Care Home: Willowdene Nursing Home

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What the care home does well The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Staff involve the person, their representatives and other professionals in the care planning which makes sure their needs can be met. Care plans are clear and up to date regarding people`s health and personal care needs. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The manager makes sure that all checks and clearances are received before staff are employed. The home supports people with dementia and other illnesses related to memory loss well. Staff are trained well so that they understand the needs and behaviours of people, which in turn promotes their well-being. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 7All bedrooms are a good size and all have their own private en-suite toilet. The staff have worked together for some time and have formed a stable staff team. People who use the service and their relatives are able to say what they think about how the home is run which helps them to have control over their lives. The registered persons make sure that the home is a safe place for visitors and those who live there. Comments from surveys sent to health professionals included: "They always carry out recommendations." "A highly recommended home." "The care staff all appear to be experienced within their role." "Always greeted with professionalism when visiting the home." Comments from staff surveys included: "Good knowledge of residents and good rapport with families." "Long serving staff with good range of experience." "We are always told about any changes to care plans and people`s health." "There are always people coming in to do training." Comments from relatives included: "I was given a tour of the home and was well impressed." "Staff are sociable and approachable." "X has improved dramatically since moving into the home." "My husband is looked after very well." "They seem to be well staffed and nursing staff are always accessible and available to answer queries or concerns." "All members of staff do a good job." What has improved since the last inspection? Staff make sure comprehensive assessments are completed before anyone moves into the home. The home is in the process of being redecorated and refurbished. There is a new manager in post who is enthusiastic and is leading a staff team who want to develop the service. Appropriate door closures have been provided. Risk management strategies are in place and staff follow safe moving and assisting techniques. What the care home could do better: Further work is needed to make sure people`s previous lifestyles and preferences are explored so that a "person centred" approach to nursing care is provided. Staff need to make sure that they follow medication polices and procedures at all times. Consideration should be given to changing colour schemes and provide pictures and signage to help people with memory loss find their own way around the unit and provide stimulating objects and activities that attract people and engage their interests. The home needs to continue with the redecoration and refurbishment programme and provide profiling beds for those who need nursing care. Staff need to make sure that no items are used communally. The manager should progress with the application to become registered with the Commission. Comments from all surveys said: "It can be problematic when staff phone in sick." "It is difficult when there are staff shortages." CARE HOMES FOR OLDER PEOPLE Willowdene Nursing Home Victoria Road West Hebburn Tyne And Wear NE31 1LR Lead Inspector Irene Bowater Unannounced Inspection 27th November 2008 08:15a 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 Willowdene Nursing Home DS0000000277.V373157.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. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willowdene Nursing Home Address Victoria Road West Hebburn Tyne And Wear NE31 1LR 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) 0191 483 7000 0191 483 7101 willowdene@new-meronden.co.uk Premier Nursing Homes Limited Manager post vacant Care Home 52 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (52), Mental disorder, excluding learning of places disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (52) Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 service users MD(E) also have a learning disability Date of last inspection 11th January 2007 Brief Description of the Service: Willowdene is a purpose-built home providing nursing, social and personal care for 52 older people that may have dementia-type illnesses or mental health needs. Accommodation is on two levels served by a passenger lift and stairs, each with self-contained facilities including lounges, dining areas, bathrooms and toilets. Both internally and externally, the property is accessible for wheelchair users. All bedrooms have en-suite toilets. A car park is available at the front of the home and there is an enclosed garden at the rear, which people enjoy using in good weather. The property is situated just off the main road running through Hebburn, and is within walking distance of a range of local amenities, including a health centre, pharmacy, library, a shopping centre, places of worship and public houses. The area is well served by public transport and the Metro station is approximately half a mile away. Fee rates are: General nursing 486:80 pounds per week. Dementia Care 415:74 pounds per week. Dementia Nursing 519:54 pounds per week. Continuing care 558:58 pounds per week. Personal items such as clothing, toiletries, newspapers are not included in this price. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality for this service is 2 star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: Information we have received since the last visit on the 11 January 2007. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The provider’s view of how well they care for people. The views of people who use the service and their relatives, staff and other professionals. Annual Quality Assurance Assessment (AQAA). The AQAA gives CSCI evidence to support what the home says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The Visit: An unannounced visit was made on the 27 November 2008. This visit was carried out by one Inspector and took seven and a quarter hours to complete. A pharmacy inspector completed a four and a quarter hour site visit and gave feedback to the manager. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 6 During the visit we: Talked with people who use the service, relatives, staff, the manager and visitors. Looked at information about the people who use the service and how well their needs are met. Looked at a sample of other records, which must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last visit We told the manager what we found. What the service does well: The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Staff involve the person, their representatives and other professionals in the care planning which makes sure their needs can be met. Care plans are clear and up to date regarding people’s health and personal care needs. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The manager makes sure that all checks and clearances are received before staff are employed. The home supports people with dementia and other illnesses related to memory loss well. Staff are trained well so that they understand the needs and behaviours of people, which in turn promotes their well-being. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 7 All bedrooms are a good size and all have their own private en-suite toilet. The staff have worked together for some time and have formed a stable staff team. People who use the service and their relatives are able to say what they think about how the home is run which helps them to have control over their lives. The registered persons make sure that the home is a safe place for visitors and those who live there. Comments from surveys sent to health professionals included: “They always carry out recommendations.” “A highly recommended home.” “The care staff all appear to be experienced within their role.” “Always greeted with professionalism when visiting the home.” Comments from staff surveys included: “Good knowledge of residents and good rapport with families.” “Long serving staff with good range of experience.” “We are always told about any changes to care plans and people’s health.” “There are always people coming in to do training.” Comments from relatives included: “I was given a tour of the home and was well impressed.” “Staff are sociable and approachable.” “X has improved dramatically since moving into the home.” “My husband is looked after very well.” “They seem to be well staffed and nursing staff are always accessible and available to answer queries or concerns.” “All members of staff do a good job.” Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: Further work is needed to make sure people’s previous lifestyles and preferences are explored so that a “person centred” approach to nursing care is provided. Staff need to make sure that they follow medication polices and procedures at all times. Consideration should be given to changing colour schemes and provide pictures and signage to help people with memory loss find their own way around the unit and provide stimulating objects and activities that attract people and engage their interests. The home needs to continue with the redecoration and refurbishment programme and provide profiling beds for those who need nursing care. Staff need to make sure that no items are used communally. The manager should progress with the application to become registered with the Commission. Comments from all surveys said: “It can be problematic when staff phone in sick.” “It is difficult when there are staff shortages.” Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 9 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. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 10 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 Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 11 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.Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information about the service and a comprehensive assessment of need before admission. This helps them make the right decision about using the service. EVIDENCE: The home sets out the aims and objectives of the service in a Statement of Purpose, which is readily available. There is also a Service Users Guide that sets out the values of the home. This makes references to supporting the diversity of needs, cultures, and beliefs of all those involved in the home. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 12 Before anyone is admitted to the home a full needs assessment is undertaken by a Care Manager, Home Manager and where necessary the nurse assessor. From this information the staff complete a care plan based on individual needs. Before coming to live in the home people can come and visit and spend some time getting to know the home. They also receive a “Welcome Pack” which gives general information about the home. Also the home confirms in writing to each individual that they can meet their needs and everyone has a contract that sets out the terms and conditions while living in the home. Surveys said: “Leaflets were given to me explaining how the home worked and which professionals visit on a regular basis.” “The staff were very helpful and approachable when the family were trying to find good accommodation. It was a very difficult time and we were well supported.” Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 13 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. Access to health care is good and detailed care planning demonstrates that peoples’ needs are being met. EVIDENCE: Each person has a plan of care based on the admission assessment carried out by care managers, the home manager and where necessary nurse assessors. Staff complete pressure ulcer risk, dependency, moving and handling, nutritional assessments, continence and fall risk assessments. The Clifton Tool is used to assess cognitive behaviours. These tools help the staff understand the level of risk each person and helps them complete a care plan. Care plans and risk assessments are reviewed and updated on a monthly basis. There is evidence that the staff involve the person and their Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 14 representatives in the care planning process and regular reviews take place with care mangers. Staff have contacted the Speech and Language Therapists (SALT) when there have been concerns about people having difficulty swallowing and being at risk of choking. Information from the SALT team is available in the care plans and staff have updated the plans to show what diet and fluids those people need. People who have been identified at having lost weight have risk assessments in place to show how they are being supported with eating and drinking. Weekly weights are recorded and the records show that weights are stable or increasing. Care plans show what management arrangements are in place to show what staff need to do when someone presents with any behaviour that would challenge. There were good examples of sensitive approaches to supporting people when they are confused, agitated and anxious. For example, “ take time to chat”, “make sure X has personal items” and “responds to diversion and prompts.” Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. Advice is sought from, occupational therapists, tissue viability nurses, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. The medication policy requires some amendment to reflect local arrangements within the home and to provide more detailed information for staff on the supply and disposal of medicines. Storage arrangements within the home require some improvement. The temperature of the medication area upstairs is regularly recorded as 29 degrees centigrade, which is outside the normal accepted range for storing non-refrigerated medicines. There are no facilities on either floor to allow for the segregation of external medication and medication for internal use. The date of opening of medicines with limited use once opened is not always recorded. This means there is a risk that the medication may be used beyond the date recommended by the manufacturer and may not be safe to administer. The controlled drug cupboard appears to meet safe custody regulations. A supply of Temazepam liquid, a controlled drug, was stored in the medicines trolley and not in the controlled drug cupboard. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 15 Morning medicines administration was observed on the first floor and was well managed and followed recommended guidance. Sufficient time was spent with each person and encouragement given to help them take their medication. Small volumes of liquid medicines are sometimes measured using syringes intended for injection administration rather than with oral syringes. No gaps were found on the medication administration record (MAR) charts and there were no significant discrepancies between the quantities of medication received, the number of doses recorded as being administered and the quantity of medication remaining in stock. This indicates that people are getting their medication as prescribed. The temperature of the two fridges is recorded daily but although maximum/minimum thermometers are in use the temperature range is not measured. This means that fluctuations in fridge temperature cannot be detected to demonstrate that medication is being stored correctly. The standard of handwritten entries on the MAR charts was generally good but some did not include a signature, a date or a witness signature to confirm their accuracy. Many of the staff have worked in the home for some time and know the people they care for well. All of the staff worked very hard to make sure everyone was treated with respect and their rights to privacy and dignity maintained. Surveys said: “X has no speech now anymore and we have found that staff to be adept at picking up none verbal signals.” “Medical advice is always sought promptly.” Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 16 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. Opportunities to take part in meaningful activities and keep control of everyday decisions are good, and mealtimes are organised. This makes sure people can lead full and active lives. EVIDENCE: There is an activity coordinator who organises events inside and out of the home. Many of the people living in the home do not respond well to group activities and daily events are then based on individual preferences. An activity programme is displayed and recent events have included a pie and pea supper, and fashion party. There was little in the way of books, puzzles and rummage boxes through out the home. People need to be given the opportunity to occupy themselves and maintain skills. Staff took time to sit and talk to individuals and they knew people’s preferences about how they wanted to spend their time. Although staff have Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 17 an understanding of people’s previous lifestyles this information is not clearly available in the care plans. Visitors are welcome at any time and are able to use the lounges or their relatives’ bedrooms for visits. It was confirmed that there are no restrictions regarding visiting times. Information about advocacy is available in the home. Many people have brought small items with them making their rooms homely and reflective of their previous lifestyles, religious beliefs or cultural backgrounds. There are dining rooms on each unit. Should anyone want to eat their meals in their own rooms or lounges, this service is provided. Menus were displayed but were set quite high up on the wall and were only in small print. The manager confirmed that alternative styles of menus were being looked at. Meals are prepared in the kitchen and brought to each unit in a “hot lock”. The lunchtime meal was nicely cooked and presented. Choices were available and drinks offered throughout the meal. Most of the people living in the home need assistance and support to make sure they have enough to eat and drink. Staff made sure the mealtime was calm and well organised. The home also tries as far as possible to “protect mealtimes”. This is so there is minimum disruption and the focus is on individual’s nutritional needs. Snacks and drinks are readily available throughout the day and staff confirmed that there is access to the kitchen area overnight should anyone be hungry. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 18 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. Good complaints and protection procedures are in place. People can be sure that their views are always listened to and that they are protected from harm. EVIDENCE: The Company have a detailed complaints procedure, which is easy to understand, and it is readily available in the home. The manager holds weekly “surgeries” in the home to allow people to discuss any issue they have. The home keeps a full record of all complaints including detail of any investigation and actions taken. There have been no complaints referred to the Commission since before the last Inspection. Since the last visit to the home there have been three complaints, one of which was upheld. One complaint was received at the home on the 2 October 2008 and was responded to by the manager within a twenty-eight day period. Clear safeguarding adults policies are available and staff were able to say what they would do should they be concerned about care practices. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 19 There are currently no safeguarding referrals reported to CSCI or Local Authority. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 20 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): 19,20,21,22,24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained and a pleasant, clean and comfortable place for people to live, however some practices may place people at risk. EVIDENCE: This is a two-storey purpose built care home. Externally there is easy access to both the entrance to the home and there us a secure garden area which is accessible from the lounge. There are lounges, dining rooms, bedrooms, bathing and shower facilities on each floor. Bedrooms are available throughout the home and they all have ensuite toilets. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 21 The manager has started a redecoration programme and many areas have been improved. This home is specifically provides care for people with dementia and mental health problems, however signage, aides and colour schemes have not been introduced to assist those with memory loss find their way around. The corridor carpets are looking worn and tread marked. There is damage to the walls, tables and chairs in the downstairs dining room. People have been encouraged to bring small personal items into the home, which has personalised their bedrooms. Several people are being nursed on mattresses on the floor following risk assessments. This may cause problems with moving and assisting and alternative profiling beds need to be provided. All areas were clean, tidy and fresh smelling. The staff have had training in infection control policies and were seen to make sure clinical waste and good hand washing procedures were followed. However there was an unnamed tub of in use Sudocrem and a bag of “netty” knickers on the linen trolley which suggests that there was some communal use which would increase the risk of cross infection. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 22 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. Staffing levels and systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: On the day of the visit there were forty-seven people living in the home. Staffing levels included a deputy manager, one Registered Mental Health Nurse (RMN), one Registered General Nurse (RGN) and eight care staff. There are also domestics, laundry, chef, kitchen assistants, maintenance and activities staff. The manager is supernumerary and is also an RMN. Many of the staff have worked at the home for some considerable time and have developed a strong team. Staff were organised and knew what their individual responsibilities were and this made sure care was given in a sensitive manner. The procedures for recruitment were being followed. There was evidence of Criminal Record Bureau checks, Safeguarding Adult checks, two written Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 23 references, proof of identity, professional identity numbers for registered nurses and completed induction programmes. Staff are updating their mandatory training and specialist training includes safeguarding adults, medication, Liverpool Care Pathways, enteral feeding, catheter care, wound care and venapuncture Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 24 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 home is run by a competent manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: The manager has previously worked at the home for a number of years and has recently returned to take up the manager’s post. She is a first level Registered Mental Health Nurse with vast nursing and management experience. She has yet to be registered with the Commission. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 25 Quality monitoring and quality assurance systems are in place, Feedback is sought from those living in the home and their representatives. The manager also sets aside time so that anyone can come and discuss any issues or concerns they may have. Regular meetings with staff are now taking place so that they can understand how the home needs to continually improve regarding training, sickness and care practices. The AQQA was completed and gave a good picture of how the home aims to develop in the coming year. The home only holds a minimum amount of personal monies. Should money collect it would be sent on to the appointee or relatives to put in people’s saving accounts. Staff have had training in safe working practices with records kept. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. In house health and safety checks are carried out weekly. Water temperatures are recorded to ensure temperatures of 44 C is not exceeded. External service contracts were available and up to date. Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 26 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 2 X 3 X 2 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 2 X 3 X 3 X X 3 Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 Requirement The registered persons must ensure medication is stored securely and safely and at temperatures recommended by the manufacturer. The registered persons must ensure that medication with limited use, once opened, must only be used in line with the manufacturer’s recommendations. The registered persons must ensure that life histories are developed using a person a person centred way to ensure that peoples’ needs can be fully met. This will mean that staff have the right information to provide individual care and support and that people will be able to take part in events and activities that interest them. The registered persons must replace the corridor carpets and redecorate and refurbish the downstairs lounge. The registered persons must ensure that profiling beds are provided. This will ensure people DS0000000277.V373157.R01.S.doc Timescale for action 26/02/09 2 OP9 13 26/12/08 3 OP12 16 31/03/09 4 OP20 23 01/09/09 5 OP22 14,16,23 01/06/09 Willowdene Nursing Home Version 5.2 Page 28 6 OP26 13,16 are kept safe and enable staff follow best practice when moving and assisting individual’s who need nursing care. The registered persons must 26/12/08 ensure that there is no sharing of clothing or creams. This will prevent infection control risks. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Temazepam preparations should be treated as a controlled drug and all transactions recorded in the controlled drug register. This will help reduce the risk of loss or theft. Maximum/minimum thermometers should be used to record the temperature range in fridges to confirm that medicines are stored within the appropriate temperature range and so are safe to use. Staff should sign and date handwritten entries they make on the MAR charts. Each entry should be checked and countersigned by a second person to reduce the risk of error when copying information. The medicines policy should be updated to reflect local requirements and practices within the home. Providing clear and up to date guidance will help staff understand how to handle medicines safely. An adequate supply of oral syringes should be available on the medicines trolley to facilitate the measurement of small volumes of liquid medicines. Syringes for the administration of injections should not be used to measure or administer oral liquid medicines. The registered persons should consider changing colour schemes and provide pictures and signage to help people with memory loss find their own way around the unit. It is highly recommended that the manager progress with the application to become registered with the Commission. 2 3 OP20 OP31 Willowdene Nursing Home DS0000000277.V373157.R01.S.doc Version 5.2 Page 29 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. 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