Care Home: Nada Nursing Home

What the care home does well The home offers a secure environment to people and ensures their personal and healthcare needs are being met, based on assessments of peoples needs. During brief discussions with people living in the home a number said they liked living there. People are provided with a contract relating to the care they receive. Procedures relating to medication were clear and protected people. Significant improvements had been made to address issues identified in the last inspection. Records were maintained of social and leisure programmes offered to people in the home. Training programmes were in place for staff to address specialist training in areas such as dementia awareness, equality and diversity and person centred care planning. Staff confirmed that team meetings and supervision sessions were provided on a regular basis. People living in the home praised the standard of food provided, saying that they were offered choice at mealtimes and snacks and drinks at any time. The home is able to cater for special diets, such as diabetic, vegetarian and Halal. Policies and procedures were in place to keep people safe and care is taken to ensure that recruitment and selection procedures, training and development plans were regularly monitored and offered to staff employed in the home Attention is given to ensuring that regular maintenance checks are carried out by qualified people and fire and other health and safety records are kept up to date What has improved since the last inspection? There was a noted improvement in procedures relating to the safe handling of medication. This included audit trails and recording procedures to ensure medication was administered in accordance with prescribing directions. Records had improved in respect of administration of creams and dietary supplements. Care plans were being reviewed monthly and were continuing to be developed to ensure care plans reflected the choices, preferences and aspirations of people living there. The owner had implemented a rolling programme of maintenance and refurbishment of the home. The home had completed a summary report on consultation programmes conducted to seek the views of people. The findings from the survey had been analysed and included in a quality report. What the care home could do better: Although there was evidence of developments in internal social and leisure programmes, additional work is required in relation to evidencing that people are enabled to follow their chosen lifestyles and where possible achieve their personal goals. Care plans required developing to evidence staff were providing consistent care that reflected people`s wishes and aspirations. The home is advised to move forward proposals relating to establishing a more person centre care approach to care planning to address this.Issues relating to internal fire risk assessments for the home required reviewing as a high percentage of people living in the home are smokers. In addition the home is advised carry out a fire drill at a minimum of six monthly intervals. Further work is needed to develop dementia-friendly designs in the home to ensure that people can develop more independence in an environment that meets their specific needs. CARE HOMES FOR OLDER PEOPLE Nada Nursing Home 451 Cheetham Hill Road Cheetham Hill Manchester M8 9PA Lead Inspector Joe Kenny Unannounced Inspection 4th April 2008 11:35 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 Nada Nursing Home DS0000021566.V361689.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. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nada Nursing Home Address 451 Cheetham Hill Road Cheetham Hill Manchester M8 9PA 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) 0161 720 7728 may.grenade@ntlworld.com Mr Pierre Grenade Mr Pierre Grenade Care Home 28 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home is registered for a maximum of 28 service users of either sex over 60 years of age suffering from either mental disorder or dementia. The maximum number of service users requiring nursing care shall be 17 and the maximum number of service users requiring personal care only shall be 11. Registration is subject to compliance with the minimum staffing levels indicated in the Notice served in accordance with Section (25) 3 of the Registered Homes Act 1984 issued on 6th March 2002. Staffing for the service users assessed as requiring personal care only must comply with the minimum levels set out in the Residential Forum Guidelines for Staffing in Care Homes for Older People. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 5th April 2007 Date of last inspection Brief Description of the Service: Nada Nursing and Residential Care Home provides accommodation with nursing and personal care for a maximum of 28 older people. The care home is able to offer accommodation to 17 older people assessed as requiring nursing care and 11 residents assessed as requiring personal care only. The home is owned and operated by Mr Pierre Grenade, who is both the registered person and the manager. The home is situated in the Cheetham Hill area of North Manchester close to local shops, Manchester City centre, social, cultural and recreational amenities. The home consists of a converted large detached house with a large, modern extension within its own small grounds. The home is able to offer off-the-road parking for approximately five vehicles in addition to the homes mini-bus. All rooms have wash hand basins and commode chairs. The home has two floors, which can be accessed by a passenger lift. There are six double and sixteen single bedrooms. There are no en-suite rooms. There are a number of communal areas for residents to choose from or, if they prefer, they can spend time in their own rooms. The home offers a limited number of in house social activities. Nada Nursing Home DS0000021566.V361689.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. The inspection of the home was carried out on the 4 April 2008 and was unannounced. The inspection looked at requirements and recommendations, made at the last inspection, social and nursing care programmes and examination of records required to be held. Discussions were held with people living in the home and staff A number of files relating to care and support offered to people were examined. Records and procedures relating to health care and medication records were also examined to ensure procedures were in place to meet the assessed needs of people being cared for. A self-assessment form referred to as the Annual Quality Assurance Assessment, AQAA, had been completed by the home and received by the commission prior to the inspection. A tour of the building was conducted and observations made during the course of the inspection of interactions between people living in the home and staff. Comment cards were returned to the commission by people living at the home and by staff and gave their views about life in the home. What the service does well: The home offers a secure environment to people and ensures their personal and healthcare needs are being met, based on assessments of peoples needs. During brief discussions with people living in the home a number said they liked living there. People are provided with a contract relating to the care they receive. Procedures relating to medication were clear and protected people. Significant improvements had been made to address issues identified in the last inspection. Records were maintained of social and leisure programmes offered to people in the home. Training programmes were in place for staff to address specialist training in areas such as dementia awareness, equality and diversity and person centred care planning. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 6 Staff confirmed that team meetings and supervision sessions were provided on a regular basis. People living in the home praised the standard of food provided, saying that they were offered choice at mealtimes and snacks and drinks at any time. The home is able to cater for special diets, such as diabetic, vegetarian and Halal. Policies and procedures were in place to keep people safe and care is taken to ensure that recruitment and selection procedures, training and development plans were regularly monitored and offered to staff employed in the home Attention is given to ensuring that regular maintenance checks are carried out by qualified people and fire and other health and safety records are kept up to date What has improved since the last inspection? What they could do better: Although there was evidence of developments in internal social and leisure programmes, additional work is required in relation to evidencing that people are enabled to follow their chosen lifestyles and where possible achieve their personal goals. Care plans required developing to evidence staff were providing consistent care that reflected people’s wishes and aspirations. The home is advised to move forward proposals relating to establishing a more person centre care approach to care planning to address this. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 7 Issues relating to internal fire risk assessments for the home required reviewing as a high percentage of people living in the home are smokers. In addition the home is advised carry out a fire drill at a minimum of six monthly intervals. Further work is needed to develop dementia-friendly designs in the home to ensure that people can develop more independence in an environment that meets their specific needs. 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. Nada Nursing Home DS0000021566.V361689.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 Nada Nursing Home DS0000021566.V361689.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment procedures were in place to assess people’s needs prior to admission. EVIDENCE: The home’s Statement of Purpose and Service User Guide had been updated since the last inspection in October 2007, to ensure prospective residents have relevant information. Files are developed in a way to ensure staff are aware of the assessed nursing and social care needs of people they support. The registered manager and /or a senior carer carries out the initial assessments of people being referred. A pre admission assessment form is used by the home to gather information about the person being referred and Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 10 additional information is received from the care manager supporting the person. The admission process also offers the person the opportunity to visit the home before moving there. 10 comment cards were received by the Commission from people living in the home. Each person confirmed they had received information about the home and had received a contract. One person commented that “everything is all right”. No intermediate care is offered at the home. Nada Nursing Home DS0000021566.V361689.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): 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. Peoples care needs are assessed and regularly reviewed. Medication procedure are regularly audited and monitored to ensure people are protected. EVIDENCE: A selection of files was examined, including the files of people most recently admitted. The care provided to people is based on assessed needs at the time of their admission. This is regularly reviewed internally and with the support of the persons’ care manager. Information in the care plan identified if a person had been assessed as requiring nursing or personal care support. The pre admission form enables the home to gather and record more comprehensive information about each person, under 15 different headings and covering areas such as personal history, medical history, social interests, relationships and religious and cultural needs. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 12 It was evident that many people have limited capacity or do not have an active relative involved in their ongoing care. The manager said he encourages staff to spend time with people to seek their views and where a relative is involved, they are involved in this process. In addition the manager spoke about how he worked closely with many people to gain their trust in order achieve basic improvements in areas such as person hygiene. Staff are assigned as key workers and are allocated daily duties as a means to monitor and ensure care is delivered. It was evident from records and review documents that staff do support people’s assessed needs. However, there is a need to further develop and implement plans in a way which reflects a more person-centred format, as staff have been supported through training in this area. Daily reports are compiled by day and night staff and are well maintained. Separate health care forms and some admission documents did not record the date they had been drawn up. The manager is advised to ensure all such forms are dated when set up in order to assist in monitoring outcomes for people. The manager said the home received “very good” support form psychiatric services, who will visit on request. The CPN also offers support and a consultant psychologist is also available to the home. There are three General Practitioner practices used to support people living in the home. Medication procedures were very clear and medication administration had significantly improved to protect people and addressed issues identified on previous inspections. Medication is held securely and the senior on duty holds the key. Prescriptions are received by the home and a copy taken and held within the service user’s Medication Administration Records sheets (MAR). Staff sign the MAR sheets when they administer individual doses and sign an medication administration book to confirm they have completed administration of all medications for each prescribing period of the day. A dietary supplement register is also maintained. Records were examined and recorded Thick and Easy, fruit juices, Procol and Ensure Plus when administered. Within each persons section of the MAR sheets there is a photo and a drugs profile listing the medication they are on. Hand written entries were signed by two staff. The medication policy was reviewed in November 2007, and provided staff with clear and detailed guidelines. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 living in the home were offered choices in respect of their daily lives and social care programmes. EVIDENCE: As stated in the previous section, assessment and care planning for people looked at the persons life history and gathered information in relation to their social interests, likes / dislikes, hobbies, relationships and religious and cultural needs. There was evidence of improvements in recorded accounts of internal social and leisure programmes of activities. Social events are held in house, such as festive events and music sessions. Staff work with service users to ensure records reflect their individual interests. Reminiscence sessions are held and look at people’s previous work experiences and, for example, time spent in the army. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 14 However a high number of people choose to remain in their own rooms. Residents have meetings every month to discuss issues. Usual topics are food, social events. A senior carer provided information sheets and daily records of events held. This detailed the event, how the activity went and who took part. The records were well maintained, however the records were not completed when the senior was not on duty. There were sections where there was a large gap in records and the home was advised to ensure all staff assist in maintaining this record in order to evidence that social care programmes were being well maintained. The only evidence of people accessing activities out of the home related to one person attending a social club one day a week and one person who regularly goes out walking on a daily basis. There is a need to evidence that people have been consulted and given the opportunity to access more community based resources and trips out of interest to them. Menu plans are rotated using a two week menu plan. Information about the meals for the day is recorded on a board in the lounge and did evidence that a choice was offered. People did comment that they enjoyed the meal and had received a good portion. People also commented about alternatives they would prefer in the morning and stated this in the presence of the inspector and the manager. The manager indicated he would take on board the person’s comments. Meals are prepared by a designated cook or by the wife of the owner when the cook is off duty. Ample provisions were available on site or purchased when required at local shops. A varied and balanced diet is provided, offering dietary and culturally appropriate meals. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints procedure enabled people to raise concerns about the service they received. Procedures relating to protection ensure staff have the skills and knowledge to protect people from abuse. EVIDENCE: The home has a clear written complaints procedure and no complaints have been registered since the last inspection. The procedure is available in the homes Statement of Purpose and in the Service Users guide. Ten people using comment cards said they knew who to talk to if they had any concerns or complaints. The manager said no complaints had been received by the home since the last inspection and no complaints had been received by the commission in the same period. Procedures relating to protection and abuse awareness are established through the home’s internal procedures and training programmes. This is supported by Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 16 the home accessing into and adhering to guidance established through the Manchester Multi Agency procedure. There had been no safeguarding issues since the last inspection and staff have also attended refresher courses in abuse awareness procedures. The manager demonstrated a clear understanding of procedures and a commitment to ensure all staff had the necessary information to deal with abuse issues. During discussion with staff they demonstrated a good understanding of protection procedures and what to do if they were to witness or be informed about an abuse issue. Staff also demonstrated a clear understanding of the home’s whistle blowing policy. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained, clean and comfortable for people living there. EVIDENCE: There are secure landscaped grounds to the side and rear of the home and car parking bays to the side of the building. The grounds offer secure areas for people to access, weather permitting. The premises were found to be generally clean and tidy. A tour of bedrooms was undertaken and the opportunity was taken to meet with people in communal areas. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 18 Programmes of floor recovering had been carried out since the last inspection. Some covering had been replaced with washable covering or laminated floor covering as opposed to carpets. There is a designated smoking area off the lounge area. Discussions were held with the manager in relation to the need to ensure the homes fire risk assessment identified a high risk in relation to service users smoking. This comment related to fact that 18 of the 26 people accommodated smoked. On touring bedrooms there was evidence of that some people continue to smoke in their rooms. This was evident from cigarette damage and smoke odour in some rooms inspected. Procedures relating to management of this risk require regular monitoring. Metal bins should be located in rooms, and as stated, a revised fire risk assessment is required to address this high risk. In the sluice and laundry area some cleaning solutions had been decanted into clear spray containers. All cleaning material should be retained in its original container to ensure COSHH procedures and directions are available to staff at all times. Decanting solutions present high risks to staff and service users. The laundry service appeared well managed and machines could be programmed for sluice washes. Suitable amounts of aprons disposable gloves were available to staff. Paper towels were however missing in one toilet and staff were seen to fill containers with towels once identified. The door to room 15b did not shut into its frame and required attention to protect people. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Recruitment and selection procedures ensure that staff with the right personal qualities, knowledge and skills are employed to work with people living in the home. EVIDENCE: The manager holds the necessary qualifications and experience to manage the service and is supported by a team of qualified staff and care assistants. Information relating to the staffing structure is regularly updated in the homes Statement of Purpose. There are three Registered Mental Nurses and three Registered General Nurses employed at the home. There are a total of 20 staff employed. On the day of the inspection, the senior nurse on duty assisted with the inspection of medication. She has been in post for three years at the home. There are three staff employed at night, one qualified nurse and two care assistants. The home does not use agency staff. Existing staff or Mr Grenade will cover any short falls during the night and day hours. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 20 The rotas for the period covering the inspection indicated a total of 366 day care hours and 40 management hours were provided. Staff are deployed at a minimum of 5 in the morning and 4 in the evening. At the time of the inspection all staff were carrying out all domestic duties. There is a need to review this in light of the size of the home, residents numbers and staff deployment. Records relating to staff were examined and information relating to their recruitment, and ongoing development of training and supervision programmes had greatly improved. Staff records are managed by the home’s administrator to ensure information was clearly set out and contained the required information to evidence recruitment and selection process. A training and development plan is in place for each member of staff, including a training needs identification form. Staff meetings are maintained at a minimum of one every two months, and specific meetings involving nursing staff are held to discuss nursing and clinical issues. Additional training programmes have been put in place to evidence staff have the necessary skills and knowledge to support people funded by the Local Authority for EMI clients A total of 12 care staff have achieved NVQ level II award this equates to 66 of the staff team. The cook is also working to NVQ in catering. All staff with the exception of one have completed palliative care and safeguarding procedures. The administrator for the home will attend training on equality and diversity and will cascade training and information to existing staff through additional training and supervision programmes. All staff files examined and had appropriate checks in place including references and Criminal Record Bureau checks. There is a checklist in each file to monitor and check the content of the files and ensure the process for recruitment and selection is adhered to. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration procedures had significantly improved to evidence the home was being run in the best interest of people. EVIDENCE: The owner/manager was appropriately qualified and experienced in managing mental health care services. There were noted improvements in health care arrangements, relating to medication and administration procedures relating to staffing records and recruitment procedures. The home conducted a survey of people’s views about the service they received and compiled a report on its findings. This document was available for examination as part of the home’s internal quality monitoring process. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 22 Procedures relating to finances were examined and evidenced that a high proportion of people receive and sign for their allowances on a weekly basis. Where cash is managed on people’s behalf, receipts were obtained to evidence how this was spent on their behalf. Discussions were held with the manager regarding the need for the fire risk assessment to be reviewed to include the risk relating to the high number of residents who smoke. Records relating to service and maintenance contracts were seen and confirmed a recent lift inspection, service of fire fighting equipment and insurance liability cover. The fire register confirmed weekly and monthly tests and checks are carried out and last conducted on the 31/03/08. The records indicated the last fire drill was on the 19/01/07 with a fire lecture on 20/06/07. The manager was advised to conduct a fire drill by the end of the month and then at the frequency recommended by the fire service. The fire register is maintained by one of the senior carers who conduct the tests and checks. No health and safety shortfalls were identified in the environment during this visit. Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 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 X X X X X X 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 X 3 X 3 X X 2 Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 12 Requirement A fire drill must be conducted by the end of the month and at a minimum of six monthly intervals Timescale for action 30/04/08 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 OP7 Good Practice Recommendations The manager is advised to ensure all health care and assessment forms are dated when set up in order to assist in monitoring outcomes for people. Records relating to social and leisure care programmes should be sustained by all staff in order to evidence that social care programmes were being well maintained. There is a need to evidence people have been consulted and given the opportunity to access more community based resources and trips out of interest to them. 2. OP14 3. OP14 Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 25 4. OP19 Procedures relating to the management of risk relating to smoking require regular monitoring. Metal bins should be located in rooms. A revised fire risk assessment is required to address this high risk. All cleaning materials should be retained in the original container to ensure COSHH procedures and directions are available to staff at all time. Decanting solutions present high risks to staff and service users. The door to room 15b did not shut into its frame and required attention to protect people. 5. OP19 6. OP19 Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Nada Nursing Home DS0000021566.V361689.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!