Inspection on 29/01/07 for Ticehurst Nursing Home

This inspection was carried out on 29th 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

Ticehurst Nursing Home 17/10/07

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 Marilyn Lewis Unannounced Inspection 29th 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 Ticehurst Nursing Home DS0000063269.V324178.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.V324178.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 Marion-Hazell Mears-Owen Care Home 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.V324178.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Ticehurst Nursing Home is a purpose built forty-eight bedded care home for residents with nursing needs, and is an initiative between Hampshire County Council, Hart Primary Care Trust and Blackwater Valley. The home was registered on the 1st March 2005. The home is in Whitchurch Close, Aldershot; a residential area, a mile from local shops. The nursing home shares the grounds of a residential home and there are corridors connecting the two homes. The kitchen and laundry facilities are shared by both homes and are situated in the residential home. Accommodation in the nursing home is provided on two floors with stairs and lifts giving access to each floor. The home’s 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 rooms that are fitted with en-suite facilities. Additional seating areas are situated around the home and there are also offices and staff rooms. The registered manager stated that, at the time of the inspection, fees for the home ranged from £425 to £430 per week. Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 29th January 2007. The inspector toured the home and met with nine residents, two visitors, two care managers, three staff, a senior nurse, the registered manager of the nursing unit and the registered manager of the residential unit. Care plans and risk assessments were sampled and records seen included those for medication, complaints, staff training and staff recruitment. Prior to the visit information was gathered from previous inspections and information received regarding the service. What the service does well: The home looked clean and welcoming. Residents and relatives spoken with were very satisfied with the care provided at the home. Residents said that they liked their rooms and the communal areas with one resident saying ‘I have everything I need’. Relatives said that they found the information about life at the home useful and had been able to visit the home and meet with staff on behalf of their frail relatives. Residents said that they were able to receive visitors as they wished and visitors said that they were always made to feel welcome. Residents said that they were able to see their GP on request and records seen indicated that staff work with other health professionals such as psychiatrists and occupational therapists to ensure the health needs of the residents are fully met. The home has clear procedures in place for dealing with medicines and staff were seen to adhere to the procedures and were therefore protecting the health of the residents. The home has provided two staff members with time to develop and improve the programme of activities provided for residents. Residents said that they were told of activities taking place but were able to decide for themselves whether to join in. Residents said that the food provided at the home was good and meals seen offered choice and were well presented. Staff supported residents who required assistance in a friendly manner. Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 6 Residents and visitors said that staff were respectful and caring. Comments received included ‘the staff are lovely, very kind’. The home employs sufficient number and skill mix of staff to meet the needs of the residents. Residents said that they did not have to wait long for assistance when it was requested. 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. The registered manager runs the home well and residents, staff and visitors said that Maizie Mears Owen was very supportive. A staff member said that she really liked working at the home. What has improved since the last inspection? What they could do better: Care plans seen had not been updated with changes in the needs of some of the residents. Residents weights had been recorded regularly but changes such as weight loss had not been followed up in the care plans and nutritional assessments, which could result in the care needs of the resident not being fully met. Six of the nineteen carers have obtained National Vocational Qualifications (NVQ) level 2 or above. A further three carers are due to commence the training in September 2007. The number of care staff who have obtained or are in the process of obtaining the qualification is below the required 50 . A staff member said that supervision meetings had not been held for some months and records seen indicated that some staff were not receiving supervision at least six times a year. The registered manager said that this was due to the change over to a new system of performance planning. Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. Ticehurst Nursing Home DS0000063269.V324178.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.V324178.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): 1, 2, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are provided with information about life at the home, are able to visit before making a decision and receive a written contract on admission. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. EVIDENCE: The home’s Statement of Purpose and Service User Guide provide prospective residents and their relatives with clear information about life in the home. However more detail is required on the admission criteria, including the age and sex of the residents and that residents are admitted for dementia care. Two visiting relatives spoken with said that they had found the information very helpful. Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 10 The registered manager said that a written contract giving the terms and conditions for residency at the home was provided for each resident on admission. Contracts seen for three residents stated what services the fees covered and services available at additional cost, such as hairdressing and newspapers. Residents had signed the contracts seen. The registered manager said that a full care needs assessment was completed for each prospective resident before a place at the home was offered to ensure the home could meet their care needs. Assessments were seen for five residents. Three of the assessments had been undertaken at the residents’ homes and two at the local hospital. The registered manager said that one of the assessments had been undertaken twice, to ensure the assessment was up to date, as the prospective resident had not been discharged from home on the date first suggested. The assessments covered all aspects of care needs including communication, behaviour, nutrition, personal care and medical history. The records seen indicated that relevant information was obtained from health professionals and care managers as well as from the prospective resident and their relatives. The two relatives spoken with said that they had been involved in the assessments for their relatives and had visited the home and talked to staff on their relatives behalf, as they were too frail to visit. The home has two beds allocated for interim care but these are currently being used for respite. Ticehurst Nursing Home DS0000063269.V324178.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. Residents feel they are involved in the planning of their care and their health care needs are met by good multidisciplinary working. However changes to care needs noted in records are not always followed through to the care plans and this could result in the resident’s care needs not being fully met. Residents feel they are treated with respect and they are protected by staff adhering to the home’s procedures for dealing with medicines. EVIDENCE: Care plans were seen for the five residents case tracked. Three of the residents had been admitted to the home in the last three months. The care plans were detailed and provided information on the resident’s preferred routine and likes and dislikes. The documents also contained risk assessments including those for pressure areas, falls, nutritional needs and moving and handling. Residents Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 12 who required turning while in bed had turn charts completed and those seen indicated that the residents were turned as needed. Records seen showed that residents were weighed but although weight loss was recorded this was not followed through in the care plans and nutritional assessments had not been updated. The registered manager said that a new tool for risk assessing nutritional needs had recently been introduced and staff were not yet familiar with the documents. One of the residents spoken with said that they knew about their care plans and said that their wishes were included. The two visiting relatives also knew of their relatives care plans and said that they had been informed of changes as they occurred. The care plans did not show any evidence of the involvement of the residents or their relatives. The registered manager said that residents or their relatives would be asked to sign the documents during reviews. A staff member spoken with said that they found the information in the care plans clear and easy to follow. A resident spoken with said that they were able to see their GP on request and records seen indicated that GPs and other health professionals such as occupational therapists visited as required. Two care managers visiting the home said that they were very satisfied with the care provided at the home for their service users. The home has clear procedures in place for dealing with medicines. A trained nurse went through the procedures for the administration of medicines, with the inspector and it was evident that the nurse adhered to the home’s procedures. Medication records seen had been completed appropriately and records seen for controlled drugs matched the stock held. Systems were in place for recording medicines brought into the home and those for disposal. The book providing staff with information about medicines was dated September 2004 and may not therefore provide up to date information. The nurse said that a new one had been requested. No residents at the home were currently self administering their own medicines. One resident spoken with said that they preferred not to have the responsibility. During the inspection staff were observed knocking on doors and waiting before entering rooms and speaking to residents and relatives in a friendly, respectful manner. Residents spoken with all said that the staff were kind and caring and always treated them with respect. Ticehurst Nursing Home DS0000063269.V324178.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. The home is working to improve the programme of activities provided for the residents. Residents feel they are able to exercise choice over their daily lives, receive visitors as they wish and enjoy well- presented meals served in a friendly atmosphere. EVIDENCE: One of the senior nurses and a carer have recently been given the responsibility for developing the activities programme for the residents. Both spoke enthusiastically about the project and had purchased items such as paints and plasticene to start simple craft work. The deputy manager said that they had started with art- work as some of the residents had expressed interest in painting. An art therapist had been contacted and was due to start sessions in the home soon. They had also started to introduce crosswords and board games on a weekly basis and were in the process of obtaining skittles Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 14 for indoor use. Some staff had been trained to provide gentle exercise sessions and sessions had been arranged for music therapy. The residents’ past interests and hobbies were documented in their care plan and the carer said that this information was taken into account when developing the programme. The carer also said that she was in the process of developing files to record the residents’ involvement in the activities programme, to include whether they had found the activity enjoyable. The deputy manager and carer had not received training in providing activities for older people and those with dementia but had discussed suitable activities with activity co-ordinators from other homes. Both said that they would be looking to attend suitable training as soon as possible. Two residents spoken with said that they preferred to spend time in their own rooms and staff respected their wishes. The registered manager said that a set church service was not held at the home but ministers from local churches visited residents on request. Children from local schools had visited the home over the Christmas period and arrangements were being made for them to visit on a regular basis throughout the year. Two relatives visiting the home said that they came to see their relatives every day and staff were always welcoming and friendly. Residents spoken with also said that they were able to receive visitors as they wished. Meals are prepared in the kitchens situated in the residential wing and transferred to the nursing wing in heated trolleys. Kitchen assistants are employed to serve the meals on each unit of the nursing wing. Residents spoken with said that they were offered a choice of meals. On the day of the visit meals for lunch were pork in a white sauce or chicken and mushroom pie, with a choice of mashed potatoes or rice and mixed vegetables. Chocolate sponge and custard was the main pudding. Meals seen were well presented, with items for meals that required pureeing, being pureed individually to provide taste and texture. Seven residents spoken with said that the meal was good and there were comments of ‘the food is always good’. Relatives also said that they thought the food provided was good. Staff seen with residents who required assistance, helped them in a quiet and friendly manner. One staff member who took a meal to a resident who was in her bedroom, took time to explain to the resident what the meal was and waited for the resident to get ready to eat their meal before leaving the room. The staff member returned to the room a few minutes later to ask the resident if they were managing or if they would like some assistance. Ticehurst Nursing Home DS0000063269.V324178.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. Residents feel that any complaints will be taken seriously and acted upon and they are protected by staff awareness of the protection of vulnerable adults. EVIDENCE: The registered manager said that the home’s complaints procedures were given to residents on their admission to the home. A copy was also available in the reception area and relatives were able to have one on request. Three residents spoken with said that they would speak to the registered manager or one of the nurses if they had any concerns or complaints and said that they felt the issue would be dealt with quickly. A relative also said that they would speak to a staff member to discuss any concerns. The registered manager said that any complaints received were discussed with the Service Manager during their monthly visits. The commission had received a copy of a letter from some relatives, to the registered manager, highlighting some of their concerns about the quality of care provided at the home. The registered manager said that the Service Manager had met with the relatives and discussed their concerns. Records seen confirmed this had taken place. The home has procedures in place for Adult Protection including Hampshire County Council’s Protection of Vulnerable Adults and Whistle Blowing. Records Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 16 seen indicated that staff had received training in the prevention of abuse and three staff members spoken with knew the procedures to follow should abuse be suspected. There have been no adult protection issues at the home. Ticehurst Nursing Home DS0000063269.V324178.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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ticehurst nursing home provides a clean, safe and welcoming environment for all who live, work and visit there. EVIDENCE: The home is purpose built and is situated in a residential area of Aldershot. The nursing wing shares the grounds with the residential wing and there are corridors connecting the homes. The nursing and residential wings share the kitchens and laundry facilities which are situated in the residential wing. The home provides accommodation for forty-eight residents over two floors. The accommodation is divided into five units, three on the first floor and two on the ground floor. All the residents have single rooms with en-suite facilities. Each unit has a lounge with dining area and kitchenette where staff are able to Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 18 prepare light snacks for residents as required. Each unit also has a bathroom with assisted bath and separate toilet room. 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. Offices are provided for the registered manager and administrative staff and there is also a staff room with showers and lockers. The home looked clean and residents spoken with said that they liked their rooms and the communal areas. Some residents had personalised their rooms with items such as pictures, photographs and ornaments. One resident said that she was very pleased to have her family photographs on the wall. Staff said that they had the specialist equipment they required such as hoists and pressure relieving mattresses to enable them to fully support the residents. Some rooms on the ground floor were fitted with overhead hoists. Problems that had been noted on the previous inspection, such as issues with the under floor heating and bubbling concrete, had been resolved and all areas of the home were now in use. An enclosed garden is situated between the two homes. The garden has been sown with plants and shrubs for a sensory garden and is accessible to residents including those who use wheelchairs. One resident said that she was looking forward to using the garden during the warmer weather. Ticehurst Nursing Home DS0000063269.V324178.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. Residents’ needs are met by the number and skill mix of staff on duty and they are protected by the home’s recruitment procedures. Staff receive mandatory training and training in specific topics relevant to the residents’ needs. However the number of care staff who have completed or are in the process of obtaining NVQ level 2 or above is currently below the required level. EVIDENCE: The home employs the registered manager, two senior nurses, ten nurses, and nineteen carers. Separate staff are employed for administration, catering, laundry and domestic duties. Rotas seen indicated that the registered manager or one of the senior nurses are on duty each day and three nurses with eight carers provide care in the mornings, three nurses and five carers in the afternoons and two nurses with four carers at night. Staff spoken with said they felt sufficient staff were on duty and three residents said they did not have to wait long for assistance when it was requested. Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 20 Six of the carers have obtained NVQ level 2 and three more carers are due to commence training for the qualification in September 2007. One carer said that there seemed to be a long wait to get a place on the training course. The registered manager is aware that this is currently below the required level of at least 50 of care staff to hold or be in the process of obtaining NVQ level 2 or above and is actively seeking additional places on training courses. Records were seen for five staff members who had recently been employed at the home. Four of the records contained all the information required and all indicated that Criminal Records Bureau and Protection of Vulnerable Adult checks had been completed before the staff members started work at the home. Information in one of the records was incomplete. The registered manager said that the staff member had recently completed an adaptation course and the information had been sent to the Human Resources Department for records to be updated. The registered manager said that if this was required to happen in the future, photo copies would be kept on file until the original paperwork was returned. Training records seen indicated that all staff except three, had attended training in moving and handling. The remaining three staff members were due to attend refresher courses in February or March 2007. Staff had also received training in Adult Protection, infection control, medication, practical care and emergency aid. One of the senior nurses had attended a course on managing services for people with dementia but there were no records of other staff attending. The registered manager later notified the inspector by telephone that eight nurses and nine carers had attended a four- day training course in dementia care. All new staff complete an induction course that covers all aspects of care provision including infection control and fire safety. Three staff members spoken with said that they felt supported and encouraged to attend training courses. Ticehurst Nursing Home DS0000063269.V324178.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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. Residents’ financial interests are safeguarded by the home’s clear procedures for dealing with money and residents health, safety and welfare are promoted by the safe working practices operated at the home. Staff are not receiving supervision at least six times a year. EVIDENCE: Maize Mears Owen is the registered manager of the home. Ms Mears Owen is a trained nurse (mental health) and has completed NVQ4 in management. Staff spoke highly of Ms Mears Owen as did residents and visitors. Two care managers visiting the home also said that they found the registered manager Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 22 very helpful and thought she managed the home well. Ms Mears Owen said that she worked closely with the registered manager of the residential unit and this was observed during the inspection visit. A carer spoken with said that she thought the home was the ‘best she had worked in ‘ and had recommended it to her friends as a good place to work. The home has a system in place for quality assurance. Questionnaires are available to all visitors on the counter at reception. Two questionnaires had recently been completed. Both gave positive feedback on the quality of care provided at the home. The registered manager said that she likes to meet with residents on a one to one basis and also with visitors as often as possible. The Service Manager also speaks with residents, relatives and staff during their monthly visit. Staff meetings are held every four to six weeks for the whole staff team and also separate meetings take place for nursing staff. Two staff members spoken with said that the meetings were informative and records seen confirmed that the meeting took place. Some relatives had recently organised meetings for relatives and residents and notices were seen around the home giving the date for the next meeting. The registered manager said that staff had not been invited to the meetings but were available in the home should they be required to discuss issues brought up at the meetings. The home holds small amounts of money for some residents. The money is kept in individual containers in a safe place. Receipts are kept for all transactions and records seen for two residents matched the money held. Some residents hold their own money and relatives hold money for others. All residents are provided with lockable storage in their rooms for the safe keeping of money or personal items. One staff member said that she received regular supervision but another said that she had not had a supervision meeting for some months. Records seen indicated that supervision meetings were not being held as often as required, at least six times a year. The registered manager agreed that staff had not been receiving regular supervision and said that the systems for supervision were changing to an individual performance plan and the change over was due to be completed by the end of February 2007. During the inspection visit staff were seen to operate safe working practices. Records seen indicated that staff had received training in health and safety, including moving and handling, infection control and first aid. Health and safety procedures were available for staff and information was displayed around the home. Hazardous substances such as cleaning fluids were stored safely. The kitchen and laundry room looked clean and in good order. Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 23 Fire records seen indicated that routine checks were made to fire safety equipment and staff received training in fire safety during induction. Fire drills were recorded and staff attendance documented. However the system for recording staff attendance 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. This indicated that a staff member had not attended a drill. Since the inspection the registered manager has notified the inspector that the staff member has now attended a fire drill. The registered manager said that a matrix was being produced that would provide clear documentation of staff attendance at drills to ensure all staff attended drills each year. Ticehurst Nursing Home DS0000063269.V324178.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 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 2 3 3 Ticehurst Nursing Home DS0000063269.V324178.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 OP7 Regulation 15(2)(b) Requirement The registered person must ensure care plans are kept under review to reflect the changing needs of the residents. The registered person must ensure staff receive supervision at least six times a year. The registered person must ensure care staff are provided with the opportunity to obtain NVQ level 2 or above. Timescale for action 31/03/07 2 2 OP36 OP28 18(2) 18(1)(c) 31/03/07 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ticehurst Nursing Home DS0000063269.V324178.R01.S.doc Version 5.2 Page 26 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.V324178.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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