Inspection on 24/04/08 for St Dominics Residential Home

This is the latest available inspection report for this service, carried out on 24th April 2008.

CSCI found this care home to be providing an Excellent service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Dominics Residential Home 19/12/05

St Dominics Residential Home 07/06/05

St Dominics Residential Home 15/02/05

St Dominics Residential Home 31/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Dominics Residential Home London Road Kelvedon Colchester Essex CO5 9AJ Lead Inspector Diana Green Unannounced Inspection 24th April 2008 11:00 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 St Dominics Residential Home DS0000017937.V363072.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. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Dominics Residential Home Address London Road Kelvedon Colchester Essex CO5 9AJ 01376 570359 01376 573668 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) www.stdominicsrh.co.uk St Dominic’s Residential Home Limited Mrs Jean Dolmor Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users accommodated in the home must not exceed 38 persons 10th May 2007 Date of last inspection Brief Description of the Service: St Dominics is registered for 38 people of both sexes, over the age of 65. Accommodation is in single rooms on 2 floors with lift access. Twenty-four bedrooms have en suite facilities. The home has large well-maintained gardens with a summerhouse, water features and patio areas. A large heated conservatory offers more than adequate communal space for residents, and there are also 2 lounges and a dining room. The home is close to local facilities in Kelvedon and accessible by train and other forms of transport. The current weekly charge for a room is between £536.00 and £625.00. Additional charges are made for chiropody, hairdressing, toiletries, newspapers and a contribution towards the cost of outings. This information was provided to the CSCI on 19/05/08. St Dominics Residential Home DS0000017937.V363072.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 3 star. This means the people who use this service experience excellent quality outcomes. This was a key unannounced inspection that was undertaken on the 24/04/08 and lasted 6 hours. The inspection process included: discussions with the registered manager, care staff, the cook, the activities coordinator, a volunteer, the laundry assistant, three residents, two visitors, and feedback from relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Evidence was also taken from completed surveys and the Annual Quality Assurance Assessment (AQAA) completed by the management of the home and submitted to the CSCI. Twenty-six standards were inspected and two requirements and three recommendations made. The registered manager and staff were welcoming and helpful throughout the inspection. What the service does well: The standard of personal care and healthcare is good. There is good liaison with GPs, district nurses and specialist nurses. When asked what the service does well, a healthcare professional told us ‘Supporting individuals to live as they wish to and being respectful to them’. There is good monitoring of nutritional intake with regular weight monitoring undertaken. Menus are varied with food choices offered and there is a good range of fresh vegetables provided with pastries and cakes baked on site. Meals were seen to be an enjoyable and social occasion. Tables were laid with tablecloths and condiments and meals served by the cook and gravy and sauces served at the table. There is a wide range of activities provided and residents are offered a choice of taking part. Residents are encouraged to keep abreast of life outside the home by a regular newsletter with current events included and newspapers provided for those who wish. Relatives told us: ’ the home has a lovely atmosphere and I have never seen anyone miserable. Always a smile. Their events co-ordinator is lovely and really reacts with the residents; and ‘There are many activities & pastimes arranged for the residents. Then there are various outside entertainers to which family members are warmly invited’; and ‘The manager goes out of her way to keep in touch with each resident St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 6 everyday and to make St Dominic’s as much like home as possible, particularly at special times such as Christmas’. The premises are well decorated and well maintained and cleaned to a high standard. There are robust policies and procedure for infection control that are well adhered to. One relative said ’the cleanliness of the home is very good. The staff help give a friendly atmosphere to all visitors’. The gardens are accessible to wheelchairs and are kept tidy, providing a very pleasant view from the home. Residents’ are encouraged to personalise their rooms with their own furniture and pictures. There is good organisation of storage. Health and safety audits have been introduced and at the site visit no issues were found. Staff retention is good and staff are well supported by the manager who ensures she is kept updated. The staff team are motivated and work well as a team. One relative told us their loved one ‘has lived in St Dominic’s for ten years and has always praised the staff. I called in regularly and have always been made very welcome’ and when asked what the service does well another said: ‘The quality of food, the standard of cleanliness, the general level of professionalism; as a family we continue to be impressed by the cheerful manner in which the staff go about their work’; and a resident said ‘the home has a particularly friendly and happy atmosphere. The staff are extremely welcoming’ when their relative visits and ‘always have time with residents and family alike’. What has improved since the last inspection? A new manager has been appointed and registered by the CSCI. She had also attended mental capacity act training and statutory training since appointment. The home had been extended and refurbished to a high standard and large screen television screens installed. Shared accommodation had been removed and all single rooms provided. A relative told us ‘The home has managed the extension and building work with minimal disruption - it all looks very sweet’. There had been an increase in staff training and regular supervision was being provided. Care staff had received instruction in care planning and record keeping and were more involved in writing care plans. There had been a reduction in stock levels of medication held. Complaint records were detailed with all issues raised no matter how minor and the action taken recorded. QA programme had been developed to include falls monitoring, health and safety audits and a residents’ questionnaire distributed. A residents and relatives’ meeting had been arranged and a further meeting was planned to review any outstanding issues there may be following completion of new wing. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 7 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. St Dominics Residential Home DS0000017937.V363072.R01.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 St Dominics Residential Home DS0000017937.V363072.R01.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): Quality in this outcome area is good based upon sampled inspected standards 1, 3 & 6. People planning to move to St Dominic’s can expect to be well informed and to have their needs assessed prior to moving in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and service user guide that were combined documents. These had been recently reviewed and confirmed to meet regulations on registration of the new wing on 17/03/08. A copy of the statement of purpose/service user guide was observed on display in the entrance hall of the home for visitor’s information and also in a resident’s room. From discussion with the manager and information received in the AQAA it was evident that prospective residents and/or their relatives would be invited to the home prior to making a decision and copies would be made available to them. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 10 The manager explained that a pre-admission assessment of care needs was undertaken by her either in the resident’s own home or hospital with full involvement of their relative or representative where possible. Three care records were viewed and all included a full assessment of care needs. Copies of care management assessments were obtained prior to admission where residents were funded through the local authority to ensure needs could be met and were held on file. This home does not provide intermediate care. St Dominics Residential Home DS0000017937.V363072.R01.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): Quality in this outcome area is good based upon sampled inspected standards 7, 8, 9 and 10. The health and personal care needs of residents are appropriately met through robust care planning and monitoring of practice that ensures residents’ privacy and dignity is respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager explained that all staff are involved in the development of the individuals care plan and that training and supervisions are on-going to try and ensure that needs are recognised and attended to promptly. A staff member stated in a completed survey that ‘All staff have a daily input to the care plans, receive information on handover.’ Three care plans were reviewed during the site visit. All included a resident’s profile and care plans for all care needs (for example personal care, oral care, foot care, sight and hearing, diet etc.) as indicated in this standard and included good detail of the residents needs. Risk assessments were undertaken and recorded for falls, nutrition, moving and handling and pressure areas/tissue viability and bed rails (as relevant). St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 12 All risk assessments and care plans had been reviewed monthly. Daily records were detailed and showed good monitoring of needs and appropriate action taken as relevant. Some care plans did not include sufficient guidance for care staff with some instructions written on the daily record rather than the care plan; and whilst changing care needs were stated on daily records this had not always been transferred to a new care plan. When asked do you receive the care and support you need residents told us: ‘completely utter satisfaction’; ‘ I would like to thank the staff for all their care support’; ‘I am very satisfied with everything - the food is good, I get what I want, when I want’; ‘Everybody treats me as a friend’. All of the 14 residents who responded said that staff always listened to them and acted on what they said. The records provided evidence of good monitoring of health care needs with prompt referral to GPs and health care professionals and appropriate follow up action being taken. The manager discussed the positive relationships the home had with the local GP practice and district nurses. The records confirmed that general practitioners and district nurses saw residents regularly and they were enabled access to outpatient services including audiology, psychiatry, dermatology, dental and chiropody and annual eye tests. One GP was seen to visit the home during the site visit. From the positive comments received from relatives it was evident that residents’ care needs were monitored and they were kept informed: ‘ I would be phoned to be given any relevant information; ‘Very quickly notified’; ‘Nowhere is perfect, but we find this home far better than others and no-one really wants to be in care, but this care home does all it can for its residents. It shows’; ‘I feel my xx has received attention and care from the staff’. ‘xx is very content and relaxed’. ‘xx has very poor sight and hearing, but still seems cheerful and relaxed’; ‘They give time or reassurance as needed’. One comment was received that indicated visits from the chiropodist were less frequent than 6 week to 2 month visit, requested on original care plan’. When asked ‘Do you receive the medical support you need? A resident told us: ‘The carers always call the doctor when needed’; ‘the staff are very good’; ‘excellent’. It was not clear if staff were following policies and procedures for the safe ordering, administration recording and disposal of medication. Two medication policy statements were seen and neither were dated. The manager said she was aware that guidance needed to be reviewed and had discussed this with the supplying pharmacist who had agreed to assist with their review as well as provide staff training. Medication was supplied in a monitored dosage system and in individual containers from the local supplying pharmacist. Senior care staff administered all medication and the manager advised that all staff who administered medication were to undergo updated training to promote best practice. A current list of those staff signatures and initials was available. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 13 Medication was stored in two trolleys stored in two separate lockable cupboards on the ground floor of the home. There was no evidence of room temperatures being monitored. The temperature taken at the site visit was 24.8°Centigrade and advice was given to ensure this was taken daily to ensure it did not exceed the recommended safe maximum temperatures of 25° Centigrade. The home had a drug refrigerator that was stored in one of the cupboards whilst temperatures was undertaken these were not recorded to demonstrate that appropriate action would be taken as necessary. Controlled drugs (CD) were stored in a CD drug cupboard that met requirements. However the fridge was being used to store the personal items of a resident recently admitted to hospital, which contravenes medicines regulations. The CD register was viewed and the records and medication supplies for two residents were checked confirmed as correct. However it was evident that staff were not recording the name and address on supply and disposal of controlled drugs. The medication supplies and medicine administration records were viewed for a further three residents. All had a photograph of the resident and a medication profile recorded with the potential side effects of each medication. All medication was available as prescribed and in the main well recorded. However for one resident there were several omissions in the records and no evidence that they had been followed up and the reason for the omission recorded. Creams were appropriately recorded by the person who administered the cream, which was good to see. Staff were observed to knock before entering residents’ rooms and to sensitive in their manner when addressing them. Residents spoken with said that staff respected their privacy and were polite, friendly and always knocked before entering. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon sampled inspected standards 12, 13, 14 and 15. People living at St Dominic’s can expect to mantain contact with their family and friends and to have a lifestyle that satisfies their cultural expectations and is enhanced by the stimulating activities and outings provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had an activities coordinator who worked 28 hours over 4 days per week and was assisted by a volunteer. She had received no formal training but from discussion it was evident that she was skilled and very motivated in ensuring residents had a full and varied programme of activities and entertainment that they all had an opportunity to take part in and seen on the notice board in the home. The home is registered with NAPA (National Association of Providers of Activities for Older People) and we were informed she regularly sought advice from them. The activities coordinator produced a monthly newsletter that was provided to residents and their relatives and displayed in the home for visitors’ their information. One relative told us ‘ they also have a very informative monthly newsletter’. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 15 From discussion with the co-ordinator and the records viewed it was evident that she discussed residents’ life history and interests with them on admission. Several residents were observed taking part in various activities during the site visit that included card bingo, ball games and individual activities such as nail manicures whist others had chosen to watch television and videos. Three residents spoken with said they were enjoying the activities provided and we also received the following comments from resident in completed surveys: ‘I am satisfied. I love the entertainment - the variety’; ‘ There are lots of activities that I like, such as quiz entertainments’; ‘There is a very wide choice of activities going on and I am not pressurised to join in if I do not want to. I like bingo, quiz, cards, one-to-one entertainment etc.’; I like to rest more than do activities. I like one-to-one chats’. The home’s statement of purpose included the policy on visiting and residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. Several visitors were seen to come and go throughout the inspection. A church service was held at the home and arrangements made for representatives of different faiths to attend the home as relevant. A relative told us ‘Different faiths are represented by visiting preachers on a regular basis’ and another said ‘they met the needs of different people’. Residents were observed to have some choice about their daily life in the home, especially in regard to where they spent their day, ate their meals etc. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them. Information on advocacy services was included in the statement of purpose and available in the home. A relative told us ’ I am very impressed by the freedom and encouragement residents get to do what they want’. Discussions were held with the cook, menus viewed and a brief inspection of the facilities undertaken. The menus were provided over a four-week rotation with seasonal variations. The kitchen was clean and well organised and food stocks were plentiful with a range of fresh and frozen produce including fruit and vegetables available. The cook explained that all meals were home cooked on site and pastries and cakes baked at the home. Breakfast comprised cereals, toast and eggs or a full cooked breakfast as chosen. Residents were observed enjoying the lunchtime meal that comprised liver and onions or sausages, boiled potatoes, broccoli and carrots, followed by a choice of apple crumble and custard or fruit cocktail. Supper was a light meal and included dishes such as quiche, or fish fingers with baked beans or sandwiches and yoghurt and cakes. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 16 Residents spoken with said their likes and dislikes were discussed with them and confirmed they could have an alternative. When asked ‘Do you like the meals at the home? Residents responded: ‘they are very nice I am very satisfied with everything - the food is good, I get what I want, when I want;’ ‘definitely’; ‘Would like to see more fish on the menu’; ‘Very good’; ‘There is plenty to eat’. The records viewed showed that residents’ nutritional intake was closely monitored and supplements provided as needed. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is excellent based upon sampled inspected standards 16 & 18. People living at St Dominic’s can expect to have their complaints listened to and acted upon and to be protected from abuse by robust policies, procedures, staff training and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that included the timescales within which complainants can expect a response and advised them of their right to refer to the placing authority. The procedure was included in the statement of purpose and displayed in the entrance of the home. Fourteen complaints had been received since the previous inspection. These comprised all issues raised no matter how minor, which is acknowledged to be good practice. The records viewed showed that prompt action had been taken to address the issues raised. A record of compliments was also held on file. When asked ‘has the care service responded appropriately if you or the person using the service has raised concerns about their care? We received the following comments from relatives ‘I have never had any reason to raise concerns about my xxx’s care. It always seems to meet….needs’. Nine of the fourteen residents who completed surveys told us they knew how to make a complaint and twelve told us they always knew who to speak to if they were unhappy. One said ‘I find that I can chat, moan and groan and the staff listen and make me feel good, and act straight away on any complaints’. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 18 The home had comprehensive policy and procedures for safeguarding vulnerable adults that were kept under review and local Essex procedures were available for staff guidance. The records confirmed that all staff had received relevant training. One referral had been made since the previous key inspection and had been referred appropriately to the local authority. From discussion with the manager and previous knowledge it was evident that she was knowledgeable on safeguarding adults and aware of the procedures to be followed in the event of any allegations being made. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is excellent based upon sampled inspected standards 19, 22 and 26. People living at St Dominic’s can expect to live in a clean, homely and wellmaintained environment that has safe standards of infection control in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, several bathrooms, a number of residents’ rooms, the kitchen, the sluice and the laundry. The home was in a good state of maintenance and decoration and was furnished to a high standard. The spacious entrance hall had notice boards with full information displayed. The home had been extended and a new wing with 12 en-suite bedrooms provided over two floors. Wooden flooring had been provided in the corridors and the walls had attractive pictures hung that enhanced the appearance. Information received from the home also stated that the kitchen had been upgraded and improved to meet the needs of the extra number of residents. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 20 Large TV screens were observed in communal rooms and residents spoken with said they were now able to see television programmes much more clearly. The gardens were attractively planted with lawn, shrubs and plants and a rockery and pond provided a focus point to view from the conservatory. Paving had been installed around the conservatory area enabling wheelchair access to grounds. However the conservatory was only partially screened by blinds, meaning that residents could be seen from outside and were not protected from the sun. One comment received from a relative raised concerns regarding the lack of screening. The manager said that arrangements were being made to furnish the windows with blinds once the seal to the window had been repaired and in the interrim agreed to provide screens to ensure residents’ privacy and dignity was upheld. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had passenger lifts to enable access throughout the premises. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was fully accessible to wheelchairs. Call systems were provided throughout all individual and communal rooms. Pressure relief equipment was assessed and provided by the district nursing service to meet the needs of residents and confirmed from discussion with the registered manager and staff. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. There were policies and procedures for infection control available for staff guidance and the records viewed confirmed that all staff received training during induction and at regular updated sessions. The home was cleaned to a high standard throughout. The laundry room was clean and well organised, with baskets and hanging rails provided for sorting residents’ personal items of clothing. There were three washing machines and one drier that were in use. Sluice facilities were located on each floor of the home. Systems were in place to minimise the risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines and washing machines had the capacity to carry out sluice wash cycles. Eleven of the fourteen residents told us in completed surveys that the home was always fresh and clean and two said usually. Information received from the manager and also observed during the site visit confirmed that soap and towel dispensers had been installed in all rooms to ensure appropriate staff hand washing facilities were available. Information in the AQAA stated that laundry and cleaning systems were now colour coded to reduce the risk of cross infection. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good based upon sampled inspected standards 27, 28, 29 and 30. People living at St Dominic’s can expect to have their needs met by caring staff that have been robustly recruited and received appropriate training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were twenty-nine residents at the home including one who was in hospital. Staffing levels comprised one senior care assistant and four care staff. The registered manager, activities co-ordinator, administrator, cook, kitchen assistant, laundry assistant, maintenance/gardener, four domestic staff and a volunteer were also on duty. There was evidence from the staff rota that staffing levels were well maintained and from observation these seemed to meet residents’ needs. Information received in the AQAA stated that the home had 8 care staff with NVQ level 2 qualifications or above which just below the 50 needed to meet the standard. However the percentage of staff with NVQ level 2 training and/or working towards the qualification is 65.2 . St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 22 The recruitment files of three recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and evidence of identification and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards and this was also confirmed from the records viewed. The home had an established training programme. The training records were viewed for one member of staff and confirmed they had completed training on health and safety, fire safety, protection of vulnerable adults, food hygiene, restraint, mental capacity, infection control, moving and handling, care planning and Control of Substances Hazardous to Health (COSHH). Information received in the AQAA stated that statutory training is provided prior to commencement of employment and induction is done at the pace of the individual and that all staff have had training in risk assessments, i.e. falls, nutrition, mobility, pressure areas, cot sides. The AQAA also stated that a policy is put up for all staff to read each week in the staff office and that team leaders monitor staff performance and support with extra supervision where needed. When asked ‘Do the care staff have the right skills and experience to look after people properly? A relative told us ‘…has not been in St Dominic’s more than 2 months. What I have seen, so far, I am more than happy with.’ St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good based upon sampled inspected standards 31, 33, 35, 36, 37 and 38. St Dominic’s is well managed and run in the best interests of residents. The health and safety of residents and staff is safeguarded by the policies, procedures and practices at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is an experienced registered nurse and holds the RMA (Registered Manager’s Award). She has previous experience of managing care homes. From discussion with the manager, former knowledge and an inspection of the records it was evident that she was skilled and competent and had undertaken recent updated training relevant to a manager of a care home for older people. The AQAA stated that staff have open access to the manager to discuss any training needs or concerns. This was also confirmed by St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 24 staff who completed surveys: ‘‘My manager is very supportive and is always available when/if needed. I feel I can approach her with anything and she does her best to help me’; and ‘My manager is the best manager Ive had throughout my working life. The home is run very well ensuring the residents needs are always met and the staff are always well supported’. A relative also told us’ I can approach the manager any time should there be a problem or the need for advice’. The home had a quality assurance programme that included consultation with residents and their relatives. The manager explained that a resident and relatives meeting had been held to discuss any issues during development of the new wing and a further one was planned to review within three months. Audits had also been introduced for falls monitoring and health and safety of the premises and that staff were now self auditing care plans which has increased their awareness. A CSCI checklist for supervision had also been introduced for staff supervision. Visits required under regulation 26 had been undertaken. Neither the manager nor staff were appointee for any resident at the home. All residents had a representative/advocate to manage their finances on their behalf. Residents’ personal allowances were held in zipped pouches in lockable facilities for safe keeping with records of income and expenditure maintained. Three residents monies were inspected: receipts were held and all cash was confirmed as accurate. From discussion with the manager and the staff records viewed it was evident that staff supervision was provided to Skills for Care standards and provided every two months to meet the standard. Records held on behalf of residents were kept up to date and were stored safely in secure facilities. Records viewed at this inspection included: the statement of purpose, service user guide, assessments/care plans, medication records, complaints, staff meetings, staff recruitment and training records, maintenance records and fire safety records. The home had health and safety policies and procedures that were regularly reviewed. The records confirmed that staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment fire alarms and emergency lighting etc.). All accidents, injuries and incidents were well-recorded and appropriate action taken. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 4 17 X 18 3 4 X X 4 X X X 4 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 3 3 St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement The home must review procedures for the administration of medication to provide people with better protection from possible mistakes. This is a repeat requirement. Original timescale of 31/07/07 not met. To ensure the safe administration of medicines: 1.Omissions must be followed up and the reason recorded. 2.The date of opening of medicines with a short shelf life must be recorded. 3.The CD register must include the name and address on receipt and disposal. 4. CD storage must be used appropriately and not for personal items. 5. Room temperatures must be monitored and recorded. Timescale for action 31/05/08 2. OP9 13(2) 31/05/08 St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP7 OP12 OP22 Good Practice Recommendations A new care plan should be developed when residents’ needs change to ensure staff have updated guidance to meet residents’ needs. Care staff should be involved in the provision of activities to provide support and enabling all residents to have the opportunity to be involved as they choose. Blinds and screening should be provided in the conservatory to ensure the privacy and dignity of residents is upheld. St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 St Dominics Residential Home DS0000017937.V363072.R01.S.doc Version 5.2 Page 29 - 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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