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

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

This inspection was carried out on 6th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home works well with people who may not readily fit in to other care services because of their mental health problems. Risks are managed well, with a good level of consultation and involvement of both the service user and other professionals involved in their support. There is a good level of tolerance of individuals` idiosyncrasies and preferences to follow their own lifestyles, balanced with an understanding of the principles of "duty of care". Recording in care plans reflects this philosophy. There is a good working relationship with other professionals, who have made comment on the home`s successes in working with clients that have been hard to place.

What has improved since the last inspection?

Care planning has improved, the documents being used providing more clarity and detail than was previously the case. Attention to physical health has also improved, with the introduction of health input from the Practice Nurse; this complements the mental health expertise of the home`s nurses. Efforts have been made to raise standards of cleanliness and working practice in the kitchen, following an Environmental Health inspection in May. Work has also continued to bring the electrical wiring up to current standards. Some new beds were purchased recently, but two of these have proved to be faulty and in need of repair already. Record keeping had improved in relation to the staff vetting procedure and efforts were still being made to obtain missing documents for all of the staff in post.

What the care home could do better:

A comment made by a social and health care professional who has worked closely with the home was, "The building could do with a facelift, but you can`t always judge a book by its cover". This echoed the inspectors` feelings, that there was some good work going on with individuals, but the surroundings are shabby and in disrepair in places and would benefit from refurbishing. It had already been identified that some of the service users that have lived there for a long time have very little activity or information recorded in their care plans. One of these people was selected for case-tracking; the records showed that attention was given to promote and address health-related issues,but that there was very little information about that service user as a person. The improvement of care planning for such individuals should be prioritised. There needs to be an improvement in written information, such as the revised Statement of Purpose and the updated policies and procedures, so that service users know what to expect of the home and the staff know how to deliver it. Social and leisure opportunities need to improve, as they are currently quite limited. Staff need to be proactive in this field, as many of the service users are not well motivated. The whole of the service provided by the kitchen would benefit from reviewing and re-organising; work has commenced to improve food hygiene standards, but the menus and the way that drinks are served need looking at, including service users wherever possible in discussions.

CARE HOME ADULTS 18-65 The Malvern Nursing Home 425 Toller Lane Heaton Bradford West Yorkshire BD9 5NN Lead Inspector Stevie Allerton Key Unannounced Inspection 6th June 2006 09:30 The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 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.V298327.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 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.V298327.R01.S.doc Version 5.2 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 rachel@malvernuk.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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.V298327.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th March 2006 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 current care fees are £444 per week. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by two inspectors (Stevie Allerton & Catherine Paling) over the course of one day. The inspection started at 9.30am and finished at 6.00pm. The nurse-in-charge, Julian Lamptey, was on duty throughout the day and made himself available to answer questions and supply care records, etc. Rachel Halsall (owner and Registered Manager) and Barry Swinbourne, (Assistant Manager) were also available for discussion during the day. They were given feedback by the inspectors on the findings of this visit, at the end of the day. The inspectors would like to thank everyone who took the time to talk to them and express their views. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, the action plan submitted following the previous inspection, and reports from other agencies, i.e., the Environmental Health Officer and Fire Officer. This information was used to plan the inspection visit. The inspectors case tracked six service users. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspectors assessed all twenty-two key standards from the Care Homes for Adults (18 – 65) National Minimum Standards, plus other standards relevant to the visit. The inspectors spoke with identified service users and relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Where possible, contact was also made with external professionals to obtain their opinions about the quality of services provided at the home. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A comment made by a social and health care professional who has worked closely with the home was, “The building could do with a facelift, but you can’t always judge a book by its cover”. This echoed the inspectors’ feelings, that there was some good work going on with individuals, but the surroundings are shabby and in disrepair in places and would benefit from refurbishing. It had already been identified that some of the service users that have lived there for a long time have very little activity or information recorded in their care plans. One of these people was selected for case-tracking; the records showed that attention was given to promote and address health-related issues, The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 7 but that there was very little information about that service user as a person. The improvement of care planning for such individuals should be prioritised. There needs to be an improvement in written information, such as the revised Statement of Purpose and the updated policies and procedures, so that service users know what to expect of the home and the staff know how to deliver it. Social and leisure opportunities need to improve, as they are currently quite limited. Staff need to be proactive in this field, as many of the service users are not well motivated. The whole of the service provided by the kitchen would benefit from reviewing and re-organising; work has commenced to improve food hygiene standards, but the menus and the way that drinks are served need looking at, including service users wherever possible in discussions. 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.V298327.R01.S.doc Version 5.2 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.V298327.R01.S.doc Version 5.2 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&2 Service users do not have access to suitable written information regarding the facilities and services provided by the home, which would assist them to make a choice about living there. Prospective service users undergo a comprehensive process of assessment, to ensure that their care and support needs can be met. EVIDENCE: The former Statement of Purpose is currently undergoing review and amendment to reflect the current situation, so is not available for service users or visiting professionals to read. There is also no Service User Guide, which would give a summary of the Statement of Purpose and outline the facts that anyone new to the home would want to know. Some of the care plans seen, for the service users who were case-tracked, contained evidence of a gradual process of introduction to the home. The nurse-in-charge described the process from referral, through assessment, to admission, involving other health care professionals and the person’s family, if appropriate. This could be seen in the care records of a person recently admitted; a care plan was agreed with the service user’s relative and put in place prior to admission, so that all staff would be aware of how best to support that person. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 10 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, & 9 Care plans were found to vary in the depth of information they provide, but both inspectors felt that the new formats give a much clearer picture about the person, assisting staff to provide the correct level of support. Risks are being assessed and managed well, without automatically removing a person’s right to take a risk. EVIDENCE: There was evidence within some of the care plans looked at in depth, that the service user, or a relative acting on their behalf, had signed their agreement to particular support plans or risk management plans. The nurse-in-charge has introduced a new format for care planning, which care staff felt was much better. Identified needs were clearer and the action or support required from staff was easier to find within the files. Service users have started to be given copies of their summary care plan, which can be kept in their room, a practice that the inspectors felt was very good and should be promoted. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 11 Six service users were selected for case-tracking, reflecting a cross-section of the clients living at the home, in terms of age, gender, cultural background and how long they had lived there. Care plans varied, so were inspected as “work in progress”. New service users and some of the established service users had personal information recorded in the newly introduced format and documentation, the standard of which was very high. Others still had the previous care planning documentation, which still had provision for the recording of the same assessment of needs and risks and action plans in response, but which were more difficult to analyse. Daily records were variable, some providing very little information about the service user as a person; other entries reflected the agreed care plans and provided evidence of appropriate support being given. Risk is addressed through detailed assessment and relevant management plans put in place. In one case, it was clear to see that the service user had signed an agreement regarding the management of a particular risk. In speaking with that service user, he confirmed that he understood why certain behaviour could be a risk to others and did not disagree with the plan in place. Good recording demonstrated that a balance was being achieved between minimising a risk whilst being mindful of the individual’s rights. A telephone discussion was held with the placing social worker of a service user, who said that the home had a good track record of managing risks well and were proactive in pressing for case reviews, ensuring that decisions were being shared with other professionals, relatives, etc. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 & 17 Service users have limited opportunities to take part in the usual everyday activities involved in living in the community. They are dependent upon the availability of staff, either to accompany them or initiate activity, and also on the individual’s preferences for what they spend their money on. The staff do try to help service users understand the balance between their rights and their responsibilities when living in a communal situation. Food provision is adequate and meets service users’ needs in general, although further improvements were identified. EVIDENCE: Care records showed some evidence of social activity or the encouragement of independent living skills, but these were limited to maintaining one’s own room tidy, or helping round the house. Service users confirmed this level of activity. Staff time is currently set aside once a week for social activity, which the staff member said might include escorting someone on a visit to relatives. There The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 13 was recognition, by the staff member and members of the management team, that this aspect of work with service users needs to be developed. Some service users are able to pass the time with each other and Scrabble continues to be popular, as was seen during the inspection. Discussions were held with some individuals in the main dining area and sitting area. Television was the main source of interest for many people, and the football World Cup was being looked forward to. There are a high number of cigarette smokers, with designated areas for smoking in the home. Staff rotas showed that there is currently not a great deal of time for staff to be able to spend one-to-one time with service users away from the home, although the inspectors were able to observe the negotiations going on between an individual and the staff, so that he could be accompanied to go shopping that afternoon. Food provision was looked at. The lunchtime meal looked and smelt appetising and service users said they enjoyed it – “It’s alright, plenty of it”, “I like all of the meals”. Some individuals need assisting to eat; this was being done in an unhurried manner by the nurse and care staff on duty. The cook and a member of the management team acknowledged that the current menu needed adjusting to reflect the summer months. There is capacity to provide different diets to reflect cultural requirements; Asian service users have a vegetarian option, supplemented by traditional dishes using Halal meat. Discussions were held around service users who need a soft diet and how this could be better achieved. A guidance document on nutrition was left with the nurse-in-charge. Efforts are being made to try to introduce more choice, for example, putting cereal containers out in the dining room to choose from at breakfast. It was observed that vacuum jugs of cold water and glasses were also available in the dining room for service users to help themselves. Some service users said that they would like to be able to make their own cups of tea – “Sometimes you fancy a cup of tea but you have to wait for the staff to bring the trolley round”. This was passed on to the Manager. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 14 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 Service users receive personal support in a way that is discussed and agreed with them. Staff are highly conscious of the balance to be achieved between promoting freedom of choice and their duty of care. Overall medication practices are safe but the lack of up to date polices and procedures could provide the opportunity for error. It also means that service users are not provided with the opportunity to self-administer their own medication. EVIDENCE: The new care plans are clear in content and provide a good basis for staff to provide care and support in the way that service users require. The former care plans also were seen to provide good content, but with less clarity about what action staff would take to meet identified needs. Inspectors queried some of the information provided by the Manager about the numbers of service users needing continence care; some service users have long standing mental health problems, which are still their primary need, but have acquired dementia since admission. There are also some people whose behavioural difficulties result in incontinence. The nurse-in-charge showed the inspectors evidence that the specialist input of a Continence Advisor had been requested. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 15 Moves have also taken place to engage the Practice Nurse from the local GP surgery, where the majority of service users are registered, to look at some of the medical/physical needs that have been identified through care assessment and planning. There was evidence in the care plans that routine health screening and regular input from dentists, opticians, chiropodists, etc., was also provided. Discussion took place with the nurse-in-charge about the possible end-of-life care to be given to service users who are frail. It was evident that, along with the expertise of the Practice Nurse and GP, all comforts and care could be provided, including the appropriate pressure-relieving equipment. A potential problem was identified with the use of an overlay type of pressure mattress, together with bed rails that were not high enough to prevent rolling out of bed. The nurse-in-charge undertook to have these replaced without delay. There are currently no service users who are self medicating and there are no policies and procedures to support this activity. However, the nurse in charge fully intends to introduce a self-medication policy in the future. It will include risk assessment to assess safety, arrangements for teaching and support, provision of secure storage in bedrooms and the arrangements for the monitoring of compliance. The medication policies and procedures are adequate but in need of review and update to make sure that they reflect current practice and provide staff with clear guidance. The medication room is cramped and does not have hand-washing facilities. Staff have to access the wash basin in the office which is close by. The nurse in charge has introduced a monitoring system of the ordering systems to provide an audit trail of medicines ordered and received at the home. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 16 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 & 23 Service users feel comfortable about raising concerns on a day-to-day basis, but should be given more opportunities to have their views listened to and acted upon. Service users are protected from potential abuse. EVIDENCE: Service users, when asked what they would do if they had a concern or complaint, were clear in their assertions that they would raise it with a named member of the management team. A suggestion was made from some of the service users about a facility they would like to see in the home. The inspector asked whether they had raised this at a residents’ meeting, but they said that one had not been held for a long time. The meetings minutes confirmed that none had taken place since before Christmas 2005. The staff have a good level of awareness of the risk of potential abuse that some service users subject themselves to when outside the home; care plans showed how the staff try to support those at risk, through assessments and risk management plans. The management team provided evidence of a training course in Adult Protection that had taken place in-house the previous month. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 17 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 & 30 Service users live in accommodation that provides the basics, with some areas of the home looking rather shabby. General maintenance and repairs need more attention, although action has been taken to ensure a safer environment. The general standard of cleanliness in the home was good, though staff should be mindful of the need to keep a tidy working environment. EVIDENCE: A recent Environmental Health Officer’s report on the kitchen has created the need for improvements in working practices to be made. Evidence that this had been started was seen during the inspection; eight staff were having a half-day Food Hygiene training course on the day, and proper records of food and equipment temperatures had been put in place. There was also a new cleaning schedule. Work was in progress to renew and upgrade some of the electrical wiring and items noted on the last Fire Officer’s report had been dealt with. Certain mechanical fans were identified as being very dusty and in urgent need of cleaning (action was taken to address this at the time of inspection); a The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 18 mechanical ventilation fan was also identified that did not have an over-run facility. One service user invited an inspector to look at the new bed in his room, which had a broken middle leg. The Assistant Manager was aware of this, also another one with the same fault, and had obtained replacement legs that were awaiting fitting. The home is without a handyman at the moment, with the result that a number of repairs were building up. The laundry and basement storage was inspected. There were a large number of boxes of paper towels stored at the foot of the stairs in the basement, which the inspectors were worried could constitute a fire hazard. The Assistant Manager agreed that these should be stored elsewhere. Ironically, the laundry itself was without soap and paper towels at the hand wash basin. The Fire Officer later confirmed that the existing fire detection and protection in the basement was adequate. Proper systems are in place to manage the laundry, including the handling of soiled and possibly infected linen. A member of staff talked the inspectors through the process knowledgably. Action had also been taken following the last inspection to improve the way that commodes are washed and disinfected. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 19 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): 34, 35 & 36 Recruitment practices have improved, resulting in a properly vetted staff team and the consequent protection of service users. EVIDENCE: An inspection of staff records showed that action had been taken to obtain the missing documents identified at the last inspection, and to ensure that all staff were properly vetted and checked under the Protection of Vulnerable Adults (POVA) procedures. Staff training has continued to progress. Food Hygiene training was being given on the day of inspection; Adult Protection training took place the previous month, along with a course in Documentation and Care Planning, led by the nurse-in-charge. He has also got courses planned that cover mandatory training, e.g., fire training, provided by an external accredited trainer, and topics relating directly to care practice, such as managing challenging behaviour. More than 60 of the care staff have NVQ qualifications. It was observed during the day that the nurse-in-charge made himself available in the central area and was on hand to offer support and guidance to staff in dealing with difficult situations, trying to ensure a consistent approach from staff to service users. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 20 Staff spoken to on the day appeared happy and relaxed in their work and expressed approval of the introduction of new care plans, which involve the care staff as well as the qualified nurses. The rotas showed sufficient nurses and carers on duty, supported by catering and domestic staff. There are a high number of staff from different ethnic and cultural backgrounds, which is not representative of the service user group. The management team expressed a view that this imbalance needed addressing, through recruitment if possible, to better reflect the cultural backgrounds of the service users and improve communication with them. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 21 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, 39 & 42 Management of the home has improved with the addition of a nurse-in-charge, co-ordinating the work of the qualified nurses and care staff. Further work is required to review and update the home’s written policies and procedures, to ensure they reflect current practice and provide the correct guidance for staff. EVIDENCE: Weekly management meetings are now taking place, which inform the monthly performance monitors that have been introduced. The written response to the last inspection report was in the form of an Action Plan with projected dates for the resolution of the issues raised, some of which had already been dealt with before this inspection. Supervision for all staff has commenced; initially, all are being done by the nurse-in-charge. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 22 There was an acknowledgement that the written policies do not always match current practice. These, along with the Statement of Purpose, are being reviewed and updated. Records seen during the inspection included: • Care plans • Food hygiene records • Maintenance records • Staff records • Minutes of service user meetings • Accident records • Medication records • Records of service users’ finances Most were found to be in order, or, like the staff records, action was being taken to get them up to a better standard. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 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 Standard No Score 1 1 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. (From previous report, agreed timescale not yet reached) The Registered Provider shall ensure that all staff receive adequate training regarding end of life situations (From previous report, agreed timescale not yet reached) The registered person must manage the home with care competence and skill, undertaking such training as appropriate to maintain the necessary management skills. (From previous report, agreed timescale not yet reached) The Registered Provider must ensure all Policies and procedures in the home are reviewed and updated. (From previous report, agreed timescale not yet reached) DS0000019899.V298327.R01.S.doc Timescale for action 31/07/06 2. YA21 12 30/09/06 3. YA37 10 31/10/07 4. YA40 17 30/09/06 The Malvern Nursing Home Version 5.2 Page 25 5. YA11 6. YA17 7. YA8 8. YA24 9. YA24 10. YA24 16(2)(m) & Social and leisure opportunities (n) must be sought for those service users who want them, supported by sufficient staff. 16(2)(i) The current menu needs revising, to take into account service users’ nutritional needs, preferences and choices. 12 Service users must be given the opportunity to contribute to the decision-making processes of the home, by way of residents’ meetings or other avenues. 13 & 23 Work must continue in the kitchen to achieve the standards set by the Environmental Health Officer. 23 Ventilation fans must be kept in a clean condition; those in internal WCs must conform to building regulations and have an over-run facility. 23 Repairs required to the furniture or fittings in service users’ bedrooms must be carried out without delay. 30/09/06 30/09/06 30/09/06 30/06/06 31/07/06 30/06/06 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 YA24 YA20 Good Practice Recommendations Ways must be sought to making areas in home identified within the main body of the report, more homely looking. When the medication policy and procedure is updated, it should include a policy on service users who have been assessed as able to self-medicate. The Malvern Nursing Home DS0000019899.V298327.R01.S.doc Version 5.2 Page 26 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.V298327.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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