Inspection on 28/03/06 for The Malvern Nursing Home

This inspection was carried out on 28th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Malvern Nursing Home 05/11/08

The Malvern Nursing Home 06/05/08

The Malvern Nursing Home 08/05/07

The Malvern Nursing Home 06/06/06

The Malvern Nursing Home 28/06/05

The Malvern Nursing Home 07/12/04

The Malvern Nursing Home 29/06/04

The Malvern Nursing Home 25/03/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Malvern Nursing Home 425 Toller Lane Heaton Bradford West Yorkshire BD9 5NN Lead Inspector Pamela Cunningham Unannounced Inspection 28th March 2006 10:00 The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 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 Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 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 Adults 18-65. 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 Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Malvern Nursing Home Address 425 Toller Lane Heaton Bradford West Yorkshire BD9 5NN 01274 492643 01274 499557 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) Mrs Rachel Halsall Mrs Rachel Halsall Care Home 28 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (28), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (28) The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: The Malvern is a 28-bedded care home with nursing, specialising in the care of adults with mental illness. The home takes both male and female service users and was established 20 years ago. The house is a late 19th century detached residential building situated on a main road approximately 3 miles from the centre of Bradford, served by a good bus route. Many of the buildings original period features have been preserved and the home includes an extension built in 1993. There is a parking area to the side of the building and a small patio area situated on the other side of the building. Access to the home is gained through the conservatory at the front and a ramp is provided for people with mobility difficulties. There are 16 single bedrooms and 6 double rooms on two floors, accessible for those with mobility difficulties by stair lift to the first floor. The home is owned and managed by Mrs Rachel Halsall, RMN. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 28 June 2005. This was an unannounced inspection carried out by one inspector who was at the home from 10.00 until 16.30. The main purpose of this inspection was to make sure that the home provides a good standard of care for the service users and to assess progress on meeting any requirements or recommendations made at the last visit. The methods used at this inspection included looking at care records; observing working practices and talking to staff, service users, and to the managers. A selection of key standards was inspected and the progress on requirements and recommendations from the last inspection was assessed. • • • • • • • Senior staff are currently working their way through the care documentation to bring it up to an acceptable standard. The aim is for it to be reviewed monthly. The provider has taken out a contract with Aqua Trust to maintain the water system. Training has been addressed. Staff involved have completed NVQ 2 and are waiting to commence NVQ 3. Residents meetings have commenced and are to correspond with team meetings. A staff training questionnaire has been issued to all staff and formal supervision has commenced incorporating identified training needs. The hard wiring system has been checked and a price given for the work to be completed, which will commence 29th March 06 following two cancellations by the electrical engineer. Mrs H alsall, who commenced, but did not complete the registered managers award undertook to make further arrangements for the completion of this award. Several residents were spoken with and others, who were reluctant to speak, were observed. One lady resident said she has no complaints, wished she could live at home but understood the need for her care to be provided. She said she needed a special diet and always received it. She said she handles her own pocket money and buys her own cigarettes. She said the staff were “mostly nice” and respected her privacy. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 6 Another lady resident said she is “suited with the home”, and goes out with her son to a supermarket. One gentleman resident said he does not control his own pocket money and is not happy with the arrangements, but understand the restriction. He said the staff are nice, and that he likes living at the home. He said the food is nice and always made from fresh produce. He also said that he couldn’t have drinks when he wants, but he is very satisfied with what he gets. One gentleman resident said he would like a full cooked breakfast, but can have beans on toast or bacon sandwiches. He also said he would like more Yorkshire puddings on the menu, and not just when a roast is done or when they have toad in the hole as they had on the day of the visit. Another gentleman resident said he would also like a cooked breakfast, but the food he does get is very good, that the staff are very good, and that he likes the new male nurse in charge. All residents spoken to said they were happy with the entertainment provided and were looking forward to the summer when they could get out more. What the service does well: What has improved since the last inspection? The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 7 The standard of care plan documentation has improved since the last inspection. Stronger, clearer leadership has been put in place with the employment of a highly qualified and experienced registered nurse. Since in post certain positive changes have been made which ensures consistency. Accident report forms are now numbered chronologically and filed in a ring binder. Formal supervision has been commenced. Care plans have been updated and a new format introduced. All work recommended by the Fire Safety Officer has been implemented. Continuity of carer has been improved by the employments of a senior nurse in charge. Quotes have been obtained and work is to commence on the re-wiring, following which, a certificate is to be forwarded to the Commission. The test for the presence/absence of Legionella has taken placed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 The admission process is good and includes introductory visits, however there is very little information available for residents to make an informed choice whether or not to live at the home. Needs and aspirations are discussed during pre-admission assessments and at trial visits. EVIDENCE: Currently there is no service user guide available at the home. Information prospective residents are provided with contains little information about the services provided. This needs updating to include a summary of all the information that should be in the statement of purpose. The provider and general manager acknowledged this. (A requirement has been made.) The statement of purpose also needs updating to reflect the recent staff changes and details and numbers of qualified staff. (A requirement has been made) The contract of residency needs amending to include the room to be occupied and to reflect the changes to the CSCI. (A recommendation has been made Residents spoken to said all their needs were being met, and that the home was better than either being in hospital or other care homes. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 10 Some said they still wished they could handle their own pocket money, but realised why the home had made arrangements to do this for them. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 10 The health care needs of residents are not always met. Care plans provide clear and detailed instructions for staff to follow. Residents are treated with respect and their privacy is upheld. EVIDENCE: Two sets of care plan documentation were reviewed and case tracking was done. The new senior nurse appointed in January has been instrumental in improving the standard of care plan documentation. The registered manager said they were working their way through the documentation to increase the standard, and intended to review the documentation monthly. I reviewed the care documentation of one recently admitted resident who had identified medical care needs. There was evidence of an in depth pre admission assessment, with medical and nursing needs identified in addition to the mental health problems. Background information from the social worker was also obtained prior to the resident being admitted. There was also a list of The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 12 names with contact telephone numbers available of other relevant healthcare professionals. Good informative information was also documented in the daily nursing record on the day of admission, which provided all the staff with immediate relevant information about the needs of the resident. Good management of continence needs were also identified and documented. However, though the resident had been assessed, as at high risk of developing pressure ulcers, there was no care plan in place to address the risk, nor did the resident have an appropriate piece of pressure relieving equipment on the bed for use at night as part of a pressure sore risk prevention strategy. There should also be a pressure relief cushion provided. (A requirement has been made) The care plans must also identify the long-term goals and the process by which the goals are to be reached, if people are to be admitted to the home for rehabilitation. (A requirement has been made.) I also reviewed the care documentation of one resident who had been admitted some months previously. The documentation was appropriate. I spoke with many residents during the course of the inspection, and they said they hoped anything they said would be treated with confidence. I spoke with the manager about the handling of intimate personal care of the lady residents. From the discussion we had I identified it would be handled appropriately. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 15, 16, and 17 To what extent residents have opportunities to take part in the activities of the local community is still largely dependent on the ability of the person to do this without staff assistance, or when there are sufficient staff available for those who need an escort. Provision of meals continues to improve. EVIDENCE: The menus that were seen showed more variety, however it was identified that mince appeared on the menu two days in succession. The manager said this had been previously identified and alternative arrangements made. At the last inspection, the senior staff said that there were plans to develop the menus further and to put up a notice board in the dining room in order to display the daily menu, however on the day of the visit there was no menu on display, and residents spoken to said they did not know what was for lunch or tea. Certain residents spoken to told me that they go out to Art groups at Walker House run by BMDC (Bradford Metropolitan District Council) The manager said it also provides therapies for people with mental health problems. One lady resident also goes out to an Asian women’s group. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 14 The manager also said that 60 of the residents attend Windmill Social Club, which survived after the closure of Highroyds Hospital. Certain other residents told me they go to Heath House therapy centre run by the Mental Healthcare Trust, which is attached to Daisy Bank. Sexual relationships are not encouraged but would be permitted (and have in the past) providing the relationship is consenting and not abusive to either party, and that a risk assessment had been undertaken. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Residents receive personal support in a way that is discussed and agreed with them. Care plans provide clear instruction for staff to follow. Medication systems and practices are sound. End of life situations are addressed sensitively, but no formal instruction has been provided regarding this. EVIDENCE: From the evidence of the care plans seen and in discussion with them, residents have access to local health care services and more specialised services where required. However, the healthcare needs of the residents are not always addressed fully as is described earlier in the report under standard 6. The home uses a pre-dispensed system of medication and has a selfmedication policy, lockable facilities for service users however are not provided, as none of the residents control their own medication. The resident’s consent to medication is recorded and kept with the administration charts. A photograph of the majority of the service user is also kept with these charts. Controlled drugs are received, administered and disposed of in accordance with the standards. The systems and records were checked and found to meet The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 16 requirements. Residents spoken to during the visit told me that they had all the support they needed, and at times and in the way they preferred. The manager said the cultural views of the residents are respected, and discussed with residents and relatives when appropriate. She also said that end of life situations are only addressed within the elements of NVQ training. However at this time carers are not given formal instruction on this subject. Mrs Halsall did however say this had already been identified, as a training need. (A requirement has been made) The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents feel comfortable in raising concerns on a day-to-day basis and have access to a formal complaints procedure that is clear. There are no residents currently living at the home that self harm. EVIDENCE: There have been no complaints since the last inspection. The manager is aware of POVA, and has obtained advice from the Adult Protection unit regarding residents who may harm themselves or others. Evidence of involvements with Adult Protection was seen. Currently there are no staff in the home that have received training in abuse awareness. (A requirement has been made) The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 and 30 Aids to enhance mobility are present throughout the home. Grab rails are present in all en-suite bathrooms, and there are privacy locks to communal WC’s. The communal areas however, (lounges and certain corridors) look quite institutional. Sluicing arrangements do not meet the standard required for care homes providing nursing care. Specialist equipment is not provided to address assessed needs. EVIDENCE: There is a potential trip hazard at the main entrance to the home. The floor in the foyer, which is carpeted, leads to a small step, which in turn leads into a corridor, covered by the same carpet. This could present as a possible trip hazard, as there is no warning to alert visitors, or new residents who may be infirm or partially sighted, there is a step to be negotiated. (A requirement has been made) The home also only has one electrical hoist; therefore residents who are not mobile are cared for on the ground floor level, as there is no shaft lift. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 19 I was told that if any of the residents accommodated on the top floor of the home became immobile; they would be consulted about moving to the ground floor level. This is not an ideal situation as it would not only inconvenience the poorly resident, but a second resident would also be inconvenienced. It is recommended therefore that the home provide a second hoist. Sluicing arrangements are also unsatisfactory. Although the home has not had any recent outbreaks of any notifiable incidents of diarrhoea and vomiting, the sluicing arrangements and sterilization of commode pots gives cause for concern. Currently used commode pots are emptied down a slop hopper type sink, and cleaned by being scrubbed with hot water and bleach. Residents are also not given the commode pot back they normally use, and this not acceptable safe practice. The manager/proprietor must therefore consult with the authority responsible for environmental health for the area in which the care home is situated, on the best way to handle the current unsafe practise, which is taking place. (A requirement has been made) Certain communal areas of the home have an institutional look, especially the dining and combined lounge area. The provider should look at ways of making these areas look more homely. (A requirement has been made) The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35 Recruitment practice are not robust and do not protect the residents. Lack of consistency is less apparent with the employment of a new senior nurse. EVIDENCE: Training was reviewed. Although all training documentation complies with TOPSS Induction and foundation training, one of the carers spoken to during the visit said she had not been provided with induction training. (A requirement has been made) Although lack of consistency is less apparent, there are only still two qualified staff that are employed on a whole time basis. All the remaining qualified staff employed are still part time. Staff currently employed at the home are picking up shifts vacant due to the suspension from duty of one qualified staff member who worked night duty. The manager was reminded of her responsibility under the NMC Guidelines of Professional Accountability regarding the qualified member of staff who has been suspended. Staffing on the day of the visit was seen to be satisfactory. Formal supervision has recently been addressed. Currently there is one full time domestic vacancy. Training is still being co-ordinated by the registered manager and non-nurse manager, however it is expected that the senior nurse will take over this role. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 21 The manager said 50 of care staff have achieved NVQ at level 2. Evidence to support this was seen in the records of achievement of various staff. The manager said all mandatory training was being addressed, with all staff being involved The manager is currently addressing Fire Safety Training, however she is not competent to undertake this, as she has not completed the Fire Safety Trainers course. (A requirement has been made) Recruitment procedures are not robust. Files of six staff were reviewed and the following anomalies identified. The provider is not checking the registered status of qualified staff employed with the NMC. None of the files reviewed had photograph identification. Unexplained gaps in employment history were seen. Four files were void of interview information. Two staff files contained evidence that the home has employed them with a disclosure from a previous employer. (CRB’s are not transportable.) Three staff files reviewed identified no CRB or POVA check had been undertaken. Certain files were void of copies of either passport or birth certificates. The non-nurse manager said he had applied for a disclosure and POVA check of the new appointed senior nurse, although there was no evidence to support this. He also said he believed disclosures were transportable. (A requirement has been made.) The provider also needs to decide on the best course of action to take regarding staff they have employed without all the relevant checks being in place, as currently the recruitment procedures currently in use places the residents at risk. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 41 Continual effort still needs to be made in implementing satisfactory systems in place for the smooth running of the home. Many of the previously agreed timescales have been addressed, however some remain outstanding. EVIDENCE: Some effort has been made to address the requirements identified in the last inspection report. The staffing situation appears to be more stable and better run with the employment of a very well experienced and qualified senior nurse. Resident meetings are to commence and will be co-ordinated to take place at the same time, as the staff meetings, where it is expected residents who can participate positively, will do so. Policies and procedures reviewed during the inspection identified they had all been written on 2002, and not reviewed since. The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 x 3 x 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 2 2 LIFESTYLES Standard No Score 11 3 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 1 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Malvern Nursing Home Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 1 x x DS0000019899.V266043.R01.S.doc Version 5.0 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 YA1 Regulation 4&5 Requirement The Registered Provider shall produce a written guide to the care home (in these regulations referred to as “the service users guide) which includes all information as described The Registered Provider shall a. ensure the long term needs of residents admitted for rehabilitation, are documented and b. ensure that those residents who are assessed as at risk from developing pressure ulcers are provided with an appropriate piece of pressure relieving equipment on their beds, and in easy chairs they sit on. The Registered Provider shall ensure that all staff receive adequate training regarding end of life situations. The Registered Provider shall ensure that all staff receive adequate training on Abuse Awareness The Registered Provider shall DS0000019899.V266043.R01.S.doc Timescale for action 30/06/06 2. YA6 15 30/05/06 3. YA21 12 30/06/06 4. YA23 13 30/06/06 5. YA24 13 (4) 15/05/06 Page 25 The Malvern Nursing Home Version 5.0 6. YA24 23 7a. YA30 13 (3) 16(2)(j) 8. YA32 18 9. YA34 19 Schedule 2 23 10 YA35 11 YA37 10 12 YA40 17 ensure there is appropriate signage placed adjacent to the step considered as a potential trip hazard at the entrance to the home The registered person must ensure that all mechanical and electrical systems are maintained in good working order. i.e. the electrical wiring is safe. (Carried over from previous reports, timescales not met.) The Registered Provider shall a. ensure that appropriate advice is taken regarding the current unsafe practice of sterilizing commode pots, and b. that a sluice disinfector is obtained and fitted in a centrally located place (by 31/07/06). The registered person must ensure that all staff receive training appropriate to their job role, to include induction training. The Registered Provider must ensure recruitment procedures are robust and protect the residents. The Registered Manager must ensure the person who provides Fire Safety Training in the home is trained and competent to do so. The registered person must manage the home with care competence and skill, undertaking such training as appropriate to maintain the necessary management skills. The Registered Provider must ensure all Policies and procedures in the home are reviewed and updated. 30/06/06 15/05/06 15/05/06 15/05/06 30/06/06 30/10/07 30/06/06 The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations Ways must be sought to making areas in home identified within the main body of the report, more homely looking The Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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 Malvern Nursing Home DS0000019899.V266043.R01.S.doc Version 5.0 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. 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