Care Home: Hygrove House Nursing Home

What the care home does well The home follows thorough admission procedures to ensure that it can meet the needs of prospective residents. Care plans are of a good quality and provide staff with information to provide individualised care. The recording of the administration of residents’ medication is of a good standard. An appropriate programme of activities is provided for all residents. Visitors are welcomed to the home and encouraged to exchange information about residents` needs. Meals are served in pleasant surroundings with residents receiving appropriate support from staff.. The home has obtained information and some staff have received training in the Mental Capacity Act 2005. The environment has been adapted to help meet the needs of residents with dementia. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 The home uses a range of quality assurance tools to check that it is meeting the needs of the residents. There are thorough safety checks in place in the interests of residents` well being. What has improved since the last inspection? Effective arrangements are in place to store resident’s medication at the correct temperature. Detailed plans are now in place for medication given on an ‘as required basis’ as well as where residents may need to take some medication in food or drink. There has been some improvement in keeping the home free from offensive odours. There are now better records kept of the meals provided to residents. The home’s fire risk assessment has now been reviewed in line with the fire service requirements. What the care home could do better: All staff recruited must be subject to robust recruitment practices with particular attention to the receipt of written references. Any menus on display should be kept up to date. Checks should be made on the functioning of the door closing devices on two communal rooms on the top floor. The registered manager should check that they receive copies of all reports of visits to the home by a representative of the registered provider. Key inspection report CARE HOMES FOR OLDER PEOPLE Hygrove House Nursing Home Hygrove Lane Minsterworth Gloucestershire GL2 8JG Lead Inspector Mr Adam Parker Unannounced Inspection 12th March 2009 07:35 DS0000038272.V374788.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. Hygrove House Nursing Home DS0000038272.V374788.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 Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hygrove House Nursing Home Address Hygrove Lane Minsterworth Gloucestershire GL2 8JG 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) 01452 750716 01452 750331 hygrovehouse@highfield-care.com www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Ltd Mr Rieke Jacobs Care Home 48 Category(ies) of Dementia (48) registration, with number of places Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Dementia (Code DE) The maximum number of service users who can be accommodated is 48 20th February 2007 Date of last inspection Brief Description of the Service: Hygrove House is part of the Southern Cross Group. Hygrove House sits back off the main A48 Gloucester to Chepstow road in Minsterworth. The house itself is a large extended period building surrounded by extensive gardens, with views over the surrounding countryside and Gloucester City. The Home cares for elderly people who suffer from a dementing illness. The building is on three levels and has a passenger lift including stair lifts where required. Many of the Service Users are prone to wander and can do so freely within safe areas to include part of the garden; the areas inside the home are secured with keypads on the doors. Fee ranges are from £578.55 to £1110.78. This includes the amount for funded nursing care (FNC). A copy of the homes Statement of Purpose and Service Users Guide is available in the main reception area. Hygrove House Nursing Home DS0000038272.V374788.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 this service experience good quality outcomes. The inspection visit was carried out by one inspector on one day in March 2009. The registered manager of the home was present for the inspection visit, which consisted of a tour of the premises and examination of residents’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of residents were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. During the inspection visit one resident, a visitor and two members of staff were spoken to, to gain their views of the service. An Annual Quality Assurance Assessment (AQAA) form was completed by the home and forwarded to the Commission prior to the inspection. This was completed in full and gave us the information we asked for. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home follows thorough admission procedures to ensure that it can meet the needs of prospective residents. Care plans are of a good quality and provide staff with information to provide individualised care. The recording of the administration of residents’ medication is of a good standard. An appropriate programme of activities is provided for all residents. Visitors are welcomed to the home and encouraged to exchange information about residents needs. Meals are served in pleasant surroundings with residents receiving appropriate support from staff.. The home has obtained information and some staff have received training in the Mental Capacity Act 2005. The environment has been adapted to help meet the needs of residents with dementia. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 6 The home uses a range of quality assurance tools to check that it is meeting the needs of the residents. There are thorough safety checks in place in the interests of residents well being. 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. Hygrove House Nursing Home DS0000038272.V374788.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 Hygrove House Nursing Home DS0000038272.V374788.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 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’s admission procedure ensures that all residents are admitted on the basis of a full assessment of their needs, so that they can receive the care that they require. EVIDENCE: The assessment documentation for a number of residents recently admitted to the home was looked at. These had been completed following an assessment of the prospective resident’s needs recorded on a comprehensive preadmission assessment document. With the first example looked at the care plan from the local funding authority had been obtained over five days after the resident had been admitted to the home. The registered manager described the circumstances around the admission which was carried out on an emergency basis. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 9 One example of a pre admission assessment form looked at was undated and another not signed by the person carrying out the assessment. This was pointed out to the registered manager. The home writes to prospective residents confirming that their needs can be met when they are admitted to the home and one such letter was seen during the inspection visit. The home does not provide intermediate care and so Standard 6 does not apply. Hygrove House Nursing Home DS0000038272.V374788.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. The home works well to meet residents’ health and personal care needs and has improved the arrangements for storing and administering their medication. EVIDENCE: Care plans examined were detailed and individualised and had been subject to monthly review, there was also evidence of ongoing evaluation. Residents had risk assessments completed for pressure areas, moving and handling, falls and nutrition. In addition a specific nutritional assessment tool known as the ‘MUST’ tool was in use. There were also specific assessments of continence needs. Residents were also being weighed on a monthly basis. Records showed that residents had been receiving visits from health care professionals such as opticians and consultant psychiatrists as well as attending hospital appointments. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 11 Arrangements for medication administration and storage were looked at. Storage was secure and temperatures were being monitored for both the storage room and the refrigerator. Records showed that appropriate temperatures had been maintained. Medication bottles and individual boxes had been dated on opening as an aid to their expiry date. The storage and recording of controlled medication was checked and was all in order. Recorded administration times showed that medication for pain relief had been given at consistent times indicating a good approach to pain management. Medication administration records (MAR) had no gaps in recording and appropriate codes had been used where medication had not been given. There was consistent practise in relation to the signing, dating and checking of handwritten directions on the MAR. However a line had been drawn on the MAR sheet in one case where medication had apparently been stopped. Any such lines on the MAR should be qualified by an explanation as well as being signed and checked. Protocols were in place to guide staff in the administration of medication prescribed on an as required basis. These were detailed and of good quality providing a clear guide for staff in administering medication. Where some residents were receiving medication in food and drink, ‘best interests, plans had been completed showing how consideration had been given to the issue. A recent copy of the British National Formulary (BNF) was in use as a reference for staff about medication. Staff were observed to be treating residents respectfully. Shared rooms had curtains between beds as an aid to prompting resident’s privacy. The home’s AQAA document told us that there are two ‘dignity champions’ who actively promote dignity in the home. One resident spoken to during the inspection visit stated “They look after us quite well here.” A visitor stated that their relative received “good care” in the home. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 varied activities programme and good degree of social contact. In addition residents receive a choice of meals served in pleasant surroundings. EVIDENCE: Residents had personal social profiles completed after admission and some had activities care plans. Some of the profiles looked at were incomplete although the home largely relies on input from residents relatives in completing these. Examples of group activities provided in the home were bingo, arts and crafts, poetry and book reading, music and movement, cooking sessions and food tasting sessions. The activities organiser described the importance of providing one to one activities for residents with dementia and particularly for those who were less active these included hand massage, manicures and reading. During the inspection visit a bingo session was taking place. Activities outside of the home are also organised with visits made to a local pub. A day out at the seaside was being planned for the summer. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 13 At Christmas local schoolchildren had visited the home to perform Carols. A service is held on each floor of the home by the Church of England once a month. Such a service was taking place during the afternoon of the inspection visit. A Roman Catholic Priest also visits the home and one resident with Ukrainian descent had contact with a Ukrainian Church and the Ukrainian community in Gloucester. The activities organiser works on weekdays, at weekends materials for activities are available and a member of a local church organises a film show every other weekend. The activities organiser had undergone training in providing activities in a care setting. One visitor was spoken to; they described how they were welcomed when they visited the home and how the staff were polite to them. In addition they praised the activities provided in the home and said that the activities organiser was “Worth her weight in gold.” The home provided communication books for relatives and staff to communicate any issues relating to individual residents. Evidence was seen of service users bringing their own personal possessions into the home including items of furniture. The home has information on advocacy services for residents. At lunchtime residents were eating lunch in the dining room on the ground floor. Tables were laid with drinks and had flowers for decoration. Menus were also placed on the tables although on examination those on display related to a Thursday and not the Monday, the day of the inspection visit. Staff were observed providing appropriate assistance to some residents with eating and drinking. The dining room on the second floor was observed during lunch and there was a quite atmosphere. Some residents were eating pureed meals and these were noted to be served in an attractive way with the different portions pureed separately. There were records of meals provided to residents. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 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. Information is available if any resident or their representative should wish to make a complaint and the homes approach to training staff should ensure that residents are protected from abuse and their legal rights are upheld. EVIDENCE: The home has a register for recording complaints. The procedure for complaints is that on receipt, a letter is sent and following investigation a response is given within 28 days. The documentation and response to the one complaint received during 2008 was looked at. This was about issues around bed linen and had been dealt with by the manager. In addition to the complaints register there is a complaints log book where any complaints received at weekends or ‘out of hours’ could be recorded. The log book contained brief details of the resolution of three complaints. Information about how to make a complaint is available in the entrance to the home along with other information about the service. The home’s AQAA document told us that they had received six complaints in the twelve months up to December 2008. In relation to residents legal rights, the home has information on the Mental Capacity Act 2005 with training provided for the majority staff. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 15 The home has a policy for protecting residents from abuse as well as a whistle blowing policy. This policy is given to all staff when they start work in the home. Training in protecting residents from abuse has been given to the majority of staff. A further group of staff had attended the Alerter’s training provided by the local authority adult protection unit. In addition training is also provided in dealing with challenging behaviour. Information from the Gloucestershire County Council in the form of their Alerters Guide was available in the home. Two staff were spoken to and were aware of the Whistle blowing Policy. They also recalled their training in protecting residents from abuse giving examples of different types of abuse and how any suspected abuse may be reported. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 & 26 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 have the benefit of living in a generally well-maintained and clean, environment suitable for their needs and with personalised individual rooms. EVIDENCE: A tour of the premises was conducted. All areas of the home inspected were found to be clean and well maintained with appropriate and attractive decoration. The entrance hall contained a wealth of information relevant to the home. On the ground floor communal areas consist of a large lounge leading on to a conservatory. Outside there was a patio with garden furniture within the enclosed rear garden. The second floor had a communal lounge and dining room. Resident’s rooms were comfortable and contained various degrees of personalisation. However two rooms were noted to be odourous and the Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 17 registered manager was made aware of these during the inspection visit. Work had been carried out to improve the environment for the needs of people with dementia by painting the doors of toilets yellow with suitable pictorial signs. In addition ‘tactile boards’ had been placed on some corridor walls which are also in line with the needs of the residents. The laundry had cleanable floor and wall surfaces although there was some peeling paint on one wall near one of the machines which needed some redecoration. Handwashing facilities were available. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Residents benefit from a well trained staff group although recruitment practices need some improvement in one area to ensure that residents are fully protected. EVIDENCE: Staffing in the home is arranged so that on a typical weekday there are two registered nurses and eight care staff on the day shift until seven in the evening. Nursing and care staff are supported by the registered manager, an activities organiser a cook, two domestic staff, and a laundry worker. In addition there is an administrator, a maintenance worker and a gardener. At night there two registered nurses and four care staff. The home had just over 50 of care staff trained to NVQ level 2 or above. Some staff from overseas have had their qualifications verified to NVQ level. Records for three recently recruited members of staff were examined. Two of these had been recruited with all the required information and documentation being obtained before they started work in the home. However on examination the records for one member of staff were lacking a second written reference although other checks had been made. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 19 A record should also be kept of the dates that references are received by the home as a clear indication that the correct sequence of recruitment procedures have been followed. Induction training provided to new care staff is in line with the nationally recognised Common Induction Standards. Other training has been undertaken in such areas as dementia awareness; ‘Yesterday Today and Tomorrow’ (accredited training course in dementia), equality and diversity, person centred care and falls awareness training. Staff spoken to confirmed the training that they had attended. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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 a variety of quality assurance audits in operation and safety checks to ensure that the home is run in the best interests of residents. EVIDENCE: The registered manager had been registered with the Commission shortly before the inspection visit. He is a registered Mental Health Nurse with a degree in Nursing Studies and is currently studying for a Masters Degree in the Psychology of Aging. The registered manager has had previous experience of working with people with dementia in a care home. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 21 Quality assurance in the home is based on a number of audits. A validation audit is carried out on a monthly basis alternately done by the registered manager and the operations manger. This is a thorough audit of quality in the home. Other audits take place concentrating on accidents, care plans, environment, and medication. The results of a satisfaction survey conducted with relatives of residents was displayed in the entrance hall. The survey had been conducted in June 2008.Some of the positive comments received about the home where “food is good.” “Home is clean” and “Home is safe and secure.” In addition unannounced monthly visits by a representative of the registered provider had taken place with a report produced and copied to the registered manager. However although it was reported that these visits had taken place each month some reports for 2008 were not in the file in the home. On the day following the inspection visit the registered manager confirmed that all of the provider’s visit reports were now in the home. The home has a bank account for holding residents money. Documentation relating to this was examined and found to be in order. The home should check that there is a record of any resident’s valuables held in safekeeping. Staff had completed training in safe working practices in fire safety, food hygiene, moving and handling, health and safety, infection control and the control of hazardous substances. The home uses a traffic light system as a way of ensuring that staff do not miss any training or training updates. A number of staff had also completed training in first aid and the safe use of bed rails. Checks had been made on gas appliances, the electrical wiring and portable electrical appliances. Servicing had also been carried out on hoisting equipment. A comprehensive environmental checking system was in place that included checks on window restrictors, hot water temperatures and wheelchairs. Work to reduce the risk to residents from Legionella had been carried out by a specialist consultant. Cleaning materials were safely stored and kept in their original labelled bottles with no decanting. The home had received a food hygiene inspection from the local authority and had achieved a four star rating. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 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 3 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 23 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 OP29 Regulation 19 (1) (b) Schedule 2 Requirement Before a person starts work in the home, all the information and documents specified in Schedule 2 of the Care Homes Regulations must be obtained to ensure that residents are protected through robust recruitment procedures. Timescale for action 31/07/09 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. 4. Refer to Standard OP3 OP9 OP15 OP19 Good Practice Recommendations Pre admission assessment forms should be signed and dated by the person carrying out the assessment. Avoid the use of marks or lines drawn on medication administration records without a written explanation. Menus displayed on tables should be kept up to date. Checks should be made to ensure the self-closing devices on the top floor dining room and lounge are in good working order and that the dining room door shuts properly. DS0000038272.V374788.R01.S.doc Version 5.2 Page 24 Hygrove House Nursing Home 5. 6. 7. OP26 OP29 OP33 8. OP35 Attend to the peeling paint on the wall in the laundry. A record should be kept of when written employment references are received by the home. The registered manager should check that all reports of visits to the home by a representative of the registered provider under regulation 26 are received and kept in the home. Checks should be made to ensure that there is a separate record made of any residents’ valuables held in safekeeping Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 25 Care Quality Commission South West 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. Hygrove House Nursing Home DS0000038272.V374788.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!