CARE HOMES FOR OLDER PEOPLE
The Gables The Gables Nursing Home 123 Wendover Road Aylesbury Buckinghamshire HP21 9LW Lead Inspector
Sue Smith Unannounced Inspection 27th July 2006 10:00 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 DS0000019226.V294510.R01.S.doc Version 5.1 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. DS0000019226.V294510.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Gables Address The Gables Nursing Home 123 Wendover Road Aylesbury Buckinghamshire HP21 9LW 01296423077 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) Mandeville Care Services Limited Mrs Minerva Patti Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places DS0000019226.V294510.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. General Nursing Care Date of last inspection 29th December 2005 Brief Description of the Service: The Gables Nursing Home is an older building with character, retaining some of its original features. The Home is situated on a main road close to local amenities. The Home provides Nursing care for 22 Service users. The staff team consists of a skill mix of qualified Nurses and Carers with a Manager who is a suitably qualified Nurse. The Home has access to a large well-kept garden, which is situated approximately five minutes away at Mandeville Grange, also owned by the proprietors. Due to the Close proximity of these two Homes the Manger is registered to manage both Homes. DS0000019226.V294510.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first key inspection of the service since the implementation of IBL2 (Inspecting for Better Lives). The inspection was undertaken on the 27th July 2006 over 7.5 hours. The Manager was available throughout the inspection. The Inspector used a triangulated methodology to complete this inspection, pre-inspection information such as the previous report, Pre-inspection questionnaire and discussion and correspondence with the Proprietor was used in the planning process to ensure hypotheses were formulated to support the inspector to explore issues of concern and verify practice and service provision. In addition feedback surveys received, which included the views of Service Users, Families and Staff, were used in the planning process. During the inspection a variety of documentation was assessed, which included Careplans, Risk Assessments, Pre-Admission Assessments, Menus, Rota’s, Training records and Recruitment records. In addition a full environmental tour took place. The Inspector identified three Service Users for Case tracking, speaking with these Service Users and available family members, and assessing the available information held in the home relating to the care provision for these Service Users. In addition the Inspector met with three other Service Users to gain their views on care provision. All Service Users and family members spoken with at the time of inspection were happy with the service provided and were complimentary of the Manager and her team. What the service does well:
The home is managed by a suitably qualified and experienced Manager, with many years experience in the care of Older People, she holds a current Nursing and Midwifery Council registration and is a professional and competent manager. Well-informed and professional private Providers who operate other homes in the County support the Manager. All Service Users are admitted based on a pre-admission assessment, which identifies whether or not the home can meet the needs of the individual. All admissions to the home are respectful of the equality and diversity of individuals ensuring any additional needs such as religion; dietary and communication are addressed in the assessment plan to provide necessary information to staff when planning care on admission.
DS0000019226.V294510.R01.S.doc Version 5.1 Page 6 Careplans in place acknowledge the preferences of Service Users, however these do need to be written in consultation with the Service User or family members where possible. All Careplans are reflective of review with assessments undertaken used to formulate individual plans of care to support Service Users. Staff are knowledgeable of the needs of the Service Users, ensuring they maintain their privacy and dignity whilst undertaking personal care. Staff were observed throughout the inspection chatting with service Users in a respectful and friendly manner. The home has robust medication procedures, which ensure the ongoing protection of Service Users. All medication is administered by qualified Nurses and is subject to audit. The home offers a varied activities programme, which is based on the likes, dislikes and capabilities of the Service Users. Service Users reported finding these enjoyable. A variety of nutritious and appetising meals are offered at the home, with alternatives to the menu available on request. A Complaints procedure is in place, which is reflective of timescales for action, ensuring all investigation findings are reported to the complainant. There have been no formal complaints made since the last inspection with two concerns raised fully investigated and outcomes reflected. The home operates the Buckinghamshire inter-agency policy for the Protection of Vulnerable Adults and is currently bringing their policy in line with the reporting systems of this policy. All staff receive ongoing training to support their professional development. Supervisions take place for all staff to ensure they are able to discuss any changes in the needs of Service Users and practice issues that may arise. A thorough and robust recruitment system is in place with all relevant security checks such as CRB disclosures and written references. What has improved since the last inspection?
The Proprietors have provided the Commission with a business plan, which outlines the improvements that will be made to the home under standards 19 to 26. The plan in place is reflective of a twelve-month work schedule. DS0000019226.V294510.R01.S.doc Version 5.1 Page 7 The Proprietors have begun working on their environmental improvement plan, this has already had a positive impact on the home with several areas of the home already painted and decorated. Doors identified as requiring repair to ensure they are providing adequate protection in the case of fire have been fixed. A replacement lock has been fitted to the downstairs sluice facility. The door to the laundry room is now kept locked when not in use. The activity management systems used at the home have been reviewed with new recording systems soon to be introduced. The home continues to provide a high standard of care to Service Users, verified by Service Users and family members during inspection and through feedback received. What they could do better:
Although the home reflects the Service Users preferences when delivering care, it was evident during discussion with the Manager that these are not formulated with the Service User or family members. It is appreciated this is not always possible, however as far as is reasonably practicable the Nursing staff need to develop individual support plans in consultation with the Service Users or family members to ensure all care is implemented in a manner preferred by Service Users. The home ensures all systems to protect the health, safety and welfare of Service Users is in place, however during inspection it was noted that Generic Risk Assessments, which outline the hazards associated with the environment, were past their review period. These do need to be regularly reviewed to ensure the ongoing protection of Service Users. During the assessment of pre-inspection information there was an area of confusion when deciding whether or not Service Users were diagnosed with Dementia type illnesses (presently the home does not have a registration category to admit Service Users with Dementia) some Social Service reports described specific illnesses such as Alzheimer’s, however this was not present on any of the specialist or medical notes. If the diagnosis of these Service Users is confirmed it will be necessary for the home to apply for a specific variation in registration (for these existing Service Users) to support them to continue provide care and support. DS0000019226.V294510.R01.S.doc Version 5.1 Page 8 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. DS0000019226.V294510.R01.S.doc Version 5.1 Page 9 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 DS0000019226.V294510.R01.S.doc Version 5.1 Page 10 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): Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Pre-admission assessments are undertaken to ensure the home is able to meet the needs of potential Service Users prior to admission. EVIDENCE: The home ensure all potential Service Users have a pre-admission assessment to ensure the home is able to meet their identified needs prior to admission. This includes information received from other specialists and family members to ensure an accurate reflection of the individuals needs is obtained. A copy of the assessment is available in the Careplan. All admissions to the home respect the equality and diversity of Service Users, ensuring those from differing cultures are supported with their dietary requirements. Support to access religious services is in place with tapes available with Punjabi Prayers. Priests, Ministers and other religious elders are welcomed at the home to meet with Service Users in Private, (presently a Roman Catholic Priest regularly visits the home).
DS0000019226.V294510.R01.S.doc Version 5.1 Page 11 There are no restrictions on admissions based on sexual preference, race or culture, the only restrictions the home have in place is for severe challenging or violent behaviour as staff do not possess the skills or training to meet the needs of such Service Users. There is presently one non-English speaking Service User, however a number of the staff are fluent in her preferred language and are supportive of the Service Users needs. There appeared to be some confusion when assessing the admission information of some Service Users whether or not they had received a formal diagnosis of Dementia, on one Social Services Careplan it stated Alzheimer’s as the diagnosis, however this was not apparent as a diagnosis on any of the hospital or specialist information. The home does need to ensure all admissions to the home are within category and will need to contact the Care Managers involved with these admissions to ascertain the actual diagnosis. Should it be found that these Service Users do have a diagnosis of a dementia type illness then the home will need to apply for a variation to its current certificate. A requirement is made to this effect. DS0000019226.V294510.R01.S.doc Version 5.1 Page 12 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. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Individual plans of care are in place, which are reflective of the Service Users needs, with care implemented in a manner preferred by Service Users. The home has robust medication procedures in place, which are reflective of current guidance, ensuring the protection of service users. EVIDENCE: Three Service Users were case tracked using Careplans and additional supporting documentation held in the home, where possible Service Users and visitors were met with to gain their views on the care provided at the home, feedback from comment cards were also used to determine areas to be assessed prior to inspection. When assessing the Careplans they were found to be up-to-date and relevant to the needs of the individual. Additional plans had recently been formulated to support Service Users during the ‘heat wave’ this included a night Careplan.
DS0000019226.V294510.R01.S.doc Version 5.1 Page 13 Risk assessments are in place for the use of Bedrails, which pertain to the particular bed situated in a particular room, this gives the risk of using that piece of equipment in the provided space with an additional area to add when a new Service User occupies the room. All of these assessments were reflective of monthly review. A falls risk assessment was in place using the PCT (Primary Care Trust) format; the home has attended talks by the Falls Nurse in the use of these assessment tools to support their use. The information contained using this tool is then used to formulate a Careplan under Mobility. All Waterlow assessments were found to be up-to-date with reviews recorded in the appropriate area, these plans were easy to read and reflective of a monthly review unless the needs of a Service User necessitated another review period. Manual Handling assessments were in place, which were also reflective of monthly review, these outlined the individual needs of the Service User and how the home would maintain their levels of independence safely. All Careplans have a day care plan and a night care plan, the quality of these was both good, all plans were reflective of review. The home does reflect the individual preferences of Service Users however Careplans are still written by the Nurses sometimes without consultation with the Service User or family members, discussion with the Manager took place to support the progression of these plans, the Manager will instruct all Nursing staff that the plans need to be written where possible with the Service User or a family representative. A requirement is made to this effect. The home operates robust medication procedures with guidance available to Nurses to support their practice. Administration records were assessed and found to be maintained to a high standard with no gaps. Medication is stored in appropriate lockable facilities with no out of date medication held in the home. Additional storage facilities have been purchased to ensure all medications are administered from the prescribed bottle. A random check of Controlled drugs took place with all accurately recorded and accounted for. A system is in place for the safe disposal of returned or spoilt medication with a contract and the appropriate storage facility available. DS0000019226.V294510.R01.S.doc Version 5.1 Page 14 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. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Activities offered at the home are suitable, flexible and enjoyable; ensuring the social needs of Service Users is met. Meals offered at the home are nutritious and appealing, ensuring the needs of Service Users is met. EVIDENCE: The home provides an activities programme for the Service Users; a designated activities co-ordinator is employed to ensure the ongoing success of the programme. An activities book was previously maintained, this system is now been updated by implementing individual activity folders, which will contain a pen picture of the Service User including family history, activities enjoyed and the aim of any planned activity for the individual. A recording sheet is provided for all activities undertaken; once these have all been completed the new system of recording will be operational. Service Users are supported to make decisions about the way care is implemented and the day-to-day operation of the home; staff are friendly and courteous towards the Service Users, informing them of the days activities and
DS0000019226.V294510.R01.S.doc Version 5.1 Page 15 special events that may be taking place. Staff endeavour to ensure the independence levels of Service Users is maintained, with Service Users spoken with at the time of inspection all happy with the care provided and their communication with staff, they and their families reported finding the Manager approachable and believed their ideas and concerns were well received with initiatives implemented to support improvements. The annual Service Users questionnaire has recently been distributed with positive feedback received, the Proprietors will now collate this information to be used to support them to further improve on the service provided. A variety of nutritious home cooked meals are available to Service Users, when assessing the menus it was noted the word ‘Casserole’ was used frequently to describe meals prepared, in some instances three times in one week, when exploring this it was noted this was a general description of how the meat is prepared to ensure it is tender and easy to chew. The description used on menus is misleading; the Cook will need to explore other ways to describe the meals containing meat as its present description gives the impression of a somewhat ‘limited’ menu. In addition to the main meals a variety of home baking is available throughout the day. An excellent initiative was noted during the inspection of having a drinks area in the dining room, this contained fresh jugs of cordial and juices with ice added to keep them cool. Disposable cups were available and the area was maintained throughout the day by the domestic staff to ensure all drinks offered were fresh and cooling. In the present ‘heat wave’ this was a quick and accessible method of ensuring a variety of fluids were offered frequently. DS0000019226.V294510.R01.S.doc Version 5.1 Page 16 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. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home operates a complaints procedure, which is reflective of current guidance and timescales for action, thus ensuring Service Users, and significant others are able to raise their concerns appropriately. The home is updating its POVA policy, to ensure it is in line with current county guidance, thus providing additional protection to Service Users. EVIDENCE: There have been no formal complaints received at the home or directly to the Commission since the last inspection, however two issues of concern were raised by a Care Manager during a review, these were thoroughly documented and investigated by the Provider with the outcomes reported to the Commission. A record of all complaints/concerns is held in the home, which was open to inspection. The home operates a complaints procedure, which is reflective of timescales for action, this policy is available to Service Users and significant others with a copy held in the home. All Service Users and family members spoken with at the time of inspection felt they could raise any issues of concern they may have with staff without fear of reprisal, they find the Manager and Deputy Manager approachable and believe any issues raised will be mutually resolved, this philosophy has supported the low number of complaints received at the home and is largely due to the ‘open door’ policy of the Management team.
DS0000019226.V294510.R01.S.doc Version 5.1 Page 17 The home ensure training is in place for the Protection of Vulnerable Adults from Abuse, all training is up-to-date with new staff accessing courses as soon as is reasonably practicable. The home are in the process of updating their own policy to ensure it is in line with the reporting systems of the current Buckinghamshire Inter Agency Policy for the Protection of Vulnerable Adults. Once this work is completed the home will ensure all staff are made aware of the new policy guidance. DS0000019226.V294510.R01.S.doc Version 5.1 Page 18 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 & 26. Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to the service. The home is working towards its environmental improvement plan to ensure the facilities available to Service Users are maintained to a high standard. All areas of the home are cleaned to a high standard with no offensive odors, ensuring the Service Users live in a comfortable and hygienic home. EVIDENCE: The Proprietors are working hard towards their environmental improvements plan, on the day of inspection the painters and decorators were busy glossing the banisters to the main staircase. In addition glossing has already taken place to the downstairs doors and frames in the older part of the house. Already with these small areas of decoration the entrance hall to the home has been lifted, providing a clean and well-maintained area. DS0000019226.V294510.R01.S.doc Version 5.1 Page 19 The small lounge situated in the older part of the house has recently been changed into a dining room, which is also utilised as a drinks station. The lounge is awaiting decoration, this area was found to be clean and tidy with additional fans in place to support Service Users during the ‘heat wave’. The lino in the downstairs bathroom has recently been changed to a non slip type, the home are now looking at how the drainage can be changed in this area due to the wet floor problems caused when the shower is in use. The upstairs bathroom has also been painted and non-slip flooring fitted. Some of the bedrooms have been decorated and are awaiting new curtains and fittings. Once the painting and decorating of the communal areas has been completed, new furnishings and fittings will be purchased to further improve the facilities available. There were no offensive odours present throughout the home on the day of inspection will all areas cleaned to a high standard. There were no items of C.O.S.H.H. left around the home with the domestic staff ensuring all such items are locked away securely when not in use. DS0000019226.V294510.R01.S.doc Version 5.1 Page 20 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. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. There are sufficient numbers of suitably qualified and experienced staff to meet the needs of Service Users. The home operates a robust recruitment system, which ensures all relevant security checks are put in place prior to a start date, ensuring the protection of Service Users. The home provides ongoing training to support the staff to meet the needs of the Service Users. EVIDENCE: The home is staffed with suitably trained and qualified staff to ensure they are able to meet the needs of the Service Users. The recent retirement of a part time RGN has necessitated the employment of a new Nurse to fill the vacant twenty-four hours allocated to the previous Nurse. Two members of staff have been recruited since the last inspection with their recruitment files open to inspection, these were found to contain the relevant security checks, which included a CRB disclosure and two written references. DS0000019226.V294510.R01.S.doc Version 5.1 Page 21 All new staff are subject to an induction process, which is undertaken by the training coordinator, documentation in relation to the induction undertaken is held in the training file for each staff member. Training is offered to all staff throughout the year. All mandatory training is up-to-date with a programme in place to ensure any up-dates are received within a recommended timescale. Training has been booked up to February 2007 to ensure the trainer is available to meet the training programme for the home. Staff felt the training offered was relevant to there roles and that they were receiving the opportunity to attend external training. DS0000019226.V294510.R01.S.doc Version 5.1 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. A suitably qualified and experienced manager who ensures the home is run in the best interest of Service Users manages the home. Staff are supported to meet the needs of Service Users with a full programme of training and supervision in place. The home ensures it follows current health and safety guidance, however generic risk assessments need to be reviewed to ensure the home continues to provide a safe and pleasant home for Service Users EVIDENCE: A suitably qualified and experienced Manager manages the home, at this time she is still planning to retire, however no set date has been given. Staff are
DS0000019226.V294510.R01.S.doc Version 5.1 Page 23 appreciative of the support offered by the Manager and report her as an approachable and competent Manager. Service Users and family members were happy with the way the home is managed and described the service as “very good” they find the manager and her staff team “approachable” and “so helpful”, should Service Users require anything in addition to what is currently provided family members are consulted. One family member felt the Manger and her team “always make sure things are done how she (the Service User) likes”. There have been no complaints or issues of concern raised throughout this inspection as to the conduct of the Manager or her team. Supervisions are taking place for all staff which are generally undertaken by the Training Coordinator, it is recommended the supervision of Nurses is undertaken by the Manager to ensure all Nurses are receiving a relevant supervision which includes their professional conduct and responsibilities to the Manager. This will also give the Nurses the opportunity to discuss any issues of concern or improvements they may have identified. The Proprietors must ensure the Manager also receives a formal Supervision at least bi-monthly with no less than six supervisions in any given year. There is a system in place to protect the finances held on behalf of Service users. Any monies are held in a non-interest bearing account with individual records open to inspection. Most of the Gables Service Users pay for any additional charges such as newspapers, toiletries and personal items through an invoicing system to minimise the need for the home to hold monies. The Organisation are presently working on improving their quality assurance documents, it is hoped these will soon be available in the homes. It is recommended the Manager meet with the Proprietors and Manager of the other homes registered with the Organisation to develop the systems for Quality Audit for the Organisation. The home has relevant health and safety policies and procedures in place, which support a safe and pleasant environment for Service Users. As previously mentioned in this report there are no items of C.O.S.H.H. left around the home with all such items stored in lockable facilities when not in use, supporting C.O.S.H.H. data sheets are available to staff. All fire prevention systems are in place with up-to-date records maintained; there are no outstanding requirements from the recent Fire Authority report. Doors previously not closing sufficiently have now been rectified with no other environmental issues that could place Service Users at risk of fire noted during this inspection. The home does have Generic Risk Assessments in place, which contain relevant measures to minimise the risks identified throughout the home. Unfortunately these have not been reviewed in the past year; therefore a requirement is made for all Generic Risk Assessments held in the home to be
DS0000019226.V294510.R01.S.doc Version 5.1 Page 24 reviewed within 1 month of this inspection. As these assessments are only marginally outside of the recommended review timescale and their were no other issues of concern in relation to Health and Safety at the home they have maintained a rating of good on the overall scoring of these standards. DS0000019226.V294510.R01.S.doc Version 5.1 Page 25 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 DS0000019226.V294510.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 Requirement Timescale for action 28/10/06 2 OP7 15 3 OP38 12 (1) a It is a requirement that a variation in registration needs to be applied for should it be found that any Service Users admitted to the home does have a diagnosis of a dementia type illness. It is a requirement that where 28/11/06 possible all Careplans are written in consultation with the Service User or a family representative to ensure the personal preferences are an accurate reflection of the needs of a Service User. A requirement is made for all 27/08/06 Generic Risk Assessments held in the home to be reviewed within 1 month of this inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000019226.V294510.R01.S.doc Version 5.1 Page 27 No. 1 Refer to Standard OP33 Good Practice Recommendations It is recommended the Manager meet with the Proprietors and Manager of the other homes registered with the Organisation to develop the systems for Quality Audit for the Organisation. It is recommended the supervision of Nurses be undertaken by the Manager to ensure all Nurses are receiving a relevant supervision, which includes their professional conduct and responsibilities to the Manager. In addition the Proprietors must ensure the Manger receives no less than 6 formal supervisions in any given year. 2 OP36 DS0000019226.V294510.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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