Care Home: Headroomgate Nursing Home

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What the care home does well This service provides good outcomes for the people who live there. People found it a pleasant and homely place to be, where the atmosphere is good and the welfare and well being of the people who use the service is taken seriously. All of the people that we spoke to during this visit said that they liked the home and the care that it offered its residents. We observed the care staff speaking to people with respect and politeness. A resident commented, ""The girls are lovely, really friendly."We spoke to the cook, and lunch was being served whilst we were there. We were told that there are regular deliveries of fresh fruit and vegetables, and that fresh meat was always part of the menu. The residents that we spoke to said that the food was good and that they looked forward to mealtimes. One resident told us that the food was "excellent". People were being served politely and there was a nice dining area for the people who use the service to enjoy their meals in. Care staff are recruited properly and there had been regular training events for the staff. This helps to ensure that the carers have the knowledge, skills and ability to care for people properly and professionally. Good recruitment also helps to ensure that the residents are protected from unsuitable staff. The home is fresh, clean, pleasant and homely. A domestic employee was working at the home during our visit and there were regular quality checks by the management team regarding the cleanliness of the home. The owners of the home maintain a positive input and regularly visit. They have invested heavily to improve both the fabric and maintenance of the home. What has improved since the last inspection? The garden area is being maintained properly in order that the residents may use this in good weather. There has been a lot of redecoration work done at this home since the last key inspection and the communal areas have been redecorated and re-carpeted. New furniture had been purchased for some of the bedrooms. New curtains and soft furnishings have been added. This means that people live in a well maintained home where the surroundings are pleasant and comfortable. The people who use the service now have a dedicated dining area, which is tastefully decorated and where people can enjoy meals in comfort. CARE HOMES FOR OLDER PEOPLE Headroomgate Nursing Home 1 Oxford Road St Anne`s Lancashire FY8 2EA Lead Inspector Christopher Bond Unannounced Inspection 8th September 2008 10:00 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 Headroomgate Nursing Home DS0000070133.V371834.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. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Headroomgate Nursing Home Address 1 Oxford Road St Anne`s Lancashire FY8 2EA 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) 01253 724326 01253 780344 Mrs Pamela Mathauda Ms Susan Jane Fisher Care Home 17 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (12) of places Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home with Nursing - code N, to people of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, (maximum number of places: 12) Dementia - Code DE (maximum number of places: 5) The maximum number of people who can be accommodated is: 17 Date of last inspection 12th December 2007 Brief Description of the Service: Headroomgate Nursing Home offers care and nursing to 17 residents. The service is registered to provide care to people with dementia and to people due to age and frailty. The home is situated within ten minutes walk of St Annes and is within reach of local shops and amenities. Headroomgate is a detached property, which has been adapted to provide seven single bedrooms and five double bedrooms, none of which have en-suite facilities. There are two large communal rooms used as lounge and dining areas and sufficient bathing and toilet facilities around the home to meet the needs of the residents accommodated. A passenger lift enables easy access between the ground and first floor and various aids are provided to meet individual needs. There is a Statement of Purpose/Service User Guide, which is available for persons making enquiries about the home. The written information explains the care service that is offered and what the resident can expect if they decide to live at the home. The owner of the home also has copies of previous inspection reports that can be made available to prospective residents and their families or representatives. Information received on the visit on 8th September 2008 confirmed that the range of fees at the home are £323.00 to £481 52.covering all aspects of care, food and accommodation. Additional charges are made for chiropody, hairdressing and newspapers. Headroomgate Nursing Home DS0000070133.V371834.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 the people who use this service experience good quality outcomes. As part of the inspection process an unannounced site visit took place over a total of 5 hours on the 8th September 2008. The residents’ personal files and care plans were examined. Care staff records and recruitment records were also looked at. Safety certificates and medication procedures for the service were also examined. We spoke at length to the manager of the service during the inspection. Four residents were also spoken to as part of the inspection process. We also spoke to three relatives of a person who used the service. We also sent out surveys to people who used the service and their relatives and carers to gather their views about the service they receive. A number of these were sent back to us and the results have been included in this report. We also sent out surveys to the care staff of this home to tell us about their experiences of working at Headroomgate Nursing Home. Every year the registered person is asked to provide us with written information about the quality of the service they provide: this is called the Annual Quality Assurance Assessment (AQAA). They are also asked to make an assessment of the quality of the service. This information, in part, has been used to focus our inspection activity and is included in this report. What the service does well: This service provides good outcomes for the people who live there. People found it a pleasant and homely place to be, where the atmosphere is good and the welfare and well being of the people who use the service is taken seriously. All of the people that we spoke to during this visit said that they liked the home and the care that it offered its residents. We observed the care staff speaking to people with respect and politeness. A resident commented, ““The girls are lovely, really friendly.” Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 6 We spoke to the cook, and lunch was being served whilst we were there. We were told that there are regular deliveries of fresh fruit and vegetables, and that fresh meat was always part of the menu. The residents that we spoke to said that the food was good and that they looked forward to mealtimes. One resident told us that the food was “excellent”. People were being served politely and there was a nice dining area for the people who use the service to enjoy their meals in. Care staff are recruited properly and there had been regular training events for the staff. This helps to ensure that the carers have the knowledge, skills and ability to care for people properly and professionally. Good recruitment also helps to ensure that the residents are protected from unsuitable staff. The home is fresh, clean, pleasant and homely. A domestic employee was working at the home during our visit and there were regular quality checks by the management team regarding the cleanliness of the home. The owners of the home maintain a positive input and regularly visit. They have invested heavily to improve both the fabric and maintenance of the home. What has improved since the last inspection? What they could do better: Some of the care plans had not been reviewed for two months; this process should be more regular for a service that cares for residents in a nursing environment. Regular reviews mean that changes in people’s condition can be monitored more closely and health issues picked up quickly. There were people who lived at this home who had dementia. There had been no recent training for the care staff regarding the care of people who had Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 7 dementia. The manger agreed that it would be advisable to introduce this training on a regular basis in order that the care staff have a good, sound knowledge base on which to base their care practice, based on current positive developments in this field. Similarly there were no special activities for those who had dementia. This is important because good, stimulating activities can help slow the progress of this condition. Although much work had been completed there were still bedrooms that needed attention and have old furniture replaced. Photographs need to be part of all medication and care records to help with identification and prevent errors being made. Similarly, all of the care staff records should contain a photo photograph of the person concerned. 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. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have the information they need to make an informed decision as to whether or not the home can meet their needs. People’s needs are assessed to ensure that the home can meet their specific requirements. EVIDENCE: The manager of the home ensured that all of the people who were thinking of going to live at Headroomgate Nursing Home had clear and concise information about the purpose and role of the home. The Statement of Purpose was given to new residents and prospective residents to ensure that they had the information to make an informed decision as to whether the home could meet their needs and was right for them. It would be advisable for the manager to ensure that a Service User Guide was available, which is a simpler, more accessible version of the Statement of Purpose. This would help to ensure that Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 10 all understood the information available about this home. The manager spoke of her intention to do this during the inspection. There were good pre-admission assessments held on the residents’ personal files: these were completed before people came to live at the home to ensure that individual needs could be met appropriately by the care staff. People who use the service also confirmed that they had the opportunity to look round the home prior to making a decision about whether the home was right for them. The home does not supply intermediate care and this standard has not been assessed. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are treated with dignity and respect in this home. Health, personal and social care needs are taken seriously. EVIDENCE: The care plans held information to show that the health needs of the people who use the service were being attended to properly. There were entries to show that the district nurse had been involved in the care of the residents and that other health agencies had been involved in providing health care. There was evidence of reviews taking place regarding each care plan: this helped to ensure that the information that was held on each care plan was current and that people were receiving continuous care. Some of the care plans had not been reviewed for two months; this process should be more regular for a service that cares for residents in a nursing environment. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 12 We saw that people were well dressed and looked well cared for. A hairdresser visited the home on a regular basis, an event that people looked forward to. The carers who were on duty during the inspection were polite and respectful when speaking to the people who use the service. All of the residents that we spoke to were pleased with the standard of care that the service gave. One resident told us: “The girls are lovely, really friendly.” There were records to show when those resident who were on prescribed mediation were given this at the correct times. There were no unexplained gaps and medication was stored and administered correctly. We looked at the medication information for most of the people who use the service and found this to be good, with plenty of information available for the carers who were responsible for giving out the medication. There had also been training in medication awareness for care staff. There were policies and procedures for the trained staff to follow regarding the administration of medication. The manager should ensure that recent photographs are available on all of the medication records to aid identification and help prevent errors. There were plans to develop the medication system and introduce a measured dosage system that is set up by the pharmacist. This would make the medication procedure less complicated and there would be less chance of making errors. There were people who lived at this home who had dementia. There had been no recent training for the care staff regarding the care of people who had dementia. The manger agreed that it would be advisable to introduce this training on a regular basis in order that the care staff have a good, sound knowledge base on which to base their care practice, based on current positive developments in this field. We found that no one who lived at this home had pressure sores and that there was equipment available within the service to help prevent these. There were pressure pads on the chairs in the lounge area, and special mattresses were available for the people who use the service to help with tissue viability. The care plans did not contain a recognised tool to assess the tissue viability of each resident and it is advisable that assessment should be done on a regular basis. The manager was aware of this and is currently looking into the forms of assessment that are available, in order that skin wounds, tears and pressure sores are identified and treated as soon as possible. There were also risk assessments available within the care pans to help ensure that people remained safe and that hazards were identified within the home. The care staff had received training in the safe moving of people who use the service about the home and there was equipment available to assist the care staff. This helps to ensure that people are assisted to move safely and Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 13 professionally. The care staff that we spoke to confirmed that they had undertaken this training and that they were comfortable when undertaking this task. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive a wholesome and appealing diet in pleasant surroundings. Activities for most of the residents were regular and interesting, meaning that people were kept stimulated and active. EVIDENCE: The service did not have a planned daily programme of organised activity for the people who use the service. There were, however, regular events for the residents to become involved in, such as bingo, sing-a-longs, themed nights, fish and chip supper evenings, dominoes and cards. There was a monthly visit to the home by professional entertainers. Three of the residents that we spoke to confirmed that there was enough to do in their spare time and that there were generally things of interest going on. One resident commented, “We love to join in with the singers!” There were no specialist activities for those people who had dementia. The Manager should consider introducing these, considering that the home is registered to provide specialist care for people with dementia. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 15 The owner of the home commented within the Annual Quality Assurance Assessment that the residents had the opportunity to follow their religious faith and that there were visits to the home by priests and other people of religion. There were also visitors to the home whilst we were there. We spoke to three visitors who said that they were pleased with the service that was being provided and that they were always made to feel welcome and valued. One person commented, “ They always look after us when we visit.” We spoke to the cook, and lunch was being served whilst we were there. We were told that there are regular deliveries of fresh fruit and vegetables, and that fresh meat was always part of the menu. There were menus available to show the range and choice of food on offer. The residents that we spoke to said that the food was good and that they looked forward to mealtimes. One resident told us that the food was “excellent”. People were being served politely and there was a nice dining area for the people who use the service to enjoy their meals in. The current owners had recently introduced this to the home. The dining furniture was new and a lot of care and attention had been taken to ensure that this room was in keeping with the building, bright and comfortable. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good safeguarding procedures help to ensure that people remain safe in this home. The complaints procedure is clear and accessible meaning that people who use the service and their representatives can voice their opinions easily. EVIDENCE: All of the staff that were spoken to said that they knew what to do if someone was unhappy about the service. The complaints procedure was displayed in the home and was part of the Service User Guide. Everyone was given a copy of this when they first arrived at the home; timescales were given for the handling of complaints and the manager confirmed that all complaints and concerns were handled properly and seriously. The manager was aware of the homes role regarding the complaints procedure and how complaints can be used as a quality tool to ensure that the home is run in the best interests of the people who use the service. It was clear that the manager and the owner of the home took safeguarding procedures very seriously and recent action had been taken against a carer suspected of mistreating a resident. There were policy documents for the staff to read about how to ensure that people were safeguarded from harm. All of the staff that we spoke to said that they had a good awareness of this Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 17 important issue and knew what to do if they were not happy about something they had seen. The manager was aware of her responsibilities and knew whom to contact should there be any question regarding how the people who use the service were being supported and safeguarded. No recent training had taken place regarding safeguarding adults but some of the carers that we spoke to said that they were taught about safeguarding people as part of their National Vocational Qualification training. It is important that all of the care staff that work at the home have access to this information as it helps to ensure that people are safeguarded from harm. Copies of all the home’s policies and procedures were available in the main office for the staff to read to help them in their roles as carers. There was also a ‘whistle blowing’ policy for staff to report incidents that they are not sure of, and assurances were given within this policy that any such reports would be taken seriously and acted upon. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 18 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 19,20,22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service live in a clean, pleasant and well -maintained environment. This was a service that was ‘homely’. EVIDENCE: There was a lot of work going on at the home whilst we were there. Repairs were being made to the outside of the building. Many of the bedrooms had been redecorated and refurnished and a lot of care was being taken to ensure that the character and style of the building was maintained. There were some rooms that had not yet been decorated or refurnished but the work on these rooms had been planned. There was a large, pleasantly decorated lounge area and a new dining room. There had been many positive changes to the environment since the last inspection and the people who use Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 19 the service that we spoke to told us that they liked living there. There were new carpets in the hallway and new flooring in many of the rooms. Many of the residents that we spoke to were complementary regarding the improvements that had taken place: it is important that people are able to live in pleasant and bright surroundings. Each of the bedrooms that we saw was personalised with belongings, ornaments, pictures and photographs. There were several communal bathrooms throughout the building with both shower and bath facilities. The garden areas had been cut back and tidied up. There is a need for the paths to be made safe as some of them were uneven and would be hazardous for elderly people to walk on. There were plans to develop the garden and have more seating areas: these were limited whilst we were there because of the repair work on the exterior of the building that was in progress. The home was clean and a domestic team were working within the home during the inspection. The home smelt fresh and clean. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good recruitment procedures at this home help to protect the people who use the service from unsuitable staff. Training for the staff was good, which helps to ensure that the care staff have the skills to do their jobs properly. EVIDENCE: Each of the care staff had an individual training file that helped to set out their training needs and documented the courses, training and qualifications that they had undertaken and achieved. We looked at several of these and spoke to the carers about them. It was confirmed that the service takes the training of its staff seriously; several courses and training events had taken place since the last key inspection. Safety training had also taken place in areas such as food hygiene and helping people to move around the home safely. Over 70 of the carers held a nationally recognised qualification in care (National Vocational Qualification level 2 or 3 in care). A well -trained staff team helps to ensure that they have the knowledge, skills and ability to provide a better standard of care. Recruitment for the service was good and each carer had the proper checks completed prior to starting work. This helped to ensure that the people who used this service remained safe and secure. Evidence was available that Criminal Records Bureau disclosures had been obtained, and checks had been Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 21 requested from employment. the Protection of Vulnerable Adult Scheme prior to Each of the care staff had a file that held their personal information. The files were held together in one bulk folder and information regarding personal information and employment was quite hard to find. It would be better for each person to have an individual, separate file so that important information could be easily and readily accessed. Similarly there were no photographs available to identify some of the staff team: these are important and should be obtained as soon as possible. There were enough care staff and trained staff on duty at the time of this inspection to ensure that the assessed needs of the residents were being attended to properly. The care staff that we spoke to were pleasant and with the residents with respect and politeness. Three people who use the service were able to tell us that they were pleased with the amount of care staff that were available, and that they felt well cared for. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of the residents and their welfare is promoted and protected. Good quality control systems help ensure the service runs well. The manager is well respected and runs the service well. EVIDENCE: The owners of the home send out regular questionnaires to the people who use the service, their families and to health care professionals to gain their views on the service and to make changes where necessary. This helps to improve the quality of the service and include the views of the people who use the service and their representatives. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 23 The manager of the home is a trained nurse and was caring and knowledgeable in her approach. She had been registered as manager of the home since the last key inspection. The care staff received regular training in areas of safety around the home: this included fire safety, food hygiene, first aid, infection control, and moving and handling training. There was equipment available to help ensure that the residents of the home were helped to move around the home safely and comfortably. The staff had received training in using this. There were records to show that major appliances within the home had been serviced properly and that safety equipment had been examined by suitably qualified persons to ensure that the health, safety and welfare of the people who use the service was being properly addressed. The gas system, electrical installation and lift had been serviced on a regular basis and there were certificates to show that this had taken place. The home was also properly insured to help protect the people who use the service. Risk assessments had been completed for areas where the residents might need extra protection. The care staff told us that individual supervision had taken place and there were records available to show this. Supervision is important because it provides support for the care staff to review their performance and training needs. The manager told us that there were regular staff meetings for both day and night care staff and there were minutes available to confirm this. There were also minutes held for residents meetings where people were encouraged to talk about the service that they received and what changes could be made to improve their lives. The owner of the home visited the service regularly. Resident and their visitors told us that the owner asked them about the service and how it was meeting their individual needs. Some of the people who use the service had small amounts of personal money that was held by the home. This was monitored by the manager and checked by the owners of the home on a regular basis. As part of the inspection process the owner provided the commission with an Annual Quality Assurance Assessment that told us about the home and how it was progressing. This was completed well and outlined in detail how the service was improving outcomes for the people who use the service and meeting their specific needs. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP19 Good Practice Recommendations The planned programme of maintenance and redecoration of the home should continue to ensure that people who use the service live in a comfortable and homely environment. Photographs should be available on the personal records of the care staff to assist with identification. Photographs should be available on all medication and personal records of the people who use the service in order that identification is made easier and to help ensure that errors are not made. Specialist activities should be available for those people who use the service who have Dementia. Specialist training should be available for care staff regarding caring for those people who use the service who have Dementia. DS0000070133.V371834.R01.S.doc Version 5.2 Page 26 2 3 OP29 OP9 4 5 OP12 OP30 Headroomgate Nursing Home 6 OP7 Care plans must be reviewed on a regular basis to help ensure that care remains stable and continuous. Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection N W Regional Office 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Headroomgate Nursing Home DS0000070133.V371834.R01.S.doc Version 5.2 Page 28 - 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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