Inspection on 20/02/06 for Tutnall Hall Nursing Home

This inspection was carried out on 20th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Tutnall Hall Nursing Home 06/11/06

Tutnall Hall Nursing Home 24/04/06

Tutnall Hall Nursing Home 14/09/05

Tutnall Hall Nursing Home 20/03/05

Tutnall Hall Nursing Home 12/07/04

Tutnall Hall Nursing Home 06/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Tutnall Hall Nursing Home Tutnall Bromsgrove Worcestershire B61 1NA Lead Inspector Jane Rumble Unannounced Inspection 20th February 2006 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 Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tutnall Hall Nursing Home Address Tutnall Bromsgrove Worcestershire B61 1NA 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) 01527 875854 01527 875742 Alpha Health Care Limited Mrs Susan Mary Dempsey Care Home 40 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40) Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 Brief Description of the Service: Tutnall Hall is situated in a quiet rural position, between Bromsgrove and Redditch, and is part of Alpha Healthcare Limited, a company that operates a number of care homes for older people several of which are within Worcestershire. The home is registered to provide nursing care and accommodation for a maximum of 40 residents over the age of 65 years. As part of this registration the home can also accommodate up to 3 older people with a dementia related illness. A trained nurse is on duty in the home at all times. Accommodation is provided on three floors that are accessed via a passenger lift or two staircases located on either side of the building. There are a total of 19 single bedrooms, 16 of which have ensuite facilities and 10 shared rooms of which 6 have ensuite facilities. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector over a day, and was assisted by the Area and Deputy Manager. 38 residents were living in the home. Information was gathered from a variety of methods, including talking to residents, interviewing four staff, observation of practice, a partial tour of the building, examination of care, staffing and health and safety records. Two immediate requirements were made at the time of this visit; and some requirements from the previous inspection remain outstanding. Following the inspection CSCI sent a letter of serious concern to the owners about the poor moving and handling practices seen. The owners have replied to CSCI to tell us what they have done to make this better. The findings of this inspection are of concern, the home is unable to demonstrate that it is providing good outcomes for residents. The Commission will undertake additional visits to ensure compliance with requirements made. This is the second statutory inspection for the 2005-2006 year and it is recommended that the report is read in conjunction with the previous inspection report of the 14th September 2005. What the service does well: The home has a stable team of care staff that have developed some positive relationships with residents. Recruitment practices are robust and contribute to protecting residents from harm Visitors are welcome to the home at any time to enable residents maintain links with their families and friends. Residents are able to bring personal possessions into the home to make their stay more comfortable. Nursing staff plan shifts well so care staff know what their individual and collective responsibilities for the day are. The home accommodates predominately white European elders. The meals provided generally reflect the cultural identity of this group. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The home must confirm to residents in writing that the home can meet their needs in respect of health and welfare prior to admission so that the prospective service user can be confident their needs will be met. Care plans need to be further developed to ensure they contain specific details of how to meet residents’ needs. Records need to be further developed so that they reflect the care provided or reasons why health care professionals visited. Staffing needs to be increased so that there is a cleaner available at the weekends, or an additional member of care staff. Attention is needed in the kitchen to ensure that both the fabric and the equipment are well maintained to enable them provide meals safely. Care staff need training in a number of areas to make sure they have all the skills and knowledge they need to meet residents needs safely. An alternative meal needs to be offered to residents on a daily basis. Records of meals provided must be kept in sufficient detail to enable anyone looking at the record to see that a healthy, varied diet is offered. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 7 The home must get better at supervising staff to ensure they are meeting residents needs safely, whilst providing opportunities for personal development. The home needs to do lots of things to make it better for people living there. Lots of improvements are needed in the home’s recording systems to enable it demonstrate better that it is meeting peoples’ needs and complying with the law. The home needs to get better at showing that it consults with residents formally to enable them have a say in the way the home is run. 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. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Prospective residents cannot be confident that the home will meet their needs. EVIDENCE: A pre-admission assessment is completed by a trained nurse. A proforma is available for this purpose. However, there is a limited space for information to be recorded. Having completed the pre-assessment the home does not confirm in writing that the home can meet the needs of the prospective residents, as required by the Care Homes Regulations 2001. The home does not provide intermediate care. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 Care plans are not in sufficient detail to ensure individual residents needs are met. Records of care provided do not demonstrate that individuals health care needs are consistently met. EVIDENCE: Each resident has a written care plan. Two care plans were inspected in detail. Care plans lacked specific detail as to how to provide care for the individual. Records did not evidence that residents’ health care needs are met consistently. For example: • A care plan to prevent pressure damage stated pressure areas to be observed. No detail of the frequency that they need observing or for what was available. Details of the pressure relieving equipment to be used was not recorded. • Repositioning charts do not evidence that 30º tilt is used. Repositioning charts are not always completed to evidence that a resident has been moved. One chart indicated that an individual had been in the same position for the majority of a day. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 11 • • • • • Where an individual has a low body weight, the care plan requires that they are weighed monthly. No evidence was available that the individual had been weighed; or that dietary supplements were to be offered. A wound care plan did not provide any detail of the dressings to be used or the frequency that they were to be changed. A care plan stated that a resident was experiencing significant pain, but made no reference to offering pain relief. For an individual with an infected wound there was no infection centred care plan in place to inform staff how to prevent cross infection. It was not possible to evidence that a high protein diet was being offered from the diet sheets available. Daily progress records need to be further developed that they are contain the detail of the care provided to individuals. Records of visits by doctors were not in sufficient detail to evidence why the doctor had visited or any monitoring of that person’s health need had taken place. The home operates some institutional practices within their recording systems that do not promote the privacy or dignity of residents. For example a bowel book is used, regardless of whether the individual has a health care need in this area. A bathing rota was on display on the bathroom wall. This was removed at the time of the inspection. Risk assessments were in place for moving and handling, nutrition, falls and pressure damage. These were periodically reviewed. However, improvements are required to ensure that the full date that they were reviewed is recorded. The home did not complete a risk assessment for the use of cot sides where it had been identified through an assessment that they were needed. It was disappointing that screening was not available in all shared rooms sampled to ensure that residents are afforded privacy whilst having personal care needs met. Bedroom doors do not have locks to enable anyone lock their door if they choose to do so, to either promote their privacy or to keep safe their personal items. It was however pleasing that residents spoken to were able to confirm that staff knocked their bedroom door before entering. It was disappointing that a number of residents were not dressed appropriately for the weather, in that they did not have either socks or tights on. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14,15 Residents have limited opportunities available to participate in leisure and recreational activities at present that meets either their needs or expectations. Contact with family and friends is well supported. Opportunities for residents to exercise choice over their lives could be improved to enable them maximise personal autonomy. EVIDENCE: Individual residents spoken to stated that there was very little for them to do within the home at present. Records supported this lack of activity. At the time of the visit both the television and music was on in the large lounge. This was an irritation to some of the residents spoken to. The television is situated in one corner of the lounge that makes it impossible to see for many of the people using the room. The home has recently recruited an activities co-ordinator for 20 hours a week, she had been in post for a few weeks only. It is clear that she is enthusiastic and has plans to improve the range of activities available for residents. It is positive that she has already spoken to every resident to find out about their individual preferences. She has also developed a system to enable her to audit who she spends time with, to ensure that all residents have the opportunity to Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 13 participate in activities. It is hoped that at the next inspection there will be significant improvements in the activities offered to people. Residents’ birthdays are celebrated. Residents confirmed that their family and friends are made welcome and were unaware of any restrictions on visiting. They are able to receive visitors within the communal areas of the home or in their own rooms. If residents choose and are able, they are able to manage their own financial affairs. Residents are able to bring into the home any personal possessions with them to make them as comfortable as possible. Residents were unaware that they could adjust the temperature within their bedrooms to meet their personal preferences. A choice of drinks is not available at lunchtimes. There is some flexibility to ensure residents choose times that they can get up and go to bed. Locks are not provided on bedroom doors to enable residents choose to lock them if the wish. The home employs a cook and assistant cook to prepare three meals a day. The dining tables were well presented, to enhance the mealtime for residents, but the dining room does not provide sufficient seating for the number of people living at the home. A number of residents take their meals within the lounge areas or in their rooms, on trays. It was observed that those residents who take their meals from trays are not offered condiments. A menu was not on display within the home to inform residents of what was available. An alternative meal is not always available routinely. The cook stated that an alternative is available if requested. Residents’ views of the food provided were mixed, with some people clearly enjoying them and others expressing an opinion that they do not meet their expectations. It was observed that meals were served on small dinner plates. Observations were that the majority of residents were of a small frame. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 14 Records of food provided are not in sufficient detail. An option of a cooked breakfast is not routinely available, and records do not demonstrate that healthy eating guidelines are complied with. Plastic beakers were observed to be available for all residents’ drinks. The Commission expect that plastic beakers would not be routinely available, but based on an individual assessment. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home does not demonstrate that it takes complaints seriously and acts upon them. All staff need training in the protection of vulnerable adults to make sure that residents are protected from harm consistently. EVIDENCE: The home has a complaints procedure within the office. This was not accessible to residents, and requires some minor amendment to reflect the current legislation. The home did not have available a record of any complaints made or their investigation and outcome. A complaint log was created by the Area Manager at the time of this visit. The home has a procedure to protect vulnerable adults from the risk of harm. However, it was disappointing that not all staff had received training in the protection of vulnerable adults. Care staff spoken to were aware of their responsibility to make senior staff aware of any allegations of abuse. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 Attention is needed to maintenance issues in the home to ensure it provides a safe and hygienic home. Bathing facilities need to be reviewed to ensure that they meet the needs of residents. EVIDENCE: A partial tour of the home and associated buildings was undertaken. The home was warm and clean. Some of the requirements made at the previous inspection had not been complied with relating to the environment. In addition the following matters require attention:• Replacement of stair carpet which was showing signs of wear on Nightingale. • Screening must be available in all shared bedrooms. • The join in the lounge carpets needs attention. • The cleaners store cupboard was not locked at the time of the visit. A suitable lock must be fitted to ensure the area is secured. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 17 • • The sluice must be kept locked to minimise the risk to residents. A fire extinguisher needs securing to the wall to prevent the risk of accidents. As previously stated there is insufficient dining space available for the number of residents living at the home, so if they all choose to eat together for special occasions they would not be able to. Residents rooms sampled were well personalised. The bathing facilities are currently being reviewed. One bathing facility is being converted into a shower to improve its access. At the time of the visit one of the ground floor bathrooms was out of order. Appropriate action to rectify the situation was being taken. One ground floor bathroom was not fit for purpose in that it contained a bath only, with no wash hand basin or W.C. A supply of unnamed toiletries and a hairbrush were observed within this area. Items must only be used for the resident that they belong to. Underneath the seats of bath hoist were in need of cleaning. It was observed that towels and flannels required auditing, and those showing signs of wear and tear need replacing. The Area Manager stated that the matter was in hand. The kitchen area caused concerns, for the following reasons:• The floor covering was lifting in places and needs sealing to ensure good effective cleaning of the area. • A number of cupboards/drawers were broken, or not closing. • Work surfaces are limited within the breakfast kitchen. • The food probe was broken. The Area Manager stated that a new one had been ordered. • The dishwasher was broken, and had been for approximately two weeks. The Area Manager stated that the matter was in hand. • Storage space is limited within the kitchen so food stocks are stored in an external building. Current practice is that it is transferred between the buildings on a trolley daily. There is no assessment of risk available for this practice to evidence that measures are in place to minimise risk. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Residents are protected by the homes recruitment procedures and practice. Adequate numbers of staff are available in the week to meet residents’ needs. Staff do not receive training they need to ensure that they can meet residents needs or ensure that they are in safe hands at all times. EVIDENCE: On the day of inspection 38 people were living in the home. The home had an adequate number of staff on duty to meet residents’ needs. A trained nurse is on duty at all times. Typically staffing shortfalls are met by staff undertaking additional shifts or the use of agency. In additional to care staff the home employs ancillary staff to undertake cleaning, laundry and catering duties. A vacancy for a handyman existed at the time of this visit. At the weekend the home does not employ cleaning staff, and care staff are required to undertake these duties in addition to care task, detracting from the time available to spend with residents. It is of concern that no additional care staff are on shift to compensate for this. The home benefits from a reasonably stable care staff team. Nurses do a daily shift plan for care staff so that they know what their responsibilities for the day Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 19 are. Records and discussions with staff do not evidence that they receive all the training they need to ensure they are competent to do their jobs. Only a small number (five) of staff have completed at least NVQ Level 2, and it was not possible to determine all staff have received mandatory training or periodic update training. The home’s recruitment procedures were sampled. All checks were undertaken prior to the person commencing work. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36,38 The home is not being adequately managed to provide good outcomes for residents. The management arrangements of this home do not enable residents to influence the way the service is delivered. Practices in the home place staff and residents at risk of harm. Systems were not apparent that demonstrate that the home is committed to continuous improvement. EVIDENCE: Staff do not receive formal supervision that covers all aspects of practice, the philosophy of care in the home, or career development needs. Staff stated staff meetings occur infrequently. There are no records available to evidence any staff meetings had taken place. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 21 Resident meets do not occur, to enable them contribute to how the home should be run to meet their needs and preferences. Residents spoken to were unaware of whom their key worker was or what the parameters of this role was. Residents stated that they are not involved in menu planning. A resident commented that on one occasion staff had turned the television over without consulting whilst he was in the middle of watching a programme. The home retains a small amount of pocket money on behalf of residents that is deposited by families. The money is stored securely within a locked cabinet. Records of the money held were accurate, with receipts available to evidence expenditure. Receipts would benefit from being numbered to enable them to be easily cross-referenced. Records of expenditure confirmed little money spent on activities. Receipts related to hairdresser and chiropody. Where a resident does not have family members to assist them manage their money the organisation collects and holds individuals benefits at head office. The home is unaware of the balance of the money held by the organisation on behalf of individuals. The inspector was informed that interest is not paid on the balance of money held. Records faxed to the home evidenced that all money held on behalf of residents was accounted for. Safe practices were not demonstrated. Manual handling practices observed, and described, place staff and residents at risk of harm. All staff had not received training in safe working practices, for example fire training, first aid, and infection control. Fire records did not demonstrate that weekly fire alarm checks have taken place, and where they have taken place the location of the call points could not be determined. Risk assessments competed in respect of the environment needs further development, as they do not include control measures in place. The EIC electrician report dated 8/4/02 showed a number of discrepancies. There was no evidence in the home that these had been addressed. The TV licence expired in 2003. The Gas Landlords Safety Certificate was out of date. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 22 There is no analysis of accidents to identify trends so appropriate measures can be taken. Staff on duty were unable to locate a quality assurance or quality monitoring systems. A number of resident’s surveys from December 2005 were in the home. It was disappointing that these had not been analysed, or an action plan developed to address the results of the survey. The lack of staff awareness of the quality assurance systems do not demonstrate that they are committed to continuing improvement. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 1 X X X X X x 3 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x X 1 x 2 1 x 1 Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? 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 2 Standard OP7 OP7 Regulation 13(4) 12(1) 15(1) (2) 12(1) 15(1) Requirement Risk assessments need to be completed in respect of the use of bed rails. Care plans must be developed to include the specific detail of the care and support required to meet those needs. Records must be kept which accurately reflect the care given to residents. Records must be weighed periodically and a record retained. Remedial work must be undertaken to the laundry room which includes resealing the floor. Requirement outstanding from previous inspection. Written confirmation must be provided which demonstrates that glazing in the conservatories meets the safety standards necessary. Outstanding from previous inspection. Fire exits onto fire escapes must be alarmed. Remains outstanding from previous inspection Written evidence must be provided to demonstrate work DS0000004149.V280645.R01.S.doc Timescale for action 01/03/06 01/04/06 3 OP8 01/03/06 4 OP19 Reg 23 10/03/06 5 OP19 Reg 13 01/03/06 6 OP38OP19 Reg.13(4) 23 Reg 13(4) 23 01/03/06 7 OP38 01/03/06 Tutnall Hall Nursing Home Version 5.1 Page 25 8 OP3 Reg 14 (17(d)) 9 OP30OP38 13(5) 10 OP19 13(4) 11 OP19 16(2)c 12 OP19 16(1)g 16(2)j identified by the fire officer has been completed as required to the required standard. Remains outstanding from 1st June 2005 The registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of health and welfare. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. The cleaners’ cupboard must be kept locked. The sluice must be kept locked when not in use. Provide in rooms occupied or used by service users adequate furniture, bedding, furnishing, floor coverings and equipment suitable to the needs of service users and screens where necessary. Privacy screens must be provided in all shared rooms. Stair carpet, Nightingale Unit must be replaced. Towels and flannels must be audited and replaced as necessary. Secure the join in lounge carpet. Provide suitable and sufficient kitchen equipment, crockery and utensils, and adequate facilities for the preparation and storage of food. Repair/Replace wall units and cupboards. Repair/replace dishwasher Make suitable arrangements for DS0000004149.V280645.R01.S.doc 15/03/06 20/02/06 20/02/06 07/03/06 01/04/06 Tutnall Hall Nursing Home Version 5.1 Page 26 13 OP30OP38 18(1)c 13(4) c 23(4)d 14 OP36 18(2) 15 OP15 Sched.4 17(2) (13) maintaining satisfactory standards of hygiene in the home. The kitchen floor needs replacing/sealing. Ensure that all persons employed 01/04/06 by the registered person to work at care home have: Training appropriate to the work they are to perform All staff must receive training in: First Aid Protection of vulnerable adults Fire prevention Dementia care Manual handling Food hygiene Infection control A record of this training must be retained in the home, to include date of training, duration and organising body. Provide an action plan identifying the courses to be attended, by which staff. The registered person shall 21/04/06 ensure that persons working in the home are adequately supervised. Care staff must receive formal supervision at least six times a year. Supervision should cover all aspects of practice, philosophy of care in the home, and career development needs. Records of these supervision sessions must be retained in the home. Staff meetings must occur at regular intervals and a record of these maintained. A record of food provided for 01/04/06 service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special DS0000004149.V280645.R01.S.doc Version 5.1 Page 27 Tutnall Hall Nursing Home 16 OP15 16(2)i 17 OP16 Reg 22 Sch4 17(2)11 18 19 OP38 OP12 Sch.4 17(2)14 23(4)c 16(2)(n) 20 21 OP21 OP35 23(2)(j) 20(1) diets prepared for individual service users. Provide in adequate quantities suitable, wholesome and nutritious food which is varied, properly prepared and available at such time as may reasonably be required by service users. An alternative meal should be available daily. Meals provided must reflect healthy eating guidelines in that five portions of fruit or vegetables are offered daily. An option of both a hot and cold drink must be offered with meals to meet individual residents personal preferences. Portion size must be reviewed. Menus must be acceptable to residents. A record of all complaints made by service users or representatives or relatives of service users or persons working at the care home about the operation of the care home, and the action taken by the registered person in respect of such complaint. Supply the Commission a statement containing a summary of the complaints made during the preceding twelve months and the action taken in response. A record of weekly fire alarm test must be available within the fire log. Provide facilities for recreation including, having regard to the needs of service users activities in relation to recreation, fitness and training. Bathing facilities must include W.C. and wash hand basin. The registered person shall not pay money belonging to any service user into a bank account DS0000004149.V280645.R01.S.doc 10/03/06 21/03/06 03/03/06 01/05/06 01/01/07 01/04/06 Tutnall Hall Nursing Home Version 5.1 Page 28 22 OP10OP14 12(4)a 23 OP38 13(4) 24 OP33 24 unless:The account is in the name of the service user, or any of the service users to which the money belongs. The account is not used by the registered person in connection with carrying on or management of the care home. The registered person shall make 01/09/06 suitable arrangements to ensure that a care home is conducted :In a manner which respects the privacy and dignity of service users. Bedroom doors must be fitted with locks on a suited system to enable residents maintain their privacy or security of personal possessions if they wish. Residents must be supported to dress appropriately for the weather 27/02/06 Existing risk assessments must be further developed to include the actions taken to minimise risk/control measures. A risk assessment must be undertaken in relation to the practice of transporting food to the kitchen from an external building. Risk assessment for pregnant staff must be further developed to accurately reflect all known/perceived risk and control measures in place. Secure fire extinguisher to the wall securely. The registered person shall 01/05/06 establish and maintain a system for: (a) Reviewing at appropriate intervals (b) Improving the quality of care provided at the care home, including the quality of nursing where nursing DS0000004149.V280645.R01.S.doc Version 5.1 Page 29 Tutnall Hall Nursing Home 25 OP8OP7 Sched.3 17(2) 26 27 OP28 OP38 18(1)c 13(4) is provided at the care home. A record of the incidence of pressure sores and of treatment provided to the service users. Records must include details of the pressure sore, dressings to be applied and the frequency they are to be changed. Arrangements must be made to ensure at least 50 of care staff are trained to NVQ Level 2. Forward the Commission an up to date:Landlords Gas Safety Certificate Evidence that the recommendations from the EIC report have been addressed Evidence of an up to date TV Licence. 01/03/06 01/06/06 27/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP10 OP14 OP12 OP12 OP14 Good Practice Recommendations The use of plastic beakers for all service users should be reviewed. The access to condiments for residents who have their meals on trays should be reviewed to enable individual preferences to be met. The siting of the television should be reviewed so that more residents can see it. The practice of having both the radio and television on in the same room at the same time should be reviewed. Review how residents are informed of who their key worker is and clarify with residents the role of the key worker. Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tutnall Hall Nursing Home DS0000004149.V280645.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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