Care Home: Shivam Nursing Home

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What the care home does well The home is being very well managed, and the Registered Manager has a clear, open and effective style of management. Comments from the CSCI comment cards received were overall very positive and many commended the home for the care provision. Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. Residents and their representatives are encouraged to visit the home prior to admission to ascertain if it meets their expectations. Staff care for residents in a gentle, courteous and professional manner, respecting their privacy and dignity. The wishes of residents and their representatives in relation to end of life care are discussed and recorded, thus respecting their wishes. There is a good activity provision in the home, to meet the needs of all residents. Information about advocacy services is available and the home. The home has an open visiting policy and visiting is encouraged. There is a good quality food provision in the home, with choices available. There are clear systems in place for the management of complaints and any adult protection issues. The environment is being well maintained with an ongoing redecoration programme, and where identified new furnishings are obtained to meet the needs of the residents. The home is appropriately staffed to meet the residents needs. There is a good training provision to include specialist needs, adult protection and health & safety, plus training in topics relevant to the diagnoses and needs of service users. Staff recruitment practices are robust. Health & safety is being well managed at the home, with comprehensive records being maintained. Overall the comments received via the CSCI comment cards were very positive. Examples of these are: `Fantastic level of care, healthy meals`. `The Manager and staff are available all the time`. `The people responsible to own the care home are very capable and are on top of every situation that may arise`. `We are always kept informed about any decisions regarding our relatives care and health`. `My family is very pleased with Shivam`. What has improved since the last inspection? All requirements from the last inspection had been addressed by the home. Review meetings were being held at least every 6 months. The crack on the ceiling in room 8 and scuffing on the wall in room 11 had been made good and redecorated. Over 50% of care staff had obtained their NVQ level 2 qualification. Minor deficiencies identified by the LFEPA had been addressed and the CSCI had been notified. What the care home could do better: Assessments for the risk of falls, nutrition and continence must be specific to meet the individual needs of the resident. Additional information regarding the necessity and appropriateness of the use of bedrail are required. Systems for quality assurance must be formalised with auditing processes in place. CARE HOMES FOR OLDER PEOPLE Shivam Nursing Home 12 Chaplin Road Wembley Middx HA0 4TX Lead Inspector Julie Schofield Key Unannounced Inspection 11:20 6 & 28th February 2008 th 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 Shivam Nursing Home DS0000022943.V358751.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. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shivam Nursing Home Address 12 Chaplin Road Wembley Middx HA0 4TX 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) 020 8903 6878 020 89036878 Chaplin Care Home Limited Khadija Naseer Khan Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability (0) of places Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 15 Adults over the age of 40 in need of nursing care Date of last inspection 8th March 2007 Brief Description of the Service: Shivam Nursing Home is a care home providing both personal and nursing care, and accommodation, for up to 15 people over the age of 40. The home is one of several care homes owned by the proprietors. Shivam Nursing Home accommodates Asian residents. All staff at the home speak either Hindi or Gujerati. The home is situated in a residential area of Wembley and is a few minutes walk from the shops and facilities on Ealing Road. It is within easy reach of public transport links and the nearest underground stations are Wembley Central and Alperton. Parking restrictions apply on the roads outside the home but there is a car park, which provides spaces for approximately 8 cars. The building consists of ground and first floors and has a passenger lift. Bedrooms are situated on both floors. Two bedrooms have ensuite facilities and 2 bedrooms are shared rooms. There are bathing and toilet facilities on both floors. The communal space is situated on the ground floor and there is a small garden to the rear of the property. The fees range from £500 to £800 per week, dependent on assessed need. Shivam Nursing Home DS0000022943.V358751.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. This was an unannounced inspection carried out as part of the regulatory process. A total of 10 hours was spent on the inspection process, and was carried out by one Inspector. The Inspector carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records and maintenance & servicing records were viewed. 7 residents, 4 staff and 3 visitors were spoken with as part of the inspection process. The preinspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives/visitors and health & social care professionals have also been used to inform this report. Following the inspection the Inspector received correspondence from the Registered Manager detailing the action that had been taken by the home in addressing the requirements of this inspection. Compliance with these requirements will be reviewed at the next key inspection of the home. What the service does well: The home is being very well managed, and the Registered Manager has a clear, open and effective style of management. Comments from the CSCI comment cards received were overall very positive and many commended the home for the care provision. Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. Residents and their representatives are encouraged to visit the home prior to admission to ascertain if it meets their expectations. Staff care for residents in a gentle, courteous and professional manner, respecting their privacy and dignity. The wishes of residents and their representatives in relation to end of life care are discussed and recorded, thus respecting their wishes. There is a good activity provision in the home, to meet the needs of all residents. Information about advocacy services is available and the home. The home has an open visiting policy and visiting is encouraged. There is a good quality food provision in the home, with choices available. There are clear systems in place for the management of complaints and any adult protection issues. The environment is being well maintained with an ongoing redecoration programme, and where identified new furnishings are obtained to meet the needs of the residents. The home is appropriately staffed to meet the residents needs. There is a good training provision to include specialist needs, adult protection and health & safety, plus training in topics relevant to the diagnoses and needs of service users. Staff recruitment practices are robust. Health & safety is being well managed at the home, with comprehensive records being maintained. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 6 Overall the comments received via the CSCI comment cards were very positive. Examples of these are: ‘Fantastic level of care, healthy meals’. ‘The Manager and staff are available all the time’. ‘The people responsible to own the care home are very capable and are on top of every situation that may arise’. ‘We are always kept informed about any decisions regarding our relatives care and health’. ‘My family is very pleased with Shivam’. What has improved since the last inspection? 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. Shivam Nursing Home DS0000022943.V358751.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 Shivam Nursing Home DS0000022943.V358751.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed and had been well completed. The home also obtains a copy of the needs led assessment undertaken by social services. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 9 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 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall service user plans were comprehensive and complete, thus providing staff with the information required to care effectively for each resident. Some shortfalls identified with nutritional, falls, continence and bedrail assessments should be easy to address. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents living at the home in a caring and professional manner, thus respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs fully discussed, recorded and met. EVIDENCE: Service user plans were sampled during the course of the inspection. The documentation had been clearly completed to identify residents needs and how these are to be met. The service user plans had been reviewed monthly and when there had been any relevant changes in a residents condition. There was evidence of input from the residents and their relatives. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 10 Risk assessments for falls, nutrition, and pressure sores were in place. The Inspector noted that the falls and nutritional assessments were incorporated in an overall risk assessment. The Inspector suggested that these assessments be more specific and individualised to the resident. Ways of addressing this were discussed with the Registered Manager. Residents are weighed monthly and more often if a problem is identified. Moving & handling assessments and documentation had been completed and provides a clear picture of each residents moving & handling needs. A book detailing the residents continence needs was being completed by the Registered Manager. The Inspector suggested that a full continence assessment be completed for each resident. Bedrail risk assessments were in place with consents being obtained. The actual reason and appropriateness of use of bedrails for each individual had not been clearly recorded. There was evidence of input from healthcare professionals to include GP, physiotherapist, speech and language therapist, podiatrist and optician. Healthcare professionals are encouraged to complete their own entries in the service user plan documentation. Daily records were clear and detailed the care being provided. Care staff records are also in place and care staff are encouraged to write about the care given to each resident as part of the multi-disciplinary records. At the time of the inspection there were no pressure sores or wounds being managed at the home. The medication records and management were sampled. All receipts, administration and disposals had been clearly recorded. A list of staff signatures and initials was in place. All liquid medications had been dated when opened. Fridge minimum and maximum temperatures were being recorded and were within safe range. At the time of the inspection no controlled drugs were in use. Medication audits were not being carried out formally. Stock checks and reviewing the MAR sheets were being undertaken informally. Lancing devices for professional use are being used for blood glucose monitoring. Stock control was checked for some residents and stock amounts tallied with the administration records. The Registered Manager stated that she was in the process of introducing a Monitored Dosage System for medication management. The need to ensure that policies and procedures to reflect this change were discussed. Staff were seen caring for residents in a gentle, caring and professional manner and excellent interaction between residents, relatives and staff was observed on both days of the inspection. The Inspector observed the staff using the preferred terms of address for each resident and in their own language. Bedrooms had been personalised and there was a very homely feel throughout. Residents can have their own telephones, either mobile or landline. Residents were well groomed and dressed to reflect individuality. The Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 11 home has a mandir (temple) in the small lounge and the Inspector was informed that daily prayers are said at the request of the residents. The Registered Manager informed the Inspector that several staff had undertaken end of life and palliative care training. Information regarding the wishes of residents and their families in respect of health deterioration and dying is being ascertained as the needs of the resident change. The Registered Manager said that some people find this a very difficult topic to discuss and the staff are sensitive to this. Shivam Nursing Home DS0000022943.V358751.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provision is good and varied, and each residents right to choose to join in is respected, thus meeting their individual needs and wishes. The home has a 24-hour open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: Activities were taking place in the home, and one carer is responsible for coordinating the activities. The activities provided at the home include exercises, yoga, arts and crafts and prayers. Dependent on the weather and individual wishes residents can also be accompanied to the local temple. There is a weekly activities programme, which is displayed. There are no equality and diversity issues at present in the home, and residents religious and cultural needs are being met. Residents are asked about their interests Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 13 and hobbies and if they would like to join in activities, and their choice is respected. Service user plans on social and cultural needs were available. The home has a 24-hour open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and refreshments are offered. Visitors commented about the homely atmosphere throughout, and one relative said that ‘it is like one big, happy family here’. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services is available in the home and this included information regarding Age Concern and the Asian Disability Alliance. The Inspector viewed the kitchen. This was clean and tidy and all the records were up to date. The home provides an Asian vegetarian diet. Residents are offered a choice of meals and documentation to evidence this was available. Menus are also available in a format, which can be read by the residents. Residents spoken with said that overall they do enjoy the food and that if there are specific requests these are met by the cook. Staff were available to assist residents with their meals as needed and have received training and are provided with guidelines to follow for any residents with eating difficulties, for example, swallowing problems. Drinks and snacks are available at all times. Shivam Nursing Home DS0000022943.V358751.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedure in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: The Registered Manager has an ‘open door’ policy for residents, visitors and staff, and responds to any concerns raised. Residents, representatives and staff spoken with said that the Registered Manager is approachable and deals promptly with any issues. The home has adult protection policies and procedures in place. Staff spoken with said that they had received POVA training and were clear to report any concerns. The completed AQAA indicated that the home had received no complaints or safeguarding Adults referrals. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 15 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 & 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 well maintained, and bedrooms are personalised, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: A tour of the home was carried out. Overall the home is being well maintained and there is evidence of ongoing redecoration and refurbishment, to include new carpets, vanity units and other furnishings. Several curtains in the residents bedrooms have been replaced. The home employs a part-time maintenance person. Individual bedrooms viewed were homely and several had been personalised with photographs and pictures. There is a rear garden, which can be accessed by the residents. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 16 The Inspector viewed the laundry facilities. The room was clean and the laundry was being well managed, to include personal clothing items. The washing machines have a sluice programme for infection control. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The home was clean throughout and overall smelled fresh. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 17 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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met. Systems for vetting and recruitment practices are in place and protect residents. There is a ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: There have been no changes to the staffing levels deployed during the waking day. In the morning there is one Registered Nurse and three care staff on duty. In the afternoon there is one Registered Nurse and two care staff on duty. At night there is one Registered Nurse and one carer on duty. There is a cook and domestic staff on duty during the day. Some staff comment cards stated that staffing should be increased. This was discussed with the Registered Manager who stated that she would review this. Two sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. The home has an induction programme that meets the Skills for Care common induction standards. The AQAA completed by the home indicated that over 50 of staff have completed or are in the process of completing their NVQ level 2. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 18 Some staff commented that more training opportunities should be made available. This was discussed with the Registered Manager at the time of the inspection. Several staff had indicated in the staff surveys that they had access to several training courses and that staff development was promoted in the home. The Registered Manager was clear that staff must be kept up to date with training to ensure they have the knowledge and skills to meet the resident’s needs. The training matrix viewed indicated that staff had received periodic training in topics relevant to the needs of the residents. The AQAA completed by the home indicated that staff have access to the company training officer and any training that is being undertaken in the sister homes. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 19 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 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is competent and skilled and has developed an atmosphere of openness and respect, thus making residents, visitors and staff feel valued. Systems for quality assurance are informal and need to be further developed to provide an ongoing process of review and feedback. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse, plus she has completed the City and Guilds Certificate in management. She is also has a teaching and assessing and care of the elderly qualifications. She has several years experience of working with older people. She has the skills and Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 20 experience to manage residents, visitors and staff effectively and with respect. Staff and visitors spoken with said that the Registered Manager is approachable and supportive and listens to their opinions, and any issues are promptly addressed. The Registered Manager stated that she is to commence the Registered Managers Award in April 2008. Comments received by the CSCI included ‘I want to say that the Manager, nurses and carers are very devoted and always treat me gently and with kindness and respect’. The home does not have in place a formal quality assurance and monitoring systems. Informal audits do take place but these are not recorded. The Responsible Individual stated that they do have a quality assurance system in their sister homes and that she would adapt this to meet the needs of Shivam Nursing Home. This will be reviewed at the next inspection. Regulation 26 unannounced visits on behalf of the Responsible Individual are carried out and copies of the report are available at the home. Annual customer satisfaction surveys are undertaken and any issues raised are addressed by the home. The home does not hold resident and relatives meetings and individual meetings are held with residents and their relatives. Staff meetings are carried out and minutes are published. The home does not hold money for any of the residents. A sample of servicing and maintenance records were viewed and those viewed were up to date. The home employs one part- time maintenance person. Fire drills were taking place for both day and night staff. The fire risk assessment had been reviewed in June 2007. Fire alarm tests were being undertaken weekly. The Inspector suggested that the home record, which fire point, is being tested. The training matrix evidenced that staff had received health & safety training to include moving & handling, fire awareness, food safety, first aid, and COSHH and infection control. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 21 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 2 9 3 10 3 11 3 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 2 X 3 X X 3 Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 13(4) & 13(7) Requirement Bedrail assessment documentation must clearly identify the need for and appropriateness of the use of bedrails for the individual. Thus the needs and wishes of the resident will be ascertained and met. Assessments to include continence, risk of falls and nutrition must be individualised in order that the residents needs are fully met. That the home further develop their quality assurance systems to provide a system for feedback and review. Timescale for action 24/03/08 2. OP8 15 & 17 24/03/08 3. OP33 24 05/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 23 No. 1. Refer to Standard OP38 Good Practice Recommendations That the home record the fire point tested at the weekly fire alarm test. Shivam Nursing Home DS0000022943.V358751.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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