Inspection on 16/07/07 for Treeton Grange Nursing Home

This inspection was carried out on 16th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Treeton Grange Nursing Home 27/07/06

Treeton Grange Nursing Home 04/01/06

Treeton Grange Nursing Home 28/09/05

Treeton Grange Nursing Home 25/01/05

Treeton Grange Nursing Home 08/10/04

Treeton Grange Nursing Home 04/02/04

Treeton Grange Nursing Home 27/08/03

Treeton Grange Nursing Home 23/07/02

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Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Treeton Grange Nursing Home Wood Lane Treeton Rotherham South Yorkshire S60 5QS Lead Inspector Marina Warwicker Key Unannounced Inspection 16th July 2007 09:20 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 Treeton Grange Nursing Home DS0000003092.V344945.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. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treeton Grange Nursing Home Address Wood Lane Treeton Rotherham South Yorkshire S60 5QS 0114 2692826 F/P0114 2692826 NONE 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) Treeton Grange Limited Post Vacant Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2006 Brief Description of the Service: Treeton Grange is a care home with nursing situated on the outskirts of the village of Treeton that is near both Rotherham and Sheffield. Buses pass by the home, though access to the village is limited for people with disabilities. The home is set in large grounds overlooking the countryside, and has ample car parking. The building was converted to a home from offices, and has had a large purpose built extension. The fee charged for a week at ‘Treeton Grange’ is between £335 and £501 at the time of the site visit. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced site visit was carried out on Monday 16th July 2007 between 9.20am and 2pm. Twelve people who use the service, two relatives who were visiting and nine staff who were on duty were consulted. A further ten service users/ relatives were contacted by post to obtain feedback about the service. Comments received from the surveys have been included in the body of the report. Time was spent observing and interacting with staff and the service users. The manager was present during the inspection. The premise was inspected which included bedrooms of people who live at the home and the communal areas inside and outdoors. Samples of records such as care plans, medication records, some service reports and staff recruitment and training files were checked. I would like to thank the service users, the relatives, all the staff on duty and the manager for their contribution towards this process. What the service does well: Prospective people who wish to use the service and their representatives have the information needed to make an informed choice. The information ensures that the home will meet their needs. The people have their needs assessed and contracts drawn telling them about the service they will be receiving. The principles of respect, dignity and privacy are put into practice by the staff working at the home in order for the people to feel comfortable, safe and part of the community. The staff offer support to the people so that they are able to maintain their life skills and thereby sustain independence as long as they are able to. Social, cultural and recreational activities are offered. The meals are served and presented in a manner, which is attractive and appealing to the people. People who use the service are able to express their concerns and have access to an effective complaints procedure. They are protected from abuse, and able to exercise their rights whilst living at the home. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 6 The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The management and the administration of the home are based on openness and respect to those who use the service. What has improved since the last inspection? What they could do better: Medication records must be kept of all medication received from the pharmacy. The manager must ensure that the recommendations by the pharmacist’s audit are complied with. The leisure, social and cultural activities offered must provide stimulation and suit the needs and preferences and capacity of the people. Those people who have their meals in their room must not be forgotten even during other emergencies within the home. There must be a mechanism to check that all people have received their meals. The central heating system must be repaired so that the people are able to control the temperature in their rooms. The care staff who have had Protection Of Vulnerable Adults first clearance must work only under full supervision of other staff. The care staff must only Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 7 be allowed to carryout unsupervised care following a satisfactory enhanced criminal record bureau check clearance. All staff must have updated manual handling training and fire safety training. The manager must seek views of the people who use the service and the staff who work at the home. The feedback must be analysed and action taken to maintain or improve the service. All staff working at the home must receive formal supervision at regular intervals. The management must ensure that fire drills and practices are arranged at suitable intervals for the staff working at the home and also for the people living at the home so that they are aware of the procedure. There must be documentary evidence to support this. The offices and the staff working areas within the second floor of the building must be risk assessed against the health & safety at work act and appropriate action taken. 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. Treeton Grange Nursing Home DS0000003092.V344945.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 Treeton Grange Nursing Home DS0000003092.V344945.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): 1,2,3,4&5 People who use this service experience Excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Prospective people who wish to use the service and their representatives have the information needed to make an informed choice. The information ensures that the staff will meet their needs. The people have their needs assessed and contracts drawn telling them about the service they will be receiving. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 10 EVIDENCE: Copies of the statement of purpose and the service user guide were displayed in the reception area of the home so that visitors were able to access the information about the home. The information made available was in userfriendly language and reflected the services offered at the home. Four people were randomly selected and their contracts were checked. All four people had contracts and they had been signed and dated by appropriate people. For example if they were self funding the person and/or their relative signed the contract. Those who were funded by the social or health service, had their contracts signed by the care managers arranging the placements. The four care plan checked had copies of the needs assessment by the placing authorities. The home manager had carried out the assessment for those who were self funding. People using the service said that they were able to decide whether they wanted to stay permanently or not after a trial period. One person said “I came here for a fortnight and then did not want to go home. So I stayed.” The home does not provide intermediate care. Treeton Grange Nursing Home DS0000003092.V344945.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, 10 & 11 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. On the whole the health and personal care of those who live at Treeton Grange are based on their individual needs. So that the care reflects each individual’s needs. The principles of respect, dignity and privacy are put into practice by the staff working at the home in order for the people to feel comfortable, safe and part of the community. EVIDENCE: Four care plans were checked and three staff were interviewed with regards to the identified care needs of those people. The care staff had good understanding of the peoples’ needs and how to get further help if they needed. The care plans had been drawn up with the involvement of those who use the service and if necessary with the help of their families. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 12 On the day of the site visit the people living at the home looked comfortable. They were dressed in clean and appropriate clothing. The staff were able to say how they prevented the occurrence of pressure sore and help the older people maintain continence. Since this is an older persons’ service some people due to their age became confused and misunderstood what was happening around them. The staff were seen listening, comforting and taking efforts to resolve the misunderstandings. In the care plans there was evidence of staff recording nutritional assessments and following up with progress. People were also referred to the community dietician for further advice. Discussion took place with the manager and the nurse with regards to the introduction of the Link system for health & social care support. For example the system can be set up by the home identifying a carer or a nurse to be the point of contact for tissue viability, continence, end of life care, nutrition and moving & handling of those who live at the home. These individuals attend community/ PCT training sessions and can be responsible for the risk assessments, training and updating of other staff working at the home. Such arrangements encourage staff to take ownership and help network with people with similar interests. All the people living at the home were registered with the general practitioner. Four Medication Administration Sheets belonging to those who live at the home were checked. There were no gaps and when medication had not been administered the nurses had recorded the reason for this. However, the nurses when receiving the medication from the pharmacy had not checked and recorded the items. The care staff said that the nurse always administered the medication. The last pharmacy audit took place on 30th May 2007. There had been several recommendations that need to be addressed by the nurses at the home. On the day of the site visit the manager said that the present group of people did not want to take responsibility for self-medication and some did not have the capacity to manage medication. Staff were heard addressing the people at the home in a respectable manner. Two people said the following, “Most staff are very good and they show respect.” “The staff don’t come into my room without asking. I am happy with that.” “Always there is the difference between the mature workers to the young ones. Suppose the young ones also need time to learn.” The staff during interviews said the following, which confirmed the general ethos with regards to the privacy and dignity of the people who live at Treeton Grange. “Always knock on the door before entering the room and shut the door behind.” When washing them I always cover the half of the body, which is not being washed. Put a towel round their knees when they are on the toilet.” “ I speak to them and chat when I am delivering personal care, instead of talk at them or talk over them.” “ Sometimes people ask us to read their letters or Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 13 open their mail and tell them who it was from and what it was about. Then I read it for them. Only if they ask otherwise leave it for the families.” Care staff said that they had not received formal training on end of life care. However, they were confident how to care for those who were nearing death. Theses were some of the comments received. “Keep them clean and dry. Keep them comfortable.” “Speak to the person as you would normally. Tell them what is going on around them.” “Give them and their families tender loving care.” One of the nurses said that she had been on a two day course on Palliative care and it was very informative. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15&15 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use Treeton Grange are on the whole able to make choices and influence the decisions made for them about their life style by the staff at the home. The staff offer support to the residents so that they are able to maintain their life skills and thereby sustain independence as long as they are able to. Social, cultural and recreational activities are offered. But these mostly did not reflect the preferences of the individuals. The meals are served and presented in a manner, which is attractive and appealing to the residents. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 15 EVIDENCE: People who live at the home and some of their relatives said that the daily routines and activities provided were flexible. But did not always replicate the interests of the individuals. On the day of the site visit people were invited to join in a game of Bingo and some people joined in and they seemed to enjoy the game. Some people said that they would rather go out than play the same games indoors. One relative said that the people were unable to go down to the village without transport due to the distance and the steep hill. Two people asked why the home did not have it’s own transport anymore. Further inquiries established that the minibus was not used enough by the home and therefore it was got rid of. The activities co-ordinator was enthusiastic and she had made arrangements to take people out on a daytrip the following day after the site visit. The staff with the help of the people who live at the home and their relatives had organised fund raising events to raise money to use for the entertainment of the people who live at Treeton Grange. The home did not have an allocated funding for activities and therefore the people relied on the money raised by the staff and them. However the provider has known to have treated the people to ‘Fish & Chips’ when they had been out on trips. People received visitors in private and were able to maintain links with the local community when they are able to. On the day of the site visit the people were observed during breakfast and also lunchtime. They were offered a choice of meals and there were care staff available to help and encourage those needing assistance. People were offered hot and cold drinks throughout the day. Food supplements and ‘smoothies’ were offered to those needing encouragement with eating. These were some comments received. ”Food is alright. There is always plenty.” “With drinks I can have a biscuit if I want. But I am not active so I just settle for a cuppa.” “I have my meals in my bedroom and sometimes I am forgotten and the staff said that I ought to have reminded them. This is not acceptable.” The manager was informed of this and she explained the background to this comment and assured that she would take action. The kitchen staff had a recent environmental health inspection and there were recommendations made by the authorities. These need to be acted upon and monitored by the manager and also during the reg26 monthly visit by the provider. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 16 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): 16,17&18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service are able to express their concerns and have access to an effective complaints procedure. They are protected from abuse, and able to exercise their rights whilst living at the home. EVIDENCE: The surveys from the people and their relatives confirmed that they were aware of the home’s complaints policy and the general comment was that they preferred to tackle concerns on a one to one basis rather than making it formal. The staff said,” If someone is unhappy about something and if we can put right then I do that and tell the nurse afterwards. Otherwise ask the nurse to deal with any complaints.” A nurse said that usually complaints could be avoided by close observation, good communication and timely staff training rather than blaming staff. A record was kept of all complaints made. Details of investigations and action taken were kept in different files. It was recommended that all aspects of complaint management was best kept together so that it would be easy to monitor and the manager agreed. Those people who had the capacity said that they knew that they could go out and do what they want. The staff said that the staff at the home or their relatives helped those people who were confused and unable to decide for themselves so that their rights were protected. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 17 During staff interviews it was established that the staff had good understanding of abuse, neglect and discrimination. Some staff had attended training on Protection Of Vulnerable Adults and were able to verbalise the actions they would take when reporting an allegation of abuse. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25&26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The building accommodates up to fifty older people on two floors, accessed by shaft lifts and stairs. Five lounge areas and four dining areas were available, with one of the lounges having access to the garden. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 19 The manager said that they did not have a yearly programme of routine maintenance and renewal of fabrics and furniture, however the provider consented to the manager’s requests as and when the need arose. The rooms were mainly single rooms and all had en-suite toilets and washbasins. During the tour of the premise it was noted that there were aids such as the hoists were in bathrooms, toilets and where necessary in the people’s own rooms. The individual accommodations were spacious and they were furnished and equipped to provide comfort and privacy to the people who live at the home. Some rooms were personalised with the individuals’ own belongings. The rooms were centrally heated and the people who occupy the rooms could control the room temperatures. However, on the day of the site visit the temperature within the rooms was too high and the manager said that they have had some problems controlling the heating. She assured that this matter had been addressed and she had arranged for the repair. Emergency lighting was provided throughout the home. The rooms were naturally ventilated by windows. Generally the premises were kept clean, hygienic and free from offensive odours throughout. The laundry was sited away from the food preparation areas. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. On the whole the staff are trained and skilled to support the changing needs of the people who use the service. The staff recruitment policy needs to be reviewed and monitored so that a thorough procedure is followed. EVIDENCE: On the day of the site visit there were 45 people living at the home. The staff on duty for the morning shift were the manager, one nurse and eight care assistants. The staff said that the present manager was ‘hands-on’ and that she made every effort to maintain sufficient staffing levels. One of the feedbacks questioned the staffing and skill mix not been sufficient. The manager was informed of the comment. Domestic and kitchen staff were also employed in sufficient numbers. Some of the care assistants had attained NVQ level 2 in care and some had completed Level3. The manager explained that she had taken charge of the home after a long spell without a registered manager and that she had identified gaps in the Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 21 recruitment files and also the inconsistencies of the staff training and development. The manager helped to check six staff recruitment files. The following gaps were noted. Not all the staff files checked had records of: • Two references, • Induction to the home and only working under supervision following POVA first check, • Staff confirmation in post after receiving a satisfactory CRB check. • Medical declaration of staff, • Proof of identity i.e. recent photograph Although the staff training and development had improved since the last inspection there were still gaps in the staff attending the mandatory training such as moving & handling, health & safety and fire safety. The staff confirmed that they have been encouraged to attend training sessions by the manager and the other nurses. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36&38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The management and the administration of the home is based on openness and respect to those who use the service. The home needs to develop an effective quality assurance system to monitor the day to day running of the home. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 23 EVIDENCE: The present manager has been in charge for less than one year. She is an experienced nurse with management experience within the company. She had completed the Registered Manager Award and is in the process of registering herself with the Commission for Social Care Inspection as the manager for this home. The feedback from the surveys confirmed that the management approach in the home created a positive, helpful and inclusive atmosphere. Very few formal quality audits had been introduced at the home. However, the provider had completed monthly visit reports and these were kept at the home. There had been meetings with people who live at the home, their relatives and the staff. The administrator of the home made the minutes available. The manager agreed that effective quality assurance and quality monitoring systems needed to be implemented and that these needed to be based on seeking the views of the people who use the service and the people who work at the home. The outcomes from these surveys needed to be actioned. The administrator had the financial records for the home and she maintained balance statements with receipts for all the transactions of the peoples’ pocket money. She explained the system she followed and the methods used to audit the accounts. There was an up to date Insurance certificate displayed in the home, which covered against the loss or damage to the assets of the business. Staff formal supervisions were one of the areas, which the manager was promoting. Out of four staff, two have had regular formal supervision and the other two did not know what it meant. The manager had carried out risk assessments with regards to the health & safety of the people who live and work at the home. There were records of fire drills and fire alarm testing. But the person responsible for the drills had not kept records of the staff that had attended these sessions hence there was no evidence of the staff participating. The maintenance person tested the fire alarm and when he was on leave no one took on the responsibility for testing the fire alarm. Therefore it had not been tested. The manager was made aware of this and she was to make sure a member of staff was to take over this task in the absence of the handyman and keep records of the staff who attended the drills. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 24 During the tour of the premise it was noted that the kitchen, the administration office and the activities store /office was located on the second floor of the home. The offices did not have any windows therefore had no natural light and these areas were uncomfortably hot. The manager needs to carry out a risk assessment based on the health & safety at work act and consult with the proprietor to act upon the results of the risk assessments. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 25 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 X 2 Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13 (2) Timescale for action • Records must be kept of all 05/09/07 medication received from the pharmacy. • The manager must ensure that the recommendations by the pharmacist’s audit are complied with to avoid any medicine errors. • Leisure, social and cultural interests of people living at the home must be recorded. • The activities offered must provide stimulation and suit the needs and preferences and capacity of the people. • Particular consideration must be given to those who are confused and have sensory impairment. Those people who have their meals in their room are not forgotten even during other emergencies. There must be a mechanism to check that all people have received their meals. 10/09/07 Requirement 2. OP12 14 3. OP15 16 05/09/07 Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 27 4. OP25 23 The central heating system must be repaired so that the people are able to control the temperature in their rooms. • The care staff who have had POVA first clearance must work under full supervision. • The care staff must be allowed to carry out unsupervised care only following a satisfactory enhanced CRB clearance. This is to protect the people who life and work at the home. Two written references must be provided for staff recruited to work in the home to ensure suitable people are being employed. Previous requirement to be complied by 01/10/06. All staff must have manual handling training to avoid people living at the home and the staff sustaining unnecessary injuries. Previous requirement to be complied by 01/10/06. All staff must have fire safety training to ensure that they are competent to deal with situation involving fire safety. Previous requirement to be complied by 01/10/06. • The manager must seek the views of the people who use the service and the staff who work at the home. The feedback must be analysed and action taken to maintain or improve the service. • The management must be able to demonstrate their success in meeting the aims DS0000003092.V344945.R01.S.doc 05/09/07 5. OP29 19 05/09/07 6. OP29 19 and Schedule 2. 05/09/07 7. OP30 13 (5) 05/09/07 8. OP30 23 (4) (d) 05/09/07 9. OP33 24 10/10/07 Treeton Grange Nursing Home Version 5.2 Page 28 and objectives and the purpose of the home. 10. OP36 18 • All staff working at the home 10/09/07 must receive formal supervision at regular intervals. • The care staff supervision must include aspects of care practices, philosophy of care and the individuals’ career development needs. So staff feel that they are valued and supported. 05/09/07 • The manager must make arrangements for all staff working at the home to receive suitable training in fire prevention. • The management must ensure that fire drills and practices are arranged at suitable intervals for the staff working at the home and also for the people living at the home so that they are aware of the procedure. There must be documentary evidence to support this. 11. OP38 23 (4) Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP25 OP38 Good Practice Recommendations The record of all complaints made including details of the investigation and any action taken should be stored together. The offices and the staff working areas within the second floor of the building must be risk assessed against the health & safety at work act and appropriate action taken. Treeton Grange Nursing Home DS0000003092.V344945.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 - 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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