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Inspection on 06/06/07 for The Glen Private Nursing Home

Also see our care home review for The Glen Private Nursing Home for more information

This inspection was carried out on 6th June 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People who live at the home, their relatives, visiting professionals and staff speak very highly of The Glen. People said they felt at ease, well looked after, comfortable and safe. They said the proprietors, manager and staff paid a lot of attention to them. One person said, "This is as near to home as you can get".People had an assessment before they came to live at The Glen. Nurses checked the assessment to make sure they were up to date. This meant that Staff understood people`s care needs well. People said staff treated them with dignity and respect, and respected their privacy. People had excellent opportunities to be involved in activities, outings and spend the day as they wished. People could enjoy walks to the garden centre, outings to the countryside and in-house entertainment. The manager and staff followed excellent practices to make sure people did what they wanted during the day. This also meant the home met people`s diverse needs, their preferences and wishes. People said they would have no worries making a complaint and the home would take action to resolve their concern. Staff had training to safeguard people from harm and abuse. People said they were very comfortable with their environment. It was clean, the home was in good repair and they had good laundry facilities. People spoke very highly about the staff. They said they were "hard working", "approachable", "very caring" and "gentle and smiling" Staff had training about people`s specific needs and over 50% had a National Vocational Qualification in care. This meant the staff team could deliver safe and consistent care. The proprietors paid a lot of attention to peoples needs. The manager managed the home well and she made sure the home carried out health and safety maintenance checks.

What has improved since the last inspection?

It is evident the home is committed to providing good services for people who live there. The last inspection identified two medication requirements, the inspector has removed these however there are further medication requirements and recommendations. Staff have continued to obtain National Vocational Qualifications.

CARE HOMES FOR OLDER PEOPLE The Glen Private Nursing Home 224 Abbeydale Road South Dore Sheffield South Yorkshire S17 3LA Lead Inspector Sue Stephens Key Unannounced Inspection 06 June 2007 10:10 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 DS0000021779.V330741.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000021779.V330741.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Glen Private Nursing Home Address 224 Abbeydale Road South Dore Sheffield South Yorkshire S17 3LA 0114 236 5580 01142363437 none 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) Mr Anthony Douglas Williams Mrs Sally Williams Mrs Christine Johnson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places DS0000021779.V330741.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: The Glen is a nursing home that provides care for up to 19 people. It is a converted house with a purpose built extension and conservatory. The home is situated within its own grounds within a residential area of Sheffield. The Glen is set within a woodland setting and is within easy access of the city centre and can be reached by bus, rail or car. The manager provided the information about the homes fees and charges on 07 June 2007. Fees range from £600 to £830 per week. The fee includes hairdressing, chiropody, manicure, laundry, aromatherapy, telephone and social activities. Prospective residents and their families can get information about The Glen by contacting the manager. The home will also provide a copy of the statement of purpose and the latest inspection report. DS0000021779.V330741.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced; it took place between 10:10 am and 16:40pm. The inspector sought the views of people who live at the home, and spent time observing other people who received support from staff. She interviewed one member of staff. Christine Johnson, the registered manager assisted with the visit in the afternoon. The nurse in charge assisted the visit in the morning. During the visit the inspector looked at the environment, and made observations on the staffs’ manner and attitude towards people. She checked samples of documents that related to peoples’ care and safety. These included three assessments and care plans, medication records, and staff recruitment files. The inspector looked at other information before visiting the home, this included evidence from the pre inspection information (sent in by the providers) last random inspection and surveys. The inspector received views from the following surveys: Five surveys for people who live at the home Three professional visitor surveys Four staff surveys. This was a key inspection and the inspector checked all the key standards. The inspector would like to thank the people who live at the home, the manager and staff for their warm welcome, help and contribution to this inspection. What the service does well: People who live at the home, their relatives, visiting professionals and staff speak very highly of The Glen. People said they felt at ease, well looked after, comfortable and safe. They said the proprietors, manager and staff paid a lot of attention to them. One person said, “This is as near to home as you can get”. DS0000021779.V330741.R01.S.doc Version 5.2 Page 6 People had an assessment before they came to live at The Glen. Nurses checked the assessment to make sure they were up to date. This meant that Staff understood people’s care needs well. People said staff treated them with dignity and respect, and respected their privacy. People had excellent opportunities to be involved in activities, outings and spend the day as they wished. People could enjoy walks to the garden centre, outings to the countryside and in-house entertainment. The manager and staff followed excellent practices to make sure people did what they wanted during the day. This also meant the home met people’s diverse needs, their preferences and wishes. People said they would have no worries making a complaint and the home would take action to resolve their concern. Staff had training to safeguard people from harm and abuse. People said they were very comfortable with their environment. It was clean, the home was in good repair and they had good laundry facilities. People spoke very highly about the staff. They said they were “hard working”, “approachable”, “very caring” and “gentle and smiling” Staff had training about people’s specific needs and over 50 had a National Vocational Qualification in care. This meant the staff team could deliver safe and consistent care. The proprietors paid a lot of attention to peoples needs. The manager managed the home well and she made sure the home carried out health and safety maintenance checks. What has improved since the last inspection? What they could do better: DS0000021779.V330741.R01.S.doc Version 5.2 Page 7 To make sure they safeguard people’s safety and welfare, the home could improve some of its records. For example people’s care plans, medication and finance records. The home can also improve some of their health and safety and recruitment records. The conservatory can get very hot, some people are unable to move themselves away. Although staff monitor this, the home does not have a risk assessment to minimise the chance of people coming to harm from the heat and direct sun. The home could put up blinds to help prevent this. For people with sight difficulties some areas of the home do not have enough bright lighting. Staff should have equality and diversity training to help them understand more about the issues. This is also important if more people with diverse needs come to live at the home. Nurses should have medication training to make sure their practices are safe and up to date. The home needs to make sure all staff follow safe moving and handling procedures. 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. DS0000021779.V330741.R01.S.doc Version 5.2 Page 8 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 DS0000021779.V330741.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People who live at the home have their needs assessed, and staff review this so that they can continue to meet people’s changing needs. EVIDENCE: People had assessments before they came to live at The Glen. This helped make sure the home understood their needs and confirm that they were able to care for them. The manager and qualified nurses assessed people’s needs, this continued after people moved in; this was good practice because it helped the home identify people’s changing needs and preferences. The manager said they consider peoples diverse needs at the point of assessment. (For example peoples, religion, culture, age and gender). DS0000021779.V330741.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. This judgement takes into account the good outcomes in other areas. However the area on care plans and medication needs attention and improvement. People have care plans and people are happy with how the home meets their healthcare needs. People are treated with great dignity and respect. People’s care plans are basic and the medication practices do not always help to make sure the system is safe and robust. EVIDENCE: The inspector checked three care plans. In the main these contained the basic necessary information. DS0000021779.V330741.R01.S.doc Version 5.2 Page 11 People did have some social history information in their plans (for example their lives, families, hobbies, careers and achievements) however; this was very basic and the home could improve them to help staff understand people’s situations and backgrounds. Two of the care plans had assessments that clearly identified people’s individual and special needs; however they did not have care plans to support these, this could lead to staff giving inconsistent or unsafe care. The care plans did not have a person centred approach. The manager said she had recognised this and was aware that they were due for re-designing. There were good daily records about people’s care and condition, nurses recorded twice a day and this formed a good account of peoples maintained and changing needs. People spoke very highly about how the home met their health care needs. Some people described the nurses as “fantastic”; one person said, “They are true professionals”. A relative said the home was very good at keeping the family informed about their family members health, and they had good access to G.P and health care services. A visiting clinical professional described the staff as being “prompt” in contacting multi-disciplinary teams for advice. Nurses kept good records of peoples health needs including when people had received health care services or seen a G.P. The home had a medication policy for nurses to follow and the storage was clean, tidy and secure. In the main the medication records were tidy, legible and up to date. However, the inspector identified the following practices that did not fully protect people’s health, safety and wellbeing. • • • Times and signatures were unclear on some ‘as required’ medication records. There is ample space overleaf to record the information clearly and help make sure staff avoid errors and confusion. People had their own homely remedies stored in the medication, but there was no label to identify who the medication belonged to. There was an opened bottle of ear drops in the cabinet. There was no date to say when the drops were opened or who they were for. This could lead to some one receiving eardrops beyond the use by date; or given to the wrong person. DS0000021779.V330741.R01.S.doc Version 5.2 Page 12 • It was unclear whether some medication was a homely remedy, or prescribed but unlabeled. And there was excess stock of the medication in the trolley. • The home had not done temperature checks on the medication fridge. Therefore the home could not be sure it always stored medication in it at the right temperatures. • Where people had hand written information on their medication record charts nurses had not double-checked and countersigned this with another competent person. • When nurses administered controlled medication they had not doublechecked and countersigned this with another competent person. • Where prescription details had changed on the record charts nurses had not signed this. • Qualified staff had not had regular up date training in medication. • The home had some homely remedies but had not sought advice from G.P and pharmacy. If the home is to use homely remedies, they should have a list of what they use in agreement with the G.P and pharmacist. DS0000021779.V330741.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People had excellent support from the proprietors, manager and staff to follow their preferred daily routines. They had good access to leisure and community activities. Families felt involved and welcome. EVIDENCE: People said they were very happy with their daily routines. The inspector noted that the manager and staff went to a lot of care and trouble to make sure people could spend the day as they wished. This included having meals in their bedrooms, if people wanted, and breakfast in bed. People had freedom to spend as much time as they wanted in their favourite parts of the house (for example the garden and outside). This approach was excellent and meant that the home was able to meet peoples special diverse needs, and give people control over their own lives. People spoke about their daily routines; they said they spent the day as they wished. One person said the staff were very respectful about this. And a DS0000021779.V330741.R01.S.doc Version 5.2 Page 14 relative said they were very satisfied with the routines and activities. They said, “People here can do their own thing”. Relatives confirmed that they were always welcome at the home. One relative said, “I can come whenever, day or night” The relative described some of the events she saw in the home and said they (the home) are “Fantastic, they do morning coffee with scones and afternoon tea with cakes.” Other activities people described in the home included: Escorted walks to the local garden centre Trips to the countryside and stately home Shopping trips Aromatherapy Visiting entertainers Music and songs and Religious worship. The manager also said they use a library resource for reminiscence sessions. People said they were very satisfied with their meals, they described them as “lovely” “plenty” and “We have a good cook”. A relative said in their survey questionnaire, “The staff are very aware of (family members) dietary needs and the cook provides tasty, varied meals”. The dining area was well decorated and furnished and provided a pleasant environment for people to enjoy meals in. The inspector noted that the home followed excellent practice for people who needed liquidised or soft meals. The cooks prepared and softened each item of food separate and they placed it on the plate in an attractive manner. This was very good because it maintained people’s dignity and respect for their food preferences and enjoyment. The cook said she had a good food budget and food supply of crockery and catering equipment. The kitchen was clean and well organised. DS0000021779.V330741.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People are protected from abuse by the homes policies and they are able to raise concerns and the home will take action. EVIDENCE: People said they could complain or raise concerns and the home would listen. Some people said they would tell the proprietors or the manager direct. And one person said the proprietors “pay a lot of attention” to people who live here and are “very concerned about their welfare”. The relative said, “Yes I can raise concerns” and explained that when they had done this the home had sorted the problem out straight away. The manager confirmed that the home had not had any adult protection issues. They were not dealing with any outstanding complaints. Staff confirmed they had attended adult protection (safeguarding adults) training and knew how to recognise poor practice and report it. DS0000021779.V330741.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23 and 26. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People were happy and comfortable with the homes environment. EVIDENCE: The owners kept the home well maintained. It was clean, comfortable and had homely furniture and fittings. People said they were very satisfied with the home. They said their rooms and the furniture they used was comfortable and suited their needs. The inspector saw a variety of bedrooms. The home had encouraged and assisted people to personalise them in the way the person preferred. This included people bringing personal possessions and choosing where they preferred to have their bed and furniture in their own room. DS0000021779.V330741.R01.S.doc Version 5.2 Page 17 One people said about their own room “This is my home, it is the way I like it and I am very happy”. The relative described the home as “perfect, always lovely”. One person replied in the surveys that the conservatory gets very hot in the summer. There is direct sunlight and some people are unable to move out of it. The manager said she was aware of this and staff had instruction to make regular checks and not leave people in there if it was hot. However the manager did not have a risk assessment to look at best possible options to minimise the risk of people’s exposure to the heat and sun. The manager agreed to do this. Another survey suggested that in some areas of the home the light was not sufficient for people with sight impairment. The inspector checked some areas; and some corridors did have insufficient lighting. People said they were satisfied with the homes laundry service. People’s clothes looked clean and well laundered. Staff said they were responsible for laundering peoples clothes and that the home provided sufficient cleaning agents and equipment to do this. DS0000021779.V330741.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People received good care and support from a caring and consistent staff team. The home needs to improve staff awareness about equality and diversity to make sure they continue to meet people’s needs. EVIDENCE: People said about staff, “They are lovely”, “caring” and “hardworking”. One person said “I never hear a cross word or raised voice, they never shout, I say that for other residents, not just myself”. Visiting professionals said about the staff team, “Always keen and enthusiastic” “They treat people as individuals” “I have excellent working relationships with all the staff” The relative said staff were, “approachable, very caring and hardworking”. “They know the people here, staff are intuitive, smiling and gentle”. And people said in the surveys, DS0000021779.V330741.R01.S.doc Version 5.2 Page 19 “All the staff are very friendly”, “conscientious” “staff are quick to respond”. People said they felt there was enough staff to help support them. And staff confirmed they had sufficient time to complete care tasks and spend time with people talking and socialising. Over 50 of staff had a National Vocational Qualification in care at level 2 or above; and more staff were working towards the qualification. This is good practice because it helps the home maintain a skilled care team who can provide consistent and appropriate care. In the main the homes recruitment procedures were good and made sure staff had thorough checks to help make sure they were suitable for the job. However the recruitment files did not have written declarations from staff about criminal offences. This is a statutory requirement and the home should obtain this prior to criminal record bureau checks and before the staff start work. A visiting professional said in the survey about staff, “The staff have been very responsive to training and following through with advice given on palliative care needs” Staff confirmed they receive training associated with the care needs of the home. Examples of training planned for staff this year included: Diabetes Parkinsonism Stroke Incontinence Communication skills and Nutrition. Qualified nurses gave the care staff the training. The inspector advised that nurses who deliver the training should check resources to make sure their information was up to date and reflected good practice. (For example they could use CSCI and Department of Health websites). Staff did not have training in equality and diversity issues. The inspector recommends all nurses and staff at the home have training in line with current national good practice developments. (See Department of Health website and the governments white paper ‘Our Health, Our Choice, Our Say). DS0000021779.V330741.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. This judgement takes into account the good outcomes in other areas. However the area on finance and health and safety records and moving and handling needs prompt attention and improvement. People are very satisfied with the running of the home. however the home can make improvements to records and moving and handling procedures to make sure they fully safeguard peoples safety and welfare. EVIDENCE: In the survey a relative said about their family members care, DS0000021779.V330741.R01.S.doc Version 5.2 Page 21 “All the time my (family member) has been in the home she has never made a negative comment. She is very at ease” Another person told the inspector about the proprietors, “They are very caring people, they have a lot of interest in the people who live here, they always come and ask you how you are”. The manager had good skills, she managed the home well and there is good evidence through out this report to demonstrate that. The manager has gained a National Vocational Qualification in the registered managers award. People who live at the home and the staff said the manager was approachable and gave good support. The proprietors confirmed they monitor the home by visiting virtually every day and take an active role in the home’s operation. They said they produce a report each month. However, the inspector recommends that the proprietors carry out audits on care plans and finance records more frequent so that they can identify and take action to make improvements earlier. The inspector checked three people’s finance records where the home held people’s own monies for safekeeping. The records were not orderly and it was difficult to follow a clear audit trail. Staff did not have a signed witness when withdrawing or depositing money. And it would be difficult for someone to request a copy of his or her own account because of the way the home arranged the finance book. The home stored the money securely, however the system to hold each person’s money and receipts separate was not secure. This was because the home stored money and receipts in paper envelopes; some were open, some were folded; they were not stored in an orderly manner. This made it difficult to see if the system was present and correct at all times. The home had records to demonstrate that they followed health and safety requirements. For example records on fire checks and fire drills. They did not maintain some of the records in an orderly manner. This could lead to the home finding it difficult to provide clear evidence that they made regular safety checks. This does not promote people’s health, safety and welfare. The inspector observed a member of staff who carried out a moving and handling procedure. The procedure did not maintain the person’s or the staff’s safety and it did not follow the technique described in the persons care plan. The manager said staff do have moving and handling training, however the home does not have a nominated person to carry out assessments and advice. DS0000021779.V330741.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 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 DS0000021779.V330741.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 2 Standard OP7 OP9 Regulation 15(1) 13(2) Requirement People’s care plans must be based on their assessed needs. There must be clear records on the administration of ‘as required’ medication. For example the information should be put overleaf on the medication record (MAR sheet) so that nurses can see clearly what the person has had and why. This will help make sure the record is clear, consistent and there is an audit trail of medication used. The practice also helps to monitor people’s health care needs. People’s own homely remedies, stored in the medication trolley must have their name on to make sure the remedy is used for the right person. Prescribed medication must have a label that indicates who the DS0000021779.V330741.R01.S.doc Version 5.2 Page 24 Timescale for action 31/07/07 31/07/07 medication belongs to and the instruction. Surplus stock must be removed from the trolley; this will help avoid errors. 3 OP19 13(2)(c) The home must have a risk assessment on the heat and sun exposure in the conservatory. The home must assess all areas of the home for sufficient lighting. Where it is not sufficient for people with impaired sight the home must take action to improve the lighting. 4 OP29 19(1)(b) When recruiting staff they must provide a written declaration about criminal offences. This is a statutory requirement and safeguards people who live at the home. 5 OP38 13(5) Staff must use safe moving and handling techniques. This will help prevent injury to people who need support to move and to staff. 31/07/07 31/07/07 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The manager should review the care plans to make sure they follow a person centred approach. For example peoples preferences about each plan of care DS0000021779.V330741.R01.S.doc Version 5.2 Page 25 and more information about their lives and achievements. 2 OP9 There should be at least daily fridge temperature records to make sure medication is stored at the correct temperature. When using hand written instruction on people’s medication records (MAR sheets) staff should use a counter-signatory to evidence that they have checked the instruction and it is correct. When staff alter a prescription (for example change of dose via G.P instruction) they should sign this and make a record of the reason for the alteration. The Royal Pharmaceutical Guidelines for care homes recommend that an appropriately trained member of staff should witness the administration of controlled drugs. The home should consider how they could do this to make sure their controlled drug procedures continue to be safe and minimise errors. Qualified staff should have periodic medication training to make sure they are up to date with current and good practice. If the home is to use homely remedies, they should have a list of what they use in agreement with the G.P and pharmacist. 3 OP19 The home should consider roof blinds in the conservatory to make sure people are protected from the heat and sun and to make sure they are comfortable when sat in the lounge. Staff should have training about equality and diversity needs. Although the home meets people’s diverse needs well, they could support this further by making sure staff have access to current equality and diversity information. 4 OP30 5 OP30 Nurses at the home who deliver in-house training should refer to resources that provide up to date information and DS0000021779.V330741.R01.S.doc Version 5.2 Page 26 good practice. For example the Commission for Social Care Inspection and Department of Health websites. (www.csci.org.uk and www.doh.gov.uk) This will help make sure people at the home receive care based on current good practice guidelines. 6 OP33 The home should improve their quality audit systems to help them identify good progress and to identify where practice and systems need to improve. This will help maintain and improve people’s quality of care and welfare. The home should maintain accurate and consistent records on people’s own monies that the home helps maintain. The way monies are stored should be secure to avoid errors. 8 OP38 Moving and handling assessments and safe procedures would improve if a nominated member of staff had the appropriate training and took on the role at the home. The home should seriously consider this to further protect people’s safety and welfare. 7 OP35 DS0000021779.V330741.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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