Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 10/07/07 for The Green Nursing Home (Hasland)

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

This inspection was carried out on 10th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

The home was found to be clean and generally tidy this was a view shared by all 18 participants of a recent survey the home undertook. The service users questionnaires and observation during the visit indicated that service users appeared to be clean, well dressed and `well cared for`.

What has improved since the last inspection?

There has been some additional information added to the care files (although not the actual plan of care), which has improved the personalisation of the care files. All staff have now received training in Safeguarding Adults and the home has an in house trainer. The procedure following an allegation made has also been amended to reflect local procedures in place.

What the care home could do better:

The care plans in place were found to be variable in the personalisation of care delivery instructions with frequent use of terms such as `supervision as required` on some care plans. More recently written care plans were better than some which had not been formally rewritten for some time but had been reviewed.The was a wide range of cleaning products and toiletries in many areas which were openly accessible to service users some of whom had a degree of confusion. The areas included the laundry, a sluice, bathrooms and service users bedrooms. There does not appear to be contingency arrangements in place which are implemented when the homes own staff are unable to cover gaps on the rota. Therefore not all shifts have been staffed sufficiently. The provider is ensuring they are recording their ongoing quality monitoring of the service on a monthly basis as required. Some risk assessments in relation to fire and legionella require development to ensure risks are minimised. Some checking of water samples has been completed for legionella but his is not supported by a risk assessment and planned interventions to limit risk. The fire risk assessment is partially in place but does not wholly meet new requirements and needs updating.

CARE HOMES FOR OLDER PEOPLE Green, The Nursing Home (Hasland) 45 The Green Hasland Chesterfield Derbyshire S41 0LW Lead Inspector Bridgette Hill Unannounced Inspection 10th July 2007 09:20 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 Green, The Nursing Home (Hasland) DS0000002084.V340927.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. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green, The Nursing Home (Hasland) Address 45 The Green Hasland Chesterfield Derbyshire S41 0LW 01246 556321 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) The Green Nursing Homes Limited Christine Eluned Innes Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2006 Brief Description of the Service: The Green Care Home is situated within the village of Hasland, close to shops, park and a church. The home provides nursing and residential care for 40 service users. The home is purpose built and is fully accessible for wheelchair users. There are two lounges, the smaller of which is designated as a quiet lounge. There is also a separate dining room. Outside there is a well maintained garden with a seating area for service users. The fees charged at the home range from £333.85 - £531.00. There are additional costs for hairdressing, chiropody, and personal newspapers. Toiletries are provided in the fee unless a service user wished to have particular branded toiletries. The Manager gave this information during the inspection. The Manager said the Inspection report was available in the home to anyone who wished to see it. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. A partial tour of the building was conducted including a sample of service users rooms. During the visit opportunity was taken to have discussions with management, staff and service users. Some service users did not have the capacity to convey their views verbally. Service user questionnaires were sent to 10 service users to the home prior to the inspection. 3 of these have been returned and comments considered during the writing of the report. Some questionnaires were completed by relatives on the service users behalf. The person in charge at this visit was the Manager Eluned Innes. What the service does well: What has improved since the last inspection? What they could do better: The care plans in place were found to be variable in the personalisation of care delivery instructions with frequent use of terms such as ‘supervision as required’ on some care plans. More recently written care plans were better than some which had not been formally rewritten for some time but had been reviewed. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 6 The was a wide range of cleaning products and toiletries in many areas which were openly accessible to service users some of whom had a degree of confusion. The areas included the laundry, a sluice, bathrooms and service users bedrooms. There does not appear to be contingency arrangements in place which are implemented when the homes own staff are unable to cover gaps on the rota. Therefore not all shifts have been staffed sufficiently. The provider is ensuring they are recording their ongoing quality monitoring of the service on a monthly basis as required. Some risk assessments in relation to fire and legionella require development to ensure risks are minimised. Some checking of water samples has been completed for legionella but his is not supported by a risk assessment and planned interventions to limit risk. The fire risk assessment is partially in place but does not wholly meet new requirements and needs updating. 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. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 7 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 Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 8 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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure service users needs were assessed and recorded prior to admission being agreed therefore ensuring that service users needs could be met. EVIDENCE: The manager said that all prospective service users were assessed at their home/hospital prior to admission being agreed. Records of these assessments were in service users files. Copies of Social Services or Free Nursing Care assessments had also been obtained. Trial visits were offered where it was possible to arrange these though it was stated that often families made decisions on service users behalf regarding choosing the home. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 9 Some service users used the home as respite placement prior to being admitted on a fulltime basis. The Annual Quality Assurance Assessment submitted from the Manager before the inspection indicated that service users admitted to double rooms will be offered the next available single room. An example of where this was offer was made and taken up was given. The home does not offer intermediate care as defined by National Minimum Standard 6. Green, The Nursing Home (Hasland) DS0000002084.V340927.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans in place were variably written regarding being personalised and had scope for improved to ensure all service users needs are met at all times. EVIDENCE: A sample of three service users care files were examined to assess how standards were being met. Since the last inspection some work had been completed in adding an additional form to improve the personalisation of how hygiene needs and some social needs were to be met. Some care plans had been reviewed but not rewritten since the last inspection and tended to be poor in describing staff intervention with frequent Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 11 terminology such as ‘staff intervention as required’ ‘supervision as required’. Generally these did however identify the service users assessed needs. A recently completed care plan was viewed and this was found to be improved regarding the level of detail included on the individual service user. The method used for recording service user consultation and participation in the care planning process was for the service user or their representative to sign the front sheet of the personal information page. This system was not reviewed and was often not dated so it was therefore not possible to establish which care plan the service user or their representative had seen and agreed with. Moving and handling risk assessments were in place for all service users and were found to be very good in the level of personalisation recorded. Tissue viability risk assessments and monthly weights of service users were recorded. Reviews were typically being completed on a monthly basis and a form to review the service user but not the actual plan of care was in use for this. The ethos being that if the needs of the service user had changed the care plan would require updating. Nursing staff completed log entries on a shift by shift basis within each service users care plan. The storage and administration of medicines was examined at this visit. The home uses a monitored dosage system and the manager said there was a good level of service from the supplying pharmacy. No gaps were evident on the medication administration records. Records were available to indicate the quantity ordered and the quantity received. Disposal records were also retained therefore a full audit trail was possible. Some controlled drugs were in the home and securely stored. Balances correlated with the records available. Some preferred routines and abilities of service users were recorded on the newly implemented social care plan, this was however not included in the main plan of care and was in a different format which offered limited options of recording the preferences and abilities of service users. All service users seen during the visit appeared to be clean and dressed appropriately sometimes with jewellery which complimented their clothing indicating attention to detail. One service user questionnaire completed by a relative indicated that the ‘staff are brilliant’ and they considered that the service user always looked ‘clean and well cared for’. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 12 Service users religion was recorded in care files and where information has been given post death wishes were recorded. Green, The Nursing Home (Hasland) DS0000002084.V340927.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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Regular externally arranged leisure activities were offered however little was offered on a regular basis from within the home to service users. EVIDENCE: Some activities are offered on a regular basis. These tended to be externally organised for example movement to music and entertainers. A Board was on display with these events advertised. A clothes party was planned in the near future, as was a Summer Fayre with cream teas. An entertainer visited the home during the visit and service users spoken with said they enjoyed this. Some games such as dominoes were said to be available but no regular structure was in place to ensure that activities were offered regularly nor were there any records of any activities. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 14 The social care plan put in place since the last inspection was separate to the main care planning format and was a core care plan where service users choices identified by highlighting them. The care was limited in its format as it contained only a defined number of choices of social activities – typically what was usually offered. A hairdresser visited the home twice per week to do service users hair. This appeared to be poplar with many service users. Some service users were able to independently go out into the local community and did so when they wished. There were visits to the home made by local churches of different denominations on an approximately monthly basis. The Annual Quality Assurance Assessment completed by the Manager prior to the inspection indicated the in house quality audit indicated that visitors to the home usually felt welcomed. Drinks were said by the manager to be offered to visitors when service users routinely had drinks or at other times when visitors had travelled some distance to visit the home. The quality audit completed by the home indicated that relatives were happy that they were kept informed of any changes in service users health. The responses given were also positive regarding the approachability of staff. The menu was displayed on a board in the dining room. A choice of main meal was listed and staff and service users said they were offered the choice of meal during the morning. The ‘soft’ diet served was served as individual portions of pureed foods. The quality audit completed in November 2006 had indicated that service users were not wholly happy with the teatime meal the choices have therefore been extended to include a hot meal option. The serving of the lunchtime meal was observed and varying portion sizes were given to different service users according to preferences. Staff wore aprons to serve food. Green, The Nursing Home (Hasland) DS0000002084.V340927.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): 16.18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that there are appropriate procedures to be followed should any complaints or allegations be raised regarding the care of service users. EVIDENCE: The home had not received any complaints in the past nor had the Commission for Social care Inspection. The complaints procedure was on display in the entrance hall. Service users spoken to said they would speak to staff or the manager if they had concerns although one service user said they did not always have confidence that their concerns would be acted on and spoke of a recent concern were there were poor staffing levels. Certificates in staff files and conversations with staff confirmed that they had received training on Safeguarding Adults. One staff member in the home has completed a trainer’s course to enable them to train other staff in Safeguarding Adults. Staff spoken to said they knew where procedures were Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 16 kept and said that if they had concerns they would report these to the nurse in charge. The procedure in place had been amended since the last inspection and referred to ensuring that service users received any urgent assistance they required and referrals to locally agreed Safeguarding Adults procedures were made. There had not been any allegations of abuse reported during the past year. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 17 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was found to be clean and well maintained and a suitable environment for service users to receive care in. There was poor management of chemical cleansers in the home which had the potential to place service users at risk. EVIDENCE: The home is a purpose built one which is wheelchair accessible with a shaft lift for access to the first floor. Bedrooms are located on both floors of the home and the sample seen were personalised with service users effects. Some fire risk assessment information was in place however this did not meet the required standard as regulations relating to fire safety changed in October 2006. Checks were completed and recording of the fire alarm and lighting. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 18 Servicing checks of the fire equipment and alarm were also documented and fire drills held. The Quality audit (November 06) conducted by the home was said to indicate that a good standard of hygiene and cleanliness is maintained. 18 surveys were returned all of which indicated that the home was always clean. On the day of the inspection this was also found to be the case with no odours evident in the home. A handyman was employed on a shared basis with another home. A book was available for reporting faults and jobs. The handyman undertook some but not al decorating of the home. A sample of service users rooms were viewed, these were found to be personalised with ornaments and photographs. Lockable facilities were available in some bedrooms but the Manager said that few service users chose to use these. The sign to indicate the name of the service user whose room it was on occasions in very large print to aid any deficits in sight/confusion. The laundry area was openly accessible to service users with chemical cleansers being openly stored when it was unstaffed. The home had two washers and two dryers and the Manager said that laundry was cleared on a daily basis. Service users spoken with said they were happy with the laundry service provided. Gloves and aprons were in place near the reception area and staff were observed to use these throughout the visit when providing care for service users. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a group of staff who receive training in order that they are able to meet service users needs. The system in place for ensuring staff absences are covered is not robust and has the potential to place service users at risk. EVIDENCE: It was evident from staff rota’s, discussions with service users and staff that there had been some recent problems with staffing due to a sickness bug. This had affected many service users and staff in the home. Staffing levels which were typically planned as 1 nurse and 5 care staff had dropped for one shift to 1 nurse and 3 care staff with a nurse working some extra hours. The procedure for covering shifts due to illness or holidays was usually that the homes own staff covered however in this instance this was not covered by this method. An alternative strategy or options to cover the shift do not appear to have been tired. Service users said that there were aware of the staff shortage and this caused some delays in care needs being met. Staff said that all care needs were met and they worked to do the best they could to ensure that service users were cared for. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 20 Typical full staff numbers for the home were one nurse for all shifts with 5 care staff for day shifts and 3 care staff at nights. The Manager of the home typically worked office hours on a supernumerary basis. The staff files examined contained references, Criminal records Bureau checks and application forms. Proof of staff identity was on file and photographs of staff were available. The good practice of interview notes being recorded and retained was in place. There were 25 care staff employed at the home 15 of these had achieved at least National Vocational Qualification level 2 in care which at 60 exceeds the National Minimum Standard. Staff training was evidenced in the home by certificates being retained in staff files. A range of staff training had been completed which included Moving and handling, fire safety, First Aid, Health and Safety awareness, dementia, continence care, basic food hygiene and management of violence and aggression. Not all staff had completed all the course listed but all staff appeared to have completed mandatory updates. No training files were available for trained nursing staff. The Manager said that a skills based induction pack had been obtained but that this had not yet been implemented. The induction process was discussed with staff who said that they had some training provided at induction but felt there were times when they felt ‘lost’ and unclear what to do. Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 21 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): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has stable management in place and some systems for monitoring the quality and responding to the views of service users. EVIDENCE: The Manager of the home has achieved a managerial qualification and has been in post at the home for 8 years. A Deputy Manager who had also worked at the home for many years supported the Manager. A quality audit consisting of surveys was undertaken at the home in November 2006. This contained a wide range of questions on many aspects of the service Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 22 provided. The response received was that 18 out of 36 surveys were received back. The findings were generally very positive regarding most aspects. Some action had been taken to review menu’s as a result of the findings of the quality audit. The provider was inconsistently completing recorded monthly visits to monitor and assess the quality of the service. The last recorded monthly visit available was dated 20.2.07. Where these were recorded the content was brief but did refer to conversations being held with service users. Small amounts of service users monies were held safely in the home. Records were available to record transactions; these were verified by one signature, typically the Managers. Balance checks were periodically completed which were evidenced by two staff signatures. The monies available correlated with the recorded balances. Where service users personal allowances were paid by Social Services into the Providers account the transactions for these were recorded. These indicated that there were infrequent intervals when the monies were paid to service users, this ranged from 1 – 3 months in the records seen. There were also some discrepancies in the amounts paid to the service user from the account and the amount they received each fortnight. Additional records indicated that some monies had been returned to Social Services. An overall record of the service users monies was not however available. Whilst a lock had been fitted to the office door since the last inspection and a locked cabinet was being used to store service users care files some personal information was found to be on the reception desk. The Manager said that this was to aid staff having access to the Moving and handling risk assessments. Discussions were held regarding service users personal data being protected at all times and that this superseded the ease of access for staff. This has been identified at a requirement at previous inspections that service users records were not being securely held. Discussions with service users revealed that some service users were unaware they could access the information being held about them. They also said that even though they were now aware of this they ‘weren’t bothered’ about seeing their records. Staff supervision records were examined. These indicated that some staff supervision was taking place. There was not a format for this and some records were brief Some staff spoken said they had not had had supervision and when their records were checked this was confirmed. A legionella risk assessment of the home had not been completed as required at the last visit. Some action had been taken however and bacteriological water testing had been completed which did not indicate any growth. No checking of the storage water temperatures was being competed. Some Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 23 checking of water temperatures at outlets, particularly baths and showers was routinely being recorded. The Annual Quality Assurance Assessment competed by the Manager before the inspection indicated that there was some ongoing problems with the heating and hot water but this was being addressed. In the past year a new boiler has been fitted to try to rectify this. This was not supported by a landlord’s gas safety certificate and the Manager said they would contact the company to obtain this. Where accidents had occurred there were forms to record these which were kept in the care files of service users. Green, The Nursing Home (Hasland) DS0000002084.V340927.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 2 x 2 Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Care plans must be sufficiently detailed to ensure all staff have clear instructions on how to deliver care to the service user Previous timescale 30/09/06 2 OP19 23 A fire risk assessment of the agency’s premises must be completed and implemented to ensure the safety of staff and visitors All chemical cleansers (including denture cleaning products) must be securely locked away to prevent accidental ingestion Previous timescale 30/08/06 4 OP27 18 The system for securing adequate staffing to the home must be extended to allow for circumstances when the homes own bank staff are unable to provide cover A system must be implemented to ensure service users monies are transferred regularly and swiftly to service users from the DS0000002084.V340927.R01.S.doc Timescale for action 30/09/07 30/09/07 3 OP26 13 30/08/07 30/08/07 5 OP35 13,20 30/08/07 Green, The Nursing Home (Hasland) Version 5.2 Page 26 Providers account 6 OP37 17 Previous timescale 30/08/06 All personal records must be held 30/08/07 securely in the home to prevent unauthorised access in accordance with data protection principles Previous timescale 30/08/06 7 OP33 26 There must be a quality assurance process in place which meets the requirements of regulation 26 with the Provider monitoring the quality of the service A legionella risk assessment must be available and identified actions to reduce risks taken in accordance with the guidance given to the home by the Health and Safety Executive Previous timescale 30/09/06 31/08/07 8 OP38 23 30/09/07 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 2 3 Refer to Standard OP7 OP30 OP36 Good Practice Recommendations The system for including and recording service users participation in the care planning process should be reviewed to improve inclusion and accountability Training files for nursing staff should be developed A planner should be developed to ensure all staff receive formally documented supervision Green, The Nursing Home (Hasland) DS0000002084.V340927.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Green, The Nursing Home (Hasland) DS0000002084.V340927.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!