Inspection on 19/10/05 for Yardley Grange Nursing Home

This inspection was carried out on 19th October 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

Yardley Grange Nursing Home 17/11/08

Yardley Grange Nursing Home 03/07/07

Yardley Grange Nursing Home 05/07/06

Yardley Grange Nursing Home 01/06/05

Yardley Grange Nursing Home 12/10/04

Yardley Grange Nursing Home 29/04/04

Yardley Grange Nursing Home 14/01/04

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

CARE HOMES FOR OLDER PEOPLE Yardley Grange Nursing Home 465 Church Road Yardley Birmingham B33 8PA Lead Inspector Lisa Evitts Announced 19 October 2005 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. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Yardley Grange Nursing Home Address 465 Church Road Yardley Birmingham B33 8PA 0121 789 7188 0121 789 5819 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) Yardley Great Trust Ms Joanna King Care Home 45 Category(ies) of OP; DE(E) over 60; DE(E) over 65; TI(E) 69 registration, with number years; TI of places Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 15 people receiving continuing care within usual staffing levels (see conditions 5 & 6). 2. Between 7 & 10 people receiving continuing care support with 1 additional carer on duty throughout waking day. 3. Any persons in receipt of continuing care are accommodated on first floor of the home. 4. The Manager to be supernumerary to registered nurses. 5. Two registered nurses will be on duty at all times, day and night. 6. In addition to registered nurses there will be 8 care staff on duty each morning, 8 each afternoon, 4 after 8pm, and 3 on duty all night. 7. That the manager successfully undertakes the Registered Managers Award or equivalent by April 2005. 8. Service users over the age of 60 at the date of admission can be cared for in this home. 9. One named service user under 60 years at the date of admission can be cared for in this home. Date of last inspection 1st June 2005 Brief Description of the Service: Yardley Grange Nursing Home was relocated to purpose built premesis during the summer of 2002. It is situated in a quiet road in a suburb of Birmingham within easy reach of public transport. The building stands within picturesque grounds with mature trees and there is sufficient off road parking with an attractive rear garden accessible to residents. The home provides twenty four hour nursing care to forty five people over sixty years of age who may have dementia or may be terminally ill. All rooms are single and have ensuite facilities and there are sufficient bathrooms, shower rooms and toilets to meet residents needs. Communal space includes a lounge and pleasant dining rooms on both the ground and first floor of the premesis. There is a range of aids and adaptations designed to assist in the management of residents with restricted mobility. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Announced inspection was undertaken by one inspector, over a full day and was assisted throughout by the Registered Manager and Deputy Manager. This was the second statutory inspection for the 2005-2006 year. There were forty-four residents living at the home on the day of the inspection. Information was gathered from talking with the residents and staff and from observing the care staff perform their duties and examining care and medication records. A partial tour of the building was conducted. No comment cards had been completed. What the service does well: What has improved since the last inspection? The documentation in respect of complaints had improved greatly and there is a clear audit trail to follow the complaint through to the outcome. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 6 Comprehensive letters are sent out to complainants with the outcome of the investigation. In addition to the automated check on Registered nurses PIN via the Nursing & Midwifery Council confirmation service, the home now also obtains written evidence of the check, which is kept on the individuals file. There has been on going decoration to bedrooms at the home, to ensure residents live in clean and comfortable surroundings. The home manager is keen to implement changes and plans to change a small lounge into a sensory room, where residents can sit and relax in a calm environment. There have been improvements to the details recorded in care plans, and this ensures that all staff are aware of the individual residents care needs. 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. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 ,3 & 4 The home has comprehensive pre admission assessments in place and this ensures that the home can meet the needs of the residents prior to admission. Residents are issued with a contract to ensure they are informed of the terms and conditions of their stay at the home. EVIDENCE: Two care files reviewed showed evidence of detailed pre admission assessments, which are completed by the Registered Manager or the Deputy Manager. Documentation used to complete the assessments is fully comprehensive and allows for a complete assessment of the potential resident. Each resident is issued with a statement of terms and condition of residency; this includes the room number, fees to be paid and a four-week notice period. One file had a signed and dated contract. Whilst the contract was in place on the second file of a recent admission, the resident was unable to sign the document and the Manager was liaising with social services as to who would sign on the resident’s behalf. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 9 On the day of the inspection, only one page of the registration certificate was on display. The manager stated that she was in the process of buying new frames as the previous ones had been broken. All pages of the certificate are required to be on display. Policies and procedures are awaiting transfer to audiotape, to assist residents to access these if required. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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 standard(s) 7, 8 & 9 Resident’s health and personal care needs were generally well met and improvements had been made to the care plans. Residents are supported in a respectful manner by the staff and this ensures that their dignity and selfesteem are maintained. Medication administration was not robust and checks were not in place, this places residents at risk. EVIDENCE: Residents spoken to appeared to be very satisfied with the care delivered by staff at the home and comments included “whoever comes in to you knows what to do”. Residents were well presented on the day of the inspection. At the last inspection, a concern was raised with the amount of time residents were waiting for staff to assist them to the toilet and this appeared to have been resolved. One resident stated, “Staff come quickly if I need the toilet” Each resident had a set of care plans and two resident files were sampled. Care plans had been written to reflect changes in resident’s conditions. Care plans seen were reviewed, signed and dated monthly although there was no recorded review of the evaluation of the care plan. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 11 The Walsall score is used each month to assess risk of pressure sores, and there was evidence of pressure relieving equipment in place and in use for residents who required this. Records were good and there was evidence of involvement from the tissue viability nurse. Care plans gave good clear instructions to the care staff in respect of each residents needs. There was some evidence of family involvement in the care planning as one file had the resident’s daughter’s signature on the care plans. Separate records of visiting Social and Healthcare professionals are maintained and there was evidence that residents had seen G.P, Tissue Viability Nurse, chiropody and physiotherapist. Daily reports provided detailed information about the resident’s interests and welfare during the day. Medication administration on the ground floor was generally good, with the exception of *Antibiotics not being signed in on receipt. *The medication room was very warm and there was no thermometer available, the temperature of the room needs to be checked to ensure that medicines are being stored appropriately to maintain their stablility. The medicine management on the first floor was poor. *Some medications had been signed in and others had not. *It was impossible to complete any audit trail to monitor if residents had received prescribed medication. On other audits completed, it was found that there were several drugs left over, when they had been signed for as administered. *One resident was found to have had their medication changed in August, and whilst this had been supplied to the home, the change over had not been implemented and the resident was still receiving the original prescription. An immediate requirement was left with the home manager to liaise with G.P and pharmacist and ensure that the resident was receiving the prescribed medication. MAR charts did not correspond to the new prescription start date, the home manager needs to liaise with the supplying pharmacist to rectify this problem, as tablets are being checked in on the previous months MAR chart. Some of the MAR charts stated that there were ten tablets being supplied when in fact there were twenty-eight. The supplying Pharmacy does not currently complete any audits and the home manager and deputy manager had not undertaken any recent audits. It is required that regular staff audits are undertaken to confirm nursing staff competence in medicine management and appropriate action must be taken if discrepancies are found. Not all Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 12 current prescriptions had been photocopied to keep alongside the MAR chart, in line with good practice. The home has a contract to dispose of medication and a dupe kit for the disposal of controlled drugs. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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) 12,13,14 & 15 Residents are able to exercise choice over their daily lives, community contact and the activities they choose to participate in, which promotes their individuality and independence. Residents receive a wholesome and varied diet that meets any special dietary needs. EVIDENCE: Residents are able to go outside of the home with family and friends as they wish; one resident stated “I sit outside in the porch when it’s nice” The home has an open visiting policy and a resident informed the inspector that her daughter could visit at anytime. Yardley Grange employs an activities coordinator and she divides her time between the two floors. Each floor had an activities notice board which displayed lists of weekly activities that included, art and crafts, flower arranging, bingo, hyms and reminisance, mystery bingo, foot and hand massages, facials and make up, cookery, karaoke and exercises. “Party days” are also arranged when activities follow a theme, and entertainment from external entertainers is arranged. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 14 Outings are arranged to garden centres, shopping trips and trips to the local Blakesley Hall. A clothing party had been arranged and letters had been sent out to families inviting them to join in. In the preparations for Christmas visits from shopkeepers have been arranged for them to sell products, and this is commended as it allows residents to purchase their own gifts and maintain their independence. Gift catalogues had been sent to the home for residents to review prior to the sales parties. The hairdresser visits once a week and one a month the home holds a church service with the local vicar. The home also has a visiting pat dog, once a week. Residents meetings are held and minutes of these are maintained. Requests for activities from residents are actioned, one resident had stated that they wanted to play pass the parcel and this had been incorporated into a party day, comments made at the next meeting were that all residents had enjoyed playing this. The lunchtime meal was observed to be very relaxed and unhurried and residents were enjoying their meals. Tables were laid appropriately, with condiments available and water was available for all residents. Food was very well presented and pureed meals were appropriately served in separate portions. Residents had their meals in the dining room, the lounge or in their own room to suit their preferences. Residents were noted to be wearing plastic aprons to protect their clothing however a more suitable alternative should be sought to promote their dignity, and the manager stated that the home were already looking into this. Staff were observed to assist residents respectfully and encourage them to feed themselves. It was noted that staff were wearing plastic gloves to feed the residents, and the manager stated that this was due to infection control and wiping of patients mouth. It is required that this practice should cease to promote the residents dignity, and unless there is an infection control risk, appropriate hand washing techniques would be satisfactory. Residents are offered a choice of meal and the cook asks residents what they would like to eat. Menus are on a four-week rota, these offer a variety of breakfast choices, two choices of lunchtime and teatime meal, plus snacks and other meals if the residents wants something different. Visitors do not eat in the dining area however they can eat in the hospitality room or with their relative in their own room. Resident’s comments included: ”I can have a biscuit or sandwich at anytime, and receive good portions for meals, so I do not normally get hungry” “ The food is brilliant, absolutely lovely, and I always get a choice” Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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 The complaints procedure is comprehensive and is accessible to residents and their representatives should they need to make a complaint. EVIDENCE: Copies of the comprehensive complaints procedure are available in the main reception area. The leaflet clearly states the procedure to follow should anyone wish to make a complaint, and provides all required contact details. There have been improvements to the written documentation of complaints and the outcome since the previous inspection. A complaints log is in place and this states the outcome of the complaint. CSCI have not received any complaints pertaining to Yardley Grange. The home had recorded nine complaints since the last inspection. All of these were tracked and had good evidence of interviews with staff, notes from relatives spoken to and copies of comprehensive letters, which had been sent to the complainants. There is evidence on staff files that they have undertaken training in Recognition of Abuse and Challenging Behaviour. Further training dates are arranged for the near future. The homes Adult Protection Policy was not reviewed on this occasion but was found to be satisfactory at the previous inspection. One resident said “I would talk to the nurse if I was unhappy and the problem would be sorted out” Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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) 19,20,21,22,23,24,25 & 26 Yardley Grange provides a clean, homely, safe and comfortable environment to live in where residents are relaxed and secure. EVIDENCE: The home was found to be clean and fresh on the day of the inspection, and there were call systems available throughout the home. There are adequate assisted bathing facilities and handrails around toilets. One toilet was out of order as the seat was broken, and the door was clearly marked out of use. One bathroom is currently being used as a storeroom as the bath was not suitable to use with the residents at the home. Corridors are wide and have handrails to both sides. The reception lounge on the ground floor is due to be redecorated and the residents will be involved in choosing the new colours. There is a hospitality room, which also has a sofa bed for relatives to use if they need to stay with poorly residents. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 17 Some bedrooms were seen and these were personalised with resident’s own possessions to ensure that their surroundings are as comfortable as possible. One resident said, “Its lovely, I’m very happy and couldn’t wish for any better” There was evidence of pressure relieving equipment in place and in use. There was a range of seating available in the communal areas, and a selection of different size slings for use with the hoist. A lounge upstairs is to be made into a sensory room, where there will be a large tropical fish tank, a light projector and fibre optic lights. The equipment is in place however the manager is awaiting new curtains for the room. The laundry room has a dirty in and clean out system. Alginate bags are used for soiled linen and there are individual residents boxes for clean laundry to be sorted into. Hygienic hand washing facilities were available throughout the home, however some bars of soap were found in the laundry and a bathroom area, the manager removed these. Staff should not use bars of soap in communal areas as this raises a potential risk of cross infection, liquid soap should be used in communal areas. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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, 29 & 30 The home maintains adequate staffing levels and staff undertake training to improve their level of knowledge of caring for older people. Recruitment procedures have improved since the last inspection, however this still requires minor amendments to fully ensure residents are protected. EVIDENCE: There have been some staff changes since the last inspection, however the core staff group remains stable. There is a vacancy for an administration assistant and another Registered Nurse is awaiting clearance checks prior to starting employment at the home. In addition to care staff, the home also employs cooks, domestics, laundry and maintenance staff. The home also uses agency staff and bank staff to cover any shortfalls. Duty rotas indicated that sufficient numbers of staff were on duty. One resident stated that they would like to see staff more during the night as they couldn’t sleep and got very thirsty. This was discussed with the manager and arrangements were to be made with the night staff to attend to this request. Comments from residents included: “The staff are great, they know what to do” “Staff come quickly if I need the toilet” “Staff are very good” Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 19 Two staff files were reviewed and these were found to contain all information required. Both files had evidence of POVA first checks being completed prior to employment commencing and Criminal Records Bureau checks were on file or waiting to be returned. Both files had two references, and this included one from the last employer. One file had some gaps in the work history and the manager stated that this was while waiting for work permits, however this had not been documented. Gaps in employment history should be explored and outcomes recorded. No interview notes had been recorded. One file contained a signed statement of main terms of employment, the second file terms had not been returned by the employee at this stage. Personal identification Number checks are carried out for all nurses. There was evidence of an induction programme and a booklet was on file. The home has 52 of staff that have completed NVQ level 2 in care. All staff have individual training records and there was evidence that staff have received training in a wide range of areas. A training plan is in place for the next year, which is also comprehensive and wide ranging. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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, 33, 35 & 38 The Registered Manager ensures that a good standard of service is provided at the home. The systems for resident consultation are good and there is evidence that resident’s views are sought and acted upon. There is a robust system in place for ensuring residents finances are safeguarded. Staff are trained in the majority of health and safety issues to ensure that the residents safety and welfare is maintained. The home is run in the best interests of the residents. EVIDENCE: The Registered Manager has much experience in caring for older people; she has completed her portfolio for the NVQ Level 4 and is awaiting verification of this. The Manager is to submit a copy of this certificate to CSCI once she has received her acknowledgement of completion. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 21 There is evidence of resident meetings taking place and this ensures that residents and their representatives are given the opportunity to discuss and share any ideas or concerns about the home in an open atmosphere. The home is in the process of formalising a quality assurance system. A new resident questionnaire has been devised by the trust and the home plans to have twice-yearly evaluation. Health and safety maintenance checks have been undertaken on all equipment used within the home. During the tour, COSHH products had been left in a unlocked store cupboard, and an immediate requirement was left for these to be stored in a locked cupboard at all times. Water temperature checks are undertaken and since the last inspection random checks have been implemented alongside the specific rooms checks. One room had a water temperature of 48.1 degrees and action had been taken to resolve this problem with the mechanism being changed, therefore reducing the potential risk of scalding. Accident records were reviewed and had been completed accurately. All forms are reviewed by the Registered Manager and are signed with an outcome. There is accident audits log in place that is completed monthly and this clearly identifies any patterns of reoccurring falls or incidents. Regulation 37 reports are sent to CSCI as required. A recent Environmental Health Service report stated “Excellent systems in place at time of inspection” Three residents monies were sampled and these were found to be correct. Only the manager and deputy manager have access to the resident monies and a monthly audit is completed. Petty cash is available from the nurse in charge if the manager or deputy manager is not on site. Bedroom doors are not linked into the fire alarm system, and although none of these were propped open, the staff would have to manually close if there was a fire. It is required that a risk assessment is in place in respect of this. The door to the manager’s office is propped open when in use and a suitable closure is required if the door is required to be open. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 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 x 2 x 3 x x 2 Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 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 OP4 Regulation Requirement Timescale for action 06/12/05 2. OP7 3. OP9 Care All pages of Registration Standards Certificate must be on display. Act 2000 Section 28 15 (1) (2) Care plan evaluations must be recorded in detail and reflect the monitoring of the particular care need. 13 (2) Insulin type, amount and regime of an identified resident, must be confirmed with the GP and administration of medication altered to reflect the GP prescription. The manager received this in the form of an immediate requirement. Temperature in the downstairs clinical room must be recorded to ensure that medicines are stored in compliance with their product licences to maintain their stability. The Registered Manager is to liase with pharmacist to ensure that MAR charts commence at the same time as the new prescription, to allow for an accurate audit trail to take place. 02/01/06 20/10/05 4. OP9 13 (2) 20/12/05 Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 24 5. OP9 13 (2) Staff drug audits must be undertaken on a regular basis to confirm nursing staff competence in medicine management and appropriate action must be taken when discrepancies are found. Medications should be recorded onto MAR chart upon receipt into the home. An alternative form of protective clothing should be sought for residents to wear at mealtimes to promote their dignity. Care staff should not wear plastic gloves routinely to feed residents. Gaps in employment history should be explored and documented on the file. 23/12/05 6. OP15 12 (3) (4) (a) 17/01/06 7. OP29 19 (1) (a) Schedule 2 23/12/05 8. OP31 Care Standards Act 2000 Section 24 24 (Previous timescale of 31/07/05 not met) The Registered Manager is 31/12/05 forward a copy of NVQ Level 4 certificate to CSCI once received. A quality assurance system must be fully implemented. (Previous timescale of 03/05 not met) All cupboards where COSHH products are stored must be locked at all times. The manager received this in the form of an immediate requirement. Risk assessments must be undertaken regarding open bedroom doors as they are not linked into the fire system. The door to the managers office 31/12/05 9. OP33 10. OP38 13 (4) (a) (c) 19/10/05 11. OP38 23 (4) (a) (c) 16/12/05 Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 25 should not be held open except by suitable means. If doors need to be held open then they should be fitted with devices that are linked into the fire alarm system. 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 OP7 OP9 OP29 Good Practice Recommendations It was recommended that a summary sheet be implemented at the front of each care plan. It is recommended that photocopies of all the prescriptions are kept alongside the MAR charts in order to assist in an audit trail. It is recommended that: *Notes of interviews undertaken are recorded. *All bank staff files are regularly updated in particular the employment record of the bank employee. Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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 Yardley Grange Nursing Home E54 S24912 YardleyGranngeNH V248410 191005 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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