Inspection on 15/11/07 for Reachout Recovery Centre

This inspection was carried out on 15th November 2007.

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 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

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westwood Nursing Home 8 Polygon Road Crumpsall Manchester M8 5SR Lead Inspector Geraldine Blow Unannounced Inspection 15th November 2007 09:45 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 Westwood Nursing Home DS0000070378.V354442.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. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood Nursing Home Address 8 Polygon Road Crumpsall Manchester M8 5SR 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) 0161 795 3776 0161 795 3776 Continuum Westwood Healthcare Ltd Muhammad Zafar Farooq Warsi Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - code N To people of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 32. Date of last inspection Brief Description of the Service: Westwood Nursing Home is registered to offer accommodation to 29 older people. The home has recently been purchased by Continuum Westwood Healthcare Ltd and the Responsible Individual is Mr Ashraf Patel. Local shops, pubs, restaurants, a shopping centre and hospital facilities are all within easy reach. The home is well served by public transport services to and from Manchester City Centre. The home is a large extended detached house set in its own grounds. There is an attractive, well-maintained garden to the side of the property. There are limited parking facilities at the front of the building. Bedroom accommodation is provided on the ground and first floor, which is split into 2 levels. The third floor comprises of office space. The home has 26 single and 3 double bedrooms. All rooms are provided with a wash hand basin. There are no en-suite facilities available. The double rooms have strategies in place for the maintenance of privacy. The communal space comprises of two lounges and dining areas and there is a conservatory at the front of the building. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents, staff and General Practitioners (GP’s) were sent comment cards. Three resident comment cards, 4 staff comment cards, and 1 GP comment card was received by CSCI. This unannounced visit, which was the first visit since the new providers have been registered with CSCI, forms part of the overall inspection process and took place on Thursday 15 November 2007. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent examining relevant documents and files, talking with the home’s Responsible Individual, the manager, several people living at the home, some members of staff, several visitors to the home and a tour of the building was undertaken. What the service does well: Visitors spoken to confirmed that they could visit whenever they wanted to and were made to feel very welcome when they did visit. Several visitors stated that they were very happy with their relatives’ care and felt they were very well looked after. They also said that the food was very good and they felt that they could approach staff if they had any concerns and that they would be listened to. Large supplies of fresh fruit and vegetables were seen and the chef stated that fresh fruit and vegetables are served every day. This was confirmed by a visitor who was spoken to. At the time of this visit major refurbishment was being carried out. All visitors spoken to confirmed that it caused little or no disruption to the residents who live there. The Responsible Individual (RI) appeared very keen to raise and maintain standards within the home. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 7 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 Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 intermediate care is not provided at Westwood Nursing home) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An assessment of prospective residents’ care needs in not always undertaken prior to their admission. EVIDENCE: The manager confirmed that where possible prospective residents and/or their relatives are encouraged to visit the home prior to a decision about admission being made. Evidence was seen that that for residents who are referred through Care Management arrangements a summary of the Care Management Assessment and/or the Funded Nursing Assessment was obtained and the manager stated that these are obtained before the resident is admitted to the home. In addition the manager confirmed that prior to admission being arranged a visit is usually made to the prospective resident so that a pre admission assessment Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 9 of needs can be undertaken. However there was no documented evidence to support this in the files examined. The manager confirmed for 1 resident that had been admitted for respite care in 2006 he did not have an assessment of needs prior to his admission in 2007. In addition the manager stated that when he has obtained the care management assessment he does not complete a documented assessment or make any notes of the consultation prior to admission. It is recommended that any consultation with the prospective resident/relative or pre assessment of needs is undertaken the assessment is fully documented. Westwood Nursing Home does not provide an Intermediate Care Service. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some shortfalls were identified in ensuring that the health care needs of residents were being met. EVIDENCE: A random sample of care plans were examined. The care files examined contained an individual plan of care, however some areas of the care plans were not person centred and were quite vague and did not clearly set out the individualised actions or personal preferences which needed to be taken by staff to ensure that residents’ individual health, social and personal care needs are fully met. For example some entries included “use correct sling” and “clean peg site daily ” yet there were not details of which sling was to be used or what to clean the PEG site with. It was of further concern that some areas of the care plans contained conflicting information about resident’s personal preferences. In one care file the nursing needs assessment clearly identified a mental health requirement, yet the plan of care did not contain any of the specific details in the needs assessment or how staff were to manage the behaviour should it Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 11 arise. To ensure that residents’ care needs are appropriately met the plans of care must accurately reflect the identified care need and how that need can be met. It is recommended that all residents’ care plans are developed using a person centred approach and contain sufficient detail for staff to meet all residents identified needs. The risk assessments that were in place relating to the use of bed rails did not thoroughly risk assess the use of the bed rail. However the manager confirmed that he did have a thorough risk assessment but he had not yet implemented its use. To ensure the safety of residents the updated risk assessment must be implemented for all residents using bed rails as a mater of some urgency. Generally the assessments relating to oral hygiene, continence and nutrition were vague and did not provide a through assessment of needs. To ensure that residents’ needs are adequately assessed it is recommended that these assessments are reviewed and updated. The manager stated that where possible residents and/or their representatives are consulted and included in the care planning process. It is recommended that this involvement be recorded. It was noted on examination of the MARs that a number of medications had not been signed into the home and some medication carried over from the previous month had not been recorded. In addition it was of concern that there were gaps in the recordings of medication and when a tablet count was undertaken of medication that was not included in the blister packs, discrepancies were found. Accurate records of medication must be kept in order to provide evidence that residents’ receive their medication as prescribed. There were records of waste medication, however it is recommended that 2 staff witness and sign for the disposal of waste medication. The manager confirmed that there was no system of auditing medication. To ensure that residents are receiving medication as prescribed by the GP medication must be accounted for at all times by means of an audit trail. From observations made and discussions with visitors and staff it appeared that the nurses and care staff did treat the residents with respect and dignity when assisting them. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited activities are provided and residents are able to maintain contact with family and friends. EVIDENCE: A care worker had been given the responsibility to act as a part time activity coordinator and the designated activity hours were recorded o the staff rota. The coordinator confirmed that the activities provided were limited, they included things like going to the shops, music and dancing afternoons although she confirmed that a Christmas party for residents, visitors and staff was in the process of being organised. The coordinator stated that she did make a record in the care file of residents when they took part in the activities but did not document any consultations regarding social interests or hobbies. It is recommended that a record be kept of any resident consultation regarding their social interests, activity requests or hobbies. Visitors spoken to confirmed that they are made welcome in the home and the visitor’s book, kept by the front door, indicated that the home had numerous visitors. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 13 From speaking to residents, visitors and staff it appeared that residents are able to exercise choice and control over their lives and that residents are able to bring personal possessions into the home. The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced. A large supply of fresh fruit and vegetables wasseen and the chef confirmed that these are available daily. An alternative to the main meal was available, but only on request and staff spoken to confirmed this. It was noted that the kitchen was in need of redecoration, which the chef confirmed was going to be done as part of the refurbishment of the home. The kitchen was found to be clean and orderly. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 14 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are systems and procedures in place to protect residents from abuse and support people to express any concerns they may have. EVIDENCE: There was a complaint procedure that had been included in the Service User Guide. It was noted that it contained the previous address and phone number of CSCI. It is recommend that this is updated. The home had a complaint record book and evidence was seen that a recent complaint had been recorded. However there was no evidence of any written correspondence to the complainant and although there was an entry by the manager, staff statements had not been obtained as part of the investigation. It is recommended that all complaints are acknowledged in writing and there is a written conclusion to the complainant following an investigation. It is also recommended that staff statements are obtained, where necessary, as part of the investigation. It was encouraging that all received resident comment cards indicated they knew how to make a complaint. There was a Protection of Vulnerable Adults policy and the manager confirmed that he had a copy of the Manchester Multi-Agency Adult Protection Procedure, which includes the contact numbers to report an allegation of abuse. The manager was reminded that if any of the residents are funded from outside of Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 15 Manchester Local authority it is recommended that their contact details are also obtained. Evidence was seen that staff had attended in-house Safeguarding Adult Awareness training and the manager confirmed that further training dates had been arranged. It is recommended that staff competence should be assessed in applying the skills and knowledge gained through the training. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All areas of the home were generally clean, however some practices did not prevent the risk of cross infection. EVIDENCE: At the time of this visit major refurbishment of the home was being undertaken. The manager’s office on the 3rd floor had been refurbished, several bedrooms had been redecorated and the ground floor corridor was in the process of redecoration. In addition work was being undertaken to the front garden area to make it more accessible and more attractive for residents. From talking to residents and visitors it was encouraging that the work was not affecting the daily lives of the residents. During a tour of the building and discussion with staff it was noted that there were some shortfalls in the prevention of cross infection. For example aprons Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 17 and wipes (PPE) are not routinely stored close to the toilets or bathrooms. In an attempt to minimise the risk of cross infection and possible distress to residents it is recommended that PPE are easily accessible to staff should they need them. It was noted that both hoists were dirty and were not being cleaned inbetween resident use. To help reduce the risk of cross infection it is recommended that they are thoroughly cleaned and wiped down in-between resident use. The manager confirmed that there were only 2 hoist slings that were shared between the residents. This increases the risk of cross infection. In addition a number of wheelchairs were seen to be dirty and had encrusted food on them. The manager did not appear aware of the recent guidelines published by the Manchester PCT on infection control. It is recommended that the manager familiarises himself with the infection control guidelines. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The recruitment procedure did not protect residents and not all staff had completed the required training to evidence that they can meet the assessed needs of the residents accommodated EVIDENCE: At the time of this visit 21 residents were accommodated. Sixteen residents had been assessed as requiring nursing care and 5 residents had been assessed as requiring personal care only. All of the returned staff comment cards indicated that they thought there was not enough staff on duty to meet the needs of the residents. In addition one visitor spoken to said that she thought there were not enough staff on duty. Staffing levels were discussed with the RI during the course of the inspection visit. It is recommended that the dependency levels of all residents are regularly reviewed to ensure that staff are provided in sufficient numbers to meet the assessed needs of the residents. Fourteen care staff are employed, 2 of whom had achieved NVQ level 3, 4 had achieved NVQ level 2 and 3 care staff were currently undertaking NVQ level 2. Staff files of 2 newly recruited members of staff were examined. It was of great concern that both members of staff had started work without a clear CRB or a POVA first check being obtained. At the time of the inspection, POVA first Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 19 checks had been obtained, however, the manager confirmed that both staff were working without being supervised and accompanied by a member of staff. To ensure that residents are not put at unnecessary risk both members of staff must be supervised and accompanied by a member of staff at all times, until a clear CRB has been obtained by the home. In addition 1 of the references obtained was not from any of the referees documented on the application form and although the application form detailed that the last employer was a nursing home both references were obtained from a restaurant. The manager confirmed that the NMC resister was not regularly checked for nurse suspension or exclusion from the register. To ensure that residents are not put at unnecessary risk it is recommended that the nurses employed are regularly checked against the NMC register. It was noted that some but not all of the photocopied documents had been signed to identify that the original had been seen. It is recommended that one reference is obtained from the current/last employer and that all photocopied documents are signed to indicate that the original has been seen. There was no evidence of a set interview format and notes were not taken. It is recommended that a set interview format is used and notes are taken during the interview process. The manager confirmed that a new induction programme was in the process of being implemented but that they were not registered with the recognised organisation, ‘Skills for Care’ and it did not include a competency assessment on completion. A recommendation has been made to address this issue. The manager confirmed that there was no up to date training record for staff and that staff had not received all the appropriate training. All staff must receive appropriate training and must be assessed as competent to be able to provide the support that residents require to meet their needs and maintain their health and safety. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements were needed in management procedures to fully protect residents and ensure the home was managed in their best interest. EVIDENCE: The staff comment cards identified that there was some unrest in the home since the new providers took over and this was discussed with the RI as part of this inspection visit. Two of the comment cards indicated that staff felt the manager did not adequately support them. It was encouraging that quality questionnaires had been recently sent out and were available in the main receipt along with CSCI comment cards for people to access. The RI stated that the administrator would be reviewing and analysing the results and then an action plan would be implemented in the Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 21 New Year. In addition the manager confirmed that he had held several staff meetings. The meetings were held exclusively for the different staff disciplines i.e. nurses, carers, domestic staff etc as he felt they were more productive than large group meetings. The manager confirmed that the policies and procedures were all in the process of being reviewed by the new providers. It is recommended that this is undertaken as a mater of some urgency as the policies and procedures in place were implemented by the previous providers. The RI confirmed that an administrator had recently been employed and he had the responsibility for recording resident’s money. The manager and the administrator confirmed that where possible residents families had the responsibility for resident’s money and where this was not possible the head office has the responsibility for the rest. The usual practice is that staff will shop for residents to get personal items and the money for this is taken from a petty cash float. The head office is then sent an invoice for the money spent. There was no written agreement between the resident and home for this to happen which could place people at risk. It is recommended that a policy that clearly sets out the procedures for managing residents money is developed and implemented and that a written agreement be developed where residents give staff consent to undertake shopping for personal items on their behalf. In addition it was of some concern that there were occasions, mainly weekends and Bank holidays, where the petty cash cannot be accessed. potentially leaving residents without access to their own money. It is recommenced that a system be implemented and included in the above policy so that residents can have access to their own money at all times. There are occasions when family members bring in cash for residents and this was not recorded or invoiced. To ensure that residents and staff are protected, all residents’ monies that come into the home must be fully recorded in the residents’ financial records. It is recommended that any person who brings in residents personal monies are given a signed and dated receipt for that money. Evidence was seen that staff supervision was in the process of being implemented. Evidence was not available that there was appropriate maintenance and servicing of equipment. The maintenance equipment part of the AQAA had not been fully completed and evidence could not be provided on the inspection. This has the potential to put residents at risk. To ensure the health and safety of residents accommodated clarification must be obtained from the Health and Safety Executive regarding the appropriate tests and servicing of equipment and services within the home. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 22 It was noted that the fire risk assessments and the evacuation procedure on display in the main reception were dated July, before the present owners took over the home. It is recommended that these be reviewed and updated accordingly. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 2 x 2 Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 24 N/A 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 OP7 Regulation 15 (1) 13 (4) (c) Requirement 1. To ensure that residents care needs are appropriately met the plans of care must accurately reflect the identified care needs and how that need can be met. 2. To ensure the health and safety of residents the improved risk assessment relating to the use bed rails must implemented for residents using bed rails to ensure that they have been adequately assessed prior to their use. 2. OP9 13(2) 1. To ensure residents are receiving medication as prescribed by the GP medication must be accounted for at all times by means of an audit trail. 2. Accurate records must be kept of all medication received into the home in order to provide evidence that residents’ received their medication as prescribed. 3. Medication must be given and signed for as being given as prescribed by the GP. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 25 Timescale for action 31/12/07 31/12/07 3. OP29 19 (7) 4. OP30 18 (1) (a) (c) (i) (ii) 5. OP35 17 (2) Schedule 4 13 (4) (c) 6. OP38 To ensure residents are not placed at unnecessary risk a new worker can only start work without a clear CRB being obtained if it has been applied for and a full and satisfactory POVA first check has been obtained and they are supervised and accompanied by a member of staff at all times. All staff must receive appropriate training and must be assessed as competent to be able to provide the support that residents require to meet their needs and maintain their health and safety. To ensure that residents and staff are protected all residents’ monies that come into the home must be fully recorded in the resident’s financial records. To ensure the health and safety of residents accommodated clarification must be obtained from the Health and Safety Executive as to their responsibility in relation to the appropriate tests and servicing of equipment and services within the home. 19/11/07 31/01/08 19/11/07 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP7 Good Practice Recommendations It is recommended that any consultation with the prospective resident/relative or pre assessment of needs is undertaken the assessment is fully documented. 1. It is recommended that the residents individual plans of care be more person centred and contain more details of the specific action which needs to be taken by staff to DS0000070378.V354442.R01.S.doc Version 5.2 Page 26 Westwood Nursing Home ensure that all individual aspects of residents health, personal and social care needs are met. 2. It is recommended that consultations with residents and/or their representatives regarding the individual plans are care is recorded. 3. To ensure that residencies care needs are adequately assessed it is recommended that the assessments of needs detailed in the body of this report are reviewed and updated. It is recommended that 2 staff witness and sign for the disposal of waste medication. It is recommended that a record is kept of any resident consolation regarding their social interests, requests and hobbies 1. It is recommended that the complaint procedure be updated to reflect the current address and phone number of CSCI 2. It is recommended that all complaints are acknowledged in writing and there is a written conclusion to the complainant following an investigation and staff statements are obtained where necessary as part of the investigation. If any residents are funded from outside of Manchester Local authority it is recommended that their contact details are also obtained. It an attempt to minimise the risk of cross infection it is recommended that: 1. It is recommended that the hoists and wheelchairs are thoroughly cleaned 2. The hoist be surfaced cleaned in between each resident use. 3. It is recommend that each resident has their own hoist sling 4. In an attempt to minimise the risk of cross infection and possible distress to residents it is recommended that Personal Protective Equipment (PPE) are easily accessible to staff should they need them. 5. It is recommended that the manager familiarises himself with the infection control guidelines published by Manchester PCT. Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 27 3. 4. 5. OP9 OP12 OP16 6. 7. OP18 OP26 8. OP27 9. OP29 It is recommended that the dependency levels of all residents are regularly reviewed to ensure that staff are provided in sufficient numbers to meet the assessed needs of the residents. 1. It is recommended that a set interview format is used and notes are taken during the interview process. 2. It is recommended that one reference is obtained from the current/last employer. 3. It is recommended that that all photocopied documents are signed to indicate that the original had been seen. 4. It is recommended that the NMC website is regularly checked for nurse exclusion or suspension from the register. 1. It is recommended that the manager seek advice about registering with Skills for Care. 2. To ensure the staff employed receive appropriate training to meet the needs of the residents accommodated it is recommended that an action plan based on individual staff training needs is developed to provide staff with those skills, knowledge and awareness. It is recommended that the new providers review and implement their own comprehensive set of polices and procedures. 1. It is recommended that any person who brings in residents personal monies is given a signed and dated receipt for that money. 2. It is recommended that a policy that clearly sets out the procedures for managing residents money is developed and implemented. 3. It is recommend that the above policy include a system where residents can access their money at all times. 4. It is recommended that a written agreement be developed where residents give staff consent to undertake shopping for personal items on their behalf. To ensure the safety of residents living at the home it is recommended that the fire risk assessments and the fire evacuation procedure are reviewed an d updated accordingly. 10. OP30 11. 12. OP33 OP35 13. OP38 Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Westwood Nursing Home DS0000070378.V354442.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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