CARE HOMES FOR OLDER PEOPLE
The Lady Nuffield Home 165 Banbury Road Oxford OX2 7AW Lead Inspector
Jan Walsh Unannounced 9 August 2005
th 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 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. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service The Lady Nuffield Home Address 165 Banbury Road Oxford OX2 7AW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01865 888 500 01865 553 040 enquiries@ladynuffieldhome.co.uk The Lady Nuffield Home Mrs Jennifer Timbrell Care Home (CRH) 27 Category(ies) of Care Home only (PC) registration, with number of places Old Age, not falling within any other category (OP) 27 The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 22nd February 2005 Brief Description of the Service: The Lady Nuffield Home provides care for up to 30 service users over the age of 65, both male and female. It is not registered to provide care for those with a disability or a dementia. The home is situated close to the Summertown area of North Oxford and is close to the shops, restaurants and community facilities. The home now offers private accommodation in single rooms, many with en-suite facilities, and updated communal areas, including a new dinning room/ conservatory. All rooms have television, digital telephone service and a call system. There are two passenger lifts to provide access to the 1st floor or ground floor, for those who find stairs difficult. The gardens provide sevice users with a useful and interesting outdoor area with trees, paving, lawn areas and seating. The registered manager runs the home with a team of care assisstants, kitchen and housekeeping staff. This management is overseen by a board of trustees. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector visited the home on an unannounced inspection lasting 6 hours. During this time a tour of the buildings including the kitchen, the laundry and the grounds was made and the home was seen to be bright, clean and well maintained. Water temperatures were taken in two rooms giving temperatures of approximately 43 C. A visiting district nurse was spoken with plus the hairdresser and the physiotherapist. The manager, the administrator, a senior carer and three carers were interviewed. Nine residents were also spoken with. The fire log, medication records and medication storage were checked. Six residents records and 5 staff records were looked at in detail. The requirements and recommendations from previous inspections were discussed. The importance of having photographs of residents and staff on records and ways of improving staff records in keeping with care standards was also discussed. Very positive feedback was received from residents and from the district nurse interviewed. Staff also spoke very favourably of the home and the management. What the service does well:
The home is bright and clean and several areas have recently been redecorated. The home is very attractive whilst remaining comfortable and homely. The tasteful furniture and fittings are of a domestic type and are appropriate to the home. Residents seemed relaxed and happy on the day of inspection. The home gives very good, well-planned care for the residents. The district nurse and the residents interviewed spoke highly about this and letters were seen from grateful families. The staff receive regular supervision and training which supports staff in their roles as carers. This leads to well trained and competent staff giving good care to the residents. There is a good range of activities residents can join in if they wish. There are activities arranged for everyday except Monday. Residents also have the opportunity to go out into the community if they wish. The meals are well planned, nutritious and enjoyed by the residents. One resident confirmed ‘the meals are excellent.’
The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better:
The radiator covers mentioned previously must be in place as soon as possible on the radiators to eliminate a risk to the residents’ safety. Fire doors must not be propped open as they are a risk to the residents in the case of fire and the manager should seek advice on other ways to safely hold the doors open. Residents’ plans of care are good. However there are some omissions in recording and updating reviews. To ensure there are no omissions and reviews
The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 7 are up to date the plans should be audited on a regular basis. It is also recommended that a photograph of each resident is kept on record to enable staff to easily identify the correct resident when administering care or medication. The home administers medication safely but to prevent any potential error it is recommended that if staff have to write instructions on the medication administration sheet two members of staff check them and the medication and sign. It is also recommended that records are kept of risk assessments for residents who are self medicating. It is recommended that copies of all evidence of identity used during recruitments of staff particularly recent photographs, birth certificates and passports are kept in the staff member’s records as requested in the Minimum Care Standards. Any member of staff who has had a recent Criminal Record Bureau check from a previous employer must now have a new one carried out for this home. The home completes an induction with it’s staff but it is recommended that a certified course is used to ensure all areas of care practice are covered at induction helping the staff member towards their National Vocational Qualifications. 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 Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 5 Prospective residents and their families are given the information required to enable them to decide if this home will suit the person’s needs. They are encouraged to visit the home before making their choice. Prospective residents are seen before admission by the manager to assess their needs and the home’s suitability as a placement for them. EVIDENCE: The manager explained the procedures for admitting a resident to the home. She explained how and what information was given to them. An example of the information given was seen. This included a brochure, and two comprehensive booklets explaining the purpose/ philosophy of the home and the facilities the home offers, plus the conditions for admission. The manager also confirmed that all residents were assessed before admission and written evidence of this was seen in a resident’s records. The form is at present being reviewed and updated. She confirmed that only residents that fit into the home’s criteria for admission are taken and that she writes to the prospective resident or their family to explain this. Prospective residents are invited for a month’s trial as soon as a room is available, during which time further assessments are made. Residents confirmed they came in for a month’s trial or longer while they considered whether the home was suitable for their needs.
The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 The residents health and welfare needs are assessed and a comprehensive plan of care is written enabling care staff to give good care. However there were a few omissions ion the plans seen such as a recording of a resident’s weight or consistency of care need reviews, it is therefore recommended that the care plans are regularly audited to amend this. It is also recommended that a photograph of each resident is kept on record to enable staff to easily identify the correct resident when administering care. The home ensures that the health care needs of the residents are fully met. The home stores and administers medication safely. However it is recommended that if staff have to write instructions on the medication administration sheet two members of staff check them and the medication and sign. It is also recommended that records are kept of risk assessment for residents who are self medicating. Residents are given privacy and treated with respect. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 11 EVIDENCE: Evidence was seen of assessments of the health and welfare needs of the residents and good care plans produced from these. However there was a few omissions such as not consistently recording residents weights and an inconsistent method of recording the monthly resident care reviews. Therefore it is recommended that a regular audit of the resident’s plan of care against the care standards is undertaken to ensure the resident gets the best possible care. No photographs of the residents were seen in the records examined and it is therefore recommended that a photograph of each resident is kept in the residents records. The residents spoken with, felt they had the best possible care and that all their care needs are met. Very positive comments were received from the district nurse interviewed. She confirmed she had been visiting the home for three years and comes into the home most days to do dressings, continence assessment and care, pressure area assessment, bowel care, chronic disease management and help with terminal care. She said the home has ‘exceptional staff’ and she is confident that they will call her in if necessary. ‘The home does an excellent job.’ Letters were also seen from grateful families. On the day of inspection the manager was organising a trip to the dentist for one of the fairly new residents. Written evidence was seen in the residents’ records of GP, district nurse, community psychiatric nurse involvement. Medication was seen to be stored tidily and safely in a locked medicine trolley. The medication is kept for individual residents in a nomad cassette system. Three cassettes were checked against medication administration records. In two instances staff had written on the administration sheet a drug that had been more recently prescribed and printed instructions had not yet been obtained from the pharmacy. It is recommended that if staff have to write on the medication sheet that two members of staff check the medication and they both sign to say the instructions are correct. Controlled drugs were seen to be kept securely, in a metal drug cupboard. Three residents’ controlled drugs were counted and checked against the records. All medication was found to be correct and records accurately filled in. Records were seen of medications for people who self medicate. A senior carer confirmed that residents were assessed for risk before they were allowed to self medicate and that if there was any risk of their safety at a later date staff took over the administration of the medication. No records were available of these risk assessments. It is recommended that a record of the risk assessments is kept either in the medication records or in the resident’s care plan. The manager confirmed that all staff designated to administer medication had been given appropriate training. This was confirmed by the senior carer. Written evidence also seen in staff records.
The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 12 During the inspection the staff were seen to treat the residents with respect, knocking of their doors and waiting to be asked in. Calling the resident by the name they had asked to be used. Residents confirmed that all staff treat them with respect and kindness. One resident said ‘they think of what you want before you want it.’ The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Residents enjoy a life style that meets their various needs. They are encouraged to keep contacts with their families and friends and the community. Help is given to enable them to have control over their lives and to exercise choice. Meals have some flexibility, are appetising and well presented. They are served in the dining rooms or in the resident’s room as requested. EVIDENCE: Residents were seen on the day of inspection welcoming their visitors and seeing off their visitors in the beautiful reception hall. Residents were seen coming to the office to speak to the manager and having their queries dealt with. During the day an exercise class was held and the physiotherapist said she usually had between 6 – 10 residents joining in with gentle exercise. The hairdresser also visited and he confirmed he visits every Tuesday. Some residents were sitting in the sitting rooms, others were sitting in their own rooms. A group of residents were sitting out in the garden with a carer enjoying the sunshine. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 14 The manager confirmed activities take place every day except for Monday. Activities included poetry, art, and massage. There is a service on a Sunday for those who would like to attend. Residents also go out to their own church services in the town. The manager said one lady likes to go out to lunch sometimes. The manager confirmed residents could have visitors in when they wished or could go out when they wished. Residents confirmed this and said visitors are always made very welcome. One resident said ‘it is better than a country house hotel.’ Residents were very positive about the food and said it was excellent. They confirmed they had a choice at meal times. A copy of one week’s menu was seen giving the choices available for each meal including a vegetarian option. A good range of foods was included, enabling residents to receive a good balanced diet. The manager said they have recently reviewed the menus and made some changes particularly about the choices for the supper menu. The home is using a catering firm and have fairly recently changed the firm providing the service. The meals are prepared and cooked in the home’s kitchen, which was seen to be clean and tidy. The manager confirmed they are very pleased with the results. The food, seen and tasted by the inspector, was well presented and looked and tasted delicious. Residents confirmed the meals could be taken in the dining room or in their own rooms as required. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 Residents and their families know how to complain and know that the complaint will be investigated and action taken. The home protects the residents’ rights and makes sure that the residents are protected from abuse. EVIDENCE: The complaint procedure was seen, included in the information given to the prospective resident and their families. The complaints procedure was seen in the entrance hall plus a book for complaints and suggestions. This had some suggestions from residents and the action taken by the management in response to this. One complaint had been received from a relative and evidence was seen of the prompt action taken by the home, and how the matter was resolved. Residents spoken with confirmed they know how to complain if necessary but said they ‘had no reason to.’ The manager said that about 20 residents had had postal votes in the last general election and 2 – 3 residents had gone to the polling stations. Several residents confirmed this. They confirmed they were able to go out when they wished and to have visitors when they wished. They also confirmed they were able to see a doctor or nurse when they required. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 16 The manager confirmed that all staff have had abuse training during induction and supervision. Written evidence was seen in the staff records. She received her training from Oxford Multi Agency for prevention of Abuse. All staff have received a copy of their Codes of Practice. A course ‘Alert to Abuse is also booked in October for all staff with an accredited trainer. The manager has referred an ex-member of staff to the Prevention of Abuse for Adults data list for possible entry. The manager confirmed that the home or it’s staff do not have any involvement with the residents’ finances. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 24, 25 and 26 Residents live in a clean, hygienic, comfortable and well-maintained environment with their personal possessions around them. However the radiators and pipe work in the older parts of the building have not yet been covered to prevent risk to the residents but the Inspector was informed that this is in hand. EVIDENCE: On the tour of the building the home was seen to be clean, well-maintained and tastefully decorated. The upstairs corridor has been redecorated. The furniture and fittings are of a tasteful domestic type. There are several different communal areas in which residents may sit. An occupational therapist has assessed the entrances of the home with steps and is sending her report. The manager confirmed that the steps are not causing residents any difficulty at present. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 18 The garden is well-maintained and has wheelchair access, several residents were seen enjoying the garden on the day of inspection. Residents confirmed they could bring in their own possessions to furnish their rooms. Examples of this were seen with the residents’ permission on the tour of the building. Water temperatures were take in two rooms and found to approximately 43 C. The radiators and pipe work in the older parts of the building have not been covered as required at the last inspection but the manager confirmed that this is in hand. The covers have been ordered and are awaiting fitting. All the new bedrooms have locks. The manager confirmed that in the case of the older rooms the residents are being asked if they would like a lock on their doors and these are being fitted at the residents’ request. All rooms that are being refurbished are having locks fitted. The manager confirmed that adjustable beds are available for residents needing extra care, examples were seen on the your of the building. There is good domestic lighting in the home and the emergency lighting was being tested on the day of inspection. The home was seen to be clean, tidy and pleasant smelling. The laundry was seen to clean and tidy with good facilities for washing and drying with the new washers and dryers. The manager confirmed they had a sluice programme and that the machines comply the water regulations. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Residents are cared for by adequate numbers of trained and competent staff. It is recommended that all new staff are registered on a certified induction course to cover all areas of care and help staff towards their National Vocational Award. The home has good recruitment practices, however it is recommended that all staff that have had CRB checks from recent previous employment now have them redone. It is also recommended that all copies of identity produced at the time of recruitment are kept in the staff records. EVIDENCE: On the day of inspection the manager was on duty, supported by two senior carers, two carers and the administrator plus the catering team and one domestic. She confirmed that adequate staff cover was also available for the rest of the day and the night. Written evidence was seen on the rota. The home has good recruitment procedures for staff as seen from the staff files examined. Examples were seen of two written references for each staff member, plus Criminal Record Bureau checks and that staff were not employed until all checks were completed. However one CRB check was from a previous employment and therefore needs updating. Records of identity seen at the time of employment have not been kept. Therefore it is recommended that copies of birth certificates, passports, a recent photograph and other means of identity produced for the CRB check are kept in the staff records. If a birth certificate cannot be obtained the Commission for Social Care Inspection should be informed with further evidence of identity collected and a note made in the staff member’s records. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 20 Written evidence was seen in the staff records of induction and staff training. Staff interviewed confirmed regular staff training, induction training and shadowing for a week. They confirmed all regulation training, including First Aid, fire awareness, moving and handling, infection control, and health and safety. One member of staff confirmed she was completing a dementia awareness course with the local college. Another member of staff confirmed one of the senior staff members was an assessor and that she had supported her doing her National Vocational Qualification in health and social care. A senior member of staff confirmed she had had safe administration of medicine training. The manager said she liked to set up a course or study day once a month and she arranged various speakers on theses days. She had arranged a representative from a cleaning substance firm to speak to the domestic staff about the benefits and hazards of cleaning chemicals. Staff identified areas in which they wanted to improve their knowledge during supervision sessions and these are incorporated into training schedule. It is recommended that the home uses a certified induction course allowing new staff to gain knowledge of all aspects of care prior to commencing their NVQ The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 Staff have appropriate two monthly supervision. The home promotes the health, safety and welfare of the residents and staff. However three fire doors were seen to be propped open on the day of inspection and this could put the residents’ safety at risk. EVIDENCE: The manager explained that staff had supervision every two months and she and the staff had found it beneficial. The staff interviewed confirmed this. A blank, staff supervision form was seen. Staff are encouraged to explore their strengths and weaknesses, to plan future action and to consider how their strengths can help the home.
The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 22 Evidence was seen of recent mandatory training in health and safety, moving and handling, fire safety, first aid, care of hazardous substances, infection control. This was confirmed by the staff spoken with, they also confirmed that this was also covered in induction training. The fire system is checked weekly and was being checked on the day of inspection. The fire log was seen. The manager confirmed that the home has two fire marshals. Baths and hoists are serviced regularly recent dates on the equipment seen. The laundry was visited and the manager confirmed the washers and dryers comply to current regulations. However on the tour of the building three fire doors were seen, to be propped open. This puts resident’s safety at risk in the case of a fire. It is therefore required that this practice stops immediately and that the manager investigates ways the doors can be held open safely in future by contacting the Fire Service. The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 x x x 3 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x 3 x 2 The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? 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 38.2 Regulation 23 (4)b Requirement It is a requirement that fire doors are not propped open and that advise is sought from the Fire Service for other approved methods of holding fire doors open. The planned work to guard pipework and radiators in the older parts of the building must be completed as soon as possible. Previous requirement for 30.6.04. Timescale for action Immediate and henceforth 2. 25 13 (4) Oct 31 2005 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 7 (2)(3)(4) Good Practice Recommendations It is recommended that a regular audit of the residents plans of care against the care standards is undertaken to ensure the resident gets the best possible care. It is also recommended that a photograph of each resident is kept in the residents records to ensure that staff can easily identify each resident to give the correct care. (Schedule 3 in the Care Standards)
H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 25 The Lady Nuffield Home 2. 9 (1) It is recommended that if staff have to write on the medication sheet that two members of staff check the medication and they both sign to say the instructions are correct. It is recommended that a record of the risk assessments of residents self medicating is kept either in the medication records or in the resident’s care plan. 3. 29 It is recommended that a staff member with a CRB check from recent employment has it renewed. It is recommended that evidence of identity including a recent photograph, birth certificate, passport etc are kept in the staff records (schedule 2 Minimum Care Standards) 4. 30.2 It is recommended that the manager introduces a certified induction course that is related to the TOPPs induction and foundation courses to ensure all areas of care are covered at induction prior to commencing NVQs The Lady Nuffield Home H57_H08_S13100_Lady Nuffield_V242891_090805_Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Burgner House 4630 Kingsgate Oxford Business Park (South) Cowley, Oxford, OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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