Inspection on 20/04/06 for The Nunnery

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

Other inspections for this house

The Nunnery 13/01/09

The Nunnery 19/12/07

The Nunnery 15/05/07

The Nunnery 17/01/07

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 The Nunnery 14 Denmark Street Diss Norfolk IP22 4LE Lead Inspector Ruth Hannent Unannounced Inspection 20th April 2006 9.00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 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.V291066.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Nunnery Address The Nunnery 14 Denmark Street Diss Norfolk IP22 4LE 01379 643201 01379 642649 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 Jane Mewse Mrs Jane Mewse 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.V291066.R01.S.doc Version 5.1 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. 23rd November 2005 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 £350 to £500 per week Email address is ‘thenunnery@aol.com’ The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In total 16 residents were residing at The Nunnery at the time of this unannounced inspection. The inspection took place over two days with a total of 10 hours spent in the building. Two care staff, one cook and one housekeeper were on duty with a senior carer arriving at 9.30 on the first day of the inspection. As the manager was on leave, a second day was required to complete the report and was carried out four days later. Staff were spoken to on arrival and most of the first day was spent with the residents gaining a full picture of the care offered within the Home. A tour of the building took place. A lunchtime meal was eaten with eleven residents. The Inspector had not received the pre inspection questionnaire and no comment cards had been received from residents or visitors. Records held at the commission show the paperwork was posted on the 23rd March 2006. (The ones that should have been issued were seen in the staff room during the inspection). The Manager had returned an action plan on the 30th January 2006 to the Commission following the enforcement visit on the 23rd November 2005 and a meeting with the Regulation Manager and Inspector on 20th January 2006. Although the dates for these actions to be completed were written by the Manager to include and up to the 31st March 2006 only some actions had been carried out by this date with many still outstanding or incomplete. By the date of this inspection and as written in the last report five requirements had been issued on previous inspection reports with two immediate requirements made. (These two have now been actioned). Three personnel files were looked at and some training records were seen. A visitor was spoken to and a professional worker was contacted prior to the inspection What the service does well: The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 6 The Manager who is an NVQ assessor has now seven staff who have achieved the NVQ qualification with another two starting the training this month and one more planned for September.. What has improved since the last inspection? What they could do better: The Manager has once again not taken the action required to ensure the standards in the Home are changed and improved as listed in the previous report. Resident’s care plans need to hold detailed information to include social care and aims and objectives for individual person centred care. Ways of gaining views of residents and families need to be developed. A draft of a questionnaire was discussed with the Inspector but needs to be changed to move away from yes/no type answers and to involve all parties in the improvement and development of the service. As mentioned in a previous report this Home needs to a plan of action for the improvement/decoration of the property to bring the environment up to an acceptable standard, especially the downstairs bathrooms. The Manager needs to ensure that when requirements by the Commission are placed that the date for completion is met and not seen as an outstanding requirement. The Home needs to be clearer when making judgements or consulting with residents that records are kept to evidence that they have been actively involved or families spoken to in relation to the care provided. The home needs to extend the way it offers choice of meals to include the midday meal. (Teatime choices are already available). The procedure for the recruitment of staff still needs to be improved as mentioned in the previous inspection, as references for staff were not on file. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 7 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 Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The quality of this outcome is poor. This judgement has been made using available evidence including a visit to the service. Residents are assessed for the care requirements but more detail is still needed on the support required for the care that would be required. Residents are not admitted for intermediate care. EVIDENCE: The care plans were looked at with evidence that each person had been assessed prior to admission and each care plan had details under headings as stated in the National Minimum Standards, including personal care, weight and diet requirements, continence, medication list and mental state. The aims and long-term outcomes for each resident were not written and of three care plans seen where information had been obtained from the assessment there were no details regarding the persons history or social needs that should be met. The assessment of individuals is necessary as previously a resident had been admitted who was unsuitable and not within the care provision of this particular home. (Requirement) The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 10 On talking to the Senior Staff member it was understood that people can be admitted for short-term care to receive respite support if required, however she was unable to show any paperwork/policies that would promote and maximise any person with independent skills in the aim to get them back home. “They are helped in the same way as all the other residents and people who have come for a short stay have ended up usually staying”. The Manager also explained that on occasions residents have been admitted for short-term respite but not for intermediate care therefore standard six does not apply. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The holistic picture for all care needs for residents are not held within the care plans and no evidence of involvement of the resident was seen. Resident’s health care needs are met. Resident’s are protected by the correct procedures of the Home with medication. Residents are not always treated with respect or their privacy upheld. EVIDENCE: The care plans are computerised with a clear format that gives some details of requirements of each resident. One resident was noted to have the weight recorded on a weight chart due to concerns over the small amount of food eaten. Another showed a recent change for one person and the new requirements of care was listed. On talking to this resident it was currently the care required. Although these forms were clear there was limited information The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 12 written on many sheets and to find the correct page for information was difficult. Some paperwork was missing signatures and dates. On searching through three care plans there was no recording of the social care support and stimulation that could be included. On the Inspector talking to one of the residents, a large amount of information was offered on the person’s social history, but nothing had been recorded in the care plan and since arrival this person has not received any stimulation that reflects their past. There was no evidence of signatures or family involvement in the collating or reviewing of the care plans. One care plan did say resident unable to sign (Outstanding Requirement) The care plans are held in an office cupboard and on talking to some residents they did not understand what their care plan really was. (Recommendation) Each resident is registered with the local GP. and the District Nurse team visit regularly. Records are held in the office and residents were able to talk about the visiting nurse. It was noted that in the daily records any medical intervention is highlighted to draw staff’s attention to any outcome of a visit and any follow up action that may be required. The chiropodist visits every six weeks and a Community Psychiatric Nurse visits as and when required. The medication is in a blister pack system and provided by a pharmacist approximately ten miles away. (Any urgent medication is collected by staff from the local pharmacist). The records are held on pre printed MAR charts that were seen and had been completed correctly. It was noted that medication issued as PRN had not been initialled or a code placed in the relevant box. To ensure that resident are asked if they would like pain relief it is (Recommended) that all boxes are completed. No one at present is on controlled medication. The trolley is kept locked and one resident who has some medication by the chair in the bedroom now has a key and lockable drawer where the medication is stored. This resident made a point of telling the Inspector that “I hold my own Key”. This was evident on the person’s care plan. The lunchtime medication procedure was observed and the carer responsible carried out the tasks appropriately. Two different residents spoken to are happy that the responsibility of remembering their medication is now carried out by staff members. Throughout observation it was noted that on two occasions staff entered residents rooms without knocking. On talking to the residents, they do not say anything because they think that is how it is and do like to say. One resident stated she is ordered about, giving an example of being told to ‘sit down’. Another resident has had the phone disconnected instead of being offered a cordless one as at present her mobility is poor and she has tripped over once. The staff were thinking about her safety, when questioned, but had not thought about the loss of some of her independence. On talking with this person it was evident that she needs to keep in touch with friends who live far away. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 13 Fingernails are long on a person who until recently could cut their own but is now needing help and on day one of the inspection was appearing unkempt yet on day two was appearing much smarter and happier on questioning of her appearance. Consistency of the care offered is important. Another resident has her bath day as a Monday but whenever there is a bank holiday she is told she cannot have her bath. (Requirement) The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14 and 15 The quality of this outcome is poor. This judgement has been made using available evidence including a visit to the service. Residents who are self motivated do have a lifestyle that matches their expectations. Those who need encouragement do not. Visitors, friends and families do come and go and remain in contact as they wish. Some residents do exercise choice and control over their lives. The meals are not always appealing and the room is not ideal. EVIDENCE: As mentioned earlier in the report the care plans show little information about the social needs of individual residents. The age range of the residents vary greatly with no evidence of the various care needs to suit the wide age range. It was noted that one person was going to have support to meet his social needs as written by the Social Worker but this was not evident. The conversations, held on the day of the inspection with residents told many a story of their past life and interests but nothing was on record. Some talked about the occasional bowls and sing a long but ‘some of us have different The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 15 interests’. One person has his interest in building construction in his bedroom, one person was on their way out, another lady has a paper and does the crossword but these are meaningful activities driven by themselves through self-motivation. Quite a few of the residents were seen just to be sitting or asleep. No sounds were heard. No radio, tape or televisions were on. (Past requirement). Visitors are welcomed, although one resident said they are not always offered a drink even when the Home knows they have travelled from a distance. Two visitors spoken to just prior to the inspection shared a concern about staff lacking the understanding of quality care and that sometimes there is a tension between the staff in the building. No comment cards were received on this occasion. Residents do have the option to bring possessions with them. One particularly large room has been personalised by the resident with all her own furniture and as this room has a patio door her dog has come too with easy access to the grounds. A meal was taken with the residents at lunchtime of steak and onion pie, mash potatoes, broccoli and mixed vegetables with crème caramel to follow. The eleven people in the dining area had no idea what was for dinner until the whole meal was placed in front of them. Many of them were not happy with some of the meals and they are never offered a lunchtime choice. (Past Requirement) Liquidized meals are all in one bowl, which gave an appearance of pea soup. On discussing this with the manager this is how the resident likes her meals but no evidence was seen of when this consultation took place. No menu’s were to be seen and according to the residents a meal is just placed in front of them and they have no idea what is for dinner before hand. It was certainly apparent on the inspection day that staff disappear throughout the whole meal period. The staff area being the other end of the building is of concern especially as before the meal a staff member explained that two residents sit away from the main table as they have problems swallowing. No one was within easy reach of a call bell if someone required assistance urgently and throughout the half hour meal no staff entered the area. No risk assessment had been completed and on discussion with the Manager it was apparent that the possible risk must be addressed. (Requirement) A choice is available at tea-time that is prepared by the care staff such as various sandwiches or salads and breakfast is served in all residents bedrooms. (Toast is cold and hard).One resident stated that she may ask for cornflakes and ends up with weetabix and is told they have run out. “But this happens quite often”. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 16 Although the main meal is now eaten in the large lounge, the opinion shared by the eleven diners with the Inspector, of eating in the dining room or lounge was divided. The residents who prefer the dining room think it is cosier and nearer the kitchen to deliver the food quicker and hotter. No one talked throughout the meal and when asked if they felt it difficult to talk as the Inspector was there it was explained they do not hear each other so they eat and then go back to their rooms with very little conversation taking place. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality of this outcome area is poor. The judgement has been made using available evidence including a visit to the service. Although concerns/complaints are listened to they are not always acted upon. Residents are protected from abuse. EVIDENCE: According to the senior staff on duty the Home has not received a complaint for many years. On talking to the residents, if they are not happy with everything, they will talk to the manager. Although their concerns/complaints are listened to they feel little is acted upon or changed and they are unwilling to pursue the complaint in fear of repercussions. On two occasions the Inspector was told, “I won’t be able to stay here if I say anything”. These kind of comments were reflected in the last inspection report and this does not instil confidence in the residents if their opinions are not taken seriously and acted upon. (Requirement) Although staff have an understanding of abuse which was identified throughout conversations no official training on the protection of vulnerable has taken place. The residents feel the staff generally treat them well and have never had cause for concern. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23, 25 and 26 The quality of this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The safety of the environment has improved but fire risk assessments must be in place as required previously. The facilities are still not suitable. The majority of the rooms suit the needs of the residents. The heating and lighting is inadequate. The Home appeared clean in parts but with poor/damaged surfaces to clean it was not always easy to tell. EVIDENCE: The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 19 The Fire department has visited the Home and all appliances have been serviced with a date of December 2005 noted on each extinguisher. The manager has yet to complete the fire risk assessments for all areas and appliances in the building. The fire officer has offered guidance but the completed document has not be finished. (Outstanding requirement). The upstairs bathrooms are near completion but although painted and fresh have no warmth by appearance or heat (The only heater is a wall electric heater which is only on when people have a bath). The residents who just wish to use the toilet move from a warm bedroom along a corridor and into a cold bathroom. The downstairs bathrooms, especially the one by the lounge is in a very poor state with the area around the toilet mouldy and difficult to clean. (Requirement). Some bedrooms have en-suite facilities that, has enhanced the room and offers privacy for residents. The majority of residents were pleased with their bedrooms and many had a nice view from the bedroom window. The heating throughout the building is covered by three different systems. Radiators, storage heaters and wall fan heaters. (One corridor was noted to have no heating). The majority of heaters are uncovered and on touching many radiators it was noted how hot they were. (Requirement). It was also noted how some corridor areas only held sixty watt light bulbs which made the area with no natural light difficult to see. (Recommendation). The Home had no offensive smell and the Home appeared clean, although due to some of the areas being in a poor state it was difficult to say if the area was clean or not. The laundry is suitable and is used only for personal clothing. On the day of the inspection two bags of linen and towels were waiting to be collected. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A copy of the hours worked and by whom, needs to be available as an ongoing rota to check day and night staff cover. Residents are assisted by some staff who are qualified. Without evidence residents may not be protected by the Home’s recruitment practices. Training needs to be updated and relevant. EVIDENCE: On the staff room wall is a copy of the name of the staff on duty but no evidence of the hours to work or who was covering nights and weekends. The rota and hours worked is according to the Manager available on the computer but was not produced as evidence and is an (Outstanding requirement). On the day of the inspection there appeared to be enough staff on duty but when the hours of work were discussed there did appear times of day that the level was inappropriate. Without evidence of a rota this could not be checked. The manager has a good level of staff with NVQ qualifications and is aiming for another three staff to complete this year. Staff in discussion confirmed the The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 21 qualification, certificates were seen and the Inspector was showed the books for the next two candidates ready to start. The manager has still to obtain two written references for staff. Three files were looked and of the three one had written references, the others only had a verbal record taken by phone. (Outstanding requirement). All three CRB’s were in the file and all had a POVA check. Identification of the staff was noted by passports, birth certificates and one with a photograph held in individual files. On discussion with the Manager all staff now have CRB’s and new staff will not be unsupervised while awaiting the disclosure. (POVA checks are done immediately). The training of staff at the appropriate times is still to be planned. The Manager had arranged some joint training with another Home but this had not happened. Dates for COSHH training are planned for May but statutory training such as moving and handling is overdue. Staff files hold certificates of training completed but some need refresher courses. (Requirement). Induction packs and skills for care paperwork is now in the Home and will be implemented thoroughly with new staff. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37 and 38 The quality of this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The Manager needs to be more organised in her management responsibilities and ensure they are carried out fully. A quality assurance system to assist an annual action plan must be put in place. Staff must receive appropriate supervision. All record keeping and reporting as stated under this standard must occur. The health, safety and welfare of residents not always protected. EVIDENCE: The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 23 The Manager has owned and managed The Nunnery for many years. She has achieved the certificate ‘Btec Higher Diploma of Management of Care Services. Level 4 and is also an assessor for NVQ candidates. The result of achieving these qualifications should show a service run competently and with quality but as reflected over the last few inspection reports this is not evident. The Manager showed the recently compiled questionnaire that was to have been distributed and collated by the end of March but to date had not gone to residents to form part of the quality assurance process. No questionnaire had been devised for relatives/friends or visiting professionals. The collating of information, the outcomes and action plan had not been thought through and is overdue to show effective quality monitoring of the service. (Outstanding requirement). All residents or their families have responsibility of handling the residents finance. The home does not handle any money and residents are billed directly for papers, chiropody, hairdresser etc. Staff supervision is still not happening and this is an (outstanding requirement) from the last three inspection. The manager stated it would be carried out in February but to date has not happened. The Manager had sent some regulation records required on the death of residents but a recent event for one person resulting in a broken leg had not been notified to the Commission. (Outstanding Requirement). The health and safety of all people within The Nunnery are potentially at some risk. Not all staff are trained and up to date. The storing of cleaning chemicals in unlocked cupboards in various areas is against COSHH guidance. (Immediate requirement) The water temperature from sink taps was too hot although bath water checked was regulated and when tested by hand was at the correct temperature. The covers for radiators/storage heaters are not in place. Risk assessment for safe working practices for all areas of the work are not in place. Fire risk assessments are not in place. All accidents, injuries and incidents are not recorded and reported. The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 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 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X 1 X 3 X 1 2 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 1 1 1 The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 25 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 OP33 Regulation 14 and 15 Schedule 1 (9) Requirement Timescale for action 01/07/06 2. OP10 3 OP12 4 OP15 5 OP15 The registered person must ensure that all information is gathered on assessment and added to care plans to also reflect the social care support required for each resident and all care plans reviewed regularly (Outstanding requirement x 3). 15 c and d The registered person must ensure that through consultation the care required by residents is adhered to 16 m The registered person must ensure that residents do pursue social interests and activities for these needs to be met. (Outstanding requirement) 16 i The registered person must ensure residents are consulted and informed of choice of meals that is varied and properly prepared. (Outstanding requirement) 13.4 c The registered person must ensure that risk assessments are in place for people who may be at risk (Risk identified at mealtimes) DS0000036034.V291066.R01.S.doc 01/06/06 01/07/06 01/07/06 01/07/06 The Nunnery Version 5.1 Page 26 6 OP16 22 7 OP19 23.4 8 OP21 23 2 d 9 OP25 13 3 a 10 OP27 17 2, 18 Schedule 4 and 7 11 OP29 19, 13 6 12 OP30 18 1 13 OP33 24 14 OP36 18 2 The registered person will ensure that all comments/complaints are taken seriously and acted upon with all residents involved consulted and kept up to date. The registered person must ensure that fire risk assessments are in place as directed by the fire officer. (Outstanding requirement) The registered person must ensure the Home is decorated/furnished to a standard that allows good cleaning practice to take place. The registered person must ensure that the heaters/radiators within the building are guarded to eliminate the risk of burning The registered person must keep a duty roster for all hours worked for every staff member, including cover for when there is sickness/annual leave or training. (Outstanding requirement) The registered person must hold two written references for each staff member before employment can commence. (Outstanding requirement) The registered person must ensure that all staff are up to date with all relevant training and able to offer the current care practise expected. The registered person must implement a monitoring system for measuring and improving quality within the service. An action plan of how the service is going to improve is to be submitted to the Commission. (Outstanding requirement) The registered person must show records of how staff supervision is carried out. (Outstanding requirement (3) DS0000036034.V291066.R01.S.doc 01/07/06 01/07/06 01/08/06 01/09/06 01/07/06 01/07/06 01/09/06 01/08/06 01/08/06 The Nunnery Version 5.1 Page 27 15 OP37 37 16 OP38 13 4 a The registered person must 01/07/06 supply a written record of every death, illness and adverse event to the commission without delay The registered person will ensure 20/04/06 that all staff are aware of locking away cleaning chemicals and any items that may be a potential risk when not in use. (Immediate requirement) 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 OP9 Good Practice Recommendations All residents should be asked if they need their PRN medication and some form of record, or if administered, signature should be in every box on the MAR chart with no gaps. It is recommended that the 60 watt light bulbs within the home, especially where there is no natural light be replaced by a higher wattage to ensure people can see clearly. It is recommended that all care plans are available in residents rooms and not stored in the staff room to enable residents to have ownership of the document and understand what their care plans is all about. 2 OP25 3 OP7 The Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Nunnery DS0000036034.V291066.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!