Inspection on 23/05/06 for The Firs Nursing Home

This inspection was carried out on 23rd May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 24 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 19/04/07

The Firs Nursing Home 11/01/07

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 23rd May 2006 10:00 The Firs Nursing Home DS0000031547.V296370.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.V296370.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.V296370.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) Craegmoor Healthcare Post Vacant Care Home 21 Category(ies) of Learning disability (21) registration, with number of places The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may care for 21 adults, under the age of 65, of either sex, who require care by reasons of learning disability. 15th February 2006 Date of last inspection Brief Description of the Service: The Firs is a care home with nursing for adults with a learning disability. Some of the service users are older adults who originally came from the closure of a long stay hospital. More recently the home has admitted a number of younger adults to the home. The Firs is a purpose built care home. The home is on two floors with a shaft lift connecting the two. The home has two interconnecting lounges and a separate dining room. The home has a mixture of single and double rooms. 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 Firs Nursing Home DS0000031547.V296370.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. The inspection was undertaken by two inspectors and took place over approximately eight 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 four staff files, four service user files, a selection of policies and procedures and health and safety records. The inspectors also toured the premises and grounds, met several service users and staff, and spoke with four service users and three staff on a 1-1 basis. The acting manager, recently appointed by the home, but not registered with the commission, was present throughout the inspection and fully contributed to the process. What the service does well: What has improved since the last inspection? What they could do better: The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 6 As a result of this inspection the home has been given a total of twenty-one requirements, twelve of which were issued immediately following the inspection. Four recommendations were also given. Areas of concern included hot water temperatures, fire safety, risk assessments and control of substances hazardous to health. One service user had been ‘transferred’ from another of the organisations home and did not have an assessment in place. furthermore they had not been admitted within the scope of the homes Statement of Purpose. Recruitment procedures were not thorough and robust and did not meet the requirements of legislation, care plans did not consistently reflect service users needs and service users did not have access to independent advocacy services so that they could be supported appropriately to make decisions about their daily lives. 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 Firs Nursing Home DS0000031547.V296370.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.V296370.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Prospective service users cannot be assured that the information they receive about the home reflects the services provided. Furthermore, they cannot be certain that the home will meet their needs and aspirations. EVIDENCE: Following a repeat requirement made at the previous inspection the homes Statement of Purpose had been updated and a copy had been forwarded to the Commission for Social Care Inspection. However, discussion with the manager and service user records examined evidenced that the Statement of Purpose did not entirely reflect the service being provided at the home at the time of inspection. The Statement of Purpose states that “it is not the intention of the home to accept emergency admissions or to have intermediate care placements”, however the manager confirmed that one service user, resident at the time of inspection had been admitted for a short term emergency placement. The manager also advised that the service user had not received a pre admission assessment to determine whether or not the home was able to meet their needs as they had not been considered a ‘new admission’ having transferred from another of the organisations home and ‘lodging’ on a temporary basis. Records indicated that there had been no other admissions since the previous inspection. The records examined of three service users admitted prior to 2004 included evidence of assessments. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Service users can expect to have a care plan in place but they cannot be certain that they will be protected by their individual risk assessments. Furthermore, they cannot be sure that they will be appropriately supported to make decisions about their lives. EVIDENCE: Four service users records were examined and included individual care plans and a range of risk assessments appropriate to the individuals needs. Risk assessments seen included manual handling assessments, water low assessments and nutrition assessments. There was also a risk assessment in place regarding the use of ‘bedsides’. However, the service user or their representatives and an appropriate professional (for example GP or social worker) had not signed the risk assessments. Appropriate individuals should sign risk assessments, particularly when related to an area such as bedsides as they can be a form of restraint as well as a potential health and safety issue. Records also indicated that the home was not complying with their own risk assessment for a service user confined to bed and requiring pressure care; there was in fact a discrepancy of ½ hour between the risk assessment and the individuals care plan. One resident’s records included speech therapist The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 10 ‘communication’ guidelines. Three of the four service users records examined included a photograph. Observations made and conversations with service users, the manager and staff on duty indicated that that most of the service users needed assistance to make decisions about their lives. Staff spoken with and entries in the visitors book suggested that many of the service users did not have regular contact with relatives or have alternative representatives, however records did not consistently detail how individual choices were made. Furthermore there was no evidence that advocacy services had been approached to support those residents requiring assistance, however the recently appointed manager advised that they intended to develop a ‘residents/relatives group’. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Service users cannot be certain that they will have appropriate opportunities for personal development, furthermore social and leisure opportunities may be limited. However, they can expect to enjoy home-cooked, healthy and appetising meals. EVIDENCE: Two service users had enjoyed a holiday at Disney world and there was some evidence that service users out and about but observations made, records examined and staff and service users spoken with confirmed that generally the majority of service users had limited access to the community and spent most of their time at the home. Care plans did include some details of individual’s likes, dislikes and interests but there was an absence of planned activity or personal development programmes. Resources within the home included equipment such as televisions, stereo and karaoke systems. One of the lounge areas also included a large fish tank. The home also had an enclosed garden area at the rear of the building but despite the nice weather there was no garden furniture in place and service users were not using it on the day of the inspection. The manager advised the inspectors that the home had recently appointed an activities co-ordinator to develop activities within and outside of The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 12 the home but they had not commenced employment at the time of the inspection. It was also confirmed that the home had recently got a new minibus and it was hoped that service users would soon be able to take advantage of it and ‘get out and about’ more often. During the inspection most of the service users were seen and spoken with in one of the communal lounges or the adjoining dining room. However, the inspectors visited one service user, confined to bed through ill health, in their own room and noted that the room appeared to reflect the service users interests. The individuals care plan did advise that the service user liked to have their television on or music playing but neither were on at the time of the visit. Records seen and staff and service users spoken with indicated that relatives were welcome at the home, however visitors were limited and staff suggested that this was due to practical difficulties for many ageing relatives. At the time of inspection staff on duty were observed interacting positively with service users. This was particularly noticeable during the evening meal. Service users needing support were appropriately assisted and there was good rapport between staff and service users. The meal itself was chicken with fresh vegetables and was well presented and appetising. Service users spoken with said that they liked the food. 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. Service users were able to take their meals in the privacy of their own rooms or in the communal lounge or dining area. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Service users receive personal support in the way that they prefer and require, however they cannot be certain that all their health needs will be met. Furthermore, they are not entirely protected by the homes medication procedures. EVIDENCE: Four service users records were examined and included details about individual’s personal support and health care needs. Appropriate information and guidelines were in place in relation to areas such as peg feeds and epilepsy. Records also evidenced that the home was appropriately monitoring service users weight and recording GP and hospital visits. Discussion with the manager indicated that the home was working closely with a GP regarding the monitoring of an individuals skin condition. However, records seen did not consistently record and ‘chart’ observations. It was also noted that the records of a service user needing to be ‘turned’ on a four hourly basis were not consistently completed and did not confirm whether or not the service user was receiving appropriate care. Staff and service users spoken with confirmed that service users had consistent support from designated ‘key workers’. The four service users spoken with on a 1-1 basis indicated that they were happy with the support The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 14 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. The home had suitable procedures in place for the safe handling and storage of medication. With the exception of the most recently admitted service user all individual’s records included photographs to avoid errors in administration. Examination of the service users medication administration records identified that two of the records had not been signed on the day of inspection, consequently they did not confirm whether or not the service users had received their prescribed medication. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Service users cannot be certain that the home ensures their safety and protection. EVIDENCE: The home had an appropriate complaints procedure in place but the copy on display in the foyer had not been amended to include updated information about the organisations contact details. Further more it did not reflect the fact that the National Care Standards Commission had been replaced by the Commission for Social Care Inspection. Records seen and discussion with the manager indicated that the home had not received any complaints since the previous inspection and service users spoken with indicated that they had no concerns or expressions of dissatisfaction. Following a repeat requirement made at the last inspection the home had forwarded a copy of their ‘Whistle Blowing Policy’ to the Commission and this was found in place at the home on the day of inspection. However the manager was unable to evidence that the home had a copy of the organisations Abuse Policy or a copy of the Suffolk Inter Agency Policy and Procedures for the Protection of vulnerable adults. Consequently staff did not have access to thorough and robust guidelines or the procedures for reporting serious concerns to the local authority. However staff spoken with and training records seen evidenced that staff had received some training in adult protection. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 & 30. Service users can expect the home to be clean and hygienic. However, they cannot be certain that the premises is safe and well maintained. 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. The grounds to the front of the building and enclosed garden were generally well maintained, however the borders to the side of the building were overgrown and there were also some loose bricks and damage to fencing in the same area. The garden shed, containing potentially hazardous equipment and chemicals was unlocked and accessible. During a tour of the premises some health and safety issues were identified; the cleaning cupboard on the ground floor was unlocked and accessible to service users, the boiler room on the first floor was unlocked despite a sign reading “fire door - Keep locked”, the ‘self closures’ on several fire doors were not working and several fire doors had been ‘wedged’ open. However, findings were that all areas seen were clean, hygienic and odour free and staff had The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 17 made a good effort to make the environment cheerful, homely and comfortable for service users. The majority of service users were seen using the communal areas that consisted of two adjoining lounge areas and an adjacent dining room. Areas seen were accessible to all service users including wheelchair users. The inspectors also found that several of the internal doors were badly scuffed and some corridors were in need of redecoration. The manager advised that the home did not have a maintenance schedule in place. One service user was visited in their bedroom. Although the service user was unable to communicate effectively with the inspectors there was evidence that the room reflected their interests and personality; pictures, posters and personal effects were in place and the room was suitably and pleasantly furnished and equipped with a television, CD player and a range of lighting. The homes laundry room was clean, tidy and equipped with washing machines that reached appropriate temperatures. However, on the day of inspection the tumble dryer was not in working order and staff advised that this had been the case for some time. At the time of inspection the kitchen was also seen to be suitably equipped, clean and hygienic. However the hot water temperature was found to be excessive and although the service users could easily access the area directly from the lounge and corridor there was no evidence that appropriate action had been taken to minimise risks from scalding or potentially dangerous equipment. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. Service users can expect staff to be appropriately trained, qualified and supervised. However, they are not protected by the homes recruitment procedures. EVIDENCE: The home employs registered nurses and care workers to meet the needs of the service users. The rota seen on the day of inspection indicated that there was always a minimum of one qualified nurse on duty every shift in addition to three to four care workers depending on the shift. Staff records examined, conversations with staff on duty and discussion with the manager indicated that several of the established staff members were going through the process of adapting to a change in management style and redefining of their roles and responsibilities. This, together with some issues around team dynamics was having a negative effect on the cohesiveness of the team. On a more positive note records seen and discussion with the manager and staff evidenced that the manager had begun to provide planned 1-1 supervisions with staff. An audit of training needs had also taken place and a programme of training was in place to ensure staff training needs would be met. Evidence of staff training included equal opportunities, health and safety, fire safety, infection control, protection of vulnerable adults, food hygiene, drug awareness and first aid. Two of the care workers spoken with were also in The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 19 the process of undertaking NVQ level 3 qualifications. One had completed an NVQ level 2 qualification. Four staff files, including recruitment records were examined. All four records included copies of each individual’s application forms, three evidenced that references had been undertaken, two files included individuals photographs and two included health ‘clearances’. The two individuals requiring work permits had copies of appropriate documents in place, however one did not have a Criminal Record Disclosure check (CRB). The manager advised that the organisation were having difficulty obtaining the check but there was no evidence in the individuals records to confirm whether or not interim measures were in place to safeguard service users. The remaining three records evidenced that CRB checks had been undertaken but one identified an issue of concern, in this instance there was no evidence that the individuals suitability to work at the home had been appropriately assessed. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42. Currently, service users views do not underpin the development of the home and their health, safety and welfare is not entirely safeguarded. EVIDENCE: Since the last inspection the organisation has appointed a new homes manager however to date the commission has not received an application for registration by the manager or undertaken a ‘fit person’ assessment. However the manager confirmed that she is a registered nurse and is due to commence her NVQ level 4 in management and Registered Managers Award in June 2006. During the inspection the manager was very open regarding the issues she had identified at the home and the inspectors were advised that with the support of the deputy manager she had begun to ‘tackle’ practice issues, staff training and supervision and was committed to the development of good practice to meet national minimum standards. The manager also recognised that the home had an absence of quality assurance procedures in place and these need to be developed to meet legislative requirements. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 21 There was evidence that the home promoted safe working practices by training staff in areas such as manual handling, food hygiene, fire safety, first aid and infection control. Records held in the kitchen evidenced that fridge and freezer temperatures were monitored daily. Electrical equipment had been PAT tested; service records were in place for the hoists and the lift. However, the home did not comply with its fire risk assessment (see section 6 Environment), further more records held to monitor the homes hot water temperatures indicated that adequate systems were not in place to protect service users from scalding or legionella. The home had not responded to recommendations highlighted in their water hygiene risk assessment to install suitable filters and thermostatic controls. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 22 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 2 2 1 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 2 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 3 2 X X 2 X The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 23 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 YA3 YA1 Regulation 4 Timescale for action The homes Statement of Purpose 31/07/06 must reflect the nature of the services provided by the home. This is a repeat requirement that has been part met since the previous inspection. The home must ensure that 23/05/06 service users are not accommodated without an appropriate assessment of need. The home must ensure that 31/07/06 service users are appropriately supported to make decisions. The home must ensure that 30/06/06 where a service user is unable to sign, risk assessments (particularly those concerning ‘bedsides’) are signed and agreed by appropriate professionals or representatives. The home must ensure that they 23/05/06 consistently record and ‘chart’ observations with regard to the individual whose skin condition is being monitored. The home must ensure that the 23/05/06 service user confined to bed and requiring pressure care has their physical and health needs met. The home must ensure that all 23/05/06 DS0000031547.V296370.R01.S.doc Version 5.2 Page 24 Requirement 2. YA2 14 3. 4. YA7 YA6 YA9 12(2)(3) 12(1) 13(4) 5. YA19 12(1) 6. YA19 12(1) 7. YA20 12(1) The Firs Nursing Home 13(2) 8. YA22 22 9. 10. YA23 YA24 12(1) 13(6) 23(2) 11. YA24 13(4) 12. YA24 16 13. YA34 12(1) 13(6) 19 12(1) 13(6) 19 19 Sch 2 9 14. YA34 15. 16. YA34 YA37 17. YA39 24 medication given is signed for; otherwise there should be clear indication why the medication has not been given. The home must ensure that service users, visitors and staff have access to an up to date complaints procedure that includes correct contact details for the organisation and CSCI. The home must ensure that all staff employed have easy access to adult protection procedures. The home must ensure that the home is maintained in a good state of repair and is reasonably decorated throughout. The home must ensure that appropriate action is taken to minimise the risks to service users from potential hazards in the kitchen area, including hot water. The registered person must ensure that badly scuffed doors within the home are replaced. This was a requirement made at the last inspection but remains within timescale. The home needs to evidence that the individual with CRB related concerns has been suitably assessed to work at the home. The home must ensure that where the CRB is absent appropriate action is taken to safeguard service users. The home must ensure that all employees have full and satisfactory information in place. The acting manager must submit an application to register as manager with the Commission for Social Care Inspection. The registered person must ensure that there is a sound quality assurance system in place including service users DS0000031547.V296370.R01.S.doc 23/06/06 23/05/06 31/08/06 23/05/06 08/08/06 23/05/06 23/05/06 01/07/06 31/07/06 31/08/06 The Firs Nursing Home Version 5.2 Page 25 18. 19. YA42 YA42 12(1) 13(4) 23(4) 12(1) 13(4) 12(1) 13(4) 12(1) 13(4) 20. 21. YA42 YA42 YA24 comments and wishes. This is a repeat requirement from February 2006. The home must take adequate precautions against the risk of fire. The home must review their water hygiene risk assessment and take appropriate action to minimise risks to health. The home must take action to minimise the risk of scalding to service users and staff. The home must comply with COSHH regulations. 23/05/06 31/07/06 23/05/06 23/05/06 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. Refer to Standard YA12 YA31 YA32 YA30 YA24 Good Practice Recommendations The home should offer a wider range of activities within the home and more opportunities to access the wider community. The home should consider providing opportunities for the staff to undertake some planned team building sessions. The tumble dryer should be repaired or replaced without delay. The home should ensure that the grounds at the side of the property are maintained and the fencing and loose bricks repaired. The Firs Nursing Home DS0000031547.V296370.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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