Inspection on 17/10/07 for Ticehurst Nursing Home

This inspection was carried out on 17th October 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

Ticehurst Nursing Home 29/01/07

Ticehurst Nursing Home 16/01/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Ticehurst Nursing Home Whitchurch Close Aldershot Hampshire GU11 3RX Lead Inspector Pat Griffiths Key Unannounced Inspection 17th October 2007 10:00 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 Ticehurst Nursing Home DS0000063269.V347349.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. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ticehurst Nursing Home Address Whitchurch Close Aldershot Hampshire GU11 3RX 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) 01252 311832 Hampshire County Council Daphne Paviour Care Home with nursing 48 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (48) of places Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 Brief Description of the Service: Ticehurst care home is a purpose built care home, which was an initiative between Hampshire County Council, Hart Primary Care Trust and Blackwater Valley. The home is in Whitchurch Close, Aldershot, in a residential area close to local shops and other amenities. The home was initially registered in March 2005 but has recently re-registered to combine the two wings, there is one registered manager and a senior nurse is in charge of the nursing wing. The home will continue to provide accommodation for up to forty-eight older persons who may have dementia and need nursing care in one wing and for up thirty-six older people who may have dementia and need personal care, but not nursing, in the other. There are corridors on each floor connecting both wings. The kitchen and laundry facilities are shared by both wings and are situated in the non-nursing wing. There is a secure garden that is accessible by residents from both wings. Accommodation in the nursing wing is provided on two floors with stairs and lifts giving access to each floor. The accommodation is divided into five units, three on the first floor and two on the ground floor. Each unit has a number of bedrooms, a lounge with dining area, kitchenette and bathroom and toilet facilities. Residents are provided with single bedrooms that are fitted with ensuite facilities. Additional seating areas are situated around the home and there are also offices and staff rooms. The manager told us that the weekly fees are currently £446 for nursing care and £434 per week for those that require personal care. Hairdressing and personal toiletries are paid for separately. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site inspection visit to Ticehurst care home, which was unannounced, took place over a one-day period on the 17th October 2007 and was attended by one inspector. The registered manager, Mrs D Paviour was present in the home and assisted throughout the inspection. The visit to the home formed part of the process of the inspecting the service to measure it against the key national minimum standards. The manager had returned the Annual Quality Assurance Assessment (AQAA) to the CSCI and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit, which was a key inspection made to the home in January 2007. Documents and records were examined and staff working practices were observed where this was possible without being intrusive. We were able to see different parts of the home, such as the different lounges, kitchenettes, dining room, bathrooms, the garden and some of the bedrooms and spoke to most of the residents, staff and visiting relatives in order to obtain their perceptions of the service the home provides. Those spoken to were generally complimentary about the care and services that are provided, but did voice some criticisms that have been discussed in the body of the report and with the registered manager. At the time of the inspection the nursing wing home was accommodating 46 residents. A number of residents were unwell and unable to communicate effectively with us so that we could gain their views of the service. There were no residents from an ethnic minority group. What the service does well: The home has a comprehensive pre-admission assessment document that is completed with the potential residents and/or their relatives and further information is shared by the care managers if they are involved. Detailed assessments and care plans are in place but are disorganised. They provide nursing and care staff information that enables them to provide the help that residents need. Residents feel safe and secure and are happy that staff could look after them properly and feel they are treated with respect. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 6 The home promoted the rights of residents to make choices for themselves and exercise personal autonomy as far as was reasonably possible. Quality assurance systems and management procedures work well in the home and include dealing with complaints and monitoring standards, the environment and health and safety matters. Robust procedures are used for the recruitment of new staff. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks were completed before staff were able to commence work at the home to ensure the safety of residents Relatives and staff meetings are held regularly to allow an open and inclusive ethos in the management of the home, where residents, relatives and staff are consulted on decisions about the quality of the service and suggestions for improving the quality of the life of the residents. The environment is pleasant and well maintained with an ongoing maintenance programme in place. Visitors commented to us ‘I am happy with the care they give my Mum’ ‘staff are very caring – lovely people’ ‘the cleaner deserves a medal’ ‘ attention to detail - nothing is too much trouble’ What has improved since the last inspection? An action point was raised at the visit as care plans that had been seen had not been updated with changes in the needs of some of the residents. The care plans are being reviewed and updated fairly regularly now, but are disorganised and efficiently managed. New care plan documentation is due to be implemented soon. Twelve of the carers have obtained National Vocational Qualifications (NVQ) level 2 or above. A further three carers have recently started the training, a further three will start in January and the senior nurse has applied to do an NVQ4 in management. Staff supervision is now being held at least six times a year and is done as practice-based observation and as one-to- one meeting. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 7 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. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 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 Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People wishing to use this service benefit from a comprehensive pre-admission assessment of their needs before moving into the home. The home does not provide intermediate care. EVIDENCE: The home has recently been re-registered as one home with two wings, one providing nursing care and the other only personal care. The new statement of purpose explains that the home will provide personal care and care with nursing for older persons with dementia. There is accommodation for a total of eighty-six people of either sex over the age of sixty-five. It also explains that all prospective residents will have a pre-admission assessment, usually coordinated by the care manager in the Adult Services area office, to ensure that the home can meet their personal and care needs. The registered manager Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 10 said that a written contract outlining the terms and conditions of residency at the home was provided for each resident on admission. The senior nurse told us that she undertakes the pre-admission assessments for prospective residents that may need nursing care. These assessments are usually completed in hospital and occasionally in the persons own home. Assessments were seen for four residents and were found to include information such as their personal care needs and physical well being, sight, hearing, mobility and dexterity, medication, mental state and cognition, social contacts and relationships. The records seen indicated that relevant information was also obtained from health professionals and care managers as well as from the prospective resident and their relatives. The home has two beds allocated for interim care but these are sometimes used for respite care. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans usually provide sufficient information to ensure that the people in the home have all their needs met, especially those with complex health care issues. Staff medication administration practices protect the residents. EVIDENCE: The care plans of four people living in the home were looked at, one was for a resident who had recently moved into the home. The files we saw were very badly organised, information regarding the care of a wound, fluid balance, ‘turning’ charts and diabetic blood sugar tests were not in the individual personal files but in the desk diary in the nurses office as staff said it was easier to remember them when they were there. All care plan information was in plastic sleeves in the files and some of them had been stapled together, making it very difficult for staff to read them. The care plans that were seen in the files contained very detailed assessments, but it was not always easy to Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 12 see the relevant information that was actually needed to provide care or support and some did not actually have plans of care. One of the care plans was for someone who had been admitted three months before our visit, but there was no evidence to suggest that their plans had been reviewed or amended since their admission. Other plans that were seen had been reviewed fairly regularly. A daily record is kept of all care and support provided by the staff and this is kept in a separate file that is completed daily by the staff and used for handover purposes at each change of shift. The staff felt that this was a satisfactory way to provide a continuity of care as any changes were documented and discussed amongst staff to ensure they were all aware of the residents care needs. Records seen indicated that GPs and other health professionals such as occupational therapists visited as required and made notes on separate pages in the files. An action point was raised at the last inspection for the care plans to be kept under review to reflect the changing needs of the residents. The manager told us that new care plans are being implemented very soon and she had been assured that they would be easier for the staff to use. Because of the proposed change in the care plan documentation nothing much had been done to improve the current care plan system. The home has clear procedures in place for dealing with medication. Medication records were seen and had been completed appropriately, with no gaps in the signatures. There was also an up to date photograph of each resident on his or her individual medication administration record [MAR] sheet. Systems were in place for recording medicines brought into the home and those for disposal. We looked in the medicines trolley and it was apparent that each resident had their own supply of medicines in individual blister packs, and other medicines such as panadol or lactulose, which are not in the individual packs, were not given from a communal supply. None of the residents at the home were currently self administering their own medicines. Residents and their relatives that spoke with to us felt that staff supported them well and made sure they were able to maintain their privacy and dignity as much as possible within the home. Staff were seen speaking quietly and appropriately to the residents during the course of the day. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 13 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. People who use this service have good quality food and their diverse needs are generally well supported EVIDENCE: The people who live in the home are encouraged to maintain contact with their friends and families. Residents told us that felt they were able to receive visitors at any time and that their visitors were welcomed into the home. The visitors’ policy was clear about the rights of residents to receive visitors and to meet with them in private. There are several lounge/dining rooms on each floor in the home where people could meet their visitors or they could chat in their bedrooms. Food in the home is provided centrally, from the kitchen in the non-nursing wing of the home by Hampshire County Councils catering staff [HC3S ], and staff involved in the preparation and serving of food in the home were Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 14 separate from and additional to the care staff. The manager said that menu planning and special diets information was available to assist with menu planning. The food is taken in a hot food trolley to the two wings of the home and the meals seen were hot and looked appetising. Staff support was available throughout the mealtime for people who needed it and this support was provided in a discreet, respectful and sensitive manner. The manager told us that activities are available in the home for the residents, but the home does not currently employ an activities organiser. The activities are done in small groups as there are no large communal areas, which sometimes means that visiting entertainers have to move between the different lounge areas to ensure that everyone sees or hears them. Activities that are currently provided include visiting musicians, painting, singa-longs, manicures and hairdressing. We were told that currently no records are kept of any of the activities or who joined in, but we were told that a member of staff is interested in developing the range of activities in the home and advice and training is being sought. During the summer a garden party was held, which was very popular as the staff dressed up as ‘singing waiters’ to entertain everyone. Activities that are planned include a puppet show, a Halloween party and an afternoon of traditional Philippine singing and a Christmas party. The manager said that a ‘Friends of Ticehurst’ group is being formed and it will raise funds to pay for outings, entertainment and activities in the home. We were told that none of the residents currently go to church, but ministers from the local churches visit the home. The home has recently started a newsletter and the October edition contained information about a fancy dress Halloween ‘bash’, a Christmas party and the monthly relatives meetings. Greetings were extended to a new resident and a new member of staff and resident’s birthdays were acknowledged. Requests were also made for contributions for future editions, such as jokes, quizzes or crossword puzzles. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training in adult protection, and the knowledge that all complaints are dealt with appropriately usually safeguard the people who use this service.. EVIDENCE: The home has a complaints procedure in place, which encourages residents or their friends and relatives to make complaints if they are not happy about the service they have received. A complaints folder was seen by the visitor’s book on the desk in reception, which was for visitors to register any complaints. Many of the complaints had not been acknowledged and there was no evidence that anything had been done about them or even if the book had been looked at. We discussed the lack of confidentiality and the possible lack of confidence people may have about the complaints process. The manager told us that the practice would be reviewed and amended to ensure confidentiality and to reassure complainants that their comments or concerns were taken seriously and acted upon. We have received information regarding complaints made to the registered manager, highlighting some concerns about the quality of care provided at the home, which we discussed with the manager. We were told that the complaints Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 16 had been investigated and the matter resolved. We were also told that there is a dedicated accident and incident reporting system. The procedures in the home for responding to instances of suspected abuse were clear and staff spoken with were clear about their role within the procedures and about the nature of abuse. Training records demonstrated that all staff received training on abuse issues as part of their induction as well as further, ongoing training throughout their employment Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service live in a safe, well maintained, clean, and hygienic home. EVIDENCE: The home is purpose-built on two floors, and the nursing wing shares the grounds with the non-nursing/residential wing and there are corridors on both floors connecting the two wings. The nursing and residential wings share the kitchen and laundry facilities which are situated in the residential wing. The nursing home accommodation is divided into five units, three on the first floor and two on the ground floor. All the residents have single bedrooms with en-suite facilities. Each unit has a lounge with dining area and kitchenette Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 18 where staff are able to prepare light snacks for residents as required. Each unit also has a bathroom with assisted bath and separate lavatory. Some rooms on the ground floor were fitted with overhead hoists and other specialist equipment such as mobile hoists and pressure-relieving mattresses are available. The decoration of the home and the furniture provided in the home were of good quality and contributed to the comfortable, homely feel in the building. During the visit the inspector saw different parts of the home, which included the communal areas and some of the bedrooms. Bedrooms that we saw had been personalised with pictures and ornaments and the manager said that if there was room, potential residents were able to bring small items of furniture with them when they moved in to the home. On the day of the visit the home was seen to be clean and tidy, with no malodours. The care staff in the home are supported by cleaners, laundry and kitchen staff. There is also a smoking room for residents who wish to smoke and smaller lounges used for meetings such as review meetings with care managers. A secure and enclosed garden is situated between the two homes and is accessible to all residents. We were told that bird feeders and boxes have been erected and the residents enjoy watching the wildlife that visits the gardens. Ticehurst Nursing Home DS0000063269.V347349.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 good. This judgement has been made using available evidence including a visit to this service. Robust recruitment practices and staff training protect people who use this service. EVIDENCE: The AQAA indicates that the home has thirty-eight full-time and seven parttime nursing and care staff, fifteen of whom are registered nurses, providing care for forty-four residents. The manager told us that the calculations for staffing numbers roster are based on a combination of a system based on bed occupancy and the care needs of the residents. We discusssed the need for sstaffing levels to be determined by only by assessing the needs of the residents, then calculating the hours of care needed and staffing numbers that are required to meet those needs, not just by the number of residents in the home. The manager told us that they wish to improve current levels of care staff, but have difficulty recruiting suitable staff. We were told that they are developing a dependency/staffing ratio tool, to review the dependency levels of the residents and reshape the staffing levels where possible, within the resources of the home. The files of three recently recruited staff members were looked at which demonstrated that the home has a robust recruitment procedure and all Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 20 necessary checks, such as obtaining references from previous employers and Criminal Records Bureau disclosures, are completed before staff start work in the home. All new staff complete in-house induction training and care staff are now being enrolled on the ‘Skills for Care’ induction training course, which will prepare them for National Vocation Qualification [NVQ] training. The AQAA indicates that there are twenty-eight care staff, twelve have obtained an NVQ in social care, three are starting the course in the autumn and a further three will start in January. The senior nurse has applied to do an NVQ4 in management to provide her with the skills needed to run the nursing wing of the home. Staff receive regular supervision, some of it work practice based, and training needs are identified through this process. Training records showed that staff are able to access a wide range of training and those staff spoken with said the training was of a good quality. Recent training has included dementia awareness, palliative care and food hygiene. Hampshire County Council arrange all training and the home is made aware of the dates when training is available. The records indicated that all staff had attended mandatory training such as manual handling and fire safety. Further training is planned and will include palliative care, medication administration, first aid, fire safety and adult protection. The manager told us that the registered nurses are also developing individual specialist areas of expertise, such as wound care, infection control, diabetes and nutritional assessments, with extra training as necessary. Staff were seen to interact well with the residents and spent a lot of time talking to them and ensuring they were comfortable and had something to do. The approach of the staff in the home was very positive and contributed to a calm and supportive atmosphere. Visitors commented that ‘The staff are very caring – thoroughly recommend the home’ ‘nothing is too much trouble’ Another commented ‘more toilet visits are needed for the residents – are they short –staffed?’ - it was suggested that this was discussed with the senior staff or the manager Ticehurst Nursing Home DS0000063269.V347349.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. People using the service are usually safeguarded by good management EVIDENCE: The home has recently registered as one home, with one manager for the two separate wings, providing nursing care in one wing and personal care in the other. The manager is not a nurse so there is a senior nurse in charge of the nursing wing. The registered manager of the home is experienced and has the necessary skills and qualifications to manage the home. She continues to undertake further training to develop her professional practice and is able to support and encourage staff to provide good care. Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 22 Anonymous complaints had been made about care practices in the home and the use of specialist equipment, but following discussions with the manager there was no evidence available to confirm the substance of the complaints. The AQAA indicates that a secure safe is provided for all monies held on behalf of the residents, with keys held by the manager and duty manager. On the day of the visit the unit administrative staff were seen checking the balances and receipts, which balanced. Residents are encouraged to maintain their financial independence wherever possible. The manager said that quality assurance surveys were being done ‘in-house’ and the results of the last survey had not been collated as only three people had responded. It is expected that the surveys will be done annually and the results made available to any interested parties. Health and safety issues are well managed within the home and staff receive regular health and safety related training. Workplace risk assessments were in place and kept up-to-date. No outstanding health and safety issues were observed during the inspection visit. Records showed that all equipment was regularly serviced. Some of the fire records were seen, which demonstrated that all equipment is regularly tested and emergency plans were in place. It had been noted at the last visit that the system for recording staff attendance at fire training did not provide clear evidence that all staff had attended drills and it was necessary to look through all the fire drill records and check it against the staff list to confirm attendance. The manager told us that a matrix had been produced that would provide clear documentation of staff attendance but the staff member writing it no longer worked at the home and their paperwork was not available. She said that the whole staff training matrix is being reviewed and rewritten and will include fire safety training, but it was not available during this visit. There was evidence of staff fire training, which had been done the previous evening for the night staff and included the agency staff that were on duty. There is a fire evacuation plan in place and each resident has been assessed and there is a record of their mobility and the assistance they would need in the event of an emergency. Ticehurst Nursing Home DS0000063269.V347349.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 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Ticehurst Nursing Home DS0000063269.V347349.R01.S.doc Version 5.2 Page 26 - 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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