Care Home: The Mains Nursing Home

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What the care home does well The home has a system in place for monitoring accidents in the home called "accidents analysis statement". This process is used to review all accidents and see if there is a pattern and corrective measures are put in place where necessary. The manager has introduced good care plans, which clearly identifies individual`s need and ways of meeting those needs are clearly set out. This new system is gradually being introduced to include every resident. There are good arrangements with the local library for delivery of library books to the residents. These include "talking books" for those who need it. The home also has good collection of novels and magazines in the lounge for residents to use. There is also good collection of video tapes for the residents to entertain themselves with. The risk assessment that is carried out when taking residents out on a trip is good. The assessment identifies possible medical emergencies that could possibly arise and plans are made to deal them. This includes making that the first aid box is available and also identifying the nearest hospital in the area. The residents and families made positive comments about the home and the care they receive. The comments include: "I am extremely happy here". " I like to have all my meals in my room and this is respected by the staff". "They are extremely kind and caring". "They are the best and respect my privacy and what I say to them". "I am very pleased with the care I receive here. No problems at all". Relatives also made positive comments about the home and the way in which the home is run. What has improved since the last inspection? Since the last inspection, new residents` assessment and care plans have been introduced and this is being extended to all residents over the coming weeks. The medication system has been reviewed and the staff now maintain the correct recording system. All staff are checked against the POVA list and Nurses and Midwifery Council register. All bedroom windows have window restrictors to ensure the safety of the resident and the security of the home. What the care home could do better: Service user guide should be update to reflect the current changes in the home, including the details of the registered manager. The nurse observation charts should be re-designed to make sure the sections relating to particular observation are included. The current form has no section for "positional changes", and the "vomit" section is being used for this. A number of residents tend to use their wheelchairs as chairs throughout the day. This must be reviewed to make sure that residents don`t suffer any illeffect from the continued us of wheelchairs and normal seats/chairs. Information about one resident`s care must be appropriately kept to safeguard her dignity and privacy. The "service request" form, which lists her care needswas displayed on the side of her wardrobe and was accessible to anyone passing on that corridor. It was noticed that during lunch that the residents` cup of tea arrived in a large teapot which had been already milked. This is an unacceptable institutional practice and must cease. The lighting on the dining should be reviewed to make sure that the lighting is sufficiently bright enough for the residents, and in particular those with poor vision. The provider should consider increasing the extra management hours available to her to allow her to concentrate on some of the management tasks that is currently trying to address. The manager should ensure that suggestions made anonymously through the "suggestion box" are addressed, and not an explanation should be provided so that the people who make the suggestion would know that their views are taken seriously by the manager or the provider. CARE HOMES FOR OLDER PEOPLE The Mains Nursing Home Drovers Lane Redmarshall Stockton-on-Tees TS21 1ER Lead Inspector Sam Doku Key Unannounced Inspection 26 & 27 March 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 The Mains Nursing Home DS0000000213.V360604.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. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mains Nursing Home Address Drovers Lane Redmarshall Stockton-on-Tees TS21 1ER 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) 01740 630017 01740 631284 Mr Paul Glen Dowell Mrs Teresa May Dowell Mrs Claire Davies Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places: 31 The maximum number of service users who can be accommodated is: 31 30th January 2007 2. Date of last inspection Brief Description of the Service: The Mains is a thirty-one bedded care home registered to care for residents requiring nursing or personal care. The home is located in the small village of Redmarshall. The accommodation consists of single bedrooms, 17 of which have en-suite facilities, and four double bedrooms also with en-suite facilities. There is a stair lift for those residents who have need of it. There are facilities available for the residents to see family, friends and visiting professionals in private. The current fees range from £353 per week for residential care to £353 Nursing Banding for residents requiring nursing care. The Mains Nursing Home DS0000000213.V360604.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 inspection was unannounced and started on 26 March 2008 and completed on a second visit on the 27 March 2008. Before the visit the inspector looked at: Information we have received since the last key inspection visit in January 2007; How the home dealt with any complaints & concerns since the last visit; • Any changes to how the home is run; • The provider’s view of how well they care for people, as highlighted in the details provided in the Annual Quality Assurance Assessment (AQUAA); • The views of the residents who use the service and their relatives. During the visits the inspector: • talked to the residents, manager, nursing and care staff; • looked at information about the residents and how well their needs are met; • looked at other records which must be kept; • checked that staff had the knowledge, skills & training to meet the needs of the residents; • looked around the building to make sure it was safe & secure; • checked what improvements had been made since the last visit; • the inspector told the provider what he found. All of these activities contributed to the inspection findings. What the service does well: The home has a system in place for monitoring accidents in the home called “accidents analysis statement”. This process is used to review all accidents and see if there is a pattern and corrective measures are put in place where necessary. The manager has introduced good care plans, which clearly identifies individual’s need and ways of meeting those needs are clearly set out. This new system is gradually being introduced to include every resident. There are good arrangements with the local library for delivery of library books to the residents. These include “talking books” for those who need it. The The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 6 home also has good collection of novels and magazines in the lounge for residents to use. There is also good collection of video tapes for the residents to entertain themselves with. The risk assessment that is carried out when taking residents out on a trip is good. The assessment identifies possible medical emergencies that could possibly arise and plans are made to deal them. This includes making that the first aid box is available and also identifying the nearest hospital in the area. The residents and families made positive comments about the home and the care they receive. The comments include: “I am extremely happy here”. “ I like to have all my meals in my room and this is respected by the staff”. “They are extremely kind and caring”. “They are the best and respect my privacy and what I say to them”. “I am very pleased with the care I receive here. No problems at all”. Relatives also made positive comments about the home and the way in which the home is run. What has improved since the last inspection? What they could do better: Service user guide should be update to reflect the current changes in the home, including the details of the registered manager. The nurse observation charts should be re-designed to make sure the sections relating to particular observation are included. The current form has no section for “positional changes”, and the “vomit” section is being used for this. A number of residents tend to use their wheelchairs as chairs throughout the day. This must be reviewed to make sure that residents don’t suffer any illeffect from the continued us of wheelchairs and normal seats/chairs. Information about one resident’s care must be appropriately kept to safeguard her dignity and privacy. The “service request” form, which lists her care needs The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 7 was displayed on the side of her wardrobe and was accessible to anyone passing on that corridor. It was noticed that during lunch that the residents’ cup of tea arrived in a large teapot which had been already milked. This is an unacceptable institutional practice and must cease. The lighting on the dining should be reviewed to make sure that the lighting is sufficiently bright enough for the residents, and in particular those with poor vision. The provider should consider increasing the extra management hours available to her to allow her to concentrate on some of the management tasks that is currently trying to address. The manager should ensure that suggestions made anonymously through the “suggestion box” are addressed, and not an explanation should be provided so that the people who make the suggestion would know that their views are taken seriously by the manager or the provider. 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. The Mains Nursing Home DS0000000213.V360604.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 The Mains Nursing Home DS0000000213.V360604.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, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to make an informed choice about the home. The home carries out care needs assessment and also obtains full assessment from the social worker or the nurse assessor before admissions are arranged. This ensures that the care needs are clearly identified and care plans are put in place to meet the needs of the individual. The home supports and encourages pre-admission visits to the home by prospective residents and or their relatives. This provides the opportunity for them to assess the home for themselves before making their decision about coming to live there. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 10 EVIDENCE: There is good information available to assist prospective residents to make decisions about the home. This is in the form of a service user guide called “This is your home”. However, the guide should be reviewed and amended to include the current managers details and also to update prospective residents on the current state of the home. The home’s policy is that a full assessment is obtained from a social worker or the nurse assessor before admissions are arranged. The home also carries out their assessment of the individual in their own setting to make sure that they can meet the prospective resident’s needs. The files show evidence of the home adhering to their policy. The files contain social work assessments and the home’s own assessments. The residents and relatives commented positively on the admissions process. They said they found the assessment process and visits to the home before admission reassuring. This gave them the opportunity to ask questions about residential care in general and have explanations given to them by the social work or the nurse who was visiting them to carry out the assessment. Relatives and some residents confirmed that they had the opportunity to visit the home when they considered looking for a care home for their loved ones. A lady who was recently admitted described the assurance she received by first coming to visit the home and to meet with the staff and some of the residents. The manager and staff stated that it is the policy of the home to ask prospective residents and their relatives to visit the home and assess the place for themselves before making up their minds. The Mains Nursing Home DS0000000213.V360604.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans set out the health and personal care needs of the residents, and provides details of how those needs are to be met, thus promoting the health and welfare. There are suitable arrangements in place for the drug administration system. This promotes the health of the residents. Residents are treated with respect and their privacy is maintained. However, the display of personal care needs publicly compromises the dignity and privacy of the person concerned. EVIDENCE: All service users have care plans, which set out their health and personal care needs and action plan for meeting those needs. The manager has recently introduced new care plans and this is being extended to all the residents over The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 12 the next few weeks. These have not been in place long enough for a proper assessment to be made about how effective they are. However, the one’s that were viewed were very promising and effective in meeting peoples needs. There are suitable arrangements in place for meeting the healthcare needs of the residents. Record of contacts with healthcare professionals, including GPs, chiropody service, dentist, optician and other healthcare services are maintained. The daily report records contain details of contact with medical practitioners and other professionals. There are suitable arrangements in place for the storage and administration of medicines in the home. The drugs administration system was examined and there were no discrepancies. Copies of prescriptions are maintained in the home to ensure medicines can easily be traced. The residents confirmed the view that the staff treat them with respect and dignity. Staff were noted to treat service users with respect and dignity. Staff were observed to knock on residents door before making entry thus promoting their privacy and dignity. Assistance with personal and intimate care was provided in a discreet and dignified manner. However, the display of one residents personal care need in what could potentially be a public place compromises her dignity and privacy. The Mains Nursing Home DS0000000213.V360604.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. The residents are supported to maintain contact with their families, friends and the local community. Such support promotes close relationship with relatives and the community in which they live. The residents generally enjoy good social and recreational activities, thus maintaining their social and cultural lifestyle. The residents receive nutritious diet, which contributes to their health and wellbeing. However, the practice of tea in a tea-pot that is already milked does not offer choice for the residents and compromises their lifestyle experiences. EVIDENCE: The residents’ religious and recreational needs are generally met. There are notices in home of the activities that have been planned. Some of the residents spoke of the Easter activities and how they enjoyed those activities. Residents said that social activities are regularly organised for them and they The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 14 described some of these events which they enjoyed taking part in. The residents stated that they are free to join in social activities if they wish and that they are not made to join in activities if they do not want to. Relatives said hey are able to visit the home anytime they want and that there are no restrictions on the visiting hours, which make it easier for them to visit more frequently to suit their domestic circumstances. The residents were very complimentary of the food. They confirmed that they are provided with good choice and that there is always plenty of food for them to eat. The inspector had lunch with the residents and noticed that some of the practices during meal times do not promote the dignity and lifestyle of the residents. It was observed that the residents were offered their tea from a large communal teapot, which contained already milked tea. This is an institutional practice. Suitable arrangement must be made to provide residents with the opportunity to help themselves to cups of tea to promote their independence and choice. It was also observed that seven residents were using their wheelchairs at the dining table. A number of these residents sat in their wheelchairs most of the day. This practice must be reviewed to make sure that people don’t suffer any ill-effect from the prolong use of wheelchairs as ordinary seats or chairs. The Mains Nursing Home DS0000000213.V360604.R02.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, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure and are protected from abuse. EVIDENCE: The Mains has a comprehensive complaints policy and this is evident in the home and in some residents’ rooms. There is also a copy in the service user guide. Residents were aware of how to make a complaint and who to speak to. Staff showed good understanding of the complaints procedure too. Staff training includes “safeguarding adults awareness” training. The record of residents’ personal allowances were examined. The home has good systems in place for managing the residents’ monies. Record of purchases made on behalf of residents are maintained and receipts provided where necessary. There is regular auditing of the balances to make sure that any discrepancies are detected in time and rectified. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24 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 offers an accommodation and an environment that is safe, clean and well-maintained, and meets the individual needs of the residents. This promotes the general welfare, dignity and comfort for the service users. EVIDENCE: The home provides good standard of accommodation. This meets the needs of the service users. Where there are only shared rooms available, this is discussed with the people concerned before admission is arranged. Very often the double rooms are treated as single to accommodate individual preferences. Bedrooms are individually decorated and reflect individual taste. The residents are encouraged to furnish their rooms with personal items, making it pleasant and familiar environment for the occupants. Access into and within the home is generally good. A stair lift is used to access the first floor of the house. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 17 Residents who use this commented that they have no problem with the use of the stair lift as staff are always available to offer assistance if necessary. Window restrictors have been fixed to all windows and all radiators have suitable coverings, which ensure security and safety for the service users. However, the residents cannot regulate the heating in their rooms as this is controlled from a central point of the home. The radiator covering also make it difficult for the residents to regulate their room temperature to suit them. Checks of hot water at randomly selected bathrooms confirmed that hot water did not exceed 43°c. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene. The home was noted to be clean and free from offensive odour. The domestic staff described the measures they have in place to ensure that the home is kept clean and tidy. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. The laundry room was well organised and all appropriate health and safety notices were on display. There is sufficient laundry duty hours to meet the needs of the residents. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Resident’s needs are met by the numbers and skill mix of staff and training provided. However, the manager’s hours should be reviewed to make sure she has sufficient time available to her to undertake all of her management tasks. The company adheres to good recruitment practices, which safeguards the welfare of the residents. EVIDENCE: Past rotas show that the home employs sufficient number of staff to meet the needs of the residents. The residents and visitors commented that there are always sufficient staff on duty. Care staff also stated that they feel that there are sufficient staff on duty at all times. There are also sufficient domestic and catering staff to meet the needs of the service users and the home. The staff have had appropriate training to equip them for their roles. The manager confirmed that the training provided include moving and handling, first aid, protection of vulnerable adults, fire safety, food hygiene and health and safety training. However, in discussions with the manager, it was apparent that staff need some training in the Mental Capacity Act 2005 to The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 19 make sure that those residents who have memory problems are protected and their rights acknowledged and respected. Staff files contained evidence of good recruitment procedures being followed. Job allocation forms are completed and appropriate references are obtained. All staff have had ID checks and enhance CRB done. The manager confirmed that the majority of the care staff have NVQ level 2 or above. The nursing staff continue to update their training and receive direct supervision form the manager. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a qualified and experienced nurse, and runs the home for the benefit of the residents. The home has procedures in place to provide supervision arrangements, but the manager should ensure the staff receive the appropriate levels of supervision. The safety and welfare of residents are protected by the regular servicing arrangements that are in place. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager is a qualified nurse and has NVQ Level 4 Registered Managers qualification. Her position is not complete supernumerary but she has allocated hours given to her by the provider to enable her to undertake purely management tasks. This arrangement should be reviewed to allow her more time to undertake supervision tasks and to introduce the new care plans that she has put in place. There is a quality assurance system in place for seeking the views of the residents and visitors to the home. However, detailed analysis of the information received indicates that the home has not always taken into consideration the suggestions or views expressed by people. For example, the there was a message from the suggestion box for a clock to be provided in the reception area where the singing-in book is placed so visitors who have not got watches could see the time and enter it in the book. This was not auctioned. In another example, a resident, through the residents’ questionnaire, said she would prefer a Lenin sheet to nylon one. Again no action was taken to meet her request. Examination of the personal allowance records and receipts of transaction show that there is a good system in place and that the residents’ monies are safe and properly accounted for. There are suitable arrangements for staff to receive one-to-one supervision from the manager. However, this is not happening at the rate to meet the national minimum standards. The company’s Health and Safety policies remain in place. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). There is evidence that staff adhere to the policies as set by the company. Servicing records confirm that all portable appliances have been tested. A record is maintained of regular water temperature tests in the home. Regular servicing of fire equipment, gas and electrical appliances have been carried out by the contracted companies. All the servicing records that were examined were up to date. These included servicing of stair lift, hoists, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 22 Records examined indicate that fire precautions relating to weekly fire alarm testing and record of inspection takes place. There are records in the home indicating fire drills and fire instructions with staff. The Mains Nursing Home DS0000000213.V360604.R02.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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 2 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 2 X 3 The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)(c) Requirement Timescale for action 30/05/08 2 OP12 16(2)(i) 3 OP19 23(2)(a) The use of wheelchairs as permanent sitting arrangement should be reviewed and where appropriate the advice of an OT should be sought in each case and record of the advice given should be maintained. The practice of providing the 30/04/08 residents with already milked tea from a communal teapot must cease. The lighting in the dining is very 30/06/08 low. The advice of an electrician must be sought to make sure the lux level for the area is adequate for the people who live in the home. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP1 OP8 OP31 OP33 Good Practice Recommendations The service users guide should be reviewed to reflect the current details of the manager and updated information about the home. The nurse observation charts should be re-designed to make sure the sections relating to particular observation are included. The supernumerary hours for the manager should be reviewed to make sure she has sufficient management hours to undertake her duties. Issues arising from the residents survey and also from the “suggestion box” should be addressed, and where possible an indication as to why the issue could not be addressed. The Mains Nursing Home DS0000000213.V360604.R02.S.doc Version 5.2 Page 26 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 The Mains Nursing Home DS0000000213.V360604.R02.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. 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