Care Home: Radcliffe Gardens Nursing Home

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What the care home does well People are provided with good information about the service. Evidence was seen to show they are enabled to visit the home to look around and chat tostaff prior to taking up a place. This helps prospective residents to make an informed choice about whether they want to take a place at the home People are provided with a good standard of care planning and risk assessment. They are reviewed monthly and they are also informed with consenting to the process. This ensures people are safe and well informed. The staff at the home communicate very well with all people at the home, regardless of varying degrees of communication. People living in the home are well informed about the complaints process and they feel very comfortable with making a complaint or concern known. The staff have a good awareness about safeguarding vulnerable people. They know what procedures to follow if an incident is identified. This helps minimise the risk of harm occurring to people living in the home. The manager has ensured there is now a rolling programme of refurbishment and specific monies are set aside to assist the process. Staff are now recruited and trained to a good standard. This means people who use the service will receive a more consistent care package. The home tries hard to ensure all people are listened to using different forums. What has improved since the last inspection? Care plans and risk assessments are now in place and reviewed regularly. People who live there and their representatives are involved with this process. The medication administration and recording has improved. There are now systems in place to ensure medications are stored and recorded safely and correctly. Improvement has been made with the provision of care with regards to ensuring privacy and dignity is promoted and respected. The way staff now work and perform tasks has improved. Staff appear less busy and rushed. They have more time to provide individual care. Recruitment procedures have improved. All the required information needed before a carer can commence work is now obtained. Staff now receive an induction programme that is based around the skills for care common induction programme. Staff now receive an improved standard of training that assists them to do their job correctly. Improved management systems and processes have been introduced that provide evidence to show the home is being managed to a good standard. Quality assurance tools are now developed and implemented to assess and improve the quality of care in the home. The system for monitoring the health and safety of all aspects of the home has improved. Regular monitoring of health and safety now takes place regularly. What the care home could do better: The manager should review the infection control practices with regards to the use of cleaning materials. This will help reduce the risk of cross infection occurring within the home. CARE HOMES FOR OLDER PEOPLE Radcliffe Gardens Nursing Home 11 Radcliffe Gardens Pudsey Leeds Yorkshire LS28 8BG Lead Inspector Sean Cassidy Key Unannounced Inspection 12th September 2008 09:30 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 Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Radcliffe Gardens Nursing Home Address 11 Radcliffe Gardens Pudsey Leeds Yorkshire LS28 8BG 0113 256 4484 0113 257 8376 radcliffegardens@btconnect.com 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) Fezdene Limited Bev Gallagher Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (1), Terminally ill over of places 65 years of age (20) Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2007 Brief Description of the Service: Radcliffe Gardens is an adapted detached property providing accommodation for twenty older service users. Nursing and residential care can be provided. Some bedrooms have a WC ensuite facility. There are a number of shared rooms and a small number of bedrooms are located on the first floor. This floor is accessed by a passenger lift. A non-smoking policy operates in the building. The home is surrounded by well-kept gardens. There is a pleasant easily accessible patio area for service users to sit and enjoy the good weather. Also available is a car park to the front of the property. The home is located in the centre of Pudsey adjacent to Pudsey Park. The local church, shops, library, bank and post office are near by. The fees paid by or on behalf of residents range from £550 to £612. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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 accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information obtained from residents, relatives, staff and other health care professionals. Information received from the Annual Quality Assurance Assessment document provided by the manager. One inspector conducted an unannounced visit to the home, which lasted one day. The majority of this time was spent looking at documentation, speaking to residents, management, staff and relatives. A number of documents were looked at during the visit and parts of the environment used by the people living there were also looked at. A proportion of time was spent speaking to the manager, the deputy manager, staff and visitors. The information required from the service in the form of the Annual Quality Assurance Assessment was obtained before this report was written. The manager was provided with feedback at the end of the inspection. The weekly fees charged at the time of inspection between £550-£612 per week. What the service does well: People are provided with good information about the service. Evidence was seen to show they are enabled to visit the home to look around and chat to Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 6 staff prior to taking up a place. This helps prospective residents to make an informed choice about whether they want to take a place at the home People are provided with a good standard of care planning and risk assessment. They are reviewed monthly and they are also informed with consenting to the process. This ensures people are safe and well informed. The staff at the home communicate very well with all people at the home, regardless of varying degrees of communication. People living in the home are well informed about the complaints process and they feel very comfortable with making a complaint or concern known. The staff have a good awareness about safeguarding vulnerable people. They know what procedures to follow if an incident is identified. This helps minimise the risk of harm occurring to people living in the home. The manager has ensured there is now a rolling programme of refurbishment and specific monies are set aside to assist the process. Staff are now recruited and trained to a good standard. This means people who use the service will receive a more consistent care package. The home tries hard to ensure all people are listened to using different forums. What has improved since the last inspection? Care plans and risk assessments are now in place and reviewed regularly. People who live there and their representatives are involved with this process. The medication administration and recording has improved. There are now systems in place to ensure medications are stored and recorded safely and correctly. Improvement has been made with the provision of care with regards to ensuring privacy and dignity is promoted and respected. The way staff now work and perform tasks has improved. Staff appear less busy and rushed. They have more time to provide individual care. Recruitment procedures have improved. All the required information needed before a carer can commence work is now obtained. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 7 Staff now receive an induction programme that is based around the skills for care common induction programme. Staff now receive an improved standard of training that assists them to do their job correctly. Improved management systems and processes have been introduced that provide evidence to show the home is being managed to a good standard. Quality assurance tools are now developed and implemented to assess and improve the quality of care in the home. The system for monitoring the health and safety of all aspects of the home has improved. Regular monitoring of health and safety now takes place regularly. What they could do better: 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. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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 Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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): 1, 3 and 6. People who use the service experience good quality outcomes in this area. All prospective service users are correctly assessed and are provided with a good standard of information prior to moving in. This assists the management team to assure themselves that they can meet the individual’s needs and the individual is making an informed choice about moving into the home. We have made this judgment using a range of evidence, including a visit to the service. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 10 EVIDENCE: The Statement of Purpose and Service User Guide have been reviewed by the manager and are both available in the entrance of the home. The most up to date inspection report from the CSCI and also recent Investors in People report is also available. People said that they were invited to come along and visit the home prior to moving in. They said they were fully informed and were provided with enough information to help them make their choice of home. The manager said everyone is assessed prior to being offered a place at the home. This means they are assured that they will be able to meet that person’s needs. The care documentation of the two most recent admissions was seen and they both contained evidence that a thorough assessment was carried out prior to being admitted to the home. Information from people who use the service also confirmed that the assessment did take place. An Intermediate Care Service is not provided at the home. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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 People who use the service experience good quality outcomes in this area. People living at the home are assured that their care needs are properly assessed and planned for. The care is reviewed regularly and altered when care needs change. People receive their care package from staff who have a clear understanding about promoting respect and dignity when providing individual care. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Care documentation of two people who live at the home showed that a full assessment of their needs was carried out when they arrived at the home. Where a care need was identified a care plan to assist staff with meeting that need was developed. All the care plans looked at were reviewed monthly. They Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 12 were informative and provided good detail as to how each need was to be met. Both care files showed the person for whom the care was prescribed was involved with consenting to their care package. This is good practice. Each file also showed evidence that people were correctly risk assessed in areas such as falls, moving and handling, pressure area care and nutrition and saw clear evidence that when a risk was identified the appropriate health professional was involved with the care package. Examples of this were involving the dietician, physiotherapist and also the occupational therapist. This is good practice. The local GP practice is also very closely involved in people’s care. Clear records were seen to show health professionals were involved with the care package when needed. People who use the service provided positive feedback about how their health care needs were met. Some comments were, “ They are very quick in responding to health problems. That’s comforting.” “ We are always informed when the home arranges for other professionals to see mum. Its really reassuring.” During the inspection staff were observed working in their roles. This observation was very positive. Staff communicated very well with those people they were in contact with. They spoke to people at the correct level and were seen to give plenty of time with allowing people to answer questions. Plenty of kindness and reassurance was seen being given. One lady with a communication problem was looking agitated. Staff saw this and they sat with her and chatted slowly. They were able to eventually identify the source of her agitation and this was dealt with to her satisfaction, which was clearly seen. This is good practice. Evidence was seen in the care plans that showed people are assessed on a regular basis by a qualified physiotherapist who works in collaboration with the rest of the healthcare team to ensure that all of a person’s mobility needs are met. In conjunction with the Primary Care Trust and Marie Curie, the home is one of nursing homes across the city who are working together in the ‘Marie Curie delivering choice Programme’ The aim of the programme is to develop and provide the best possible service for palliative care patients allowing them to be cared for in the place of their choice and to receive the best possible care. Care plans showed the home works in collaboration with the resident and their relatives and have taken steps to plan for people’s palliative care needs and to discuss their specific wishes through advance care planning. This shows evidence of how the home empowers and enables dignity and respect in relation to palliative care. Information received from people who use the service was very positive about the staff group. They said, “ They can’t do enough for me. They are very respectful and helpful.” “ Mum thinks the staff are lovely. They always make sure she is dressed well and that her clothes are always clean.” Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 13 People looked very clean and tidy. The home has a hairdresser who comes once a week and provides a service to all people living in the home. The carers are also attentive to detail. They were observed examining people’s nails and offering a manicure if people wanted one. The medications were observed being administered during the visit. The nurse involved with this process followed the correct procedure as highlighted in her code of practice for the administration of medicines. People were observed taking their medications and they were also provided with sufficient time to do this. A random audit of the medication charts showed the standard of recording in this area was good. The record of storage of controlled drugs in the home was looked at and this was in order. The manager has implemented a process whereby the registered nurse checks this record at the end of each shift. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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): 12,13,14 and 15. People who use the service experience good quality outcomes in this area. People living in the home are provided with a variety of activities to suit their needs. The standard of food provided by the home is good. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The people spoken to said that they are provided with a good standard of activity within the home. They gave examples of the activities they were involved in and talked about planned raffles and parties. Some said they had the opportunity to go out with their families on a regular basis. There are attractive gardens at the front and side of the house that are accessed in the good weather. The manager has encouraged staff to develop the daily records of care so that they reflect the activities which people are involved with over the course of each day. The activities planned for the week are displayed in the Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 15 hallway and a book is used to record what activities took place. These records were looked at and they contained evidence that staff do make these records in the care documentation also. The home arranges for newspapers and magazines to be delivered daily so that people are able to keep up to date with the news if they choose to. People spoken to said their visitors were able to call at any time. There was a public telephone in the foyer for people to use when they wished. Some people had their own mobile phones in their rooms. The lunchtime meal was observed. I was able to join people eating their meal. The menu was displayed on the board in the dining area for people to view. There was a choice of two hot dishes and other alternative cold choices. The meal was very tasty and everyone said that they enjoyed it. People needing assistance were provided with this in a dignified manner. One lady refused to have her meal. Staff kept this meal warm for her and returned an hour later to ensure that it was still offered. A staff member later assisted her with the meal. The home has recently employed a new chef who has made an instant impact on the home. He is well known by all the residents. One person said, The meals are excellent. I have the meals specially prepared for me and I get a variety of tastes.” He was aware of the likes and dislikes of the people living in the home. He also showed a good awareness of those people who were having special diets such as those who were diabetic. People said special meals are prepared for different occasions. A recent staff meeting identified that they would like sausage and mash. This was duly provided. One person said they told the chef they fancied chilli for tea. This was provided. A relative spoken to said the meals provided in the home had definitely improved since the new chef started. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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): 16 and 18. People who use the service experience good quality outcomes in this area. People living in the home feel well protected. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The home does have a complaints procedure and policy in place. This policy is well displayed in the entrance of the home and is also contained within the Statement of Purpose and Service user Guide. People spoken to said that they knew what to do if they did have a complaint. A complaints register is kept and there were three complaints investigated since the last inspection. These were investigated correctly following the internal procedure. A safeguarding adults policy and procedure is in place. All staff have now received training in this area. All members of staff spoken to during the Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 17 inspection had a good understanding and awareness of this issue. There have been no safeguarding referrals made by the home since the last inspection The people living in the home said that they felt very safe and comfortable in the home and that staff were very respectful. They said they felt comfortable raising any complaints or concerns with the manager and staff. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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): 19 and 26 People who use the service experience good quality outcomes in this area. People in the home are happy with the environment and the way the home is laid out. The standard of cleanliness was good. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The manager acknowledged that there were issues with the amount of space that was available to people in the lounge and dining area. However, people spoken to were quite happy with what was available. Some comments made were, “The space is fine. It suits my needs.” “ I don’t need much space. I’m Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 19 quite happy with the way the home is set out.” “ The layout of the home is good. There are always staff around.” The manager has been able to review the use of space and storage in the home to good effect, as the environment did not appear as cluttered as it did at the previous inspection. People spoken to were happy with the cleanliness of the environment. They said it was clean and tidy and it was nicely decorated. There is a maintenance man who updates the environment at regular intervals. The lounge has undergone recent decoration and is awaiting new blinds to be installed. The manager has access to monies that are used specifically for the upkeep of the environment. This home provides care for nursing residents who are physically very dependent. There is level access into the home via a ramp to the main door. There is nearby parking for visitors. The garden is easily accessible. There is a passenger lift. The bathrooms and WCs are fitted with hoists, handgrips and high seats. There are a number of different types of mobile hoists to use if necessary. A wheelchair friendly shower is available on the ground floor. All these aids help to meet the diverse needs of physically dependent people. A housekeeper spoken to during the inspection gave a brief overview of her daily duties. She was confident that there were enough housekeeping staff employed to ensure the cleanliness of the home was maintained to a good standard. Some concerns were raised with the storage of cleaning materials. The cloths that were used for cleaning toilets and bathrooms were being washed out and re used. This poses a potential cross infection risk in the home and should stop. The manager was informed at the time and assurances were given to change this practice with immediate effect. There was an identified infection control issue within the home during the inspection. Staff were dealing with the situation using a barrier nursing method. This helps minimise the risk of infection to other people in the home. The manager provided evidence that showed there were close links with the community infection control team. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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): 27,28,29 and 30. People who use the service experience good quality outcomes in this area. People receive care from a well-trained and supervised staff group. All new carers are properly checked before they are employed by the home. This minimises the risk of harm to those people living in the home. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: I spoke to staff in the home about their specific roles. They all said that there has been an improvement in many staffing areas since the last inspection. They said staff morale is much better. They have altered the way they work which they think has had a positive outcome for the people who live there. An example of this was reviewing how they took their breaks. They said there is now a larger group of staff on duty to assist all those people who need help with their meals. This was observed over the course of the day and seemed to work well. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 21 The two most recent staff files showed evidence that there is a good induction programme and a period of secondment provided before staff are able to work independently. The recruitment documentation of the two most recent care staff employed by the home was looked at. The files contained all the required information needed prior to a carer commencing work with vulnerable people. There is also a clear recruitment policy and procedure to assist the process. I saw evidence to show both mandatory training and general training has improved. Chatting to staff and the people who live in the home reflected this. People said they were confident in the staff group. The staff showed good awareness of the care needs of the people who live in the home. The staff appeared to work very well as a team. The staff spoke highly about their working environment. They said, “ I actually look forward to coming to work.” “The best thing I have done was to come and work here.” In total 74 of my care assistants have either achieved their NVQ 2 or 3. The manager has implemented a reward and recognition scheme ‘Care Heroes’ where staff that have gone the extra mile are nominated every month. The winner is celebrated at the monthly team meeting and wins a prize and certificate. The recruitment documentation of the two most recent care staff employed by the home was looked at. The files contained all the required information needed prior to a carer commencing work with vulnerable people. There is also a clear recruitment policy and procedure to assist the process. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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): 31,33,35 and 38 People who use the service experience good quality outcomes in this area. The management systems and processes used by the manager help to ensure that the home is managed in the best interest of the people who live there. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 23 The manager has been in post for just over a year. Evidence was seen to show that she has worked hard to improve the management systems and processes so that they have a direct improvement on the lives of the people living there. All people spoken to on the day of the inspection were aware of who the manager was. They gave positive responses about the improvements she has carried out during the last year. They said, “ She is very approachable. She listens to what you have to say and actually does something about it if it is beneficial to the home.” “ We can approach her at any time with any concerns we might have. We know everything will be treated with the strictest confidence.” The Annual Quality Assurance Assessment document provided by the manager stated that an internal quality assurance system to check performance in areas such as medicine administration and care planning had been implemented. Evidence was found during the inspection to show this work had been completed and also showed that practice had changed as a result of issues identified. For example, the care planning audit showed carers were not having enough input into recording the care they provide people over the course of the day. A new system was implemented and all carers are now responsible for completing their own documentation so that the care they provide is accurately recorded. This is good practice. All people living in the home and their relatives are now surveyed annually and an informative report has been developed and tells the reader what responses to the survey were. It also highlights what improvements are planned as a result of the survey information received. This document is made available with all other information at the entrance of the home. Quality checks have also been established for monitoring the performance and sickness of the staff. The manager said that this has helped her with ensuring the home is staffed at the levels that she would expect. People spoken to said they felt the staffing levels of the home were right for the level of care that was provided. The manager has now introduced regular meetings for all members of staff. There is a full team meeting and also separate meetings for the qualified and unqualified staff. Staff spoken to said these meetings did take place and they were very beneficial. They said they felt they had a voice and that it was being listened to. The manager has also introduced a box for points to be raised at the meetings. This was to help staff that don’t like speaking at open meetings. Staff said this was helpful. Regular resident and relative meetings are now implemented. The manager has set these out so that they are now in smaller focus groups. Tea and cakes are served to help people be more relaxed. A resident meeting had been planned for the day of the inspection. This was observed and was seen as very informal. The manager attempted to make sure everyone had Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 24 a say. People with communication difficulties were provided with plenty of time to have a say. This is good practice. The manager said that they only look after the personal monies of two people. A policy and procedure for dealing with resident monies is in the policy folder. Evidence was seen to show health and safety of the home is monitored regularly. Fire training and drills regularly take place. The environment of the home is also assessed regularly. The accident book is regularly audited and this was evidenced on the day. The manager uses the information to review care input to the resident group. The information was recently used in the review of a person’s care and it helped to secure the funding for a one to one care package from the local commissioners. This is good practice. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x 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 4 x 3 x x 3 Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 26 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 OP26 Good Practice Recommendations It is recommended that some of the cleaning practices are reviewed to ensure they do not pose a potential infection risk to people living in the home. Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Radcliffe Gardens Nursing Home DS0000067049.V371814.R02.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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