Inspection on 23/05/06 for 14-15 St James Road

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

14-15 St James Road 03/09/08

14-15 St James Road 05/03/08

14-15 St James Road 27/09/05

14-15 St James Road 25/04/05

14-15 St James Road 22/11/04

14-15 St James Road 15/07/04

14-15 St James Road 16/03/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 14-15 St James Road 14-15 St James Road Exeter Devon EX4 6PY Lead Inspector Stephen Spratling Key Unannounced Inspection 23rd May 2006 9:00 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 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 14-15 St James Road DS0000021830.V290776.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 Adults 18-65. 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. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 14-15 St James Road Address 14-15 St James Road Exeter Devon EX4 6PY 01392 670160 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) Mrs Deborah Veronica Phillips Mr Warwick Nicholas Phillips Nebojsa Jokanovic Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The manager must obtain the Registered Manager’s Award by 1st December 2006 The manager must obtain NVQ 4 in Care or Registration as a 1st level Nurse with the Nursing and Midwifery Council by 1st December 2006 27th September 2005 Date of last inspection Brief Description of the Service: 14-15, St. James Road cares for a maximum of seventeen people, both men and women who have or have had a mental illness and who are between the ages of eighteen and sixty-five. The home comprises two adjoining semidetached houses, which have an intercommunicating door at second floor level. To the rear of one is a small garden and to the rear of the other is a patio. One house has a roof garden accessible from the first floor. Each house has its own kitchen and living rooms. The home is situated in a residential area close to the city centre. The home’s statement of purpose says that at the home “therapeutic care is delivered…To enhance personal esteem and confidence.” And to help service users “To achieve or regain individual life skills required to attain or return to a more fulfilling lifestyle.” Currently the fees of between £375 & £500 are charged. Copies of the inspection report are available from the home manager. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over six hours on Tuesday 23rd May 2006. The home manager was on leave at the time of this visit so a second visit of about two hours, by appointment, was made on the 12th June 2006 to gather additional information and meet with the manager. During the course of the inspection the inspector spoke with eight residents, three members of care staff, the manager and one of the owners of the home. He looked closely (case tracked) the care of three residents, speaking with them, staff who care for them and reading their care records. He also looked at other documents/records e.g. policies, maintenance records and recruitment records. The inspector also walked around the shared areas of the home, looked in some of the private rooms and walked around the grounds. Before the inspection site visit the inspector sent out a total of 22 questionnaires, seeking peoples views about the home. Questionnaires from six residents, two care staff, one doctor and three from care managers were returned. What the service does well: What has improved since the last inspection? Some areas of the home have been decorated and some repairs made. Safety checks on electrical wiring have been done. All fire doors seen were appropriately secured or held open with automatic closure devices. Care plans are now regularly reviewed. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 6 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. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information about the service and good assessment practices helps to ensure that prospective residents needs could be met at the home. EVIDENCE: One resident, admitted since the last inspection, said they visited the home before deciding to move in; they did not remember receiving anything in writing about the home but felt they had been given enough information about what to expect to allow them to make a positive choice to move in. All six residents responding to the Commission questionnaire answered yes to the question “did you receive enough information about this home before you moved in so you could decide if it was the right place for you?” The home’s statement of purpose provides basic information about the service and what can be expected; some inaccuracies need to be amended. Three residents’ care records read by the inspector contained varied relevant and fairly detailed assessment information; with some provided by hospital staff and care managers and then further developed through the homes own assessments. A staff member said that they had been provided with “good assessment” information about two residents admitted since the last inspection, to help them know what care and support they would need. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning provides some of the information needed by staff to care for residents, but improvement is needed to ensure all the needs residents have are recognised and met. Residents benefit from the home’s respectful approach to their right to choose how they spend their time, but risk assessments should be done to ensure that threats to residents’ personal safety and/or wellbeing are managed in the best way. EVIDENCE: Three care plans were read by the inspector. All three contained good description of basic needs and how they should be met, some had description of individual’s goals and limited recognition of risks to individuals’ wellbeing and how they should be responded to. One resident told the inspector about their long-term goal for more independence and wish to return to work but their care plan did not provide adequate description of how the home would help them to work towards these goals. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 10 All care plans seen showed evidence of regular and recent review. A staff member who is a “key worker” for 2 residents said that she is involved in reviewing care plans. Residents asked were aware of their care plans and confirmed they are invited to contribute to them. Two of the longer serving staff members displayed a good knowledge of residents in their care but were not clear about the goals of care and how these goals might be achieved (see Staffing). In discussion with the manager he described clear strategies for promoting the independence of particular residents but acknowledged these strategies are largely not reflected in care plans. All six residents responding to the Commission questionnaire indicated they are free to do what they want to do. All spoken with confirmed that they come and go as they please, spending time where and with whom they chose. Only one recorded individual risk assessment was seen in relation to one area of risk for a resident in all three files seen. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are limited opportunities for personal development within the home, but many service users find that the home meets their needs. Food provided at the home is generally adequate. EVIDENCE: One resident wrote on their commission questionnaire that St James Road is a “great place to live”. All residents spoken with and completing questionnaires indicated that they are free to come and go from the home as they like and spend time as they like. The home’s statement of purpose indicates that the service works to promote the independence of residents. One resident, at the home several months, who 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 12 spoke with the inspector said that long term they would like to live more independently and to return to employment. However they said and their care (diary) records also indicated that they had not been involved in any structured activity within the home (e.g. shopping, cooking, budget management), work or educational activities outside since arriving at the home. Staff told the inspector that this person did have weekly contact with a community rehabilitation worker and that efforts to access supported work placements had so far been frustrated by lack of available places. In a questionnaire this resident’s care manager indicated they believe the home works well to help residents develop independent living skills. Since the inspection the home manager has explained that activities are offered but residents always decline to take part in what is offered. Staff said that some residents attend educational activities in the community and one resident spoke about attending a local college adult education class. Other residents mentioned attending local community groups and playing snooker, two residents were going swimming on the day of the inspection. Two residents living in one area of the home confirmed that they each cook once a week and with staff support keep that part of the home clean and tidy. Staff said that all but one of the residents can go out alone; the one person who needed to be accompanied had a care plan that directed staff to encourage and escort them out every day. Diary records read for one month indicated that this had happened eleven times in that 28 day period, the resident was unable to comment but staff said that they go out most days but that it is not always recorded (see conduct and management); the manager also said that this was the case. Two staff completing questionnaires indicated that they think the service could be improved by offering more opportunities for residents to be active outside the home. When discussing a particular resident a staff member was able to demonstrate a clear knowledge of their extended family and relationships. Residents confirmed they can see who they wish and have visitors. The homes statement of purpose also confirms that visitors are welcome at the home and can stay for meals. All residents asked said they like the food provided. Residents have free access to the kitchen and were seen helping themselves to drinks. Care Records showed evidence of specific dietary needs being considered e.g. weight loss; but this guidance was very general in nature. Staff said that one person had seen a dietician, but this advice did not appear to have been incorporated into a care plan nor was it influencing the diet this person received nor the menu provided. The manager said that he and staff try to encourage healthy eating but no specific provision is made; he indicated that residents are not motivated to follow diets. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 13 Menus seen for the hot meal of the day offered variety over the week but no choice and did not offer any special diets, although the manager said that residents only have to ask is they want an alternative. A recent survey conducted by the home showed mixed views about the food provided with some residents happy and some requesting more choice. The manager reports that residents are asked what they want on the menu each week. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health care needs of residents are well met with residents being helped to access health care as they need it. The management of medication is poor and places service users at risk. EVIDENCE: Staff said that only one resident needed direct assistance with their personal care and this person was seen to be well groomed. Others receive some prompting and the need for this was described in care plans read. The inspector was told by several residents and saw in records that they have regular access to medical and community psychiatric nurse (CPN) support. A CPN and a social worker responding to questionnaire confirmed confidence that the home works in partnership with them, that they believed their clients medication was managed properly and an overall satisfaction with the service. A psychiatrist and a GP responding to Commission questionnaire indicated that the home communicates with them clearly and overall confidence in the care provided at the home. Residents confirmed they can see a doctor when they want. Diary entries showed reference to residents being accompanied to clinic appointments and the dentist. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 15 The inspector observed that medications were left in labelled pots unsecured in the lounge when no staff were present, two residents and a staff member confirmed that residents “help themselves” to the pot with their name on when they get up; this is a dangerous practice as it increases the risk of residents taking the wrong medication. Staff were asked to secure medications which they did. Medications are stored in an unlocked file cabinet in a locked office. Three medication charts seen were properly completed. One resident’s care plan and medication sheet indicated that they manage some of their own medication; there was no evidence of a risk assessment having been conducted nor record of how this was monitored despite this persons care assessment noting that they have a history of not taking their prescribed medication. Care staff reported having received training in administration of medication from the manager. The home’s medications policy was read and does not provide adequate detail to guide staff e.g. it does not describe the procedure to be followed when a resident wants to manage their own medication. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confidant that their complaints will be taken seriously and that they are protected from abuse. EVIDENCE: All six residents completing Commission questionnaires confirmed that they know who to speak to at the home if they are unhappy and that they know how to make a complaint. All residents spoken with said that they can speak with staff or the manager if they have a concern and that where possible something is done. The manager said and staff spoken with confirmed, that all care staff (excepting one new member) have attended Protection of Vulnerable Adults training. Staff spoken with demonstrated an understanding of their responsibilities to report abuse. The home has a procedure document to guide staff in recognising and reporting abuse, though some amendments were recommended to make it more user friendly. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home is comfortable and pleasant to live in. However the poor state of the kitchens makes it impossible to maintain satisfactory standards of hygiene. EVIDENCE: The inspector walked around the shared areas of the home and looked in some of the private bedrooms. Most of the bedrooms were basically but adequately furnished, the hallways and most of the woodwork in the home has been repainted since the last inspection, brightening up the home and a new shower room is being installed. The kitchens still need refurbishment, cracked work surfaces being impossible to keep properly clean. The owner said this is planned for September 2006. The patio and gardens were clear of rubbish and accessible. Residents said they are happy with the accommodation provided, that it is kept generally clean and that they are content with pace of maintenance. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are kind and have personal qualities which mean they are liked and trusted by residents, however they do not have the training/knowledge they need to ensure they know how to care for and promote the independence of residents in the safest and best way possible. Recruitment practices are not sufficiently robust to protect residents from people who are not suitable to work with them. EVIDENCE: The home’s statement of purpose states that the “therapeutic care is delivered…To enhance personal esteem and confidence. To achieve or regain individual life skills required to attain or return to a more fulfilling lifestyle.” It goes on to say that “ staff attend courses outside to meet specific needs of service users.” As noted earlier one of the three residents case tracked was admitted to the care home with the goal of regaining the skills to live more independently. Some care staff have no experience of caring for people with mental health difficulties prior to working at this home. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 19 Record of the issues covered during staff induction was seen in one recently employed member of staff’s file and included looking at policies, being familiarised with house routines, issues relating to health and safety, and some of the common mental health difficulties people experience. Another very recently employed member of staff said they were being given a lot of information and support as new member of staff and were enjoying their new job. The manager reported that the home does not have a training budget and a training needs assessment for care staff had not been done, evidence was not available that staff have received up to date training in food hygiene, first aid, health and safety. The manager said three care staff have first aid certificates. Care staff have not received any formal training to help ensure they have the skills needed to meet the needs of people with mental health problems in the best way. They did however report that the manager provides informal training about issues affecting residents. When discussing individual residents with the inspector, staff displayed a good knowledge of residents’ personal details. Of three care managers responding to the commission’s questionnaire two said they believe staff demonstrate an understanding of the care needs of residents and one said they were unsure if staff have a clear understanding. Staff and residents confirmed that there are always at least 2 staff on duty during the day and two sleeping in at night. All residents spoken with were positive about staff with one person describing them as “friendly and kind”. Three staff recruitment files were seen: one was almost complete but did not contain up to date references; in the other two, Criminal Records Bureau/POVA first checks had not been received before the person had started working in the home as they should have been. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager runs the home in the best interests of residents. However the lack of a systematic approach to a managing the service means that the quality of the service provided and the health and safety of residents are not suitably monitored and assured. EVIDENCE: The manager reported that he has nearly completed the registered managers’ award and the inspector was shown a letter from a national qualifications board confirming that his Nursing Qualification, achieved outside the UK, is equivalent to NVQ 3 in care. The manager demonstrates a good understanding of the needs of residents at the home and can describe strategies he employs to support them and promote individuals’ independence and quality of life. The inspector is aware of a number of occasions over past months where the manager has advocated strongly for residents. Residents spoken with indicated 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 21 that they like and trust the manager and owners. Care staff completing Commission questionnaire indicate they are well supported by the manager. The inspector was shown results of a recently conducted quality survey, which asked residents views about elements of the service. The manager said that comments made on the survey had been discussed with the owners. There are no other systems in place to monitor the effectiveness of the service or to ensure that the aims and objectives of the home are met and improvements needed are recognised and acted upon. The home’s policy file was seen; it was not in good order, and it was difficult to find specific policies within it. Most policies seen had not been reviewed since November 2003. From discussion with staff and the manager and reading the care records (diary records) of three residents it was apparent that these records do not provide an accurate or sufficiently comprehensive reflection of care/support provided (see Lifestyle outcome group). A gas safety certificate dated 12/06/06 was seen and since the last inspection an up to date electrical wiring safety certificate has been seen by the inspector. Records seen indicated that the fire alarm is tested every week and two fire extinguishers checked were dated as having been serviced within the last year. Records of staff training were not available and the manager confirmed that staff are not receiving fire training as regularly as recommended by fire officers (quarterly for night staff and twice a year for day staff), though staff confirmed that some of them and residents had recently taken part in a fire drill that went well. An environmental risk assessment has been conducted but this does need more information about what control measures were being put in place where raised levels of risk were identified e.g. how the home is to minimise the risk in relation to individual service residents smoking in their rooms. Upper floor windows do not have restricted opening and individual risk assessments regarding restricting upper floor windows have not been done as previously recommended. As mentioned earlier (see staffing) evidence was not available that staff have received up to date training in food hygiene, first aid, infection control or health and safety. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 2 2 2 1 X 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13 (2) Requirement The registered person must make arrangements for the… safekeeping, safe administration… of medicines... (Previous requirement timescale of 29/12/05 not met) Medicines must be given directly to the person they are intended for at the time of administration and should not be left unattended and unsecured 2. YA24 23 (2) (b) The registered person must, 01/10/06 having regard to the number and needs of the service users ensure that the premises are of sound construction and kept in a good state of repair externally and internally. Kitchens needs to be refurbished Previous requirement timescale of 25/04/06 not met Timescale for action 24/05/06 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 24 3. YA32 YA42 18 (1) The registered person must having regard to the size of the care home, the statement of purpose and number and needs of service users(c) ensure that person employed to work in the care home receive training appropriate to the work they are to perform. All care staff should receive up to date training in relation to food hygiene, infection control, health & safety and care of people with mental health problems 12/12/06 4. YA34 19 (1) The registered person must not employ a person to work at the care home unless (b) he has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of schedule 2. Current references and Criminal Records Bureau checks must be obtained before a new member of staff starts working in the home. 12/06/06 5. YA42 13 (4) The registered person must make sure that suitable arrangements are made for the training of staff in first aid. 12/12/06 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 25 6. YA42 13 (4) (c) The registered person must make sure that risks to the health and safety of residents are identified and so far as possible eliminated. Risks to individual residents regarding smoking in bedrooms and unrestricted upper floor windows should be assessed, recorded, kept under review and suitable control measures implemented 12/09/06 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 YA6 Good Practice Recommendations Care plans should reflect all needs and how they are to be met e.g. how a resident is to be supported to develop/retain their independent living skills; how identified risks to wellbeing are to be minimised. Risks to residents’ personal safety and welfare should be assessed and where risks are identified strategies developed, recorded in care plans and action taken to minimise them. Staff should enable residents to have opportunities to maintain and develop independent living skills. Where care needs assessments identify that a resident wishes to develop their independent living skills they should be actively supported to help plan, prepare and serve meals. 2 YA9 3. 4. YA11 YA17 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 26 5. YA20 The registered manager and staff should encourage and support service users to retain administer and control their medication, within a risk management frame work, and comply with the home’s policy and procedure for the receipt, recording, storage, handling and administration and disposal of medicines. (The home’s policy needs developing further) Medicines in the custody of the home should be handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society of Great Britain and the requirements of the Misuse of Drugs Act 1971. Care staff should receive accredited training; training should include basic knowledge of how medicines are used and how to recognise and deal with problems in use; the principles behind all aspects of the homes policy on medicines handling and record. 6. YA32 Staff should have skills and experience necessary for the tasks they are expected to do, including knowledge of the specific conditions of service users; techniques of rehabilitation and recovery. A staff training needs assessment should be conducted and recorded, and a training and development plan developed. The home should have a staff training budget and each staff member should have at least five days paid training and development training a year. 7. YA35 8. YA39 The quality assurance activities currently implemented need to be developed to ensure that they effectively measure the success in achieving the aims and objectives and statement of purpose of the home. An improved system should also be used to help identify where improvements in the service could be made and to ensure that the views of residents are noted and where possible acted upon. Policies and procedures should be kept in good order to allow ease of use. Policies and procedures should be reviewed, updated as required, and signed & dated by the registered manager. 9. YA40 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 27 10. YA41 Care Records (daily care diary) should be maintained so as to reflect accurately the wellbeing and activity of residents on a day-to-day basis. 11. YA42 It is recommended that the home follow Devon Fire and Rescue service recommendation that staff receive fire training twice a year if working on days and four times a year if working nights. 14-15 St James Road DS0000021830.V290776.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 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 14-15 St James Road DS0000021830.V290776.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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