Inspection on 19/04/07 for The Firs Nursing Home

This inspection was carried out on 19th April 2007.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Firs Nursing Home 04/12/08

The Firs Nursing Home 26/11/07

The Firs Nursing Home 11/01/07

The Firs Nursing Home 23/05/06

The Firs Nursing Home 15/02/06

The Firs Nursing Home 23/06/05

The Firs Nursing Home 27/01/05

The Firs Nursing Home 01/09/04

The Firs Nursing Home 22/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Firs Nursing Home Kings Hill Great Cornard Sudbury Suffolk CO10 0EH Lead Inspector Tina Burns Unannounced Inspection 19th April 2007 11:00 The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 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 Firs Nursing Home DS0000031547.V336728.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 Adults 18-65. 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 Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Firs Nursing Home Address Kings Hill Great Cornard Sudbury Suffolk CO10 0EH 01787 371301 01787 880603 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) www.craegmoor.co.uk Craegmoor Healthcare Post Vacant Care Home 21 Category(ies) of Learning disability (21), Learning disability over registration, with number 65 years of age (6) of places The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may care for 21 adults, under the age of 65, of either sex, who require care by reasons of learning disability. The home may care for 6 named service users over the age of 65 years, under the category of Learning Disability as named in the letter to the Commission dated 10th November 2006. 11th January 2007 Date of last inspection Brief Description of the Service: The Firs is a care home with nursing for adults with a learning disability run by the large organisation Craegmoor Healthcare. It is located in Gt Cornard close to the town centre of Sudbury. The home is on two floors with a shaft lift connecting the two. It has two interconnecting lounges and a separate dining room and a mixture of single and double bedrooms. The premises are set on a compact site that allows for parking of several cars to the front. There is a small garden area to the entrance of the home and an enclosed garden at the rear. Daytime activities tend to be provided by and based at the home. The current base line accommodation fees are £953.08 per week but are variable according to service users needs. The Firs Nursing Home DS0000031547.V336728.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, which focused on the core standards relating to care homes for young adults. It was undertaken by one inspector over a two-day period covering approximately nine and a half hours. The report has been written using accumulated evidence gathered prior to and during the inspection. The inspection process included examination of a range of documents including staff records, service user’s files, a selection of policies and procedures, and health and safety records. The inspector also carried out some observations, toured the premises and grounds, and spoke with several service users, staff and a service users visitor. The acting manager was absent for most of the first day of inspection but was present throughout the second day and fully contributed to the inspection process. The area Business Support Manager was also at the home for some time over both days and also contributed. Nursing and care staff were cooperative throughout the visit and particularly helpful on the first day during the manager’s absence. What the service does well: What has improved since the last inspection? Since the last inspection twenty-one of the twenty-four previous requirements were met. The home has appropriately amended its Statement of Purpose and Service User Guide. Care plans are being developed to promote service user involvement and person centred care. Links have been made with independent advocacy services and risk assessments have improved. Social and leisure opportunities have also improved. Meal times have become less hurried and more dignified and quality assurance procedures have been developed to include feedback from service users and/or their representatives. Staff records evidenced that recruitment procedures are more thorough and robust and staff training and supervision has improved. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users can expect to have their individual needs assessed before they move into the home. However, although they can expect to receive adequate information about the home, it may not be in a format suitable to their needs. EVIDENCE: Requirements regarding the detail of the homes Statement of Purpose were made in May 2006, August 2006, September 2006 and January 2007. The acting manager has since amended the document together with the Service User Guide and submitted them to the Commission. Overall they had been appropriately amended to reflect information required by legislation and included detail about the nature of services provided, the age range of service users, the fees charged and detail about what is and is not included in the fees. A range of pictures & symbols had been added to the Service User Guide but on the whole the format was not in a style suitable for the capacity of the service users. Discussion with the acting manager indicated that they understood the need to ensure that these documents were regularly reviewed and remained current and up to date. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 9 Since the last inspection there had been no new admissions but service user records examined included local authority assessments of need and assessments undertaken and reviewed by the home. The homes assessments covered areas such as maintaining a safe environment, communication, breathing, eating and drinking, elimination, personal hygiene and dressing, controlling body temperature, mobilising, social care/family involvement, sleeping and pain. Further assessments included nutritional assessments, moving and handling assessments and waterlow pressure sore assessments. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect to become increasingly involved in decisions about the home and their every day lives. EVIDENCE: Records seen and discussion with the acting manager and staff on duty evidenced that since the last key inspection the home had introduced a new care plan format with the intention of promoting service user involvement and developing a more person centred approach to care planning. Although new care plans had not been completed for all service users at the time of inspection the home had made a start and staff seemed to be enthusiastic about a training session on care planning organised for later in the month. The new care plans had been developed by Craegmoor Healthcare with the needs of the service user group in mind. Sections included; Dates that are important to me, What I do now and what I’d like to do, Social interaction, Health and keeping safe, Finances, Personal Care, Mental health/behaviour, Communication, Independence and When I become sick or might die. The The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 11 examination of three service users current records evidenced that care plans and risk assessments were in place and had been regularly reviewed. Risk assessments included manual handling assessments, ‘waterlow’ pressure area assessments and nutrition assessments. An appropriate risk assessment had also been completed following the last inspection for a service user with a specialist chair/lap belt. Due to the complexity of needs most of the service users resident at the home require assistance to make decisions about their every day lives and past inspections found that many service users did not have personal representatives or access to independent advocacy services. On this occasion the acting manager was able to provide evidence that contact had been made with several advocacy groups and the local authority advocacy rights officer. One service user had also attended a local self-advocacy group, the home had started to have regular residents meetings and Craegmoor Healthcare were said to be ‘setting up’ service user forums. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect the home to support them in maintaining relationships with their friends and families. They can also expect to enjoy healthy meals and participate in a range of group and individual activities. However, they cannot be sure that their daily routines will reflect their individual wishes and preferences. EVIDENCE: The home employs two part time activities co-ordinators, one works on a Monday to Friday between the hours of 9.30am and 3.30 pm and the other works two mornings a week. Observations made, staff spoken with and records seen also indicated that nursing and care staff also assist service users with a range of social and leisure opportunities. Each service user had a care plan in place regarding their social and leisure needs that included a record of activities undertaken. Records seen included a wide range of indoor and The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 13 community activities for example aromatherapy, musical entertainment, karaoke, cookery, pottery, pub lunches, trip to the zoo, bowling, swimming, library, picnics and shopping. One service user was also assisted to attend their favourite football club regularly on a Saturday afternoon. Another, with very complex needs, had their care plan developed since the last inspection to include more social contact and daily activity. On the day of inspection a local artist was undertaking a ‘workshop’ with a group of service users in the dining area. Records seen and staff and service users spoken with indicated that social and leisure opportunities had improved during recent months, one member of staff said “we do get out and about a lot more now”, the acting manager also advised that short break holidays for several of the service users had also been planned for later in the year. Records seen and staff and service users spoken with indicated that relatives and visitors were welcome at the home and service users were supported to maintain relationships and friendships outside of the home. On the day of inspection one visitor was spoken with and confirmed that they always felt welcome and the manager and staff were friendly and approachable. Findings at the last inspection indicated that staffing levels at the home in the evening did not promote individual choice regarding bedtimes or social/leisure activities. Shifts changed at 8.30pm when the night staff started their duties and staffing levels were reduced from five to three. On this occasion staffing levels/shifts remained the same and guidelines were in place regarding bedtime routines. These guidelines specified which service users should be put to bed before the night staff came on duty and which service users should be left up but in their pyjamas. The guidelines did allow for some flexibility but overall they did not promote individual choice and autonomy. These findings led to some discussion with the acting manager who felt that the evening routines were not as ‘rigid’ as they seemed and were not as a result of staffing levels. Consequently it was agreed that a requirement made at the last inspection to review staffing levels would not be repeated. Instead, it was felt more appropriate that the home should ensure that service users are fully consulted about their evening routines and their care plans reflect their needs and preferences. At the last inspection the midday meal was hurried, unrelaxed, and ‘cramped’ and assistance given to service users that required feeding was poor. Since then, and with the lack of space to create a second dining area, the acting manager had introduced two sittings to improve the mealtime experience for service users. At this visit observations were made at the second lunchtime sitting and the overall atmosphere was much calmer and relaxed. There was adequate space for service users and staff assisting service users that needed feeding sat beside them and fed them at their own pace with positive and appropriate interaction. Examination of the homes menu and discussion with the chef, service users and staff on duty indicated that the home offered a choice of suitable meals that reflected service users likes and special needs. On The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 14 the day of inspection the main meal was pork casserole, mashed potatoes and vegetables. Meals, including the soft food for special diets, looked and smelled appetising. Records of meals chosen and taken by service users were in place. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall service users can expect to receive appropriate personal and health care support. EVIDENCE: Records seen and staff and service users spoken with confirmed that service users continued to receive consistent support from designated ‘key workers’. Service users spoken with indicated that they were happy with the support they received. Observations were that service users seemed physically well cared for and their personal tastes and personalities were reflected in their dress and hairstyles. During the visit staff were observed in the lounge area assisting a service user to transfer from a wheelchair into an armchair. This involved the use of a hoist. Unfortunately the process, which was rather undignified, was carried out in full view of several other service users and staff. The matter was discussed with the acting manager and business support manager who agreed to take immediate action to provide support in a more appropriate manner. A referral was made to occupational health services immediately so that specialist advice could be given about more appropriate equipment or transfer methods. They The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 16 also agreed to consult the service user about interim measures that could be put in place to safeguard their dignity in the meantime as a matter of urgency. Service users records examined included details about individual’s health care needs. Information and guidelines were in place in relation to areas such as peg feeds and epilepsy. Nutrition and pressure area risk assessments had been undertaken and were reviewed regularly. Records also evidenced that the home was appropriately monitoring service users health and recording GP and hospital appointments/admissions. Since the last inspection the medication room had been fitted with a new sink and work surface and had become the new ‘treatment room’. Medication was administered by qualified nurses only. At the time of the visit all medication was safely stored. Medication Administration Records examined had been appropriately completed, signed and dated. The home had begun to complete new, person centred care plans with service users. These included a section that would detail service users wishes and preferences concerning their death and dying. On the morning of the first day of inspection several staff and service users were attending the funeral of a resident. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Overall service users can expect the home to respond appropriately to complaints and concerns but they cannot be certain that their finances are handled appropriately. EVIDENCE: The home had a complaints procedure in place and on display in the entrance hall. The acting manager confirmed that there had been no complaints received since the last key inspection in January 2007. A copy of the local authority policy and procedures for the protection of vulnerable adults was available at the home. Furthermore, the acting manager confirmed that following two safeguarding adult investigations appropriate disciplinary action had been taken against two members of staff. During the past twelve months a number of requirements have been made relating to financial concerns and residents monies, three were outstanding and not met at the time of this inspection; The company had not produced a current and up to date policy for the administration of clients accounts, the company had not repaid monies into deceased residents estates and outstanding interest owed to service users had not been paid to their accounts. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home does not promote choice and independence. EVIDENCE: The Firs is a large property situated on a main road in the village of Great Cornard. It has parking to the front of the building with paved and bedding areas to the entrance of the home and a small but enclosed rear garden. During the inspection a tour of the grounds and premises was undertaken and the home was found to be warm, safe, clean and free of offensive odours. In terms of space and facilities the premises is not ideal for the numbers of service users that it is registered to care for. Although staff have made a good effort to make the environment cheerful, homely and comfortable service users continue to share communal areas that consist of two adjoining lounge areas and an adjacent dining room. This does not meet standard 24.3 that sets out The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 19 that there should be no more than ten people sharing a staff group, dining area or other common facilities by 1st April 2007. At the time of the inspection fence panels in the garden were being replaced. Some redecoration had occurred since the last key inspection but some areas still seemed a little ‘shabby’ where doors and paintwork remained scuffed. However the acting manager had begun to develop a maintenance and renewal plan in consultation with the company and the homes gardener/handyman. Since the last inspection the home had recruited a dedicated laundry assistant. At the time of the visit the laundry room was clean, tidy and appropriately equipped. Records examined and observations made indicated that appropriate infection control procedures were in place. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to be protected by the homes recruitment procedures. Furthermore, they can expect to benefit from staff that are appropriately trained and supervised. EVIDENCE: The acting manager confirmed that there had been no change to staffing levels since the last inspection; there was a minimum of one qualified nurse on duty every shift in addition to four to five care workers during day time hours and two between the hours of 8.30pm and 7.30am. Record seen and staff spoken with confirmed that 1-1 staff supervision’s had taken place since the last inspection and were planned for each individual on a bi monthly basis. Further more individual training plans were seen to be in place for all staff for the year 2007. Training planned for the months of April and May included moving and handling, food hygiene, fire safety, health and safety and first aid. Training in palliative care had also been arranged and several staff were receiving training regarding special soft food diets on day two of the inspection. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 21 There was also evidence that one new worker on duty was receiving appropriate induction and foundation training. However, less than fifty percent of care workers had achieved National Vocational Qualifications. The recruitment records of three staff were examined and included all documentation required for example; written references, application forms, declarations of health, individual’s photographs, evidence of personal identification and Criminal Record Bureau disclosure checks. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect to benefit from a well run home. However, they are not entirely safeguarded by the organisations policies and procedures. EVIDENCE: Since the last inspection in January 2007 the acting manager had clearly worked hard and met many of the requirements made. Feedback obtained during the visit indicated that the manager was competent, approachable and well liked by service users and staff. Comments received indicated that staff felt valued, motivated and committed to the job and the atmosphere was warm and relaxed. The acting manager is a registered nurse and has completed the NVQ level 4 in management and Registered Managers Award. Discussion at this visit confirmed that their application to register as manager was in hand. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 23 With the exception of three requirements concerning the handling of service users monies all outstanding requirements from the previous inspection were met. However, it was disappointing that ongoing concerns regarding the handling of service users monies remained. (See section Concerns, Complaints and Protection). Information was provided about a new company quality assurance initiative called “Your voice”; eight principles for involving service users and their carers. Relatives and residents questionnaires had also been developed and the manager had started regular residents meetings. The staff handbook included summaries of many of the organisations policies and procedures for staff reference, further more many of the policies and procedures in the homes manual had been replaced with up to date copies since the last inspection. On this occasion records examined evidenced that a previous requirement regarding the use of hoists in bedrooms had been met. Furthermore the manager had liaised with the local authority fire officer and completed the fire risk assessment that was outstanding at the last inspection. Discussion with the chef and records seen also confirmed that Hazard Analysis of Critical Control Points were in place regarding the production of food. Three hot water temperatures were tested and found to be close to forty-three degrees centigrade. Records indicated that temperatures were tested randomly on a daily basis and maintained appropriately. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 X 3 X The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 02, 03 & 04. 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. 01. Standard YA16 Regulation 12 Requirement The registered person must ensure that evening and bedtime routines promote service users choice, dignity and independence and reflect individual’s needs, wishes and preferences. The registered person must ensure that all monies owed to resident’s estates are paid without further delay and notify the Commission that this has taken place. The registered person must ensure that the homes policy for the administration of service users accounts is current and up to date and forward a copy to the Commission. The registered person must ensure that evidence is forwarded to the commission to confirm that all outstanding interest owed to service users has been paid into their DS0000031547.V336728.R01.S.doc Timescale for action 30/06/07 02. YA23 13(6), 20 01/05/07 03. YA23 13(6), 20 01/05/07 04. YA23 13(6), 20 01/05/07 The Firs Nursing Home Version 5.2 Page 26 accounts. 05. YA24 23(2) The registered person must ensure that the physical design and layout of the premises is suitable to the service users needs. 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 01. Refer to Standard YA32 Good Practice Recommendations The home should enable staff to access National Vocational Qualifications as a matter of priority. The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. Extracts may not be used or reproduced without the express permission of CSCI The Firs Nursing Home DS0000031547.V336728.R01.S.doc Version 5.2 Page 28 - 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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