Care Home: Amberley Nursing Home

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What the care home does well There are systems in place to assess prospective service users and allow them to visit the home before being admitted to ensure they are happy to move in. Resident’s healthcare needs were well documented and where care instructions had been given by healthcare professionals these were incorporated into the care plans. At mealtimes we observed a range of methods being used to help residents to maintain their independence to eat.Amberley Nursing HomeDS0000002035.V377309.R01.S.docVersion 5.2 What has improved since the last inspection? Since our last visit the Manager has been formally registered with the Care Quality Commission. The home had begun to develop person centred plans in formats which residents could become involved in. What the care home could do better: The medication administration records did not include instructions where oxygen was prescribed for residents for as required use, this is to be included to ensure a complete record of treatments is kept. Where some painkillers were prescribed the medication administration records stated the number of tablets to be given and not an actual dosage range, as tablets come in varying strengths for accuracy the dosage is to be included. Some requirements have been made after the most recent visit from the Fire Officer, the work required has yet to be actioned. The environment of the home shows some signs of wear and tear and discussions with the Manager, reviews of residents meeting and the surveys we received indicate that works are not tended to quickly. The home is not using a skill based induction pack which would ensure staff have access to information and learn the skills required to meet resident’s needs. Key inspection report CARE HOMES FOR OLDER PEOPLE Amberley Nursing Home Off Cedar Close Eckington Sheffield Derbyshire S21 4BA Lead Inspector Bridgette Hill Key Unannounced Inspection 3rd September 2009 09:40 DS0000002035.V377309.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amberley Nursing Home Address Off Cedar Close Eckington Sheffield Derbyshire S21 4BA 01246 436850 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) Enable Care & Home Support Limited Mary Woulfe Care Home 15 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (15) of places Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th September 2008 Brief Description of the Service: Amberley House Nursing Home provides nursing and personal care for up to fifteen Older People with Learning Disabilities, aged over 65 years, and for up to 5 people with Learning Disabilities aged under 65 years. The Home is situated on the edge of the North East Derbyshire boundary within the village of Eckington. It is close to shops, a post office and all local amenities, and near to a direct bus routes to both Chesterfield and Sheffield. The Home provides single bedroom accommodation on the ground floor. There is a large lounge and one dining room and an additional smaller lounge area, to provide a quieter area for people. There is adequate toilet and bathing provision, with suitable adaptations and equipment provided. There is access to a garden/patio area with seating provided. Nurse cover is provided at all times by Registered Nurses (Learning Disabilities) and there is a team of care and domestic services support staff. The charges made for a room at Amberley House are currently range from £1141.00 - £1181.00 a week. This fee does not include hairdressing and personal toiletries but is inclusive of a 6 monthly clothing allowance and a contribution to an annual holiday. Written information about the home, in the form of a service user guide, and a copy of the Commission for Social Care Inspection (CSCI) latest inspection report are available from the home. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 stars. This means the people who use the service receive good quality outcomes. The inspection visit was unannounced and took place over 7 ½ hours. Additionally, time was spent in preparation for the visit, looking at previous reports and other relevant documents and preparing a plan for the inspection. The Annual Quality Assurance Assessment which the home completes was considered as part of this inspection. Surveys were sent out prior to the visit to residents and staff and where these were returned to us the information received has been included in this report. For most of the surveys staff had assisted service users to complete them. There were 14 people living at the home on the day of the inspection with all service users being assessed as having nursing needs. As part of our visit we spoke to residents and staff to find out their views about the home. As part of the inspection a sample of service users care files and a range of documents were examined. The communal areas were viewed along with some bedroom, bathrooms and the laundry area. Information sent since the last inspection told us that any incidents that have to be reported to us such as events that affect the well being of residents appear to have been sent. The Manager Mary Woulfe was not initially on duty during the visit but arrived during our visit. What the service does well: There are systems in place to assess prospective service users and allow them to visit the home before being admitted to ensure they are happy to move in. Resident’s healthcare needs were well documented and where care instructions had been given by healthcare professionals these were incorporated into the care plans. At mealtimes we observed a range of methods being used to help residents to maintain their independence to eat. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Amberley Nursing Home DS0000002035.V377309.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 Amberley Nursing Home DS0000002035.V377309.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are arrangements in place prior to admission to ensure that resident’s needs are assessed and the home has information to ensure residents needs will be met. EVIDENCE: In the entrance hall there was a range of information available this included the last inspection report and a combined Statement of Purpose/Service User Guide. The Statement of Purpose required some updating and the Manager told us that this was in the process of being reviewed. The home has had one new resident since our last visit and we were told that prior to this there had not been any new residents for around 3 years with the residents at the home mainly having long term needs. The most recent new Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 9 resident had visited the home in the past and was familiar with it prior to moving in full time. The Annual Quality Assurance Assessment told us that the home manager and other qualified staff would meet with the prospective resident prior to admission. We were told visits to Amberley by the prospective resident and their family were positively encouraged and welcomed. The surveys we received told us that not all residents knew if they had terms and conditions contracts in place to tell them what to expect from their stay at the home. This was discussed with the manager who said that there were contracts in place but we were unable to view them as they held at the head office. Some information was in residents files which detailed the fees to be paid and what was included however these were not contracts and did not include information on notice periods to be given should a service user leave the home. The majority of the surveys we received indicated that residents felt they had received enough information about the home before moving in. The residents meetings records also indicated that current residents were informed where new residents would be moving into the home. The home does not offer intermediate care as defined by the National Minimum Standards. Amberley Nursing Home DS0000002035.V377309.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans were in place which were detailed enough to ensure service users needs would be met. Medicines are generally competently handled to ensure residents receive prescribed treatment EVIDENCE: We looked at 2 care files to assess how staff were recording residents care needs and examined if this was supported by the required equipment. The care plans were written as ‘activities of daily living’ which described the day to day care residents required. These considered the choices and preferences of the residents and acknowledged their abilities and choices. There was no recorded reviews of the activities of daily living and whilst these seemed largely still relevant one needed updated in one of the areas. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 11 The longer term care plans recorded resident’s wider needs and considered medical needs, social needs and where risk assessment identified risks there were plans in place to detail how these would be limited and managed. A system for ensuring the long term care plans were reviewed monthly was in place. There were records that staff wrote on a daily basis which told us how residents had been and recorded any progress or concerns that had arisen. The Annual Quality Assurance Assessment told us ‘We are currently in the process of developing person centred plans with our service users’. One of these was viewed which was partially completed. This had partly been completed from the residents perspective but parts were also included that were written from a staff view. A range of information was available in the home on the Mental Capacity Act and some staff had received training. This had however not be considered practically when planning care and no care plans were in place for medications which considered the residents capacity and understanding. In each care file were a wide range of risk assessments including tissue viability, falls, Moving and handling and other aspects such as holidays and wheelchair use? The care files we looked contained a clear overview of the visits from GP’s, chiropodists, opticians and other healthcare professional such as Occupational Therapists and Speech and Language Therapists. Where care advice had been given by healthcare professionals this was found to be recorded within the service users care plans. A resident also told us they had chosen their own glasses after the optician visited. From records it appeared to have some time since service users had seen dentists, we discussed this with the Manager who told us there had been some difficulty accessing dentists but this was hopefully going to be rectified shortly. We examined the storage and administration of medicines during our visited. A dedicated room with appropriate storage for all types of medications was available in the home. A full audit trail of medicines received into the home and administered or destroyed was available from the varying records held. The medication administration records were generally found to be completed using a range of codes which described the administrative actions taken. Only one gap where no code was entered was seen. Some medication administration recorded the number of tablets prescribed rather than the actual dosage to be given which as medicines are available in varying strengths does not ensure the actual prescribed dosage is always given. It was also found that one resident required occasional oxygen, Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 12 prescribed by the GP which was not recorded on the medication administration record. One resident told us they got their tablets on time each day and they always got the right ones. Whilst there was no definite post death wishes for residents recorded some views had been sort with consideration being given to the resident’s family history. Where there was concern about residents condition relatives were informed of this. The manager told us that where residents had passed away staff attended funerals and sent flowers. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a range of activities that are offered and have opportunities to go out of the home. EVIDENCE: The home has a dedicated activities staff member who works in the home on a full time basis to organise social and leisure activities for residents. The home has its own minibus and car and identifies in care plans what support is required to enable residents to go out. A suggested schedule of events was on a notice board in the lounge and on the day of our visit staff were observed painting the nails of a resident however the activities coordinator was on leave during our visit so care staff were doing some activities. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 14 A contribution was included for each resident in the fees for a holiday. Some residents did go on holiday last year however so far this year the monies had been used to go on day trips to seaside resorts. Some of the surveys we received particularly from staff told us they thought that there could be ‘more outings’ for residents. One barrier identified for this was that not all staff were able to drive the minibus. The surveys from residents indicated that they did go out, one commenting that they had recently been shopping for new clothes. Staff told us that other activities offered included chair based exercises, pamper days, clothes parties and external entertainers. Some residents also attended day centres on a regular basis. One resident told us they enjoyed this and regarded it ‘like going to work’. The care plans we saw considered contact with relatives and detailed any communication with relatives. Residents told us that their relatives were made welcome by staff when they visited. We observed the teatime meal at the home and examined the menus which were on a three weekly rolling programme. There was not a choice of meal offered routinely however we were told alternatives would be offered if residents didn’t want the meal on the menu. Residents told us the quality of the food was ‘good’. Residents were observed using non slip mats, bowl and spoons to help them eat independently. Some residents required foods to be of a mashable consistency due to choking risks and where specialist advice had been sought re speech and language difficulties the advice given was included in care plans. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are in place to safeguard service user’s welfare and ensure that their concerns are listened to and acted upon. EVIDENCE: There was a Safeguarding Adults policy in place along with a copy of Derbyshire County Councils adult protection policy. Staff we spoke with told us that they would report any concerns to the nurse in charge or manager. The training records and discussions with staff indicated that staff had received safeguarding adult training. All the surveys we received told us that residents say there is someone service users can talk to about worries although some did not know about complaints procedure. One resident told us that they would speak to the Manager who they knew by name if they had worries. The complaints procedure was available in the entrance hallway and was in an easy read/picture format to enable service users to easily understand this. It informed residents of the timescales that their concerns would be dealt with. It Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 16 had the name of the previous registration authority on it so requires updating to ensure service users get relevant contact details. The Manager told us that there had not been any complaints or safeguarding adult concerns received since the last inspection Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable and suitably equipped however a delay in redecoration works adversely affects the experience for residents who live in the home. EVIDENCE: The home provides single bedroom accommodation for all residents and we viewed a selection of the rooms and the communal areas. All residents’ areas were on the ground floor so were fully accessible for wheel chair users. The home has an outdoor paved area with some features such raised flower beds, although these were somewhat overgrown, and a water feature. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 18 The home has one large lounge which is L–shaped and provides some quieter areas than others for service users to use. The conservatory is used as a dining room. The home was found to be clean and tidy throughout. Information on infection control was available for staff and we observed them wearing aprons when serving meals. The residents meetings indicate that some residents had been requesting over a period of months for their bedrooms to be redecorated. This was also mentioned in one survey and some of the rooms we looked at had patches of bare plaster and wall damage. The Annual Quality Assurance Assessment also told us that it was considered that parts of the home were in need of redecoration. We were told that some quotes had been obtained for redecorating but no dates were set for the work to be done. Some new furniture had been purchased for the lounge from monies raised through fund raising events. There were other areas where maintenance had been outstanding for some time; this included an unpainted fire door. The most recent visit by the Fire Officer has indicated that some works are required, this includes updating of the fire risk assessment and sealants strips on doors require replacement, at the time of our visit these had not been addressed. The fire alarm was being checked by an external contractor on a three monthly basis, the records for this indicated that some works were needed which had again not been rectified despite being identified on the last two inspections. The laundry was fitted with 2 washers and 3 dryers all of which were working and under contract for repairs if they broke down. Residents told us their clothing was well cared and service users appeared well dressed in clean and pressed clothing. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to ensure suitable staff are recruited and trained to meet the resident’s needs. EVIDENCE: The home one nurse one nurse As well as had 14 residents on the day we visited. The staff on duty included and 4 care staff. On the day of our visit staff told us that there was on duty where there were normally two due to short notice sickness. care staff Domestic and kitchen staff on duty 7 days per week. The Annual Quality Assurance Assessment told us there had been some difficulties with trained staff and recruitment of nurses was in process. At the present time existing staff were working shifts to cover absences and the Manager told us that they were also working on shift as opposed to managerial days to ensure there was cover. The home had a group of 20 permanent care staff plus its own bank staff. Of these staff 6 staff had achieved their national vocational qualifications level 2. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 20 Whilst 3 staff were waiting to commence course this falls significantly short of the National Minimum Standard which describes that of at least 50 of staff should hold national vocational qualification level 2 or above. The staff recruitment files we viewed indicated that references, Criminal Records Bureau and other checks were in place prior to staff commencing work at the home. We discussed the induction process with the Manager and was told that new staff attended a course through the companies training department when they commenced work. The Annual Quality Assurance Assessment completed by the Manager was ticked to indicate a skill based induction pack was available for staff but on discussion this was not available for staff to complete. We were told that a checklist type induction is used alongside some formal training days. A training file for each staff member was available as well as an overview although the one available was a little out of date. There appeared to be a range of regular training taking place and some had been prioritised where they were due. Staff told us they felt the home met ‘individual needs were well met’ and the care was ‘good quality’. We were told the staff group got along well and the home had a ‘nice atmosphere’. Staff we spoke told us they had received a range of training at the home and felt sufficiently skilled. The staff also appeared knowledgeable about the residents needs. A key worker system was in place and some staff took on responsibility for ensuring service users had all the toiletries and clothing as well as assisting service users to buy presents and cards for their families. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed with systems in place to monitor the quality of the service that residents receive. EVIDENCE: Since our last the manager has been formally registered with the Care Quality Commission having been assessed as suitably ‘fit’ to manage a care home. The Manager is a qualified nurse but has not completed any formal managerial training. The Manager told us they had applied for this through the Provider training department but had not yet had confirmation of a place. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 22 Staff and residents told us that the Manager was approachable and easy to talk to. We discussed the quality assurance processes in place and was told that Residents meeting were held to allow service users to have an opinion in the running of the home. Items such as social activities were discussed at the meeting. The Provider had a service manager in place who visited the home to conduct quality monitoring visits. The documents for these indicated that this included discussions with service users and examination of a range of records at each visit. We discussed how resident’s monies were handled. The Manager told us each service user had their own bank account with some monies being held safely for everyday use. The records for these were accurate to the amount of monies being held. Reviewing older records it was apparent that on one occasion a resident had been loaned another service users money until cash could be obtained, we discussed if the resident whose money had been loaned had given permission for this and was told they would not have capacity to do this and it would have been a decision taken by staff, this had since been fully repaid. The Annual Quality Assurance Assessment and a sample of records in the home confirmed that all the serving checks were up to date. Suitable ongoing bacteriological checks for legionella were completed and the water temperatures were checked and regulated to prevent scalds. Amberley Nursing Home DS0000002035.V377309.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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x 3 3 x x 3 Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement Medication administration records must record the actual dosage of the drug prescribed to ensure errors are not made The medication administration records must detail all the prescribed treatments which the service users receive The requirements listed in the Fire Officers report must be rectified to ensure the home meets all fire safety standards The faults on the fire alarm checks must be rectified to ensure systems of alerting staff and service user to a fire are satisfactory There must be a skill based induction pack available for new staff to ensure they have the appropriate skills to meet the service users needs Timescale for action 31/10/09 2 OP9 13 30/11/09 3 OP19 23 31/12/09 4 OP30 18 30/11/09 Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 25 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 OP7 OP28 Good Practice Recommendations The care record and documents should consider the service users mental capacity and ability to give meaningful consent to receiving care The activities of daily living care plan should be reviewed and updated as necessary as part of the longer term care plan A training programme should be developed to work towards 50 of the staff team should be trained to NVQ level 2 in care to benefit people living at the home. Financial systems in place must ensure that service users monies are not loaned to each other 4 OP35 Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Amberley Nursing Home DS0000002035.V377309.R01.S.doc Version 5.2 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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