Inspection on 12/02/08 for St Michael`s House

This is the latest available inspection report for this service, carried out on 12th February 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Michael`s House 08/06/06

St Michael`s House 27/01/06

St Michael`s House 20/10/05

St Michael`s House 21/12/04

St Michael`s House 18/05/04

St Michael`s House 29/10/03

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Ravenhurst

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE St Michael`s House Hewitt Street Chell Stoke on Trent Staffordshire ST6 6JX Lead Inspector Linda Clowes Unannounced Inspection 12th February 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 Michael`s House DS0000032516.V359772.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 Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s House Address Hewitt Street Chell Stoke on Trent Staffordshire ST6 6JX 01782 233435 F/P 01782 233436 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) Stoke on Trent City Council Mrs Lesley Kokai Care Home 30 Category(ies) of Dementia (5), Mental disorder, excluding registration, with number learning disability or dementia (5), Old age, not of places falling within any other category (30), Physical disability (30) St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC; to service users of the following gender either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places 30); Physical disability - Code PD (maximum number of places 30); Dementia Code DE (maximum number of places 5); Mental Disorder - Code MD (maximum number of places 5). The maximum number of service users who can be accommodated is 30. 25th January 2007 2. Date of last inspection Brief Description of the Service: St Michael’s House, Chell is a purpose-built, Local Authority managed home that is registered to accommodate 30 older people. The home is owned by Stoke-on-Trent City Council and operated by Stoke-on-Trent Social Services Department. It was located within a residential area, close to local community amenities and public transport. It had the benefit of its own garden and patio area with panoramic views over the city. Pathways were appropriately ramped to provide ease of access and there was a car parking area to the front and side of the building. Accommodation is provided on two floors accessed by a shaft lift or staircases. There are 30 single bedrooms, none of which had en-suite facilities. There were, however, toilet facilities within easy access of all bedrooms. There were also 4 assisted bathrooms and 1 disabled shower. The home is moving towards allocating all its beds for Rehabilitation Services but retained 6 beds for six of its long-stay residents. There will be no further permanent admissions to this care home. The rehabilitation service is to enable individuals over the age of 55 who have been assessed as requiring a period of Rehabilitation/Assessment to regain skills and confidence so as to reach their optimum level of independence to return to live in the least dependent setting. The home is undergoing a complete refurbishment to provide small lounge/dining/kitchenette areas close to bedrooms to enable service users the means to prepare their own meals and in order to assist the move on to more independent living. A main cooked lunch-time meal is provided. However, the large ground floor dining room will no longer be used by residents and will be St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 5 converted in to separate day care facilities and office space. There was a designated smoking room for residents on the ground floor. Bedrooms were located on two floors together with small lounge/kitchenette areas to accommodate small numbers of residents. There was a smoking room for residents on the ground floor. On the first floor there was a hair dressing and beauty salon and a gymnasium/physiotherapy room. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. One inspector carried out this unannounced inspection and inspected against the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The inspection took place over a period of 7.5 hours and included an examination of records, service user plans, personnel files and associated recruitment procedures, complaints files, health and safety records and a feedback session. Various methods were used to obtain information regarding the services provided. Questionnaires were forwarded to all service users and we had twelve responses. Surveys were also returned by three relatives and three health/social care professionals. The manager has completed an Annual Quality Assurance Assessment (AQAA) which comprises a self assessment and statistical information regarding the service. Information provided in the AQAA has been used as part of this inspection report. St Michael’s is currently undergoing extensive renovation and refurbishment and is moving from the provision of permanent residential care services to becoming a Rehabilitation Unit with 30 beds. Within the building will be offices for social and health care teams, a domiciliary care service and a day care service all working towards rehabilitation services. As a consequence, the building was not fully occupied by service users as building works were taking place. Discussions took place with the manager regarding security of the building and the need to ensure that there are separate entrances to for the other services in the building in order to protect the health and safety of service users and provide a calm and peaceful environment in which people can concentrate on their rehabilitation programmes. These discussions will continue with the local authority outside of this report. The inspection found that high quality services continued to be provided in spite of the building works. Service users, relatives and professionals all expressed satisfaction with the service provided by St Michael’s and the dedication of the staff. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 7 Five requirements and one recommendation have been made as part of this report. What the service does well: What has improved since the last inspection? There are improved staffing levels There has been refurbishment and renovation in some areas of the home. A new sluice room has been provided The home had made an application to change its certificate of registration and this had been renewed on 12th October, 2007. General Social Care Council Codes of Conduct have been issued to all staff. COSHH posters were appropriately displayed throughout the building The daily report was complete and up to date. A policy had been introduced for the prevention and management of pressure sores. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 8 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 Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 9 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 Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Since the last visit there has been a change of focus in service from provision of permanent care to a rehabilitation service. The Service User Guide and Statement of Purpose had been reviewed to reflect this change of emphasis. However, consideration should be given to providing written information to prospective service users at an early stage in order that they may have the means to make an informed choice about whether the service is suitable for them. EVIDENCE: The focus of the home had changed. St Michael’s was now operating as a Rehabilitation Unit and was providing rehabilitation and assessment services to enable individual’s to return to the least dependent setting. Several permanent residents remained in the home and would continue to stay as long as they wished to do so. However, no future permanent admissions will take place. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 11 A high proportion of residents were admitted directly from hospital. It was identified that it had not always been possible to provide written information about the home prior to admission. One service user has commented “I did not have enough information before moving in. Whilst recovering from a stroke in hospital I was asked if I wanted to go to St Michael’s for rehabilitation. I had to make this decision too quickly”. This issue was discussed with the manager who agreed that further consideration needed to be given to ensuring that people assessed for the service had access to information in order to enable them to make an informed choice about whether the service would be suitable for them. A recommendation has been made regarding this matter as part of this report. (Recommendation 1) The home had a Statement of Purpose and Service User Guide that had been reviewed and updated to reflect the current service. Admissions only took place following multi-agency assessments of the needs of prospective service users. The management team were actively involved in pre-admission assessments. The rehabilitation programme covers a six-week period for which there is no charge. It is understood that any extensions to this period would incur a charge. An Agreement for the Provision of Intermediate Care form/contract giving detail about the point at which charges are made is signed by service users at the time of admission. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 12 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 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home maintained comprehensive and informative plans of care for each individual to ensure a person centred approach to service delivery. The people who used the service were treated with respect and their rights to privacy upheld. EVIDENCE: The care records of three service users were case tracked. One for a permanent resident, one for a rehabilitation resident and one for a resident undergoing assessment. Individual care plans reflected individual choices and goals and were regularly reviewed with input from service users and relatives. Information focused on how individuals will develop their skills and recorded their future aspirations. Details of progress and achievements were recorded. The records informed staff of the aims and objectives for the individual in relation to their health, personal and social care needs. Staff spoken with were aware of the needs of service users and confirmed that they referred to the care plan documentation on a daily basis. There were good shift change-over procedures to keep staff informed of any changes that may have occurred. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 13 The inspector spoke with the three service users who were part of the case tracking, as well as many other residents on the day, regarding the service they received. Each was satisfied with the support they received in the home and confirmed that staff were attentive and sensitive to their needs. Each had a Keyworker who took the lead in monitoring that the service focussed on identified aims and objectives to promote independence. All service users on rehabilitation programmes are visited by a General Practitioner within 24 hours of admission. Those spoken with confirmed that they received visits from GP’s and Community Nurses and that their health needs were promptly addressed. Service users wishes regarding arrangements at the time of their death are recorded and respected. Two permanent service users had died in the home since the last inspection. An inspection was made of the medication procedures for each service user being case tracked and found satisfactory storage, handling and administration of medicines. The medication administration records for each person were fully and accurately completed. The inspector observed respectful, kindly interaction between service users and care staff throughout the day. The following comments were made in surveys returned by service users and relatives:“I feel comfortable that my father is being looked after. I don’t think that anything can be improved”. “Staff always inform District Nursing Team of all changes”. “I expected my mother to have had more physio to enable her to recover more fully from her stroke”. The following comments were added to surveys by health and social care professionals:“Appropriate equipment is available. GP’s are contacted if person is feeling unwell. The home offers a very individual approach to care. I have known people to manage their own meds (medication) which are locked away securely. Very competent, friendly staff who work well with the (service users) and with each other. The staff are warm and friendly and get to know individuals who they care for – they are hard working. The service treats St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 14 people as individuals. Relatives are able to visit and observe treatments by OT/physio if they wish to do so”. “All care staff have direct links to health care staff including district nurses. Individual needs are met following care plans. The service is based upon rehabilitation principles always recognising individual goals and promotion of independence. The service provides person centred individual care”. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 15 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. Service users are helped to exercise choice and control over their lives. Family and community links are promoted. Service users were provided with and encouraged to maintain a wholesome, balanced diet. Rehabilitation service users were assisted and encouraged to prepare their own meals. EVIDENCE: The refurbishment that is taking place has affected the in-house Activities Programme as there is limited space to provide entertainment for all service users. The manager is aware of this and encourages staff to provide dedicated activity hours for personal shopping trips, manicures or similar activities requested by service users. The manager was also aware of the balance that needed to be struck between the activities for people who are long-term residents in the home and those on rehabilitation programmes. The completion of the building works will provide space for a gymnasium/activities room. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 16 In the rehabilitation setting many of the planned daily activities were focussed on targeted input from physiotherapists, occupational therapists and care staff to work towards the goals outlined in care plans and took into account the accessibility to community facilities by the person upon their return home. General activities will reflect the individual’s interests, hobbies and lifestyle. Service users were seen chatting to one another, receiving visitors, attending medical appointments, watching television, knitting, reading and ‘people watching’. They were observed moving freely around the home or with the assistance of care staff – some choosing to spend time in the lounges with other service users whilst others preferred to spend their time in their own bedrooms. Two of the people being case tracked confirmed that they had been taken individually by staff on shopping trips or outings during their stay. Two visitors spoken with confirmed that managers and staff always made them welcome in the home. The home provides a cooked lunch-time meal for all service users. Without exception service users confirmed that they enjoyed the food served. There was a three-week rotational menu with options to the main meal for those who preferred something different. Sandwiches and hot light meal options were available for tea for permanent residents and for those on the rehabilitation programme who may not be able to prepare their own tea, particularly those who may be convalescing at the start of their programme. Specialist diets were catered for e.g. gluten free and liquefied meals. The following comments were made in surveys by a relative: “I have no complaints about the care my mother has received at St Michael’s. She has been looked after extremely well. However, I do feel that from my mother’s point of view she sometimes needed more stimulating activities i.e. organised games, draughts, chess, cards, etc”. One social care professional who responded to the surveys commented as follows:“The service could improve by providing extra activities to give the clients something to do”. St Michael`s House DS0000032516.V359772.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Michael’s has a comprehensive complaints policy and procedure in place. The home had an open culture that allowed service users and others to express their views. Staff were aware of and knew the procedures for safeguarding vulnerable adults from abuse. EVIDENCE: The complaints procedure was outlined in the Service User Guide and displayed in the home. The home maintained a Complaints Record. There had been two complaints since the last inspection which had been investigated by the manager and amicably resolved. The CSCI had received no formal complaints regarding St Michael’s since the last inspection. All people who returned surveys confirmed that they were aware of the home’s complaints procedure. An inspection of the home’s Staff Training Programme found that staff had attended Protection of Vulnerable Adults Training. Any new staff in the home would undertake Vulnerable Adults training as part of their induction training. “Whistle Blowing” procedures are also provided for staff during their Induction. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 18 The manager and staff spoken with on the day understood the procedures for safeguarding adults. There had been two referrals made by the home which had been appropriately investigated under safeguarding procedures since the last inspection. All staff were provided with the General Social Care Council Code of Conduct booklet. All service users who were case tracked confirmed that they felt safe in the home and would be confident raising any concerns they might have with the manager or care staff and felt confident they would be promptly dealt with. On the day the inspector observed that service users appeared relaxed and confident in their approaches to all staff in the home. Staff were seen responding in a friendly, positive and respectful manner to all service users. St Michael`s House DS0000032516.V359772.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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is currently undergoing extensive renovation and refurbishment. There were reduced numbers of service users whilst work was being carried out and management had worked hard to limit the effects on service users. However, this has had an impact on long-stay service users. Despite the upheaval the home is to be commended for maintaining a clean, pleasant and hygienic environment. EVIDENCE: One requirement was made in this outcome area as part of the last inspection report for the home to ensure that the Registration Certificate was accurate. A new registration certificate was applied for and was issued by CSCI on 12th October 2007. It must be acknowledged that the extensive building works have had an influence on the quality outcome for this section. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 20 The inspector carried out a tour of the building. Several areas had been completed and bedrooms upgraded. Discussions took place with the manager regarding the disruption that having to move permanent residents has had on them. It was evident that every consideration had been given to this group of residents but those spoken with did feel that it had been a little disorientating. On the day of this inspection visit there were loud bangs and drilling sounds throughout the day which all service users found annoying. It is understood that the work should be completed by the end of April 2008. There were some concerns regarding security of the building which were discussed with the manager. It was noted that the wash basin waste outlet in service users bedrooms featured prominently under the basin and restricted the area where service users legs would be positioned if they were sitting to have their wash. As part of this inspection report a requirement has been made for the manager to risk assess this situation to ensure that it does not impact on the health and safety of service users. (Requirement 1). There are plans for a day care centre, social and health care workers and the Domiciliary Care service to be located in the home. Discussions took place regarding the impact this may have on service users. A requirement has been made for separate entrances/exits for the day care centre and offices of social and health care workers based in the building to reduce the impact on service users and care staff of the home. Consideration must also be given to maintaining the external patio areas for the benefit of service users. This will also promote the security of the building. Discussions and liaison will continue with the local authority regarding this issue outside of this report. (Requirement 2). As a consequence of the building works, there were reduced numbers of service users in the home. All bedrooms and communal areas in use had been updated and redecorated and service users were satisfied with the facilities available. The home was warm, clean and hygienic and it was clear that domestic staff had worked hard to maintain a tidy and pleasant environment. The following comments were made in surveys by service users and relatives:“Considering the work being done the cleanliness of the home is 1st class”. “The accommodation was very good”. St Michael`s House DS0000032516.V359772.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): 27.28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured that there are sufficient care staff with the skills mix to meet service users needs on duty at all times. Robust recruitment practices ensured that service users health and safety was protected. EVIDENCE: St Michael’s is registered to provide personal care to thirty people. On the day of this inspection visit there were six permanent, eight rehabilitation and eight assessment service users in residence. The home had sufficient staff to meet the needs of service users. Indeed, at the present time there was a surplus on some shifts. The home had a total of 41 staff with 26 care and 15 ancillary staff. The manager confirmed that there were no care staff vacancies as experienced staff had been redeployed from other establishments. The period of reduced numbers of service users had also enabled staff to attend training. There had been no recruits since the last inspection. The home had a high number of long-standing experienced care staff. Of the 26 care staff, 21 had attained National Vocational Qualification (NVQ) level 2 in Care and 3 were working towards this award. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 22 The manager confirmed that there were plans to incorporate the new NVQ in Rehabilitation at Level 3. Mandatory moving and handling training was up to date. A number of staff had attended Mental Capacity Act training and more had applied. The files of two care staff were inspected and found to be satisfactory. One of these staff was spoken with extensively by the inspector. She confirmed that she had received thorough induction and on-going training and that she was put forward for the majority of training that she applied for that related to her role as a care worker and increased her knowledge and understanding of the client group. She confirmed that she attended regular staff meetings and regular supervision sessions. She also stated that she enjoyed the change of focus of working in the rehabilitation unit which she found challenging but satisfying. She was key worker for several service users and in particular for one person who had been part of the case tracking for this inspection. The inspector spoke with them together and it was clear that there was a good working relationship with mutual respect and sensitivity. The following comments were added to surveys by service users and relatives:“The staff can’t be more friendly, excellent people without exception”. “They were very good to my wife whilst she was there. A very good place to be”. “Staff always show me respect. First Class”. “Couldn’t fault the care I received. The staff were friendly and efficient”. “I would like to say that all the staff have been very nice. On every visit I have found the staff to be helpful and the home is very clean and well run”. “The approach to the people living in the home is excellent, they treat them as individuals with utmost care and attention. I can go home with peace of mind knowing my mum is safe and well”. “The staff at St Michael’s are excellent. I have been looked after extremely well”. The following comments were added to a survey completed by a health care professional:“Staff are always guided by professional occupational therapists and physiotherapists. All skills are in the context of a multi disciplinary service”. St Michael`s House DS0000032516.V359772.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): 21,33,34,35,36,38 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 and managed by a person who is fit to be in charge and who upholds the best interests of service users. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The Registered Manager is qualified, competent and experienced to run the home. She has worked at St Michael’s for many years and both service users and staff benefit from the ethos and style of leadership she brings to the home. She has a clear understanding of the key principles and focus of the service. The service had undertaken a recent quality audit (QA) and this had been analysed. The result showed that service users were in the main satisfied with St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 24 the service. The manager was aware of the need to ensure that the outcomes of the QA are published to enable access by service users, relatives, prospective service users and other stakeholders. The home is allocated 8 hours administrative support and the Business Support Assistant was working in the home on the day. An inspection was carried out of the financial records and monies held for service users and these were found clear, accurate and satisfactory. Staff supervision records were monitored. Care Staff are supervised by Assistant Managers. The records showed regular supervision that covered all aspects of practice, philosophy of care in the home and career development needs. Ancillary staff were also subject to regular supervision monitoring. An inspection of maintenance records for the shaft lift, lifting equipment, hoists, gas and electrical appliances and legionella testing found all up to date and satisfactory. The fire safety records showed that there had been no individual fire risk assessments carried out for each service user in the home. It was also noted that night staff had not received three-monthly training as required by regulation. There were gaps in the weekly fire alarm record which indicated that the fire alarm may not have been tested each week as required by regulations. Requirements have been made as part of this report in relation to these issues. (Requirements 3, 4 and 5). The Registration Certificate was inspected and found satisfactory. There was current and appropriate insurance in place. Health and safety posters were displayed throughout the building as required. There was a full and accurate record of Accidents in the home and how these had been addressed. St Michael`s House DS0000032516.V359772.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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 3 3 3 x 2 St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 13(4)(a) Requirement Risk assessments should be undertaken in relation to the waste outlet of basins in service users bedrooms which may be a health and safety risk to people who wish to sit at the basin whilst carrying out their ablutions. Consideration must be given to providing appropriate entrances/exits to the offices, occupied by social and health care workers, the domiciliary care team and the day care centre, that will be located at the home. This will ensure that the daily visits of professional staff based at the home do not impact on the lives of service users and care staff. The home’s patio area must also be maintained for service users benefit. This will improve the security of the premises. Fire risk assessments must be carried out for all the people who use the service. This will ensure that there are adequate arrangements for their evacuation in the event of fire. DS0000032516.V359772.R01.S.doc Timescale for action 15/03/08 2 OP19 23(1)(a), 23(2)(a) 15/03/08 3 OP38 23(4)(c) (iii) 15/03/08 St Michael`s House Version 5.2 Page 27 4 OP38 23(4)(e) 5 OP38 23(4)(v) Arrangements must be made for 15/03/08 night staff to receive threemonthly training on the procedures to be followed in case of fire. This will protect the health and safety of people who use the service Regular weekly testing of fire 15/03/08 alarms should be carried out and records maintained. This will promote the health and safety of people who use the service 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 OP1 Good Practice Recommendations Consideration should be given to ensuring that prospective service users have written information about the services provided at St Michael’s prior to admission to the home so that they can make an informed choice about whether the service is suitable for them. St Michael`s House DS0000032516.V359772.R01.S.doc Version 5.2 Page 28 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. 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