Inspection on 20/06/05 for Uplands Nursing Home

This inspection was carried out on 20th June 2005.

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

Uplands Nursing Home 30/06/09

Uplands Nursing Home 07/01/09

Uplands Nursing Home 02/04/08

Uplands Nursing Home 16/04/07

Uplands Nursing Home 09/10/06

Uplands Nursing Home 14/01/06

Uplands Nursing Home 13/01/05

Uplands Nursing Home 27/07/04

Uplands Nursing Home 11/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Uplands Nursing Home Church Road Maisemore Gloucester GL2 8HB Lead Inspector Janice Patrick Announced 20 & 21st June 2005 10:15am th 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 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. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Uplands Nursing Home Address Church Road Maisemore Gloucester GL2 8HB 01452 505629 01452 307399 Uplandsnursinghome@lineone.net Mr Graham James Rigby Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Welch Care Home 50 Category(ies) of OP Old Age (35) registration, with number DE (E) Dementia (15) of places Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) The total number of beds includes 3 beds for persons under 65 years of age. 2) Tempoarary Variation - One named service user under the age of 65 years of age. Date of last inspection 27 July 2004 Brief Description of the Service: The Care Home is an extended House within the village of Maisemore directly off the main through road. It has car parking to the front and side and has a small enclosed garden within the centre of the Home. A number of care needs are catered for which include general personal and nursing care needs, care of those with dementia and 3 places are designated to the care of those under 65years of age. There has been a fairly consistent turn over of staff, but there is a committed and loyal, core group of staff. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days by one Inspector and lasted a total of 12 hours. The Registered Manager was present and was helpful and willing to discuss issues raised. The Care Services Manager supplied the Inspector with information as requested during the inspection. Several residents were spoken with, including four relatives. The main staff group were spoken to including kitchen, domestic, maintenance and administrative staff. The Provider was on holiday. A tour of the entire building was carried out and care documentation along with many other records were examined. A selection of Policies and Procedures were seen including additions to the Statement of Purpose. What the service does well: There is a general consensus amongst residents said that staff are kind and helpful. Staff appear to know the residents well. Many residents made comments such as: ‘they cannot do enough for you’ ‘they bend over backwards’. There are several residents within the Home that have very individual needs and require their routine to be kept stable, the staff seem very good at allowing this to happen and to ‘fit in’ with the residents preferences. Visitors are clearly made to feel welcome when visiting their loved ones. What has improved since the last inspection? Several things have improved since the last inspection in January of this year. Many of the environmental issues have been addressed and the Home is beginning to feel decoratively more light and tidy. Some bedroom carpets have been replaced with laminate flooring, which has made a huge difference to the odour of some rooms. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 6 The organisation of the cleaning and the auditing of soft furnishings has been handed over to the Senior Housekeeper. She has brought positive energy into this area and has to be commended for her efforts, seen during this inspection. Changes to the medication system have enabled a more efficient stock control and has improved the secure storage of certain medications. Areas of care documentation identified within the last report, have been evaluated and a lot of work carried out to ensure good documentation of care practices is recorded. The identification of and management of risks has vastly improved. The Manager has developed a system that offers the resident or their representative involvement in the devising and review of care plans. A more ‘person-centered’ approach of care has been adopted for those with a Learning Disability. Various Policies and Procedures have been reviewed or implemented. A full programme of Dementia Care Training for staff has commenced. Those with dementia now eat together within their own familiar surroundings. What they could do better: Considering its size and the needs of some of the residents the opportunities to go out would be vastly improved through the purchase of a mini-bus. Again the size of the Home, the varying needs of the residents and the demand on staff warrants the specific employment of an activities coordinator. Some environmental issues have been mentioned in the report, these will need attention and it is hoped that the improved standard seen at this inspection will continue. Staffing at nighttime generally and during the evening time on the dementia care unit is inadequate and must be addressed. The planned programme of refurbishment and structured maintenance would benefit from being brought together with the auditing that the Manager and head housekeeper are carrying out. A structured Quality Assurance System could then be developed, which would also encompass the opinions and a view of residents and visitors on subjects such a care, food, activities, environment and management of the Home. Lighting in some areas of the Home needs to be improved to meet the needs of an older person. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 7 The Provider must explore the allocated lines of accountability between the Registered Manager and the role of the Care Services Manager and clear defined boundaries must be drawn up relating to the decisions made about recruitment, training and induction of staff. 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. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 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 standard(s) 2, 3 & 4 Residents have the benefit of receiving adequate literature and contractual information prior to admission and can be assured that their care needs will be adequately assessed and that admission is only considered if those care needs can be suitably met. EVIDENCE: Several contracts with Terms and Conditions were seen which gave all the information required. Relatives who spoke with the Inspector had clearly been informed of the correct information regarding the Registered Nurse Care Contribution (RNCC) and were aware of the amount that the Home retains as an administration fee. Additional letters were seen informing residents of annual changes to the fees and of changes following reassessment pertaining to the RNCC. Examples of the initial assessment process were seen and discussion held about who is involved in giving this information apart from the resident. This includes other health care professionals and any one else that may have been involved in the care of that person. The case of a resident being admitted to hospital from the Home was discussed. Transfer back to the Home only occurred following a review by the Manager of her changed care needs. A Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 10 previous assessment showed that the Home would not be able to meet this person’s needs and therefore the admission did not go ahead. Input from healthcare professionals assists experienced and trained staff to meet the residents’ needs. The fixing of a catheter bag was not correct during this inspection. This was pointed out to the Manager and was an example of where simple, specific training maybe required. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 10 A comprehensive care planning system ensures that all health care needs are met or explored as needed with other health care professionals and delivered in a manner that, in most cases preserves the residents’ privacy and dignity. EVIDENCE: Many care plans were read and discussed during the course of this inspection. Some showed evidence of being agreed by the resident or their representative. Getting representatives involved in the care planning has been difficult, with a poor response to individual invites. However, one relative took the opportunity to discuss her relatives’ care with the Manager during this inspection. The Manager has decided that certain areas of care have to be agreed upon or at least discussed. Hence some risk assessments showed joint agreement and any care that is ‘peculiar’ to the individual, is usually discussed with a representative if the resident is not able himself or herself. A specific protocol was seen to accompany a care plan for epilepsy. Individualised night care plans are also in place. The care required for one resident with a Learning Disability has been explored with Community Learning Disability Specialists and the care plan reviewed with an aim to working towards a more ‘person-centred’ approach. Specific instructions for communication had been given by the Speech and Language Therapist and one member of staff was seen to be following this very well Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 12 when communicating with this resident. The care of another very poorly resident was witnessed by the Inspector and appeared to be following the written care plan. Both of these events indicated to the Inspector that there had been an improvement in how the care being delivered reflected the actual written plan. The residents’ right to privacy is upheld during the times when care is being delivered. Staff closed doors when starting any care procedure and knocked on doors before entering. The Inspector spoke with 3 residents who prefer to remain in their bedrooms, 1 in particular rarely comes out. In all cases their choice to lengthy periods of privacy was being respected. Residents’ dignity is upheld and was done particularly well in a conversation witnessed by the Inspector between the Manager and one resident on the dementia care unit. Residents were also fed in an unhurried and dignified manner. The only exceptions to this were two toilets. One on the dementia care unit and one right by the main entrance, neither have the opportunity to be locked by the user. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13 The Home helps some residents to maintain their lives as they choose within the care setting. Some have their expectations and preferences met. For others, either their health compromises this or inadequate opportunities are afforded by the Home, mainly to do with being able to have trips out and having that added quality and normality to life. EVIDENCE: It was evident that residents were making many choices in the two days of this inspection. These included where and how they spent their day, what they ate, where they ate, the freedom to sit outside if they choose and for some how and when their care was delivered. Visitors said they are able to visit as they choose and took advantage of an open door policy both to the Manager and the Administrator. There are no volunteers currently working at the Home. During the inspection care staff held a cinema afternoon. A video was put on and popcorn and choc ices were enjoyed. One carer has responsibility for co-ordinating activities and is helped by the other care staff when needed. A programme of activities is advertised. Staff clearly enjoy the opportunity to have additional interaction with residents, but Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 14 have commented that this can be difficult to maintain when there are poorly residents or residents that require more supervision in the Home. A monthly Communion is held and the needs of several faiths can be met locally. Two residents have had opportunities to attend certain clubs but have not continued with these. The Home arranges a pub meal twice a year and a trip to Western Super Mare or a trip up the River Severn is organised, but many residents said they would like to get out more frequently on an ‘ad hoc’ basis. For those in the dementia unit, the ability to go in small groups on a short, outings would increase their quality of life. It is therefore recommended that the Provider consider the purchase of the Homes’ own transport, able to meet the needs of the residents. It is also strongly recommended that a designated activities coordinator be employed. A requirement from the last report was followed up; this was pertaining to standard 15 and choice of food. The Cook demonstrated that choice is available in the Home and that every effort is made to accommodate particular requests. For those that are at risk of not maintaining an adequate nutritional state, staff have access to advice from a leading nutrition company, where after consultation with the GP, supplements can be used. The Cook demonstrated knowledge of how to get additional calories into food, of other dietary issues and an awareness of small problems that the elderly may have such as problems with false teeth. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 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 standard(s) 16 There is a Complaints Procedure, which is well advertised, and residents and visitors are assured that their complaint or concerns are listened to and dealt with. EVIDENCE: The Complaints Procedure is on the Homes notice board and within the literature given to residents prior to admission. According to the Manager and the Complaint Log only one complaint has been received by the Home since the last inspection. This has been responded to and the Manager is awaiting a response from the complainant. This complaint challenges drug administration practice within the Home. The Inspector recommends that any nurse who has not recently had an update in drug administration and related Law does so. One resident was concerned that there had not been a lock on his bedroom door. The Inspector could see that this had been fitted soon after his request. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 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 standard(s) 19, 25 & 26 There has been a huge improvement in the decoration, cleanliness and general maintenance of the Home. If this can be sustained, then residents will continue to have pleasant surroundings to live in. EVIDENCE: There have been several ongoing requirements regarding the general environment. At this inspection the Inspector could see that many of these had been met and that there was a vast improvement in both decoration and cleanliness. Several corridors and bedrooms have been decorated and carpets replaced with laminate flooring. A bathroom had been cleared of storage and rubbish. Various maintenance issues had been met. Some areas of the older building remain tired with obvious decorating needs. The Provider is working his way around the building at present. The areas seen by the Inspector as still requiring attention are: • The bath in a ground floor bathroom, opposite room 23 still has a broken side panel. This has been broken for sometime now and poses a risk to frail skin and hygiene. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 17 • • • • • • The keys to various lockable top draws in bedrooms must be located and made available. Bedroom 6 requires decoration. Bedroom 5 requires decoration as the wallpaper is ripped alongside the bed and the carpet requires securing by the door. Room 4 requires new floor covering and is in need of enhanced lighting. Room 35 requires the boxing in around the toilet to be completed. Outside window frames are in severe need of decoration, those in the courtyard are due to be painted in July. The laundry, although very small looked organised. A new washing machine had been recently installed. An older one still leaks at the front. It was recommended that a nailbrush and bar of soap be thrown away and a soap dispenser be put in place, as both of these are excellent mediums for cross infection. Soap dispensers were seen in other areas. Systems are in place to reduce cross infection, such as appropriate laundry bags, plastic aprons and gloves. Staff must remember to use these bags appropriately at all times, as some laundry was seen to be put straight on the floor, something the inspector has witnessed before at the Home. All portable heaters except one have been removed. New boilers have been installed which the Inspector understands will now heat the entire building. Most light bulbs are energy saving, (15W= 60watt) but many bedrooms did seem very dark, particularly those in the older part of the Home. Older people quite often need additional lighting. The Home has acquired 4 new profiling beds, from the continuing health care nurse for those with a high degree of physical need. One resident explained that he bought his own profiling bed and had brought it with him. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 The staffing levels within the Dementia Care Unit are not consistently adequate to ensure all residents’ needs are met and to adequately maintain the safety of those who are confused and wandering. EVIDENCE: The Home relies on minimum staffing levels. On the Dementia Care Unit staff have found that care needs have increased, particularly around continence issues, but staffing has remained at 2 during the day. From 7.45pm onwards residents’ needs and their safety is compromised. Once the day staff go off duty, the staffing reduces to 3 in total. Therefore, when the nurse is administering medications and care staff are handing out evening drinks and attending to residents who are poorly or who are due to go to bed, the Dementia care unit is uncovered for several hours at a time. Several staff spoken to felt the present staffing at night was ‘unsafe’ ‘running at a risk’. It was also clear to both day and night staff that residents’ on the dementia care unit were not receiving adequate supervision in the early hours of the morning, due to the early morning pressures on night staff. This has been evident by the mess and muddles that early morning day staff have found when coming on duty. A previous requirement relating to inadequate staffing levels was issued in the last inspection report, therefore an audit was carried out during this inspection in relation to the night hours Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 19 There were 9 residents that wander on a regular basis in the Home. 13 required 2 care staff to attend to them. 7 are potentially aggressive on intervention and 15 are often awake during the night, requiring some form of attention at some point, 7 of which are on the Dementia Care Unit. Between 30/11/04 and 20/6/05 there were 80 reported accidents, 50 occurred at night. On the basis of the above information the night staffing at Uplands must be increased to a minimum of 4 night staff, one of which must remain on the dementia care unit at all times. This must be reviewed when the Manager feels that dependency levels are increasing. It is also strongly recommended that a twilight member of staff also be considered (for example 6pm-10pm) for the Dementia Care Unit. The Care Services Manager informed the Inspector that the Home has been advertising for an extra night carer for sometime, however this increase must be met within the date shown on this report. The Induction training for new staff was not inspected in full. New staff are however, supervised until felt to be competent and are in addition to normal staffing during their first few days. One such carer said that she worked with another more experienced carer when she began and felt that everyone had been really supportive. She was able to discuss some of the training she had undertaken. The Manager was unaware of a recorded induction system and staff files were not inspected during this inspection. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 38 A lack of effective communication, clearly defined roles between senior staff and the Provider and a purposeful Quality Assurance System has hampered the Homes ability to provide consistent direction for staff and improve standards for residents. Health and safety systems within the Home help promote residents’ safety but this is compromised by a lack of staffing. EVIDENCE: The Manager is trained in Mental Health nursing and therefore compliments his Deputy who is a General Nurse. He has many years experience in Care Home management and liaising with external health care professionals. He has good support from his senior staff regarding the care of residents and each have certain responsibilities delegated to them. Short and infrequent staff meetings are held, but staff confirmed that communication amongst them is good and that many issues are discussed in Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 21 ‘handover’ meetings. Several residents agreed that the Manager was approachable. One resident said ‘he gets things sorted out’. A few comments were passed about the Manager having a ‘short temper’ or ‘a short fuse’. The Manager agreed that where he has to keep reminding staff of certain issues in the Home, he does loose his temper. The Inspector is under the impression that there has not been a recent resident meeting. There was also no record of one being held, but a relative confirmed that an open door policy seems very much in place and a resident’s satisfaction survey has been carried out, but the Manager was unaware of the findings. Lines of accountability regarding the Registered Manager’s involvement with such systems as: Quality Assurance, Recruitment, Training and Induction remain unclear. The boundaries between the Care Services Manager and the Registered Manager also appear unclear. The Manager has met requirements from the last inspection that he felt related to the nursing care. This work met with the Manager’s job description, but the Care Home Regulations make it clear that responsibility for the systems discussed above lie with the Registered Manager. Environmental requirements were passed onto the Provider and the maintenance team. A list of ongoing maintenance has been forwarded to the Inspector. All risk assessments have been reviewed since the last inspection. Records could only be found for the electrical testing of main domestic items. Smaller items such as lamps, personal TV’s and radios etc. had no records or stickers indicating testing. All staff except two have received recent Fire training and manual-handling training is also ongoing. An appointed contractor checks all Fire prevention systems. The last recorded maintenance check for hoists was July 2004. Guidance from the Health and Safety Executive says that 6 monthly checks should be carried out. Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x 2 3 STAFFING Standard No Score 27 1 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 2 1 x x x x 2 Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 23 Yes 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. Standard 10 Regulation 12(4)(a) Requirement All toilet doors must have appropriate locks fiited in case the occupant wished to lock the door whilst using the facility (timescale of the 25/2/05 not met). Additional lighting must be provided in bedrooms and removed if the resident does not choose to keep it. Staff must ensure that the use the appropriate laundry bags provided. There must be a minimum of 4 staff on duty at night, 1 of which must remain on the Dementia Care Unit at all times (timescale of 27/9/04 & 25/2/05 not met). Clear lines of accountability, responsibility and effective communication must exisit between the Provider and all Managers. A Quality Assurance System must be implemented to help improve the care given and maintain other standards within the Home. The Registered Manager must ensure that Portable Appliance Testing is being carried out on all Timescale for action 31st August 2. 25 23(2)(p) September 2005 30th 3. 4. 26 27 13(3) 18(1)(a) 31st August 2005 31st August 2005. 5. 31 12(5)(a) 31st August 2005 6. 33 24(1)(2) & (3) Septemeber 2005. 30th 7. 38 13(4)(c) 31st August 2005 Page 24 Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 electrical items within the Home. 8. 19 23(2)(b) & 23(2)(d) The following decoration and 30th September 2005 mainatance must be carried out: · The bath in a ground floor bathroom, opposite room 23 still has a broken side panel. This has been broken for sometime now and poses a risk to frail skin and hygiene. · The keys to various lockable top draws in bedrooms must be located and made available. · Bedroom 6 requires decoration. · Bedroom 5 requires decoration as the wallpaper is ripped alongside the bed and the carpet requires securing by the door. · Room 4 requires new floor covering and is in need of lightening up. · Room 35 requires the boxing in around the toilet to be completed. · Outside window frames are in severe need of decoration, those in the courtyard are due to be painted in July. 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. Refer to Standard 12 26 27 Good Practice Recommendations That the Provider should provide the Home with its own Mini-Bus or equivilent transport to meet the needs of all residents and employ a full time activities co-ordinator. That all nailbrushes and bars of soap be removed. That an extra member of care staff be employed on the Dementia Care Unit during the hours of 6pm and 10pm. D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 25 Uplands Nursing Home Commission for Social Care Inspection Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 Uplands Nursing Home D51_D03_16643_Uplands N H_v228040_200605_AI_stage4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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