Care Home: The Shrubbery Nursing Home

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What the care home does well The Home is actively, and very effectively, led by a Manager who is constantly seeking to improve the quality of the environment for the Residents, and of the services they receive. Care services are provided in a comfortable, homely environment, which is decorated with the particular needs, and preferences, of the care group in mind. Of particular note is progress being made in addressing the specific social care needs of individual residents. What has improved since the last inspection? At the time of the previous inspection, whilst the overall the home was rated `good` it was reported that activities were limited, and the appearance of some areas were spoilt due to worn carpets, chairs and furniture. The home now has a full time activities coordinator who is actively, and effectively, leading development of the social/leisure component of care provision. In respect of the appearance of the home there is firm indication of action to maintain and improve residents` environment through an ongoing refurbishment programme. This has included the purchase of specialist equipment to ensure the home can provide care needs to a client group which has shown a marked increase in levels of dependency over recent years. The home has also completed a full review and reprinting of information documentation. The kitchen has also benefited from a recent refurbishment programme, which has included installation of a commercial size cooker, a dishwasher, new refridgerator and freezer and replacement floor coverings. All other equipment has been serviced and a deep clean carried out. What the care home could do better: Since January 2008, following appointment of the current manager, many changes have been made, with more planned. As stated above, these changes have already resulted in improved care provision, however, the main task in this section, i.e. `What they could do better` will be to build on the processes, which have already commenced, e.g. development of the `quality assurance systems (particularly the use of questionnaires), enabling staff to improve care planning and report writing skills, and continuation of the planned refurbishment of the home. CARE HOMES FOR OLDER PEOPLE Shrubbery Nursing Home, The Birmingham Road Kidderminster Worcestershire DY10 2JZ Lead Inspector Keith Salmon Key Unannounced Inspection 30th June 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 Shrubbery Nursing Home, The DS0000004143.V366734.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. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shrubbery Nursing Home, The Address Birmingham Road Kidderminster Worcestershire DY10 2JZ 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) 01562 822787 01562 68122 Minster Care Homes Limited Vacant Care Home 33 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (33), of places Physical disability (33) Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2007 Brief Description of the Service: The Shrubbery Nursing Home is a Grade II Listed building situated approximately half a mile from Kidderminster town centre, providing nursing and personal care for up-to thirty three elderly persons, a small number of whom may have dementia related care needs. Accommodation is provided over two floors and comprises mainly single rooms - some with en-suite toilet facilities, and four shared rooms. There is a large lounge, separate dining room and a large conservatory leading to a generous patio area. Access to the upper floor is via a passenger lift, and handrails are fitted throughout to assist those with mobility difficulties. There is a large garden, with car parking facilities, to the front of the property and a secure rear garden, which residents can access via the conservatory. Whilst the fees charged by the home are not published in the Service User Guide they are discussed with prospective residents, and/or their relatives at pre-admission assessment, with the actual amount being dependant on the care the home will be required to provide in order to meet assessed care needs. Chiropody, hairdressing and newspapers are additional to the fee. Persons may wish to obtain more specific information from the service. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This Unannounced ‘Key’ Inspection of the service commenced at 9.30am, concluded at 4.00 pm, and was conducted by Mr Keith Salmon, representing the Commission for Social Care Inspection (CSCI). Present, on behalf of the Home, were Margaret Green (Matron), and Sandra Bell (Deputy Matron). Unannounced ‘Key’ Inspections address all essential aspects of operating a care home and seek to establish evidence, which shows continued safety and positive outcomes for residents. Relevant information is gathered through observations made during a tour of the Home, a review of care related documentation, staff files and duty rotas, plus a range of other documents/records reflecting the general operation of the home. The report also utilises information submitted by the home to CSCI, prior to the inspection, through the Annual Quality Assurance Assessment (AQAA). The content of this, which includes information relating to the Home’s policies, procedures, achievements, and plans for improvement, provide a useful framework for us to evaluate quality of service and progress made. Individual discussions were held with four residents, three visitors, the manager, and several other members of staff. What the service does well: What has improved since the last inspection? Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 6 At the time of the previous inspection, whilst the overall the home was rated ‘good’ it was reported that activities were limited, and the appearance of some areas were spoilt due to worn carpets, chairs and furniture. The home now has a full time activities coordinator who is actively, and effectively, leading development of the social/leisure component of care provision. In respect of the appearance of the home there is firm indication of action to maintain and improve residents’ environment through an ongoing refurbishment programme. This has included the purchase of specialist equipment to ensure the home can provide care needs to a client group which has shown a marked increase in levels of dependency over recent years. The home has also completed a full review and reprinting of information documentation. The kitchen has also benefited from a recent refurbishment programme, which has included installation of a commercial size cooker, a dishwasher, new refridgerator and freezer and replacement floor coverings. All other equipment has been serviced and a deep clean carried out. 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. Shrubbery Nursing Home, The DS0000004143.V366734.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 Shrubbery Nursing Home, The DS0000004143.V366734.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): 1 & 3 (6 - not applicable). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home may readily access information relating to the home, which is easy to understand, accurate, and up to date. Prospective residents can be confident the home will be able to provide care which will meet their needs as assessed at the time of admission. EVIDENCE: People wishing to move into the home are provided with information to assist them in making an informed decision. Evidence supporting this view was observed in the new resident’s ‘Welcome Pack’, which incorporates a service users’ guide, which has recently been reviewed and reprinted. We were shown a copy of this document, which now provides a comprehensive range of information, including reference to the home’s aims and objectives, accommodation provided, ‘Who’s Who at the Shrubbery’, meals provision, access to medical care, personal items which may be brought into the home, spiritual care, activities, and fees information. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 9 Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied, and subsequent findings are utilised to ensure appropriate placement and care provision. A detailed review of three residents’ records/care plans provided evidence the manager, or the deputy manager, complete a pre-admission assessment of each resident’s care needs, in order to judge whether the home can safely meet these assessed needs. If these needs can be met, and the person is admitted to the home, there was clear evidence this information is utilised as the basis for development of the resident’s written care plan. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Residents can be confident their assessed care needs will be clearly stated in a written care plan, are reviewed regularly, and their needs effectively met through care delivered considerately, effectively and with residents’ privacy and dignity being respected. Residents can be confident the process of administering medicines will be completed in a safe and considerate manner. EVIDENCE: A detailed review of records/care plans relating to three residents demonstrated detailed content, including risk assessment, relevant to assisting in ensuring provision of good quality care. Entries were clearly written with up to date entries relating to personal hygiene, mobility, nutrition, continence and pressure sores. Evidence was also observed confirming regular care needs review is undertaken, by the manager, on at least a monthly basis, and of the signatures of the resident (or relative Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 11 where appropriate) confirming their involvement in the development of the care plan. Specialist equipment, necessary to meet assessed care needs, was observed in use, e.g. specialist nursing beds (‘profiling’ beds), variable air pressure mattresses, cot-sides, and mobile hoists. Throughout the tour of the home, and during our movement within the home (e.g. visiting residents who chose to remain in their bedrooms for private discussion), we noted staff were considerate and friendly, though not familiar, towards residents and visitors alike. Practical examples of this included staff knocking on doors before entering bedrooms, and ensuring privacy by closing bathroom doors. Residents and visitors commented to us how the manager and staff were thoughtful and kind towards them. Comments included -…“The staff always have time to look after us properly.” … “My (relative) receives the very best of care.” We undertook a full review of the home’s practices in respect of the storage, reception, disposal, and record keeping, relating to medicines’ administration. We found them to be fully in accordance with accepted ‘good practice.’ Examples of evidence supporting this view included; up to date records of medicine receipt and disposal, medicines administration records (MAR sheets) with up to date entries showing no gaps, and full records of medicines’ refrigerator temperatures. We also observed evidence of monthly audit of the medication system by the manager or deputy manager. . Shrubbery Nursing Home, The DS0000004143.V366734.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. Those residents, who are able, choose their life style, social activity and keep in contact with family and friends. Opportunities for contact with family/friends/community are established and encouraged. The Home provides a daily choice of attractive and nutritious meals based on residents’ preferences. EVIDENCE: The home has a staff member of who is designated ‘Activities Leader’, and whose main responsibilities are to plan and organise the activities programme, as well as conducting a major part of it. An activities record is maintained for each resident with regular entries – sometimes day to day. Activities recorded, and informed to us by residents have included crafts (e.g. celebration card making), watching DVDs as a group and individually, skittles, painting, exercise sessions, knitting, listening to the ‘talking newspaper’, hand massage, facials, make-up, and fingernail painting. One member of staff who has musical abilities plays piano and sings to the residents (most Friday Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 13 afternoons). During the tour of the home we observed the home has a welltended ’safe’ garden, to the rear and side of the property, which offers opportunity for all residents to sit outside and enjoy a wide range of flowers and shrubs. Residents also stated they enjoy visits from local choirs and musical entertainers, and sometimes visit the local public house (The Land Oak) for a ‘pub lunch’ – which they very much enjoyed. A church service (Church of England) is held at the home every month. We were told the home will make arrangements to assist residents, wishing to visit churches, of whatever faith. We were advised the home now has a small group of Polish residents who receive regular visits from friends who are also Polish, and arrangements are in hand to facilitate contact with the local Polish Club, which it is hoped may result in future attendance at the Club. During the tour we noted the home had made efforts to ensure, wherever possible, the bedrooms of the Polish residents are grouped in close proximity. One of the Polish residents told us … “I am very happy here and the home works hard to try and make sure our personal needs are met.” Another stated the efforts to help them realise the lifestyle they wished… “is very much appreciated.” In addition to this, the home is making a conscious attempt to recruit Polish speaking staff. Currently, meals are based on a four-week menu with a choice of two dishes at both the lunchtime meal and afternoon tea, and we observed evidence that drinks and small snacks are provided throughout the day. We were informed plans are in hand to review menus, part of which will be to move to a six-week cycle. As part of the development of meals provision residents are offered the opportunity to have wine with their Sunday lunch. All staff were observed interacting well with the residents during the inspection, and a pleasant, relaxed atmosphere was evident. Shrubbery Nursing Home, The DS0000004143.V366734.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. Residents and their relatives can be confident their views are listened to and acted upon, and that residents are safe and protected from abuse. EVIDENCE: Residents and relatives told us they were aware of the complaints procedure, including how to complain to the Commission for Social Care Inspection by way of information provided by the home, e.g. the ‘Welcome Pack’ and notices displayed in the home’s entrance hall, alongside copies of the complaints form. Records demonstrated complaints are investigated by the manager, discussed with the proprietors at their weekly meeting with staff, responded to within given timescales, and appropriate action taken. Review of the current accident book showed no occurrences, or trends, in the nature and type of reported accidents, which caused us concern. The home’s thorough approach to the prevention and management of incidents, such as falls, was evident through crosschecking with individual resident’s documentation. These showed residents recorded as having had falls, had all been risk assessed with regard to their mobility and potential for falling. The home operates an open door policy to allow service users/families to voice their concerns at any time. Residents and relatives confirmed to us they would have no hesitation in raising concerns they might have. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 15 Policies and Procedures on whistle blowing and advocacy information is available on display for all staff and service users, and all staff receive abuse training during their induction, including ‘adult protection’ and managing of challenging behaviour. In addition, all staff are given the ‘Worcestershire Booklet’ on abuse and reporting, and a booklet about the Mental Capacity Act. Review of the Accidents/Incidents record book presented a picture of reported accidents, which caused us no concern. We had discussions with four staff, all of whom were able to describe the action they should take if they were in receipt of a complaint, or observed abuse of a resident. Training records confirmed they had all received relevant ‘adult protection’ training. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment in which residents live is pleasant, safe, and clean, with satisfactory standards of hygiene, and the home provides equipment consistent with providing necessary care. EVIDENCE: The report arising from the previous inspection by the commission (June 2007) recommended: • That the home reviews carpets, furnishings and furniture and develop a replacement programme to further enhance the homes appearance. A tour of the home showed us that since the previous inspection the home has benefited from the commencement of an extensive refurbishment programme. All communal rooms have been upgraded with redecoration of walls and ceilings, replacement of curtains and some soft furnishings, plus provision of Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 17 circular tables in the dining room. The lounge has been recarpeted, and wood effect laminate layed in the hallway and the dining room. We talked with residents who had been at the home for a number of years and all agreed the environment had recently undergone noticeable improvement – a change which they much appreciated. Single room accomodation is provided to twenty five of the total of thirty three residents the home may accommodate. There are four shared rooms (double bedded), which are separated by curtains for privacy. Most bedrooms have en-suite toilet and washing facilities with the remainder having a wash basin, and commode provision. All rooms are furnished to a comfortable standard and when redecoration is undertaken this is carried out, where possible, in accordance with the resident’s preferences – some resident determined colour schemes were seen during the tour. All corridors, both upstairs and downstairs, are to be recarpeted with work commencing the day following this inspection. The home has a large garden with car parking to the front, a secure garden to the rear, which all residents, including those with mobility problems, can readily access via a conservatory. The conservatory, which has recently benefited from all new furnishings, provides a light and airy room and has blinds, and an air conditioning unit, to ensure an equable temperature during the summer months. The gardens are very well maintained with an interesting range of attractive plants. There is good provision of specialist equipment, consistent with meeting the assessed care needs of service users, and the demands of tasks carried out by care staff. During recent months the home has purchased eighteen specialist ‘profiling’ beds and mattresses, with a further ten on order. Records demonstrated maintenance and servicing of care related equipment is regularly undertaken and appropriately documented, e.g. passenger lift, hoists, wheelchairs and call bell system. A new telephone system has been installed so enable the nurse in charge to carry a telephone at all times. The kitchen has also benefited from a recent refurbishment programme, which has included installation of a commercial size cooker, a dishwasher, new refridgerator and freezer and replacement floor coverings. All other equipment has been serviced and a deep clean carried out. The house keeping department has been given new equipment to enable them to be more efficient in their work, a fact reflected in that we found the home to be clean, tidy, and odour free. All rooms are routinely given a thorough clean as part of the housekeeper’s maintenance programme, including carpet cleaning. Residents and relatives confirmed to us they were pleased with the cleanliness of the home and found their rooms to be comfortable. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Residents can be confident staff numbers on duty, and skill-mix, are sufficient to meet their assessed care needs, and that recruitment and employment practices are consistent with safeguarding them from abuse. The commitment of the Home in providing training for care staff is good, and in accordance with individual staff member’s learning needs. EVIDENCE: A review of recent duty rosters, and staff numbers, skill-mix and deployment at the time of the Inspection, demonstrated staffing to be sufficient to meet the assessed care needs of current residents. Furthermore, the Manager is usually supernumerary with good support from an experienced deputy, a full time activities coordinator, kitchen staff, domestic staff and the full-time maintenance man. A review of files relating to the three most recently employed staff demonstrated recruitment practices to be satisfactory, with all elements required by the Care Homes’ Regulations being completed, and evidence retained on file. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 19 We held discussions with four staff members, all of whom described the robust recruitment process they had experienced prior to appointment, and commencement of work at the home. Evidence was observed in staff files, demonstrating references had been obtained, and checks had been made by the Criminal Records Bureau (CRB), and PIN numbers for registered nurses checked with the Nursing and Midwifery Council before new staff commenced working at the home. All staff interviewed said they enjoyed working at the home, and were able to give a detailed account of their initial orientation/induction and subsequent training. A review of staff training records, by means of staff training matrices, and individual staff members training records, provided evidence of a training programme, which includes the ‘basics’ (e.g. lifting and handling, safe food handling, fire safety, infection prevention and control, health and safety, adult protection), as well as an opportunity to undertake National Vocational Qualifications (NVQ). Review of staff training records showed the proportion of staff who have attained NVQ Level 2, or above, to be at good levels, i.e. from a complement of twenty care staff, thirteen (65 ) have attained that standard. New staff have been employed in the kitchen, housekeeping and laundry to ensure they do not have to rely on care staff supporting these areas at the same time as caring for the residents. All new care staff have three days induction, have a mentor allocated to them during the first three months, and are supernumery during their first two weeks of employment. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from effective management provided by an experienced manager, who ensures the main focus of care provision is in meeting individual residents’ care needs, and enabling realisation of their aspirations, wherever possible. Residents and their relatives can be confident their views on the provision of service quality will be sought and, wherever possible, acted upon. Residents and their relatives can be confident transactions involving expenditure of residents’ personal monies are safeguarded. Residents, relatives, other visitors to the home and staff, can be confident their health, safety, and welfare are safeguarded. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 21 EVIDENCE: The matron, (Margaret Green) who commenced at the home at the beginning of January 2008, is in process of making application to the commission to become Registered manager. Ms. Green is an experienced person, who holds the Registered Managers’ Award Level 4, and has worked in the capacity of manager in nursing homes, and in care of the elderly, for many years. Regular support is provided by the joint proprietors who have very ‘hands on’ involvement in the running of the home, and by the Regional Director, Harriet Caffrey, who attended the home on the day of this inspection whilst coincidentally undertaking the monthly unannounced inspection required by the regulations. The manager is currently undertaking a review of quality assurance systems. A recent memorandum from the proprietors was seen, which requires the home to commence residents’ meetings as soon as possible. These would be attended, and facilitated, by one of the proprietors. We were shown the beginnings of this task in the form of a draft questionnaire aimed at all employees, which addresses such matters as their understanding of what is expected of them in meeting there responsibilities when working at the home, the environment and equipment available to enable them to work effectively, and the support offered by managers and staff. Expressions of appreciation by relatives regarding the care of their relative were seen (one arriving on the day of the inspection). These included comments such as… “We would like to say thank you to you all for taking care of our (relative), you made her very comfortable, and she was happy to be with you.” We also saw an example of the Residents’/Relatives’ Newsletter for Spring 2008, which introduced people to the new manager (known as Matron), provided an update on progress about refurbishment, together with news of future plans, and mention of the submission of the home’s Annual Quality Assurance assessment (AQQA) to the commission. Residents are encouraged to handle their own financial affairs and, where they do not wish to do so, or are unable to manage their financial affairs, they are assisted to manage their finances in their best interest and encouraged to obtain a ‘lasting power of attorney’. A review of systems relating to this provided evidence the Home’s arrangements for safeguarding personal monies were appropriate, thorough, and subject to regular audit. The home ensures all its staff have received induction training, followed by yearly appraisals. The Deputy Matron co-ordinates training and holds formal Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 22 qualifications to support this role e.g. English National Board teaching qualifications (998), and is an NVQ Assessor (A1). A review of staff personal files, related records and discussions with staff confirmed staff are subject to regular supervision. All systems such as fire alarms, emergency lighting, gas, and electricity are regularly maintained, checked as required, with certificates to evidence this. The home has infection control policies and procedures, and staff training files contained records of staff being provided with infection control training at induction. During the tour of the home we observed adequate provision of aprons, gloves, hand wash soap, alcohol gel and paper towels to help prevent the spread of infection. Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 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 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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. Refer to Standard Good Practice Recommendations Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Shrubbery Nursing Home, The DS0000004143.V366734.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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