Inspection on 17/01/07 for The Nunnery

This inspection was carried out on 17th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Nunnery 13/01/09

The Nunnery 19/12/07

The Nunnery 15/05/07

The Nunnery 20/04/06

The Nunnery 23/11/05

The Nunnery 13/04/05

The Nunnery 29/10/04

The Nunnery 23/05/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE The Nunnery 14 Denmark Street Diss Norfolk IP22 4LE Lead Inspector Ruth Hannent Key Unannounced 17th January 2007 09:30 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 Nunnery DS0000036034.V327863.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 Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Nunnery Address 14 Denmark Street Diss Norfolk IP22 4LE 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) 01379 643201 01379 642649 Mrs Jane Wentford Not applicable Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (22) The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old age, not falling with any other category (OP), twenty two (22) of either sex. Mental disorder, excluding learning disability or dementia (MD), One person (1) male, who shall be named in the records. 20th April 2006 Date of last inspection Brief Description of the Service: The Nunnery is situated close to one of the roads leading from the market town of Diss. Gardens to the rear slope steeply down the banks of the Mere, and there are panoramic views across the water to the town. The street frontage and main building is old, and there is a newer extension to the rear. A shaft lift provides access to the first floor. There is a lower ground floor (as a result of the sloping site), which is accessible via stairs or a stair lift. The home is registered to provide care for 23 people, and three of the rooms would be double. These rooms are currently being used for single occupancy as these residents do not wish to share. The current fees range from £340 to £520 per week Email address is ‘thenunnery@aol.com’ The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been completed after a visit to this Home to inspect the service against key standards set in The National Minimum Standards, Care Homes For Older People. This key inspection follows five visits in total from the inspector over a period of nine months to ensure the service is meeting the minimum standards required. Prior to the visit the Commission had received a pre inspection questionnaire and one comment card. The day started at 9.30 and ended at 13.30 with information gathered from records, conversation with groups and one to one chats with residents, observation and a tour of the Home. Records that were seen included assessments, care plans, medication records, personnel files, servicing of equipment, staff training, policies and procedures and contracts. On the day of the visit 15 residents were living at the Home and on duty there was one manager, three care staff, two domestics, one cook and a new staff member starting an induction programme. This key inspection has seen an improvement in the service at the Nunnery but there is still work to be done to ensure the home meets all the standards required. What the service does well: What has improved since the last inspection? The manager has improved the quality monitoring system and should, by the end of the year have a picture of how the next years improvement plan will look. The choice of food and the variety on offer is more person centred. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 6 The radiators are now all covered throughout the Home. The shower room is now refurbished and being used. The single toilet has been refurbished\and is much improved. 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 summary of this inspection report can be made available in other formats on request. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are issued with a contract to sign and do have a copy of the terms and conditions. Residents are assessed and assured their needs will be met but concerns on admitting residents outside the registration category is a concern that must not happen in the future. EVIDENCE: For this Inspection the Commission had received only one comment card. The person had placed a tick in the box to say a contract had been received and on looking through the files of two residents both recently admitted a copy of a signed contract of both the Manager and the resident with term and conditions were in the documents held. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 9 Two assessments were seen of the most recent people to be admitted. Clear evidence of a full assessment was documented. One concern discussed was the admission of one person who had been diagnosed with dementia. This Home does not have a registration for people who have dementia and in the future must not accept people who have this diagnosis. (On meeting and talking with this person who has been at the Home for some months the needs are no different to residents without dementia at present and the Home is able to meet those needs). The resident stated how happy she was and thought the Home was ideal for her. (Requirement) The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents do have a care plan that shows the individual care needs. The resident’s health care needs are met. Residents are protected by the Homes procedures for dealing with medication. Residents are treated with respect and their privacy is upheld. EVIDENCE: The care plans have improved and more information is being placed on the documents. There is a digital photograph of the resident placed in the front of the folder and the evidence by signature (and comments in the recent quality assurance questionnaire) show residents are involved in the review. On talking to residents (4 in total) the care provided is suitable and the care staff help The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 11 when ever they need assistance. One said ‘This is the best place ever’ another ‘I couldn’t be cared for better’. The daily records need to improve to ensure that the information is personalised and not have general comments such as ‘up and washed’ or ‘ate breakfast’. (Recommendation). Each resident is registered with the local GP and the home is visited by the Community Nurses on referral from the GP. The Home has recently had a visit for one resident from the Community Psychiatric Nurse and the local pharmacist is in regular contact with the Home. On talking to the residents in the lounge they are happy with the support they receive from the health service. (One resident spoken to in her bedroom is not so happy with the support and the Manager is trying to help this resident in getting further pain relief as the present pain-killers are not working so well). The medication administration was observed at lunchtime with the correct procedure of checking name, dosage, time and observing of the ingestion, all carried out correctly. On looking at the MAR charts all medication administered had been signed for correctly with no gaps shown on the chart. All staff are trained who administer medication with records seen within training records. The Home does not have a medication fridge or a controlled drugs cabinet and although no resident has a controlled drug at present it would be advisable for the home to have one installed along with a small fridge purchased for items such as eye drops or insulin. (Recommendation) The staff member responsible for medication was using a dinner type trolley to move the medication around the building, which appears unsafe and not watched at all times. A locked medication trolley is required to ensure safety. (Requirement). After discussion with the Manager it was also decided to ensure good safe practise that all returned medication will be checked and signed by two staff members before being placed in the returns container. (Recommendation). Many of the residents have a phone for their own use in their bedrooms and on discussion feel they can have privacy when they require it. Mail was being delivered to a resident during the tour of the building to open in private and doors were open or closed according to the wishes of the residents. While walking from room to room the manager knocked on each door before entering and was welcomed into the room by each resident. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 12 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. The recreational needs of resident’s is growing and the preferences are listened to. Residents do maintain contact with people they wish to but some visitors need more encouragement. Resident’s do have some choice and control over their lives. Meals do appear balanced and wholesome with just some small alterations to the menu to improve them further. EVIDENCE: The Home has listened to comments from some residents and increased the activities available by getting speakers to come in and give interesting talks. (Date for the next talk is March). Over Christmas the Home arranged for the pantomime to be in the evening and invited families but had a poor turn out. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 13 The carols service also was not well attended by friends and families. The Manager has written newsletters and invited people to try to include others but as yet there has been little interest. It may need more thought to think of ways to get families and friends involved such as open days, or cheese and wine evenings. (Recommendation). The residents do appear to enjoy the bowling that takes place regularly with competitions and cups played for. On the day of this visit residents were reading the paper and magazines. Some were having a conversation. One was talking to the bird in the lounge. One gentleman was enjoying his favourite folk music in his bedroom and another building a model with Lego on a big table full of these bricks in his bedroom. The Manager has again asked the residents if they would like to form a committee and have meetings to include their friends and family but no one has shown an interest. (This was a topic in the newsletter). Some residents spoke of the visits from their family and how they have different areas or their own room they can meet and talk in private. Residents are offered choice and issues that involve the home are discussed together. One resident told of the recent discussion about the layout of the lounge/dining room and the moving of some of the furniture ‘it was a 50/50 decision so the room has been changed as a trial, and seems to be pleasing most people’. The residents also have choice over what they would like to eat. The manager had sent a copy of the menu’s with the pre inspection questionnaire which showed some choice although on certain days the choice was still the same meat such as roast chicken or chicken salad. On other days the alternative was soup, which is not ideally a second choice for offering as a main meal. Although the menu’s did not appear to always offer a good choice, on the day of the site visit far more varied ways of serving was evident than shown on the menu. The meal was roast pork or chilli jacket potato yet some had rice with their chilli some had just a jacket potato and the residents who had chosen pork had mash and broccoli. These meals were discussed with the residents who all said the food was good. On talking to the Manager it was decided in the future that soup would be a third choice for those not feeling able to eat a full meal. (Recommendation). The residents are still left out of ear-shot of staff to eat their meal which is their choice but a risk assessment must be in place to ensure that all elements of risk are eliminated as much as possible such as choking. One person said he does not have yoghurt anymore as he cannot remove the top. If a staff member was close by these issues could be resolved. This was a recommendation previously but is now a requirement. (Requirement) The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Although the information is available for relatives to know how to complain they do not always feel they are listened to or acted upon so do not share their concerns. Residents are protected from abuse EVIDENCE: There has been one complaint received at the Commission about the Home since the last key inspection, which has yet to be investigated by Social Services. The Manager told the Inspector that she will deal with complaints appropriately and has recently left copies of the complaints procedure in different areas around the Home. At present these are loose pieces of paper and to ensure the visitors and residents read the notices it has been recommended that a laminated copy be on full display both in the entrance and on the notice board in the lounge. (Recommendation). Since the visit to the Home the Commission has received an anonymous call with a complaint and that they did not wish to contact the Manager as they were very concerned about the repercussions. This causes concerns as to the way Management receive complaints. The actions taken when a concern/complaint is shared and the ways of receiving complaints positively, promptly and effectively needs to be in place to ensure all complaints are dealt The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 15 with appropriately. The Home is now aware of the complaint following a call from the Inspector and is to carry out an investigation and monitoring the concerns with an outcome report to be sent to the Commission. (Recommendation) The residents do also have details of how to complain with their term and conditions on entering the Home. The Manager will not employ a staff member until the POVA registered has been checked and will only allow induction under supervision to take place while awaiting the CRB. A staff member on induction had received the POVA check (Seen). Staff are behind with the training in the Protection Of Vulnerable Adults which is to be part of the training planned for this year but not yet booked. (See staffing standard requirement) The Home has a whistle blowing policy and staff are aware of this policy which is held in the staff room. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 16 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, 20, 21, 24,25 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Home need to ensure service dates are adhered to and not allow dates to expire. Residents do have reasonable areas that they can share that are comfortable. The bathrooms that have been upgraded are suitable but some are still in need of improvement. Some rooms are suitable but others are in need of decorating and improving with better furniture, curtains and carpets. The water supply is good and baths run at the correct temperature. Radiators are now covered but bathrooms with only wall heaters need to improve. Certain areas of the Home appear clean. The surface areas are seen as clean but looking underneath items such as commodes the cleanliness could be improved. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 17 EVIDENCE: The Nunnery is a building that is old in some parts and has been added on to at different times and has some double glazing in parts and old sash windows in another. The general appearance of some of the areas is poor with stained carpets, worn furniture, curtains that are not hanging due to missing fixing, shades not on light bulbs or badly hung. Hooks that once held pictures are still in the walls and one or two rooms have an odour with some commodes stained and dirty. (Requirement). The few rooms that have improved still lack homeliness while awaiting a new resident The areas that have been improved include a new shower room that is light, clean and bright but has nothing in it to make it cosy. The window is without a blind or curtains and no colour is in this white ‘clinical feeling’ type room to make it appear warm and homely. One bedroom in the basement has recently been decorated with a new carpet and the resident has made it very personalised and cosy. The bathroom this person has to use is poor, dark and in need of decorating and brightening up. The toilet on the ground floor has been upgraded and is much improved. Some of the bathrooms have small electric heaters that are not switched on until someone is planning a bath. (To bath someone without time to plan would mean entering in to a cold environment). (Requirement). The fire equipment in the building was due to be serviced in December 2006 and is overdue. The Manager had received a letter from the company who are to visit in February to carry out the service. Service due dates should be added to a diary to prompt reminders and not allow dates to expire. (Recommendation). The temperature of the bath water was hand checked and ran at a temperature to make bathing safe. There is also a thermometer in the bathroom and staff check the water temperature before someone is bathed (records not seen). The Manager has just completed buying radiator covers for all the radiators with some already fixed and some waiting to be fixed and painted and was a requirement outstanding from the last inspection. The laundry has one washing machine that is of an industrial type and will heat to a sluice temperature wash. The tumble dryer is in the area where clothes are ironed and aired. All bed linen is sent to an outside laundry. Some parts of the Home are clean but more in-depth thorough cleaning such as cleaning commodes, shampooing carpets and regular cleaning of upholstery needs to be part of a regular cleaning routine. (Requirement) The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 18 The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff do have the skill but numbers need to be increased especially at weekends and before more residents are offered a place. Residents are in safe hands. The Home does follow a good procedure for recruitment that protects the residents. Staff are trained and competent to do their jobs. EVIDENCE: The Manager had sent a partially completed copy of the staffing rota. On discussion the weekends do cause concern with only two staff members on duty plus a cook to care for 15 residents (no Manager and no domestics). Once the cook leaves in the afternoon there is only two staff members. (Requirement) As the rota stands and looking at the type of needs the residents have, this rota is just adequate for the 15 residents who are at present living at The Nunnery during the week. If the number of residents goes higher or a resident is admitted with high care needs the staffing levels will need to be reviewed again. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 20 The Home has 50 of the staff who have gained the NVQ qualification. The manager does not employ agency staff at present. On the day of the site visit a new staff member was shadowing the care staff on his second shift. The file for this person was looked through. All the correct paperwork was in place except for a work related reference. (Two from friends had been received and the Manager was liaising with this persons last employment which was in 2004). The Pova check, three forms of ID and an application form were all in place. The Manager values training and ensures staff have the opportunity to develop their skills. A copy of all the training attended since staff were first employed was shared. It was noted that some health and safety training such as infection control and fire safety were overdue and on discussion this was noted to be planned for the next three months.(Seen) The one training not yet planned is the POVA training that needs to be booked for all staff as soon as possible. (Requirement). One staff member is taking a Management training course as he would eventually like to be a Manager and on talking to this person the course is going very well and he is encouraged by the Home Manager to do well. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents do live in a home that is managed by a person who is fit to be in charge. The Home is beginning to measure the quality, taking note of the best interests of residents. The Home does not get involved in any of the residents personal money. The health, safety and welfare of residents and staff are protected. EVIDENCE: The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 22 The Manager has been in the position for many years and has the understanding and qualifications of the role of a Manager. She is working on a training course at the present and is about to go with the care staff on a days training on visual awareness. (At the end of the last year the team went on a days training on dementia). She is only registered for the one Home and is also the owner. Over the past nine months the Inspector has visited five times to ensure the Home improves and meets standards set. The quality assurance monitoring system implemented has helped move the Home towards improvement. Questionnaires had been sent to all families and relatives in the autumn with a total of 8 returned. The Manager had concentrated on the National Minimum Standards and worded the questions around the standards up to number 12. The aim is to send out questionnaires three monthly and by the end of the year they will have covered all the 38 standards. The results of this recent survey, has been placed in the Nunnery Decembers newsletter and left in the entrance and around the Home for all interested parties to read. The positive action that came from this monitoring was to ensure the complaints procedure is more evident around the Home so people understand clearly how to complain. The Home does not handle, directly, resident’s personal money. Any items purchased, hair done, newspapers read, chiropody etc is paid for by the Home and then a bill is sent to the families who have the responsibility of the residents finances. Some residents manage their own money and do not require assistance. The Homes manager has a stable staff team that are aware of health and safety. This was observed throughout the day. One small concern was shared over the hoisting practice of two residents and will be discussed with the team to ensure best practice is in place. The training planned and the training that has taken place over the past year covers all areas of health and safety such as moving and handling, first aid, infection control, food handling and fire training. The chemicals used for cleaning in the Home all have a safety data sheet held in a folder accessible to all staff that was seen and complies with COSHH regulations. The Manager had received a whole new set of safety data sheets in the post on the day of the inspection to replace the out of date ones. When a domestic staff member was seen at one of the previous visits she knew where the safety data sheets were and understood what COSHH stood for. Servicing of appliances for the gas, water and lift were all dated within the past 6 months and all the invoices for the work was seen. The Environmental Health Officer had also visited twice in the last twelve months after two falls had caused injury. Both report letters were seen and showed there were no concerns within the environment that could have contributed to the falls. The accident reporting forms were seen and appeared correct. The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 23 The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 2 2 x x 2 2 1 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 The Nunnery DS0000036034.V327863.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 OP3 Regulation 14.1 c Requirement The Registered Manager must ensure the potential residents assessed, prior to admission, are discussed fully with the professionals involved so someone entering the Home is within the registration category. The Registered person must ensure medication is moved around the Home in a locked trolley that is suitable for safe administration of medication. The Registered Manager must complete a risk assessment for the mealtimes to ensure all needs are met during this period and any potential risk is eliminated. The Registered Manager must ensure that the Home is reasonable decorated and items damaged or missing be replaced. The Registered Manager must ensure adequate heating is available and constant in the bathrooms. The Registered Manager must ensure ALL areas of the Home are kept clean DS0000036034.V327863.R01.S.doc Timescale for action 01/03/07 2 OP9 13.2 01/04/07 3 OP15 13.3.b 01/03/07 4 OP19 23.2.d 01/04/07 5 OP25 23.2.p 01/05/07 6 OP26 23.2.d 01/03/07 The Nunnery Version 5.2 Page 26 7 OP27 18.1.a 8 OP30 18.1.c i The Registered Manager must increase the staffing levels throughout waking hours at the weekends to ensure three staff members are on duty. The registered Manager must ensure that all staff are trained in the Protection of Vulnerable Adults. 01/03/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations Staff should be offered training to help them complete daily records that include social activities in a professional, informative, person centred manner. To ensure a safe audit trail is in place for medication returns two staff signatures should be in place on returns records. The Manager should purchase a small fridge and a controlled drugs cupboard for future use. (Kitchen fridge can only be used if the medication items are in a locked container in the fridge). The Manager should think of fresh ideas on how to get families and friends more involved within the Home. The Manager should display the complaints procedure more effectively to ensure the customers see it clearly. The Manager should think about ways to make anyone who wishes to complain feel able to do so. The Manager needs to think of a method that will ensure any equipment that needs servicing does not miss the due date. 4 5 6 7 OP13 OP16 OP16 OP19 The Nunnery DS0000036034.V327863.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Nunnery DS0000036034.V327863.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. 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