely meet their needs. Resident’s families and visitors are made welcome. EVIDENCE: Residents prior to taking up accommodation at the home have are assessed to ensure that the home can safely meet their needs. This was verified in two of the records reviewed. The residents who have lived at the home for some time did not contain these details. Each resident receives terms and conditions of their stay. Residents recently admitted to the home suggested that they, or their families had opportunities to visit the home prior to moving in. Several residents left much of the ‘arranging’ to their families, as they were unwell or in hospital. Visitors are welcomed into the home and the front entrance door and porch area houses a visitor ‘signing in’ book. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Improvements have been made in the involvement of the residents in their plans of care and risk assessments. Care plans must reflect the care provided whether at night or day to safeguard the residents. Resident’s privacy and dignity are considered by the staff. Risk assessments are completed but did not have written care planning in place to mitigate these risks, in some of the records reviewed. Medication storage had significantly improved as well as the administration and recording procedures. EVIDENCE: Since the last inspection the care plans have changed over to a new typed format. Each of the five care plans seen were re evaluated on a monthly basis. One care plan seen only included a ‘night care plan’ with no details of the care provided by staff at other times. This was further explored with the Registered Manager. It was clear that the resident, although generally self-caring, receives care, support and monitoring, which should be contained within a care plan. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 10 Residents met felt they received good care. The staff did not rush them, took their time to chat with them, and were ‘kind’ and listened. Whilst chatting to one resident the provided did reflect that which was written in the plan of care, which is good practice. A few residents gave examples of how their privacy and dignity needs were met by the staff. A copy of a letter from the Deputy Manager given to residents in November this year is held with the resident’s records. This outlined the residents right to access their records, the residents meetings and the fact that the staff welcome their suggestions with a suggestions box set up. The aim of the letter was to improve the resident’s involvement in their care planning and for improving the quality assurance monitoring at the home. Resident’s life histories their social preferences, likes and dislikes are explored within the care documentation now held which is good practice. Risk assessments are undertaken. It was evident however, that the process of ensuring that the risks identified had care plan actions in place to mitigate the risks, were not. In one example, a mental health risk assessment suggested that, regardless of the completed assessments numerical figure, if any shaded areas were completed, a referral should be made. This assessment had no numerical indicators and no shaded areas. On discussion with the registered manger it was agreed that the documentation was did not provide clear guidance for staff. There was also repetition in some of the risk assessments especially with regard to moving and handling. Since the last inspection the storage of medications had significantly improved with a lockable wall cabinet now in place. Boots provides the supply of medication in ‘blister packs’ where able. Cannon Hygiene Ltd disposes of the pharmaceutical waste with a copy of the license seen. Medication administration procedures are generally robust. One of the three Medication Administration Records seen did not have the correct number of stock to that which was signed for. It clear from the stock audit control measures were in place and every effort had been made to ensure safe practice. Signatures of those trained nurses who can administer the medications listed. There is a separate medication fridge which has records kept of the temperature. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Account is made of resident’s preferences regarding activities. There has been a loss of the variety of visiting entertainment previously offered to the residents and outings of late and improvement is needed to address this. Residents remain in control of their daily routines and the choices they make. The kitchen has been refurbished and food storage rearranged for the benefit of the residents. EVIDENCE: Resident’s activity preferences are recorded in their care documentation. Several residents take care of their own entertainment needs, preferring this to attending arranged activities. Some residents enjoy sitting in the lounge areas of the home with others watching television or listening to music. Activities are arranged by an in-house activities co-ordinator. In the activities lounge a cupboard appeared well stocked with a variety of puzzles, board games and activity craft materials. Activities have included, clothes sales, musical entertainment and some residents attend community activities such as the Salvation Army and college. It was difficult to ascertain from the records who attended the arranged activities or if those who did not attend had chosen not to. The Registered Manager said that it had been some time since an The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 12 ‘outing’ had been arranged or outside entertainers and was hoping to refocus on this in the New Year. Residents decide what they want to do with their day, choosing when to rise and retire. Several residents said they remain their own ‘decision makers’ and that staff assist them to remain independent for as long as possible. A few residents have become frailer, one remarked that staff assist him in his daily routine but the routine is one he has agreed. Following a re inspection of the kitchen via the Development and Environment Office the schedule of works recommended had been completed to their satisfaction. The kitchen was not inspected by the commission during this visit. Feedback from the residents was positive with regard to the food and menus. Menus are decided upon by gathering resident’s opinions at the residents meeting and on ensuring a healthy balanced diet. The resident’s enjoy the recently refurbished dining room and the larger separate dining room is also well used. This second dining room is scheduled for refurbishment in the near future. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 13 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 & 18. There has been improvement made in documenting ‘niggles’ or complaints, which further safeguards the residents. Staff demonstrated awareness of adult protection policies with training planned for February 2006. EVIDENCE: Registered manager advised that Adult Abuse Awareness training was planned for February 2006 for staff to attend. The home has a complaints procedure in place. Complaint recording and action planning following complaints had improved. Niggles or complaints no matter how minor are now recorded, the manager ‘signs off’ and dates the complaint once complete. Residents meetings are held each three months with the next planned for January 2006; resident’s families are also invited should they wish to attend. This gives a further opportunity for the home to listen to resident’s opinions on the services and facilities provided. Although residents stated that they ‘had no cause for complaint’ at the time of the inspection, all felt that they could complain to any of the staff and that it would be acted upon appropriately. The staff said that they would ‘let the manager, deputy, or senior nurse on duty know’ if a resident raised a concern or complaint. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 14 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, 22, 23, 24, 25 & 26 The home presents as clean and tidy. It is an older building, which is in the process of refurbishment. The standard demonstrated in the areas already refurbished is very good. The home provides some specialist equipment to meet the current residents needs however it was noted that there is a lack of adjustable nursing ‘beds’ at the home. Maintenance at the home needs to improve to safeguard the residents. EVIDENCE: The home is arranged over two floors with a stair lift to the first floor. It presents as homely, odour free, clean and tidy. The communal accommodation is on the first floor. It comprises of two lounge areas, two separate dining rooms, an ‘activities’ lounge area and a conservatory area. The conservatory area is a designated smoking area for the residents. One of the lounge rooms and a dining room had been beautifully refurbished to a good standard. Call bells are available in each room. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 15 There are thirty-three single rooms, six ensuite and four double with one ensuite. There are various size bathrooms on each floor and four showers. It was noted that a couple of the bathrooms were used as storage rooms for other equipment. The registered manager stated that ‘these’ bathrooms were not used by the residents or the staff in assisting the residents. These bathrooms should not be used as storage areas. Some weeks prior to the inspection the maintenance person had left the homes employ, the home has advertised the position but at the time of the inspection he had not been replaced. Maintenance work needed during this interim period is being sourced according to need. Radiators have older style low temperature guards in place, a few needed repainting. Water temperature monitoring had not been undertaken recently, however the water heating checks for compliance with Legionella risk reduction had. The maintenance logbook was not available to review. The home has a lack of specialist ‘nursing beds’ at present with the majority of the beds being domestic ‘divan’ types. The registered manager felt that should the need arise for specialist beds in order to meet the residents needs these would be purchased or hired in. Residents had personalised their own rooms with pictures, photographs and in some cases furniture. One resident described how the staff had assisted her in rearranging the room to suit her needs. One bedroom had been refurbished and a large vacant room was in need of refurbishment, which the manager advised was scheduled for refurbishment. During a tour of the premises there were a few maintenance repairs noted which required urgent attention, outlined in the requirements made. The laundry room is housed in the basement area of the ‘nursing side’ of the home. It was suggested that instructions regarding the use of the ‘sluice cycle’ to deal with soiled laundry is available to staff. The home has a ‘sluicing disinfector’ and a separate sluicing area. Alcohol hand wash gel was seen in the reception areas of the home, which is good practice. The staff remarked that they did not have many areas in the home to hand wash other than in the resident’s own rooms. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 16 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, 30 Staff undertake NVQ Level 2 training in order to safely care for the needs of the residents. Improvements are needed to ensure that all staff receive regular updates of mandatory training, such as manual handling. Recruitment procedures at the home demonstrated good practice. EVIDENCE: The rota demonstrated that there are five care staff on duty in the morning, four in the afternoon, and two on night duty, with each shift supported by a qualified nurse. The personnel list records that currently there are seven registered general nurses working at the home, of which five are ‘bank staff’. The home also offers placements for two ‘Adaptation Students’, who are qualified nurses from overseas, completing a course of study. Effectively, the general nurse cover relies on ‘bank staff’. This needs to be regularly reviewed to ensure consistent levels of staffing are available. Recruitment files were held securely in the office located in the grounds of the home. The recruitment records demonstrated good practice with references Criminal Record Bureau checks and POVA checks made prior to appointment of new staff. The pre-inspection documentation notes that staff training over the last twelve months has included mandatory training in safe working practices such as fire. Qualified nurses have attended updates in venepunture, The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 17 immunisation and flu vaccinations. There are eight care staff with NVQ Level 2 or above and two staff currently on the course. Plans for 2006 training include first aid, abuse awareness and mandatory training updates. It was noted that the induction training program needed to be reviewed to ensure that it reflected current practice and to ensure it is line with ‘Skills For Care’. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 & 38 The registered manager was found by residents and staff to be both open to ideas and approachable. A more proactive approach is needed by the manager to ensure that health and safety checks are regularly undertaken to protect staff and residents. EVIDENCE: Sue Welsh is the homes registered manager she is an experienced registered general nurse, currently on the Registered Managers Award course. The residents and staff respect the homes management team, Sue Welsh and the homes Deputy Manager. There is an ‘open door’ management approach with residents and staff finding the manager approachable and willing to listen to their suggestions and ideas. Residents meetings have commenced which is good practice. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 19 Residents, or their representatives manage their finances. Residents’, who choose to have some money kept safe by the home, have account records kept by the homes administrator. During the inspection one of these records were reviewed, the cash exceeded that which was written on the account record. The manager felt that this was an accounting error. The inspector suggested that the monies should be checked and signed by two staff members. Since the last inspection the office based inside the home is now lockable. As the Responsible Individual is not in day-to-day contact with the home the inspector suggested that regulation 26 visits must take place as a quality assurance monitoring measure. At the time of the inspection the home did not have an appointed maintenance person. There were several records including servicing of heating systems and electrical checks which were not available during the inspection. The registered manager must ensure that the premises are kept in a good state of repair externally and internally and that equipment provided at the home is maintained in good working order. The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X 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 3 3 2 3 2 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X 3 1 The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15 Requirement Care plans must be provided which outline the provision of care needed to meet the resident’s needs. A day care plan is needed if the care plans are separated into night and day. Risk assessments when undertaken must relate to the care planning needed to mitigate the risks. The designated smoking area must have a safe place to dispose of cigarette stubs. Call bell to one toilet was absent. (The socket for this was on the ceiling and was left exposed, this is to be repaired). Water temperature checks must be undertaken and a record kept. Resident’s bathrooms must not be used as storage areas. Small upper window in Fridge/Freezer storage room cannot be closed this needs to be repaired. Until such time as this work is completed the door must remain locked to this room for added security. Regulation 26 visits to be undertaken on a monthly basis. Timescale for action 06/01/06 2 OP8 13(4) 06/01/06 3 4 OP38 OP22 23 23 06/01/06 06/01/06 5 6 7 OP25 OP38 OP38 23 23 23 06/01/06 06/01/06 06/02/06 8 OP33 26 06/01/06 The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 23 9 OP38 13(4) 10 OP30 13(6) 11 OP38 23 12 OP38 23 13 OP38 23 14 OP38 13(4) 15 16 OP24 OP38 23(n) 23(2)(b) Drinks boiler in the resident’s dining room area must be risk assessed and contained within the homes general risk assessments. Staff must complete mandatory training in safe working practices, such as manual handling. Staff must be available on all shifts that are qualified in first aid. COSHH training to be undertaken. Gas, central heating systems, and electrical systems must be serviced regularly with certificates held on file at the home. Portable Appliance testing must be undertaken periodically or as and when new appliances are allowed and brought into the home. Carpets in corridor area next to kitchen threadbare/worn posing a trip hazard, need to be replaced. First floor bathroom carpet to the residential side of home needs to be repaired/replaced with consideration made regarding infection control. Ground floor room overlooking garden with patio doors had steps down to garden area. This should be ramped for the resident’s safety and risk assessed. Adjustable beds to be available for those residents receiving nursing care. Curtain rail and curtaining had been pulled down in residents’ ensuite this needed to be repaired. DS0000062713.V260024.R01.S.doc 06/01/06 06/03/06 06/02/06 06/02/06 06/02/06 06/02/06 06/02/06 06/02/06 The Ellenborough Nursing and Residential Home Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations Activities offered to the residents should be surveyed to ensure that they meet the resident’s needs. Activities previously offered such as outside entertainers and outings should form part of this survey. (Regulation 16 2 (m)) Review of permanent registered general nurse numbers is needed to ensure that the needs of the resident’s can be safely met. A programme of routine maintenance regarding the premises should be produced and implemented with records kept. Review the homes induction program to ensure it is in line with Skills for Care. Two staff to check and sign the resident’s money account record. 2 3 4 5 OP27 OP19 OP30 OP35 The Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Ellenborough Nursing and Residential Home DS0000062713.V260024.R01.S.doc Version 5.0 Page 26 - 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. 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