Care Home: Fulwood Lodge Nursing Home

What the care home does well People living in the home said that the care they were receiving was good. They made comments such as: "Staff are kind". "They know what I like". "I`m well looked after". "I am satisfied". Comments received from relatives` questionnaires were positive and included: "My Mothers care is excellent". "I have great respect for the professional attitude of the staff at Fulwood Lodge". "They treat the people in their care with patience, respect and understanding". "I feel that my Mother is receiving the best care possible". "The care service tries their best". The interactions observed and overheard between staff and residents appeared respectful and caring. Each person living at the home had a written care plan. People`s health care was monitored and access to health specialists was available. Relatives could visit the home at any time, to maintain contact. People said that they had a choice of food and that the quality of food served was "good", and "acceptable". There was a complaints procedure and adult protection procedure in place, to promote peoples safety. People said that they felt safe living at the home. There was a maintenance programme to keep the home clean and well decorated. Some training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? All of the interaction observed between staff and people living at the home appeared respectful. Staff were seen to sit with people whilst offering assistance to eat so that they could give them their full attention. Staff used footplates on wheelchairs so that people were moved safely. Some activities had been organised to give people more choice about how they spent their time. People`s bedrooms had significantly improved with the provision of profile beds, new carpets and redecoration. People were provided with individual accommodation of a high standard. Some new special easy chairs had been provided so that people were more comfortable. Uneven paving slabs had been repaired so that people could choose to sit outside and be safe. The organisation had employed a training officer to make sure staff training was up to date and to enhance staff skills. The staff recruitment files checked contained an employment history, to show that full checks had been carried out before staff were employed. The results of annual surveys had been published and were available to people so that they had full information about the home. CARE HOMES FOR OLDER PEOPLE Fulwood Lodge Nursing Home 379a Fulwood Road Ranmoor Sheffield South Yorkshire S10 3GA Lead Inspector Mrs Janis Robinson Key Unannounced Inspection 12th May 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fulwood Lodge Nursing Home DS0000021778.V364030.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. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fulwood Lodge Nursing Home Address 379a Fulwood Road Ranmoor Sheffield South Yorkshire S10 3GA 0114 230 2666 0114 230 1713 fulwood@silverhealthcare.co.uk None Silver Healthcare Limited 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) Mrs Susan Farrington Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 10 of the beds registered OP for Older People aged 65 years and over, may alternatively be used for the category PD Physical Disability, for people aged 60 years and above and whose disability is related to the ageing process. One service user who is under the age of 60 and who is named on the application (V37029) dated 04/12/06, may reside at the home. 15th May 2006 2. Date of last inspection Brief Description of the Service: Fulwood Lodge is a three-storey home registered to provide nursing care for up to forty-two older people. Thirty single and six double bedrooms are provided, each with en-suite toilet facilities. Each floor has a communal lounge. The ground and first floors are provided with communal dining areas. A central kitchen and laundry serve the home. Sufficient bathing facilities are in place. The home is situated within easy access to shopping centres, pubs, post office and clubs. The bus service to the town centre is a short walk away. The home has pleasant grounds and a car park. Current fees range from £465 to £499. Additional charges included newspapers, hairdressing and private chiropody. Copies of the homes most recent inspection report, and statement of purpose, are available from the home. A poster was on display in the entrance area, stating that these documents were available and describing what information they contained. Fulwood Lodge Nursing Home DS0000021778.V364030.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 star. This means that people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Janis Robinson, regulation inspector. A site visit took place between the hours of 09:00 am and 16:30 pm on the 12th of May. The registered manager, Susan Farrington, was present during this visit. As part of this visit we looked in detail at how people were protected from harm. Prior to the visit the registered manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires regarding the quality of the care and support provided were sent to people living in the home, their relatives, staff and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received three questionnaires back from relatives. Comments and feedback from these have been included in this report. On the day of the site visit staff were observed interacting with people that live in the home. A partial tour of the premises was made and records relating to care and the running of the home were checked. Seven people that lived at the home were spoken with, three of whom were able to share their views of living at the home. The majority of the staff on duty, including, qualified nursing staff, care staff, the administrator, the cook and domestic staff were spoken with about aspects of their jobs. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in May 2006. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, the manager, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 6 What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “Staff are kind”. “They know what I like”. “I’m well looked after”. “I am satisfied”. Comments received from relatives’ questionnaires were positive and included: “My Mothers care is excellent”. “I have great respect for the professional attitude of the staff at Fulwood Lodge”. “They treat the people in their care with patience, respect and understanding”. “I feel that my Mother is receiving the best care possible”. “The care service tries their best”. The interactions observed and overheard between staff and residents appeared respectful and caring. Each person living at the home had a written care plan. People’s health care was monitored and access to health specialists was available. Relatives could visit the home at any time, to maintain contact. People said that they had a choice of food and that the quality of food served was “good”, and “acceptable”. There was a complaints procedure and adult protection procedure in place, to promote peoples safety. People said that they felt safe living at the home. There was a maintenance programme to keep the home clean and well decorated. Some training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Peoples care plans should include more details on the staff actions required to meet personal care needs and preferences so that staff know how to meet these. Medication Administration Records (MAR) must always be fully completed to make sure safe procedures are followed. The medication policy should be updated to provide staff with clear details of how to record PRN (as and when required) medication so that all staff record in the same way. Staff should be provided with further Adult Protection training so that they can help keep people safe. Access to the garden from the bottom floor should be made safe so that people can access the garden safely. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 8 Some communal rooms would benefit from redecoration to maintain and match the high standard of individual accommodation that is provided. Staff recruitment records should detail the full dates of previous employment so that thorough and complete records are obtained. Staff supervision should take place more frequently to develop and support staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 9 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 Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 10 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): Standards 1,3 and 5. Standard 6 is not applicable to this home. People who use 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. A statement of purpose and service user guide were available, to give people information about the home. Assessments of needs were undertaken prior to admission, to make sure all needs were identified and could be met. People were able to visit the home prior to admission, to help them make a decision about moving in. EVIDENCE: A notice was on display in the entrance area informing people that they could see the homes statement of purpose if they chose. A service user guide, in the form of an ‘Information guide’ was available at the home. The staff spoken Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 11 with confirmed that each person living at the home and their representative had been provided with a copy of the booklet, to inform them about the home, their rights and choices. A copy was seen on display in the entrance area so that visitors could read this, if they wished. It contained a range of information and was available in large print if required. Copies of the booklet were seen in all of the bedrooms checked so that this information was always readily available. The manager confirmed that she, or the deputy, carried out detailed needs assessments with people and their representatives to ensure identified needs could be met. Copies of social workers full needs assessments were obtained, where available, to provide the home with all relevant information. The manager, or deputy, visited people and their representatives in their own home or hospital to meet them and gather information. The manager confirmed that people were only admitted to the home once they were sure that they could meet their needs. Copies of needs assessments were in place in the three care plans checked. Information gathered on assessment was used to write the care plan so that all relevant information was available to staff. People, where able, could visit the home and have a look around before choosing to move in. The manager stated that as most people came to the home straight from hospital, it was usually their relatives that came for a look around on their behalf. In surveys, relatives said that they had been given enough information about the home to help them make a decision. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9 and 10. People who use 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. People’s health, social and personal care needs were set out in an individual plan so that these could be fully met. People’s health care was monitored and access to health professionals was provided to meet health care needs. On the whole, people were protected by the homes policies and procedures on medication administration. However, a small minority of medication administration records had not been fully completed to make sure safe procedures were followed. People’s privacy and dignity was respected. EVIDENCE: Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 13 Three care plans were checked. They included information on all aspects of personal, social and health care needs. The plans included some information on the staff action required to ensure assessed needs were met. Sections on moving and handling contained specific information on individual need and how this was to be met. Whilst sections on personal care contained some information on the staff actions required to meet individual need, they could be improved with more detailed information about peoples preferences. The manager had a system in place to audit and monitor care plans to ensure they contained relevant, up to date information. Qualified staff reviewed the plans each month. The staff spoken with were aware of peoples individual needs. Moving and handling, and falls risk assessments had been undertaken to keep people as safe as possible. Skin risk assessments were undertaken and equipment to aid tissue viability was available. Regular weight checks took place. The plans contained detail of all health care contacts, appointments and treatments, and access to these was available to ensure health was maintained. People said, “Staff make sure you see a doctor when you need to” “I am getting new glasses, the optician visited me here” In surveys, all three relatives said that their loved ones health and medical needs were “Always” met. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and people living at the home appeared respectful and caring. People made positive comments about their care, comments included, “Staff do their best” “The older staff are very respectful, younger staff are ‘allright’ ”. “I am well looked after” A policy on medication was in place. Medication was stored securely and administered by qualified nursing staff. Three medication administration records (MAR) were checked in detail; a further selection was briefly checked. The drugs held corresponded with the medication administration records. The majority of administration records were fully completed and up to date. However, on two sheets checked staff had not recorded the code to indicate that PRN (as and when required) medication had not been administered. Three gaps in other medication administration records were noted in all of the records checked. Whilst this is a small minority, it is important that staff Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 14 always complete administration records so that people’s safety is promoted. Clear guidelines should be provided to staff regarding the procedure for recording PRN medication so that all records are consistently kept. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 15 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): Standards 12,13,14 and 15 People who use 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. People had a choice of lifestyle within the home and were able to maintain contact with family and friends so that they continued to be involved in community life. Some activities were on offer, further activities would promote choice and maintain peoples interests. Meals served at the home offered choice and ensured people received a healthy balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Some people chose to spend time in the privacy of their bedrooms. Some social opportunities both in and outside of the home was available, such as trips to the local pub, or shopping. Visiting entertainers were organised on an occasional basis. Since the last inspection the manager had organised more planned activities within the home, such as cards and dominoes. The hairdresser also provided manicures for people that wanted them. Some Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 16 people spoken with said that they did not wish to join in any organised activities. Other people were unable to participate in any planned events due to their ill health. Some people said that they enjoyed the activities on offer. Comments included, “I am happy in my room and chose not to join in” “I really enjoy the sing-a-longs” “It would be nice to have more activities on offer” The manager was in the process of developing an activity plan so that further events were organised and put on display to inform people. The manager stated that the organisation was looking to recruit an activities worker that would be shared with two other homes, to improve the choices on offer. The people spoken with confirmed that their relatives were free to visit at any time. The menu was varied and a balanced diet was provided to maintain peoples health. People said the food at the home was good, and choices were offered on a daily basis. Comments included, “The food is fine” “I can have a cooked breakfast when I fancy it” “I prefer to eat in my room” “The food is acceptable” The cook on duty confirmed that people had a choice of food and she knew peoples individual preferences. Special diets were catered for to meet people’s health needs. The lunchtime meal was partially observed. Staff sat with people that required help with eating, talked to them and offered assistance respectfully. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 People who use 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. A clear and accessible complaints procedure was in place, to ensure any concerns listened and responded to. An adult protection procedure was in operation, to keep people safe. However, staff had not been provided with formal training in adult protection to promote safe practices. EVIDENCE: Each person living at the home had been provided with a copy of the homes complaints procedure. A copy was also on display in the entrance area of the home. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the people spoken with, who were able to express an opinion, said they had no concerns and could go to the manager and staff to sort out any worries they had. The staff spoken with were confident that the manager would listen to them and take any complaint seriously. As part of this visit we looked in detail at how people were protected from harm. The manager and staff were asked about adult protection procedures. The manager was aware of the action to take if an allegation was made and knew which other agencies should be contacted. Staff undertook some basic Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 18 training on adult protection during their induction to equip them with the skills needed to respond appropriately to any allegations. The manager and deputy had undertaken formal adult protection training and had made plans to cascade this training, using video guidance, to all staff. Dates for this training had been arranged. In addition, adult protection guidance was provided at staff meetings and in supervisions. Further formal training on protection had been agreed to ensure all staff had full knowledge to recognise abuse and respond appropriately if an allegation was made. The manager stated that she had contacted the Popps (Partnership in Older Peoples Projects) team and arranged for formal adult protection training to be provided to the staff team from them. The dates for this training had not been arranged at the time of this inspection. The manager is to confirm in writing to the CSCI that this training has been booked. It is important that this training is provided so that every effort has been made to minimise risk and keep people safe. An adult protection procedure was in place and available to staff. A copy of local multiagency adult protection procedures had been obtained to ensure staff were fully aware of all available information. All of the people asked said that they felt safe living at the home. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 19 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): Standards 19, 24 and 26 People who use 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 was clean and generally well maintained, to provide a pleasant environment for people. Individual rooms had been significantly enhanced from redecoration and the provision of specialist beds. One small paved area outside the home had not been maintained and created a potential hazard. EVIDENCE: A partial tour of the environment was carried out. The home was mostly well decorated and well-maintained, homely touches were provided to create a comfortable environment for people. A handy person was employed to help maintain the environment. A rolling programme of redecoration and replacement was in place. The homes gardens appeared mostly well Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 20 maintained. However, the paved area outside the lower floor had overgrown weeds and posed a tripping hazard if people wanted to access the garden. This had been identified for urgent maintenance during the visit. Since the last inspection the majority of bedrooms had been recarpeted and redecorated. Special profile beds had been provided so that people were comfortable and their needs could be better met. This greatly improved the individual space offered to people. All of the people asked said that they were happy with their rooms. Comments included, “I love my room, it is very big. I’m very lucky” “I have everything I need in my room and I am very comfortable” “I enjoy spending time in my room, I love the views” Parts of the decoration in the ground floor dining room and lounge were worn and would benefit from redecoration. It is recommended that they be given priority within the homes maintenance plan to maintain the good standards set in the bedrooms. Control of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30. People who use 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. Sufficient staff were provided to meet people’s needs. The home had recruitment systems in place to protect people. Induction and training was provided to staff so they were competent to do their jobs. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained so that peoples needs could be met. People spoken with felt that enough staff were provided to meet their needs. Staff spoken with said there was a good staff team, and they all worked well together. Agency staff were not used at the home. A programme of NVQ training was in place, to ensure staff developed the skills required to carry out their duties. Of the twenty care staff, three staff had achieved NVQ level 2 in care. Five further staff were undertaking the training at levels 2 and 3. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 22 A policy and procedure for staff recruitment was in place. Three staff files were checked. These contained all of the required information to show that thorough checks had been carried out and included proof of identity, CRB checks, a contract and two written references. All of the application forms checked gave a full employment history. However, two of the forms only gave the year of employment and did not detail the full date. It is recommended that full dates of previous employment be obtained so that full and thorough checks are made. Since the last inspection the organisation had employed a training officer to make sure staff training was up to date and to enhance staff skills. Staff were provided with monthly training events to improve their knowledge and skills. The manager had undertaken a matrix, to provide ‘at a glance’ information so that staff training was kept up to date. The training matrix and three staff training files were checked. These showed that staff were provided with regular training events that included topics that would improve staff skills, for example; diabetis care and palliative care. All new employees were provided with induction training to give them the basic skills needed to carry out their duties safely. Individual training profiles were maintained for all staff to detail the training they had undertaken. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38. People who use 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 manager’s approach benefited people living at the home, and staff. Systems were in place to ensure people’s monies were safely managed. A quality assurance system was in operation, to obtain and act upon people’s views. A rolling programme of staff supervision was in place to develop and support staff. Some staff had not been provided with supervision at appropriate frequencies to ensure levels of support were maintained. People’s health and safety was promoted. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager was a qualified nurse and had completed NVQ level 4 in management. All of the staff spoken to said the manager was approachable and supportive. People said “Her door is always open”. “I know that I can go to her and she will listen to me” Insurance cover was provided and a relevant certificate was on display in the reception area. A quality assurance system was in operation. Annual surveys were undertaken with people living at the home, where able, their representatives, and professional visitors. The results of these surveys had been published and a notice was on display in the entrance hall informing readers that this report was available to them. Three records of people’s finances were checked. Individual financial transactions were recorded, and all receipts were retained. People received interest on their bank accounts. Money was stored securely. This made sure peoples money was safe. Informal supervision took place on a daily basis. However, records checked showed that formal staff supervision, to support and develop staff, did not take place at the recommended frequency. Annual appraisals took place to make sure staff were progressing as they should. A health and safety policy was in place. Records seen showed that systems were checked and serviced to maintain a safe environment. Weekly fire alarm checks were recorded. A mandatory staff-training matrix was in place, to ensure staff were up to date with all relevant training. All staff were up to date with mandatory training, with the exception of adult protection that has been reported on in the relevant section of this report. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 25 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 3 X 3 X 3 X 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 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 be fully completed. Where medication is refused, or not required, this must be recorded. (Previous timescale of 15/05/06 not met) All staff must be provided with further adult protection training to keep people safe. All parts of the home must be safely maintained. The paving stones outside the lower floor must be cleared of weeds to create safe access to the garden. Timescale for action 01/07/08 2 3 OP18 OP19 13 13 31/08/08 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 27 No. 1 2 Refer to Standard OP7 OP10 Good Practice Recommendations Peoples care plans should include full details of individual preferences relating to personal care, and full details of the staff actions required to meet these. Staff should be reminded of the procedure to record PRN medication so that consistency is achieved. The policy on medication should be updated to ensure clear and specific guidelines for recording PRN medication informs staff. A plan for activities should be made and put on display so that this information is available to people. Consideration should be given to employing an activities worker to extend the range of activities on offer. Communal lounges and dining rooms should be considered for redecoration in the homes maintenance plan so that the high standards achieved in peoples bedrooms is provided in all areas. A minimum of 50 of the care staff team should be trained to NVQ level 2 in care. Full dates of previous employment should be obtained so that thorough checks can be made. All staff should be provided with supervision at an appropriate frequency for development and support. 3 OP12 4 OP19 5 6 7 OP28 OP29 OP36 Fulwood Lodge Nursing Home DS0000021778.V364030.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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