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Inspection on 16/04/08 for The Limes Nursing Home

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

This inspection was carried out on 16th April 2008.

CSCI found this care home to be providing an Good service.

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

During this visit there was a relaxed and informal atmosphere, and people living in the home appeared settled and at home in their environment. People who were spoken to said they felt comfortable with the staff team and that they could approach them with any concerns. Staff were observed as they engaged in meaningful conversations with residents, and where appropriate, they offered support and reassurance in a sensitive and caring manner. Comments from residents included: "The staff here are very good, they are hard working and very conscientious". "The staff are lovely". ""Staff treat me very well". One visitor said she thought that the staff provided good support to the residents. She said, "You always feel the staff are open and welcoming. Nothing is too much trouble if you have a query."

What has improved since the last inspection?

Pre- admission assessments have improved and assessments are completed on all residents prior to arranging the admission date. Care plans have been reviewed and there are further plans to improve care plans. This involves further staff training in developing a person centred approach. Medication systems have improved and the requirements from the previous inspection report has been addressed. There had been improvements to the environment. New large flat screen televisions had been provided in lounge areas, and new carpets, flooring and redecoration to other areas.

CARE HOMES FOR OLDER PEOPLE The Limes Nursing Home 816 Wilmslow Road Didsbury Manchester M20 2RN Lead Inspector Ann Connolly Unannounced Inspection 16th April 2008 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Limes Nursing Home DS0000021648.V361487.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. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Nursing Home Address 816 Wilmslow Road Didsbury Manchester M20 2RN 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) 0161 446 2141 0161 445 9524 Britannia Care Homes Limited Mrs Ntswaki Elizabeth Moiloa Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 42 Date of last inspection 10th July 2007 Brief Description of the Service: The Limes Nursing Home is a care home providing nursing care for a maximum of 42 older people. The Limes Nursing Home is formed around an adapted and refurbished Victorian house with a modern extension set in its own grounds. Accommodation is on 4 floors all of which have lift access and are wheelchair accessible. Facilities within the home are located in two separate wings, each with a communal lounge and dining area. The kitchen and administration office is located on the lower ground floor, next to one of the dining rooms. There is a central office and separate staff room located at the main entrance to the home, which is central to the two wings. There are two treatment rooms, located in each of the two wings. In one wing there is a large lounge on the ground floor, which gives access to an enclosed conservatory providing a bright, airy view of the grounds of the home. There is a dining room on the lower ground floor. The second lounge has a French window that gives direct access to the garden and has a small dining area. There is a small kitchen next to the lounge where visitors and staff are able to make light refreshments. There are 20 single bedrooms, and 11 double rooms with en suite facilities. The gardens are laid to lawn, and well maintained with sufficient car parking The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 5 available for visitors and staff. The home is located within a short walking distance of Didsbury village and all its amenities. There are two local parks within short walking distance from the home. Bus stops to Manchester and surrounding areas are within 100 yards of the home. The home’s fees for residents vary from £380 to £670 weekly. Charges for hairdressing, newspapers and chiropody are extra, but are invoiced following supply. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means the people who use this service experience good quality outcomes This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect; this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit a selection of records, care plans, policies and procedures were examined. Discussions took place with the manager, staff working in the home, and some relatives who were visiting. Prior to the inspection, questionnaires were sent out to the people who live in the home, asking them to comment on how the home is run and managed, and for their views about how the staff supported them. Only one of these was returned. A tour of the home was undertaken and residents were asked for their comments and views about the environment. Several residents living in the home were spoken to in private during the visit, and discussions took place with them to find out what they thought about the home and what they felt about how the staff supported them. Before the inspection, we also asked the manager of the service to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This is one of the ways that we get information from the manager of the service about how they are meeting outcomes for people using their service. This document was completed by the registered provider with input from the manager. Since the last inspection visit, which took place on 10th July 2007, the Commission for Social Care Inspection has received one concern about this service. One complaint was received which was investigated through Manchester City Council’s safeguarding adult’s procedures. Information in the AQAA shows that the service received 4 complaints directly and that all of these were resolved within 28 days. Records show that none of these were upheld. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Feedback from residents indicated that there was dissatisfaction about the activities available in the home. Comments from residents included: “It’s quite pleasant here, but it can be boring. There are not many activities.” “”There are only a few activities, most of the time I just watch T.V.” “There are no activities, I would like to see more going on”. There was evidence to show that the service was being pro-active about addressing this issue. There were discussions taking place with the provider The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 8 and manager to explore way in which this aspect of the service could be improved. A staff training and development plans needs to be in place and kept up to date to ensure that staff have the relevant training and skills to meet the needs of residents in the home. 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. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed prior to admission into the home and trial visits are arranged to help prospective residents make an informed choice about their future care arrangements EVIDENCE: A comprehensive admission policy was in place, which included information about opportunities for people to visit the home on a trial basis, stay for a meal and talk to existing residents and staff. Information provided by the manager before this visit in a self-assessment document called an AQAA, stated that all existing and prospective residents were provided with the statement of purpose and service user guide. These documents are useful in helping prospective residents to make an informed choice about their future care arrangements. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 11 Since the last inspection visit, work had been carried out in developing the preadmission assessment document. Three care plan files were looked at. These contained assessments carried out by the care manager from the placing authority and an assessment of care needs carried out by the manager or a registered nurse from the home. The information obtained was used to develop a detailed care plan for each resident. The pre admission assessment included personal details and information on personal care, past history, continence issues, mobility difficulties and medical history. Intermediate care is not provided at The Limes. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided staff with the information they need to meet and monitor the residents’ needs. Medication practices have improved since the last inspection visit and protected residents. EVIDENCE: Three care plan files were looked at during this visit, including the file of a resident who was recently admitted into the home. The new file showed that improvements had been made to the pre admission assessment documentation, which enabled staff to obtain a clearer overview of resident’s abilities and how they wanted to be supported with any care needs. Most care needs had been included in the care plans, but there was an example where a newly identified need had not been added to the plan. It is important that all newly identified needs are added to the care plan as they arise to ensure that care needs are not overlooked by staff. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 13 Discussions took place with the manager and the owner about developing the plans further using a person centred approach, where residents are in the centre of the process and regularly consulted on their perception of their care needs, their strengths, and on how they wanted to receive their support. Information in the AQAA states that care planning is an area for improvement, and discussion indicated that there was a commitment to using a person centred approach and improving documentation to support this. A variety of risk assessments are completed by staff. This is to ensure that any risks that are taken by residents can be done in a safe way where possible. Records and discussion with residents showed that a variety of health workers visit the home to assist with residents’ care. These are people such as dentists, opticians and dieticians. The home has developed links with the local surgery and information in the AQAA states that the General Practitioner from this surgery visits weekly. Examination of residents’ medication administration records showed that medicines were administered satisfactorily. The home had recently changed their supplier, and felt that this had improved the way in which medication was managed in the home. A registered nurse checks all medication when it is received by the home and the prescription is checked against the Medication Administration Records (MAR) sheet to ensure that the correct medication has been delivered. It was found that medication stock levels balanced with the MAR sheets, and there were good recording systems in place to record the receipt and disposal of medication. There were specimen signatures of all staff responsible for the administration of medication, so that any tracking of administration could be undertaken. There were occasions where hand written entries of medication had not been countersigned by a second member of staff to ensure accuracy in the detail. Some minor adjustments were needed to the recording of the administration of Warfarin. The procedure was changed following the inspection with written evidence provided to the commission. The Limes Nursing Home DS0000021648.V361487.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were offered, but these need to be expanded to ensure that the social, cultural and recreational needs of residents are met. Residents were encouraged to maintain contact with family and friends. Meals served to residents provided a nutritionally balanced meal. EVIDENCE: All residents who were spoken to during this visit were complimentary about the meals served in the home. Comments included: “The meals are lovely here, I’ve just had a lovely dinner ”. “I’m quite happy with the meals here”. Quite a few residents said that there wasn’t a menu choice, “We don’t usually have a choice but the meals are pretty good”. The staff team said that if a resident did not like what was on the menu, an alternative was offered. It was The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 15 evident from discussion with residents that not everyone was aware that choices are made available. It is recommended that residents are made aware of the range of choices available to them at mealtimes so that they can choose what they prefer. During this visit a number of residents received visits from their friends and relatives. Most people spoken to said they felt that the staff made them feel welcome. One relative said, “ I always feel that staff are welcoming. Nothing seems to be too much trouble if you have a query for them”. An activities organiser is responsible for providing some of the leisure activities in the home, and a physiotherapist visits on a regular basis to provide staff training, to advise on moving and handling techniques and to provide some activities for residents. There are arranged visits from local schools and churches. There was an acknowledgement from the registered provider in the information provided in the AQAA that the activities programme needs further development so that the interests and preferences of residents are fully met. This reflects comments made by residents and visitors, who highlighted views and concerns that there were not enough activates available. Comments about the lack of activities included: “ It’s very pleasant here but it can get a bit boring, there are not many activities”. “”There aren’t many activities, just watching television or reading, not much to do, but I am happy here.” “There are not many activities, I would like it if there was a bit more going on”. From discussion with the registered owner and the manager, it was evident that there was a commitment to review and develop the activities programme. There needs to be a pro-active approach in consulting with residents about their interests so that their social, cultural, religious and recreational interest are met. The Limes Nursing Home DS0000021648.V361487.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to ensure that residents are protected and systems are there to support residents to make their concerns known. EVIDENCE: There is a complaints policy in place and it is available to residents and their families. This is located in reception areas and in the statement of purpose and service user guide. Responses from residents during this visit indicated that on the whole, people knew how to voice their concerns and complaints. One family member said that she felt confident and able to go to see the manager or staff with any issues of concern. Since the last inspection visit, one complaint had been made directly to the manager at the home which was concerning issues raised by a family during a review. There was documentary evidence to demonstrate that the manager had followed procedures, and had investigated the concerns appropriately within the timescales set down by the ‘in house’ policy. A written response was sent to the complainant, and highlighted an action plan to show how the shortfalls were going to be addressed. The Commission for Social Care Inspection received one complaint about this service since the last inspection visit which was investigated under safeguarding procedures by Manchester social services. Advice was subsequently given for management to ensure that The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 17 strategies are in place to promote positive communication to reduce the likelihood of misinterpretation. A number of staff were spoken to about their understanding of adult protection issues. Most staff were able to demonstrate a sound understanding of the procedures for adult protection, and were aware that any allegations of abuse must be reported to social services and the Commission for Social Care Inspection. Since the last inspection visit, some progress had been made to ensure that staff received appropriate training to help them to develop awareness and a sound knowledge base of adult protection and safeguarding issues. The manager has put an information file in place, which provides staff with useful information on issues surrounding abuse. This also included the safeguarding adult’s procedures, and the forms which staff are required to complete in the event of any allegation of abuse. This provides staff with a useful overview on local procedures and the systems in place for holding strategy meetings. Some progress had been made in meeting the previous requirement for all staff to receive training in adult protection. In March 2007, three staff attended a course in safeguarding adults, the manager attended training in May 2007 and training has been scheduled for additional staff in December. The manager said that December was the earliest date that she could obtain in securing this training for staff. As an interim arrangement, and until all staff have been enrolled on this training, the remaining staff team have watched a DVD on safeguarding adults and completed a questionnaire which enabled the manager to assess staff awareness and understanding of the training material. The manager was aware that this type of training should not be used as a substitute for formal training. There was evidence in the supervision programme, that the one to one supervision sessions were used to re-in force good practice in care related topics, which included safeguarding adults. The Limes Nursing Home DS0000021648.V361487.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant and comfortable, and provides residents with a relaxing environment to live, and to invite their friends and family. EVIDENCE: Residents were asked for their views about the environment during the site visit and the majority of responses were positive about the environment. Residents who were spoken to said that the home was always clean and tidy. During the site visit, all areas of the home were clean and tidy and there were no unpleasant odours. In the previous inspection it had been noted that there was an absence of hand towels, aprons and soap dispensers to ensure that infection control was prioritised. These issues have now been addressed, and paper towel and soap dispensers have been fitted to a number of rooms where these had been missing. The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 19 Some of the cords from the alarm call systems in bedrooms were missing. These need to be re-placed so that residents can use the system effectively if they need to call for assistance. Some doors remained wedged open, and this was noted at the last inspection visit when a requirement was made. Where residents wish to have their doors held open advice must be sought from the local fire officer with regard to appropriate automatic door closure systems. Since the last inspection visit some areas of the home have been redecorated. The main lounge area was tastefully decorated and had been fitted with a new wall mounted digital television to improve viewing for residents in the home. Some hallways have been newly decorated and new flooring has been fitted in one of the lounge areas. The external area has been improved with the addition of a new water feature to provide a pleasant relaxing area for residents to enjoy in the warmer weather. These improvements demonstrate a commitment to maintaining the home to a good standard so that residents and their families can feel safe and comfortable in their environment. The Limes Nursing Home DS0000021648.V361487.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment and training programmes for staff had been improved. Staff receive support and training to help them to meet the needs of the people they provide care and support to. EVIDENCE: During this visit, there appeared sufficient staff on duty to meet the needs of the residents in the home. Staff were observed engaging in meaningful conversations, and seemed to respond quickly to any resident asking for support. Three staff files were looked at. All of them contained Criminal Record Bureau checks, and pin numbers were available for nursing staff. Two written references were on the files of the recently recruited staff. Information provided in the annual quality assessment states that 87.5 of staff have, or are working towards NVQ level2 or above in care. Staff who were spoken to confirmed that they had access to training and development opportunities. The training record for staff was not up to date, and the manager did not have a system in place that provided an overview of staff training, for example, a The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 21 training matrix. There should be an up to date training record that identifies that staff have received appropriate training and provides evidence that staff are informed about the different health conditions that effect older people in order to promote the well being of residents. Information in the AQAA showed that the manager and provider were aware of the shortfalls and concluded that they needed to further develop individual training and development assessments for each member of staff. This will ensure that training needs are identified appropriately and that training is planned in a way that develops the skills of the staff team enabling them to effectively meet the needs of residents. Residents and visitors were spoken to during this visit, and all of them were complimentary about the staff. Comments included: “I feel staff do really well and they do their best. In other places my friend was left in bed all day, but here they help and people to get up, and that lady there (pointing to a member of staff) is lovely- so very caring”- a visitor “If there was a problem I would speak up, but all I have seen is a very caring attitude”. – visitor “The staff are very good, they help me to manage my medical condition. The owner call, in sees if we are alright, we see him most days”.- resident “It’s lovely here and the girls are so good with me”. –resident. The Limes Nursing Home DS0000021648.V361487.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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures were being reviewed to protect the safety and well being of residents in the home. EVIDENCE: Since the last inspection the manager has worked with the provider to address the previous requirements. Staff who were spoken to said that they found the manager approachable, and that they felt confident in raising any issues of concern. Staff confirmed that they were in receipt of supervision. In the self-assessment document, completed by the manager before the inspection, the manager and provider identified that it was necessary to continually improve staff training and supervision programmes. A formal staff supervision system needs to be The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 23 developed and implemented, to ensure staff receive regular individual, documented supervision and periodic performance appraisals. Information in the AQAA provided confirmation that the home had introduced the use of resident and relative surveys. Questions on the surveys consulted residents on all aspects of the service. The provider outlined plans to use the findings to improve service delivery and to produce a report on outcomes as a result of the quality assurance process. Information in the assessment document provided evidence and confirmation from the manager and provider that all policies and procedures in the home were being updated and reviewed. The Limes Nursing Home DS0000021648.V361487.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 3 X 3 X X N/a 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Limes Nursing Home DS0000021648.V361487.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 OP19 Regulation 23 (2) Requirement Cords for call bells should be replaced so that residents can use the system effectively if they need to call for assistance. Where residents wish to have their doors held open advice must be sought from the local fire officer with regard to appropriate automatic door closure systems. Timescale for action 01/06/08 2 OP19 23 (2) 01/06/08 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 Refer to Standard OP7 OP15 Good Practice Recommendations Using a person centred approach when developing care plans would ensure that residents received care and support in a way that suited them. Menu choices should be made available so that residents are aware of alternative meal choices that are available to them. DS0000021648.V361487.R01.S.doc Version 5.2 Page 26 The Limes Nursing Home 3 OP12 Consultation should take place with residents about their interests so that their social, cultural, religious and recreational interest are met by a varied leisure activities programme. Staff training records and a matrix needs to be in place and regularly updated so that the manager can monitor and ensure that staff have training and skills to enable them to meet the needs of residents in the home. A staff training development plan should be developed that is kept up to date and reviewed on a regular basis in order to be able to evidence the staff have the skills to meet residents’ needs A staff supervision system needs to be developed and implemented, to ensure staff receive regular 1:1, documented supervision and periodic performance appraisals. 4 OP30 5. OP36 The Limes Nursing Home DS0000021648.V361487.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 The Limes Nursing Home DS0000021648.V361487.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!