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Inspection on 09/08/07 for The Green Nursing Home

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

This inspection was carried out on 9th August 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 are cared for in a respectful manner by staff working at the home and this ensures that their self-esteem and dignity are maintained. People have access to a wide range of health and social care professionals and written records regarding these visits are kept. The home provides a range of activities and outings and people are encouraged to maintain activities outside of the home, maintaining their independence. Choices of meals are offered and food is well presented. The home can cater for special diets, including individual preferences, dietary and cultural needs.The home has not received any complaints and the manager has an open door policy so that she can be spoken with at anytime. One visitor said, "From what I have seen everything is on top form". Aids and adaptations are provided so that the independence, choice and dignity of people living at the home are promoted whilst maintaining their safety. Regular maintenance checks of this equipment ensure that they are safe to use. Meetings are held so that people are given the opportunity to voice concerns or make suggestions about how improvements could be made. There is a robust system in place for the safekeeping of small amounts of personal money should people choose to use this facility. Comments received included: "Its a very good home" "Its excellent, nothing is too much for them" "They couldn`t do more, they take good care of me and everything is good" "She seems positive about the care" "I can visit at anytime, staff are welcoming and bring me a cup of coffee" "Meals are very acceptable" "I have no problems about this home" "The home is spotless" "Staff are friendly" "Staff are always available to provide for his needs"

What has improved since the last inspection?

The detail of pre admission assessments has improved to ensure that both the home and the prospective person know that the home can meet their needs prior to admission. Infection control practice has improved to ensure that people live in a safe environment where infection risks are minimised. New carpets have been laid and some bedroom furniture has been purchased to improve the surroundings of the home. The number of staff with National Vocational Qualification (NVQ) level 2 has increased to 80% and this should ensure that a knowledgeable and skilled workforce provides care.

CARE HOMES FOR OLDER PEOPLE Green Nursing Home, The Wharf Road Kings Norton Birmingham West Midlands B30 3LN Lead Inspector Lisa Evitts Key Unannounced Inspection 9th August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000024842.V342621.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. DS0000024842.V342621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Nursing Home, The Address Wharf Road Kings Norton Birmingham West Midlands B30 3LN 0121 451 3002 0121 486 3360 Flintvaleltd@btconnect.com 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) Flintvale Limited Andrea Hinton (Acting Manager) Care Home 59 Category(ies) of Dementia - over 65 years of age (59), Old age, registration, with number not falling within any other category (59), of places Terminally ill over 65 years of age (59) DS0000024842.V342621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to accommodate 59 people over 65 years of age who are in need of nursing care for reasons of old age or dementia. Registration Category 59 OP DE (E) TI (E) (Currently under review) Due to the layout of the building, in particular the distance from the main lounge to the rest of the home, a member of staff must be supervising the service users in the main lounge at all times. (Currently under review) 7th November 2006 2. Date of last inspection Brief Description of the Service: The Green is a purpose built facility, which offers nursing care for up to 59 older adults, and can accommodate residents with Dementia care needs. The home has a mixture of shared and single bedrooms, some of which have en-suite facilities, spread over the ground and first floors of the building. There are communal bathing, shower and toilet facilities on both floors. The building has basic adaptations for residents with limited mobility, including two passenger lifts. Communal lounges are situated on the ground floor and the lounge doors open onto an enclosed garden with a water feature, which has wheelchair access. Laundry and kitchen services are located on the ground floor, as are the dining rooms. There is off road parking to the front of the property, which is sufficient for the home, and is situated close to bus links to the centre of Birmingham. There are a range of local shops and community facilities nearby. The current scale of charges for the home is £349 - £500. This depends if the person is privately funded or funded by Social Care and Health. Charges vary, on the assessed banding and type of room chosen and a top up fee is payable. Hairdressing, chiropody, opticians and dentists visit the home, and are available for additional fees. Previous inspection reports and leaflets of interest are available inside the reception area of the home, for anyone who wishes to read them. DS0000024842.V342621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The visit to the home was undertaken by two inspectors over eight hours and was assisted throughout by the acting manager. The home did not know that we were visiting on that day, when there were 54 people living there. Comments received from residents and visitors were all very complimentary. Questionnaires were sent out to relatives and healthcare professionals but none had been returned at the time of writing this report. Information was gathered from speaking to four residents, five staff and three visitors. Four people were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at care and medication records and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. Prior to the inspection the acting manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave information about the home, staff and people who live there that was taken into consideration. Regulation 37 reports pertaining to accidents and incidents in the home were also reviewed in the planning of the visit to the home. No immediate requirements were made on the day of the visit. What the service does well: People are cared for in a respectful manner by staff working at the home and this ensures that their self-esteem and dignity are maintained. People have access to a wide range of health and social care professionals and written records regarding these visits are kept. The home provides a range of activities and outings and people are encouraged to maintain activities outside of the home, maintaining their independence. Choices of meals are offered and food is well presented. The home can cater for special diets, including individual preferences, dietary and cultural needs. DS0000024842.V342621.R01.S.doc Version 5.2 Page 6 The home has not received any complaints and the manager has an open door policy so that she can be spoken with at anytime. One visitor said, “From what I have seen everything is on top form”. Aids and adaptations are provided so that the independence, choice and dignity of people living at the home are promoted whilst maintaining their safety. Regular maintenance checks of this equipment ensure that they are safe to use. Meetings are held so that people are given the opportunity to voice concerns or make suggestions about how improvements could be made. There is a robust system in place for the safekeeping of small amounts of personal money should people choose to use this facility. Comments received included: “Its a very good home” “Its excellent, nothing is too much for them” “They couldn’t do more, they take good care of me and everything is good” “She seems positive about the care” “I can visit at anytime, staff are welcoming and bring me a cup of coffee” “Meals are very acceptable” “I have no problems about this home” “The home is spotless” “Staff are friendly” “Staff are always available to provide for his needs” What has improved since the last inspection? The detail of pre admission assessments has improved to ensure that both the home and the prospective person know that the home can meet their needs prior to admission. Infection control practice has improved to ensure that people live in a safe environment where infection risks are minimised. New carpets have been laid and some bedroom furniture has been purchased to improve the surroundings of the home. The number of staff with National Vocational Qualification (NVQ) level 2 has increased to 80 and this should ensure that a knowledgeable and skilled workforce provides care. DS0000024842.V342621.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000024842.V342621.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 DS0000024842.V342621.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): 1, 2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have some information they need to be able to make an informed choice about living at the home. Pre admission assessments ensure that individual needs can be met on admission to the home. EVIDENCE: The certificate of registration was clearly on display in the reception area of the home, should anyone wish to see this information. Some changes are required to the certificate so that it reflects the current service on offer and CSCI will address this. The home has introduced a “Welcome Pack” which is given to people when they come to live at the home. This consists of a welcome letter and some information forms, which the home requests are completed to assist in the collection of information relevant to that person. This will assist the home to meet all the needs of individual people who chose to live at the home. DS0000024842.V342621.R01.S.doc Version 5.2 Page 10 Contracts have been supplied so that people who live at the home are aware of the terms and conditions of their stay. The contracts provided sufficient information but it is recommended that details of the room to be occupied are included. Three files were reviewed and these were found to contain good pre admission information about the individual needs of the prospective person. This will ensure that both the home and the person being assessed know that the home can meet their needs prior to moving in. This should prevent unsuccessful admissions into the home and prevent people from having to move out because needs cannot be met. One person had spent a day at the home prior to moving in to sample what it would be like to live there. The home does not offer intermediate care. One person said “Its a very good home” and a relative said, “Its excellent, nothing is too much for them”. DS0000024842.V342621.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples health and personal care needs are generally met by the care staff but care plans do not consistently detail the care required in all cases and this may result in inappropriate care been given. The management of boxed medications does not ensure that people receive their medication as prescribed. EVIDENCE: Each person has a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for them to maintain their needs. Four people who live at the home were case tracked and one file was partly reviewed. As at the last inspection many of the care plans were pre printed and this does not always allow for changes to be documented and for individual preferences and needs to be recorded. Some care plans were detailed but this was not consistent and other plans did not always provide DS0000024842.V342621.R01.S.doc Version 5.2 Page 12 specific details for staff to follow to meet the individual needs of the people living at the home. Waterlow scores (which indicate the risk of sore skin developing) were not always completed and handling risk assessments did not always contain information about what equipment should be used. One care plan stated to refer to the manual handing assessment but this had not been completed, therefore there were no guidelines for staff to follow. Risk assessments for bed rails were in place but used the terminology of “cot sides”. It is recommended that this is reviewed, as it does not promote the dignity of people living at the home. A care plan for reduced mobility stated to review after one week but the review was not documented and therefore the plan may not have been an accurate reflection of the care required. Another care plan had been written for a person who did not want to be disturbed during the night, this was to be reviewed after two weeks but there was no evidence that this had taken place. A care plan for personal hygiene referred to the person preferring care from female staff and this is seen as good practice as promotes the dignity of the people who live at the home. Care plans for being prone to skin sores did not detail any specific equipment to be used. Preferences and likes and dislikes were not consistently recorded, but some plans gave information such as “likes to apply perfume and deodorant”. Some plans were updated when changes occurred and short-term care plans had been written, so that staff knew what they needed to do. One person had communication difficulties, which had been identified, but there was no plan in place to guide staff on how they may be able to communicate with this person. Another person had a care plan which stated that they were un cooperative during the mornings but there was no guidance as to what behaviour was displayed, any triggers or how this could be minimimised. There was evidence that external healthcare professionals such as dentist, optician, chiropodist, GP and social workers see people who live at the home and this ensures that all care needs are met and specialist advice is sought. People appeared well kempt and were dressed appropriately for the time of year, and to reflect individual preferences. Some people were assisted to wear jewellery as they chose. Staff were observed to interact well with people living at the home and were observed talking to people about what they were doing and why, so that people were informed. Comments received included: “They couldn’t do more, they take good care of me and everything is good” DS0000024842.V342621.R01.S.doc Version 5.2 Page 13 “She seems positive about the care” “My husband is well looked after” The management of medication was reviewed. Copies of prescriptions are kept so that staff can check they have received the correct drugs into the home. Identity photographs are taken to minimise the risk of medication being given to the wrong person. Medication in blister packs had been administered as prescribed however some of the audits carried out on boxed medications were not correct. This does not ensure that people are receiving their medication as prescribed. Inhalers had not been dated upon opening and this does not ensure that they would be disposed of at the correct time to prevent any cross infection. Eye drops and ointments were dated upon opening. Controlled drugs were stored appropriately and balances were correct. DS0000024842.V342621.R01.S.doc Version 5.2 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. 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 this service. Activities provided meet the needs and expectations of the majority of people and people can choose what activities to participate in which promotes independence and individuality. The meals offered were varied and nutritious and choices are available. EVIDENCE: There are a number of activities on offer at the home including quizzes, games, manicures and arts and crafts. Trips outside of the home are organised and include outings to local parks and museums. A barbeque was advertised on the notice board and friends and family were invited to join in. There are a number of photographs on display entitled ‘memory lane’ and this will encourage people to reminisce about the area. One person continues to visit a day centre, which assists in maintaining links with the community. Entertainers are provided at least once a month for people who wish to participate in this activity. A monthly church service is held and a priest visits every fortnight enabling people to continue to follow their chosen faith. Some people have newspapers DS0000024842.V342621.R01.S.doc Version 5.2 Page 15 and magazines delivered so that they can continue to read the material of their choice. A hairdresser visits each Wednesday to tend to individual hair requirements. The home has an open visiting policy, which means that people can have visitors when they choose. One relative said, “I can visit at anytime, staff are welcoming and bring me a cup of coffee” There was evidence that not all of the people living at the home can be assisted with activities/social needs due to time constraints on the activity coordinator. This was particularly evident for people who required one to one assistance. It is recommended that consideration is given to increasing the number of hours for activities staff due to the size of the home and range of different needs, to ensure that the needs of all the people who live at the home are met. A four-week rolling menu is in place and the main meal of the day is served at lunchtime. There are a number of alternatives available to the main menu and people are given a choice of what they would like each day. Cooked breakfasts can be ordered and soft options are catered for to assist residents who may have swallowing difficulties. Pureed meals were well presented in separate portions to enable people to experience the taste of different foods. The dining room is large and has good access for people who need to use wheelchairs, dining tables were attractively laid at lunchtime and staff were observed to assist residents appropriately while maintaining their dignity and independence. One person had an alternative, which wasn’t on the alternatives choice, and this shows that extra requests can be accommodated to ensure people have the food of their choice. Staff record what each resident has eaten in order to monitor dietary intake. No one required any special diets for cultural reasons at the time of this visit but these could be catered for if required. We sampled the dessert, which consisted of fresh fruit on a flan base and this was well presented and appetising. Comments received included: “Meals are very acceptable” “Food is excellent” “He has gained a stone in weight” DS0000024842.V342621.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure, which is accessible to people if they need to make a complaint. Lack of staff training for protection of vulnerable adults may potentially put people who live at the home at risk. EVIDENCE: There is a comprehensive complaints procedure which is on display in the reception area of the home, making it accessible to people who live there and their representatives should they need to make a complaint. CSCI have not received any complaints pertaining to the home since the last visit and the home had not received any complaints. The home has a whistle blowing policy, which ensures that staff have the knowledge to protect residents from harm without the fear of reprisals. The home has a copy of the Birmingham Multi Agency Guidelines and an adult protection policy in line with the Departments of Health’s “No secrets” and this should ensure that staff have guidelines to follow in the event of any allegations of abuse. While there are guidelines for staff to follow, the training matrix showed that only one member of staff had received training in the protection of vulnerable adults and this does not ensure that staff have the knowledge to deal with any situations or allegations of abuse and it is recommended that the manager makes provision for training in this area. This DS0000024842.V342621.R01.S.doc Version 5.2 Page 17 had been highlighted at the previous inspection. There had been one report of an adult protection nature and this had been resolved and the case closed. The policies had recently been reviewed to make sure that the information was current and up to date. One relative said “I have no problems about this home” DS0000024842.V342621.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A homely, clean and comfortable environment is provided for people to live in where they appear to feel safe and secure. EVIDENCE: The home was found to be clean and fresh with no offensive odours and one relative said, “The home is spotless”. Entry to the home is via a bell and this means that staff know who is entering the building in order to safeguard the people who live there. The corridors are wide and spacious and allow people at the home freedom to move around with any equipment they are assessed as needing. The home has a number of hoists available for use with people who need this assistance and a range of pressure relieving equipment to prevent skin sores. The home have DS0000024842.V342621.R01.S.doc Version 5.2 Page 19 five profiling beds and these enable people who remain in bed to alter their position independently with a control button. There are three assisted baths, two non-assisted baths and four showers to meet the needs of the people living at the home. One of the bathrooms remained out of order following a previous water leak and it is recommended that this is now repaired, as has been out of order since the last visit to the home. Toilets have handrails in place to assist people to maintain their independence for as long as possible, and all door locks were in working order. At the last visit to the home there had been a number of issues found regarding infection control. Significant improvements have been made in this area and action has been taken to address the concerns previously raised. The home has recently been deep cleaned by an external source. There are three lounges in the home and one of these is used as the activities room, a range of comfortable seating is available and social interaction is promoted. There was a friendly and relaxed atmosphere at the home. New carpets had been laid on the first floor to promote a clean and homely environment. Bedrooms of the people who were case tracked were reviewed and were found to contain personal items, which reflected individual choices and preferences. All rooms have a lockable facility so that personal items can be locked away if chosen. Six sets of bedroom furniture had been purchased to replace furniture that was no longer fit for use. One bed had soiled bed rails in place and this was brought to the attention of the deputy manager at the time of the visit. There is an attractive garden area with a gazebo and a pond and people who were living at the home used this. A variety of seating and tables gives people a choice of where they may like to sit. There is a ramp so that people in wheelchairs can access the garden independently. Maintenance requests are dealt with as soon as practicably possible. There is a full time maintenance person and extra hours are in place for someone to assist with meeting maintenance needs. The manager had started work on a buildings audit and five out of seven rooms had required some remedial work. The trend indicates that some repair work will be required to ensure that the home remains appealing and safe for people to live in. Based on the completed audit the manager should continue to demonstrate that improvements and repairs are carried out. It is recommended that consideration is given to the number of hours/people employed to maintain the home as it is very large and the current maintenance person is fully utilised. DS0000024842.V342621.R01.S.doc Version 5.2 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. 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 this service. The home maintains adequate staffing levels to meet the individual needs of people who live at the home. Staff undertake some training to ensure they have the knowledge to perform competently within their roles. EVIDENCE: There are eight care and three trained staff on duty throughout the morning, seven care and two trained staff throughout the afternoon/evening and four care and two trained staff during the night. The home maintains a core group of staff and currently had no vacancies and this means that people at the home know who will be assisting them to meet their care needs. In addition to the nursing and care staff the home also have laundry, domestic, kitchen, maintenance and administrative staff to meet all the needs of the people who live in the home. The home was currently trialling an 8-11 shift to provide extra staff at the busiest time. This has resulted in breakfasts been given in a timelier manner and activities starting earlier in the morning. Comments received included: “Staff are quite good” “Staff seem to be ok to me” “Staff are friendly” “Staff are always available to provide for his needs” DS0000024842.V342621.R01.S.doc Version 5.2 Page 21 There are 80 of staff who hold the National Vocational Qualification (NVQ) Level 2, and the remaining staff are working towards achieving this. This is a significant improvement since the last visit to the home and will ensure that care is received from knowledgeable and competent staff. It was not possible to fully review the recruitment procedures as no new staff had been recruited and retained since the last visit. One file was reviewed in order to review the process and was found to contain all of the required information. It is recommended that the reference forms are amended to include a space for the date and signature of the author so that the home can provide evidence of from who and when they were obtained. There was evidence that some staff have received training in moving and handling, basic first aid, administration of medicines, fire, verification of death and nutrition. Since the last visit to the home, the manager has produced a staff-training matrix, which assists in the retrieval of information and planning of future training. There is an induction pack for new staff at the home and in addition a workbook to complete based on Skills for Care and this will assist in the provision of a knowledgeable workforce. DS0000024842.V342621.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is striving to improve the services provided for people living at the home. A formal quality assurance system needs to be implemented to ensure a consistently improving standard. The home regularly undertakes health and safety checks and this safeguards people who live at the home and staff. EVIDENCE: The acting manager is a Registered Nurse and has experience of working with older people and within managerial roles. She is working towards the Registered Managers Award and has attended training for moving and handling, first aid and verification of death. This shows that she is keen to keep her knowledge and skills updated in order to lead the staff team. It is DS0000024842.V342621.R01.S.doc Version 5.2 Page 23 recommended that an application is submitted to CSCI to become the Registered Manager of the home. Staff and relatives meetings have taken place and the minutes from these were available. These meetings enable people who live at the home, relatives and staff the opportunity to raise concerns or ideas about the home and how it can be improved. The manager undertakes night ‘spot checks’ to ensure that night staff are performing competently within their roles. The providers of the home visit regularly to monitor the service being provided, however do not complete Regulation 26 visit reports each month as required. The last report received was April 2007. This has been a previous requirement and the providers must take action to meet this requirement as outstanding requirements may result in further action being taken. A Regulation 26 visit report was received by CSCI on the 17th August 2007 which stated that it was for month ending July 2007. The provider briefly visited the home during the visit and confirmed that no reports had been written and that one would be completed the following Friday. The report would therefore not be an accurate reflection of the visit to the home. The manager audits care plans, accidents, finances and medication to ensure that any concerns or trends are identified. No further progress has been made towards a formal quality assurance programme, which takes into account the views of people who use the service, their relatives and external stakeholders. This must be developed to ensure that the service continues to develop and meets the needs of the people who live there. There is a robust system in place for recording personal money, which should ensure that it can be held safely at the home, on behalf of the people who live there. Records of servicing, tests and maintenance in respect of health and safety for utilities, appliances and equipment such as electricity, fire; emergency lighting and hoists are well maintained and this should ensure they are safe to use. Staff receive fire training and complete fire drills to ensure they have the knowledge to act appropriately to safeguard people in the event of a fire. Accident and incidents were recorded appropriately and CSCI are informed as per Regulation 37. During the partial tour of the home, three bedroom doors had been wedged open and this does not promote safety in the event of a fire. One person had a risk assessment in place for this, as it was her request to keep the door open. Risk assessments should be in place for anyone who wants to have their doors propped open. Consideration should be given to door guards, which would automatically close in the event of a fire. DS0000024842.V342621.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 2 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X 3 X X 2 DS0000024842.V342621.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 13(4)(b,c) Requirement Moving and Handling risk assessments must provide details of equipment to be used so that people are safeguarded. Care plans must be evaluated to ensure that care reflected is current. The administration of boxed medications must be reviewed so that people receive their medication as prescribed. All staff must receive training in POVA and challenging behaviour so that people and staff are safeguarded. (Previous timescale of 06/10/06 & 31/01/07 not met) Opinions must be sought about the service provided and an annual report written so that the service continues to improve. Regulation 26 visit reports must be written monthly and be available to the manager and CSCI. (Previous timescale of 31/12/06 not met) Timescale for action 28/09/07 2. 3. OP7 OP9 15(2)(b) 13(2) 28/09/07 21/09/07 4. OP18 18(1)(c,i) 31/10/07 5. OP33 24(1) 09/11/07 6. OP33 26(5) 30/09/07 DS0000024842.V342621.R01.S.doc Version 5.2 Page 26 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. 5. 6. 7. 8. 9. 10. Refer to Standard OP1 OP2 OP7 OP8 OP12 OP19 OP21 OP29 OP31 OP38 Good Practice Recommendations The statement of purpose and service user guides should be updated and available in other formats. Room numbers should be identified on terms and conditions of residency. Care plans should provide details regarding likes, dislikes and personal preferences. The use of terminology of “cot sides” should be reconsidered to promote the dignity of people at the home. The number of hours available for activities staff should be reviewed so that the needs of all people who live at the home are met. The number of hours available for maintenance staff should be reviewed so that the home is safe and attractive to live in. The bathroom should be repaired so that they are all in working order for people to use. Reference forms should have a signature and date so that the home knows who wrote the reference and when it was completed. The acting manager should submit an application to CSCI to become the Registered Manager. Consideration should be given to the use of door guards to promote the safety of residents who wish for their doors to be left open. DS0000024842.V342621.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham West Midlands B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000024842.V342621.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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