Inspection on 13/06/06 for East Cosham House

This inspection was carried out on 13th June 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

East Cosham House 11/11/08

East Cosham House 20/11/06

East Cosham House 17/10/05

East Cosham House 25/04/05

East Cosham House 11/10/04

East Cosham House 11/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE East Cosham House 91 Havant Road East Cosham Portsmouth Hampshire PO6 2JD Lead Inspector Clare Hall Unannounced Inspection 13th June 2006 09:00 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 East Cosham House DS0000012360.V289183.R02.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. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service East Cosham House Address 91 Havant Road East Cosham Portsmouth Hampshire PO6 2JD 023 9232 1805 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 P Drabble Mr G Drabble Mrs Kim Ina Shelton Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (24) East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: East Cosham House is registered with the Commission for Social Care (CSCI) to accommodate up to 24 residents who are over 65 and have an age related mental health need. The home is a large detached property and is situated up a short drive; it is just off the main road through East Cosham and provides easy access to the town centre. The home has two gardens, one that is enclosed to the rear of the premises, with seating areas for residents. There are 18 single and 3 double bedrooms. The home has three communal lounges and a dining room, which are all pleasantly furnished and decorated providing a valuing environment for the people living there. There is parking for up to 6 vehicles. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook a visit to the premises and during the nine hours spent there, spoke with service users and their visiting relatives, the provider, the manager, deputy manager, care and ancillary staff. A full tour of the premises was also undertaken. A total of five relatives were spoken with and comment cards were provided to service users, relatives, visiting health and social care professionals and all of the homes staff were provided with comment cards pre inspection. Feedback has been considered and reflected in this report. Staff were also observed throughout the day assisting and supporting clients and their practices observed for good practice. Service users were observed making use of shared facilities and taking breakfast and lunch. Case tracking was undertaken as part of the evidence gathering process, with the involvement of service users. Information was requested from the manager four weeks prior to inspection to evidence that the service was operating in line with the National Minimum Standards. Unfortunately this information did not arrive at the Commission and was subsequently provided post visit but the outcomes will be included in this report. All contact with the home, events, Regulation 37 Notifications and Regulation 26 reports have been considered with the evidence collated throughout this visit to inform this report. Ten requirements have been raised as a result of this audit process, one of which have been raised previously and a previous recommendation regarding dementia mapping has been raised again. What the service does well: There are no concerns in respect of promoting core values and there are also some good practices in relation to supporting individuals with their social preferences. The manager has ensured the service users live in a well-maintained environment. The manager has completed appropriate management training and has been supervising staff appropriately. Quality assurance audits are undertaken and all relatives and service users spoken with were very complimentary regarding the staff and the quality of the environment. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Only one of three requirements raised at a previous visit have been met and the recommendation previously raised has been raised again, recommending the home develop dementia mapping to improve further the care provision. The current written contract/statement of terms and conditions were not consistently providing all the relevant information and the lack of preadmission information indicates that prospective service users needs are not being established or identified that they can be fully met. The care plan is not driven or informed by the pre admission assessment information. The service user’s plans of care need to be developed further and will also need to include assessment of mobility and nutrition. They also need to indicate that the mental health needs of clients are being addressed especially in respect of challenging behaviours. The practice observed for the administration of medicines was considered safe but the home needs to improve the accessibility to up to date medication references and recommended guidance. There has been a concern raised with the manager regarding the provision for adequate fluids and the identification of individuals with weight loss and the lack of nutritional risk assessment. A serious concern identified for which an immediate requirement was made to the registered manager at the time of the visit and subsequently followed up for by letter was the poor recruitment practices in the home. It was established that staff have been employed without the appropriate checks being undertaken. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 7 Improvements are also required for the improvement in safe bathing and for the prevention of cross infection. A tour of the premises identified that one toilet was without a wash hand basin and there were not adequate procedures and policies for the prevention of infection provided to staff. A further concern raised during the visit was that hot water provision in older parts of the home is being delivered without safety measures to control the temperature and ensure it is free from bacteria. It was also identified that the quality of risk assessments and associated actions to be undertaken needs improvement and the manager needs to ensure that service users are not placed at risk from the homes water provision. It was established that the manager does undertake quality assurance audits but the process requires significant development to ensure that all aspects of the provision of care are assessed and monitored and being delivered in line with the National Minimum Standards. 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. East Cosham House DS0000012360.V289183.R02.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 East Cosham House DS0000012360.V289183.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about where to live. The current written contract/statement of terms and conditions were not consistently providing all the relevant information. The lack of preadmission information does not indicate needs can be met nor does it inform the care plan. EVIDENCE: The inspector read the homes service user guide and statement of purpose. Service user guide states type and needs and category of residents accommodated and the level of support provided. Support from district nurses which equipments and hoist seen to support one elderly frail service user evidenced. The guide describes the physical environment and the room furnishings, which on a tour of the premises were seen to be to a good standard. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 10 All rooms and communal areas were visited and are decorated to a high standard. The home does not have a shaft lift but has a stair lift, which has recently been maintained. The statement describes the staff and managerial set up within the home, which is reflective of the current situation. The qualifications of staff are described and the statement states that staff are provided with regular supervision which records identified was taking place. Admissions it is stated are undertaken on a trial basis to ensure the clients’ needs can be met and that all clients are given a contract of terms and conditions and this was confirmed during conversations with staff and family. A description of social activities is also stated and the activities book identified that there is a good range of activities happening in the home. The home states there is constant dialogue between residents and relatives and staff regarding the operation of the home and that service users are provided with a satisfaction survey. These were seen and audited. The service users’ files were audited and letters to residents were seen to the next of kin /representatives stating what the charges were. A compliment letter was seen on one service user’s file stating, “ We do appreciate the considerable effort you and your staff have made to help X settle.” A new resident s file only had an invoice on the file with the terms and conditions of stay but there were no pre admission papers with assessments. Another resident’s file did not appear to have a pre-assessment paper prior to admission. One service user’s pre admission assessment document was not dated or signed by person filling it in and very poor information, some areas not completed at all i.e., religious and cultural needs, when they last saw the doctor, do they need the service of the district nurse and a statement to the effect of whether East Cosham House can meet their assessed needs. This had not been signed by the staff member who took the information was not dated and didn’t state where the information was sought. Another file seen held no assessment papers and the only other information seen on it was the agreement, which did not describe the room to be occupied. East Cosham House DS0000012360.V289183.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. The service users plans of care need to be developed further and include assessment of mobility and nutrition. There is a safe standard of administration of medicines but the home needs to improve the accessibility by staff to an up to date drug reference material and recommended guidance. EVIDENCE: The current service users’ plans of care are not generated from a comprehensive assessment and so do not fully reflect the basis for the care to be delivered. The service user’s plans audited did not adequately reflect the mental health needs of service users especially those identified with challenging behaviors, nor do they identify relevant health information such as weight loss despite regular review. Two service users were noted to have significant weight losses recorded but there were no auditable records of any actions taken within the care plan or daily records. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 12 It was established that assessments regarding nutrition and manual handling are not undertaken despite one resident currently being supported by district nursing service for specialist equipments and intervention for immobility. A file at hand in the utility room identified that the manager ensures that professional advice about the promotion of continence is sought. The care plans though do not reflect the reasons for incontinence or how the incontinence for individuals can be managed. Programmes for the promotion of continence and self-care are not being developed in the care plans. The service users daily records read do not fully demonstrate that the service user’s psychological health is monitored regularly and preventive and restorative care provided. Daily records identify statements regarding behaviors and health issues in good details but this is not then reflected in the care plan. The daily records maintained are not a continuum of the care assessment and actions identified in the plan. The care plans have been improved since the last inspection and the development of night care plans is considered good practice but overall the plans need further improvement. The inspector observed medication being given in a respectful, supportive and safe manner. It was identified that the homes drug reference was very old and the home does not have a Controlled Drugs register or the Royal Pharmaceutical Society Guidelines. The deputy manager explained that prescriptions are always secured and the MARS sheets printed by the chemists. It was also explained that the Community Psychiatric Nurse (CPN) gave medication training relating to dementia drugs over four hours to staff and that the local chemist has also provided medication training. Some staff have also undertaken training at Highbury College, which is over a six-week period for medications. Staff were asked what the home’s policy was for disguising medications and it was stated that permission of the relatives were sought before this is undertaken. Pharmacist consultation was not identified and the home will need to provide clear guidance to staff in relation to the covert administration of medications and for crushing. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 13 It was observed that service users have easy access to a telephone for use in private and receive their mail unopened. It was also established through chatting with staff, relatives and service users that service users wear their own clothes at all times. Admission records identify that staff actively seek the term of address preferred by the service user and during a tour of the premises it was confirmed that where service users have chosen to share a room, screening is provided to ensure that their privacy is not compromised when personal care is being given or at any other time. East Cosham House DS0000012360.V289183.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. There are no concerns in respect of promoting core values and there are also some good practices in relation to supporting individuals with their social preferences. Unfortunately there is a concern regarding the provision for adequate fluids and the identification of individuals with weight loss and the undertaking of nutritional risk assessment. EVIDENCE: The home’s statement of purpose states that care staff will ensure privacy and dignity are respected at all times and that this is demonstrated in the following ways. It states care staff will provide a level and standard of care, which meets the needs of residents whilst encouraging them to maintain the maximum amount of choice, privacy and independence. It was observed through-out the visit that staff were dealing with clients in a dignified manner and dealing with their needs in a sensitive manner. The statement of purpose states the residents have the opportunity to have consultations with professional and advisors in private and that residents are encouraged to maintain social contact with relatives and friends who may visit at any reasonable time. Relatives confirmed that they are treated with respect East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 15 and the inspector was told that they can hold small parties for their relative in the back lounge and that they are free to come and visit. One relative stated that the family members are encouraged to treat the home like their own and on the day of the visit relatives and friends were seen chatting with the residents and family members. Two relatives confirmed residents wear their own clothes and the term of address preferred by the resident was being established on admission. A tour of the premises identified that screening was being provided to those residents in shared rooms. An entertainments folder is kept with records of entertainment provided. On the day of the visit the residents and their relatives were enjoying an entertainer and singer. There is a log of all provided entertainment and this is quite extensive. One service user had it in his notes that he is being supported to cultivate his own tomatoes and staff were seen supporting him to look after them. The activities record indicated the following activities have taken place, board games, arm chair exercises, videos, sing along and making pictures. One service user was seen colouring. Overall very good records of entertainments and social activities are kept. One service user spoken to stated she was going off for the day to the day service, which she enjoyed. It was established that there are two service users that are supported to attend day services. One lady stated she used to go to day services when she was at home and this has continued after she moved into East Cosham. It was further established she goes to church on a Sunday and plays on the organ on a Sunday evening at the local Baptist church. An audit of the care records indicated that one client noted in care records to not be eating or drinking adequately did not have this identified in her care plan nor was an accurate record kept of foods offered. As there is a lack of formal nutrition assessment service users weight loss is not being managed as previously discussed. The day of the visit it was very hot and the inspector was concerned that the clients were not left with drinks nor were there drinks at hand .The manager stated that due to some challenging behaviors of residents and drinks cannot be left on tables. The inspector has asked the manager to address this as it is considered that the current arrangement is unsatisfactory. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 16 The inspector was informed of and shown the new EHO guidance provided to care homes called the safer food, better business guidance by the Food Standards agency. This guidance is self-explanatory and guides providers in how to reduce cross contamination by providing records for cleaning, chilling, cooking, management of catering facilities. Relatives complimented the home on the cleanliness of the kitchen. Eleven quality assurance feedback letters identified that service users were very happy with the food provision. East Cosham House DS0000012360.V289183.R02.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. It would be considered that residents are not protected by the homes recruitment practices. EVIDENCE: Adult protection procedures were seen on policies and procedures files and there was also a policy addressing aggression towards staff. The homes complaints procedure seen and read by the inspector identified that it has all the relevant information. There have not been any complaints made regarding the home since the last inspection. It was established when auditing the staff recruitment files that robust recruitment practices have not been undertaken, thus placing vulnerable persons at risk. A letter was seen on residents file acknowledging a receipt of application to vote by post. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The manager has ensured the service users live in a, well-maintained environment but one toilet was without a wash hand basin. Rooms were personalized but the homes procedures and policies for the prevention of infection need significant improvement. There is some question over the homes water in older parts of the home places not being thermostatically controlled. EVIDENCE: The inspector made a tour of the premises and overall the establishment is well maintained. Relatives complimented the homes décor and stated that it is clean comfortable and homely. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 19 Records indicate there is a programme of routine maintenance and renewal of the fabric and decoration of the premises is undertaken and implemented with records kept. The grounds were tidy, safe, very attractive with all the summer blooms and accessible to service users. It was noted that the dining room can only accommodate 16 service users but service users were observed taking meals in either of the two lounges. It was established that one upstairs toilet did not have a wash hand basin. The service users’ rooms were seen to be clean and well decorated and nicely furnished. An adjustable bed was seen provided for service users indicating this need. Discussions with the manager and provider did not establish that water is stored at a temperature of at least 60oC and distributed at 50oC minimum, to prevent risks from Legionella. Temperature records could not be evidenced and a bacterial test of the water has not been undertaken. Some of the older rooms do not have mixer valves. One-service users rooms’ water was tested by the inspector and was hot to touch. Despite the premises being clean and hygienic throughout the systems in place to control the spread of infection are not in accordance with relevant legislation and published professional guidance is not available. Articles, clothing and linen were seen being carried by a member of staff who was not wearing an apron and no receptacle was being used. It was further noted that the laundry floor and wall finishes need some attention to ensure they are impermeable and these and wall finishes are readily cleanable. The rusty surfaces on the fridge units in the utility must also be given some attention. The home’s current policies and procedures for control of infection do not adequately address the safe handling and disposal of clinical waste, dealing with spillages, provision of protective clothing and hand washing. The home does not have a sluicing facility. During the visit the provider and manager enrolled on the local infection control training provided to managers of care homes and contacted the public health nurse to get information regarding infection control procedures. The provider and manager demonstrated a keenness to address this shortfall. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 20 The audited maintenance folder indicated lockable space and cash boxes have been provided to all service users and it identifies all the up keep and maintenance of all the bedrooms. One relative stated “Lovely home, good points is that its homely, this is like a living room, its a good size, we have made good use of the gardens and staff know the needs of the residents. My mother became unwell and was moved downstairs due to the difficulties with her mobility. Another relative stated, “Nice staff, I come three times a week and I looked at other homes and this was the best “. Three other relatives stated the home seems friendly and decorated nicely. Records identified that eight staff have undergone food hygiene training. East Cosham House DS0000012360.V289183.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. Service users are not supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staffing numbers observed throughout the visit appear appropriate to the needs of the residents at that time. The home has separate cleaning maintenance and kitchen staff. The provider confirmed that there is a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent). Three staff files were audited and the manager has failed to ensure that two written references are obtained before appointing a member of staff, and that any gaps in employment records are explored. It was established that that all new staff are not confirmed in post only following completion of a satisfactory police check, and satisfactory check of the Protection of Vulnerable Adults. The homes current application form does not allow for the relevant information required to be recorded and needs further development. Forms of identification were not on files and nor were there interview notes. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 22 Files did not indicate that terms and conditions are consistently provided and signed for by staff nor that they were signing to state they have been provided with relevant information i.e. the homes policies and procedures prior to starting work. The last three employed staff was working prior to relevant and necessary checks being undertaken. Care workers surveys and training records indicate staff undertake training in challenging behaviour, basic food & hygiene, infection control health and safety and dementia awareness. Comments received in one comment card was that the “home offers good training courses”. East Cosham House DS0000012360.V289183.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The manager has completed appropriate management training and has been supervising staff appropriately. Quality assurance audits are undertaken but the process requires significant development to ensure that all aspects of the provision of care are being delivered in line with the National Minimum Standards. The quality of risk assessments needs improvement and the manager needs to ensure that service users are not placed at risk from the homes water provision. It would be considered that residents are not protected by the homes, bathing procedure and the current practices for the prevention of cross infection. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 24 EVIDENCE: It was established during the visit that he manager has just completed her NVQ 4 and will start her RMA later in the year. Staff Job descriptions were seen and the manager states these are not kept on the files but given to staff. It was stated by the inspector that a record of evidence to identify these were given to staff should be kept. All staff within the home was given the opportunity to comment on the home. Service users record audited indicated chargeable items and receipts clearly indicating charges for hairdressing and chiropody. The inspector viewed a folder provided to staff giving them Information and guidance on cares practices. Within this folder there was a health and safety policy dated 2003, a document on mental health problems in old age include both functional and organic illness and continence guidance from the continence foundation written August 1994. Other policies and procedures seen were also out dated and in need of review. One service user had a risk assessment on her file with no date. It stated that she likes to spend a lot of time in her room and does use the taps independently. The risk assessment stated that the service user would react to an uncomfortable stimulus (hot water) so it is likely she would withdraw her hand if the water were too hot. It further stated that there is some risk that she could burn herself with hot water and that staff should be vigilant for any areas of redness on her hands and reports this immediately to a senior and who will enter the details on the accident book. The inspector then checked this service users bedroom water and it appeared hot but home has no thermometers. The manager states she doesn’t undertake temperature checks but someone comes in annually to do it. There are no records available to audit. Following a phone call between the manager and the plumber it was identified that some of the older water outlets have not got thermostatic controls on them. One concern identified was that the bathing procedure which states: “ To run a bath put cold water in first”. The deputy manager during a tour of the premises also referred to this and stated when bath is run the staff are always told to put the cold water in first. There are no bath/water thermometers available. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 25 It was observed that the home’s infection control procedure of half a page is not adequate in detail and would not direct staff safely in ensuring the prevention of cross infection. Observed staff practice when handling dirty linen also raises concerns in respect of cross infection. All of the three staff files had up to date and regular records of supervision on them with up to date appraisals. Quality assurance questionnaires were also seen and of the thirteen read it was established that the majority of responses were positive. The provider explained that Annual reviews are taking place with the resident and their relatives and it will be at this meeting that satisfaction surveys will be undertaken and the care plans will be discussed and agreed. This was considered good practice. The homes questionnaire will require some further development along with the providers current Regulation 26 notifications in respect of ensuring all aspects of the home in relation to the National Minimum Standards are audited in view of Inspecting for Better lives and the new process of visits undertaken by the Commission and this was discussed with the provider and manager. Comments received were that staff were kind, there was satisfaction with the care provided and confirmations that staff always knock before going in service users rooms and that rooms are comfortable. East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 27 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 OP30OP26 Regulation 12-13 Requirement The registered persons must consult the environmental health department with regard to guidance to promote best staff practices in the areas of food hygiene and infection control. Appropriate staff training will be put in place in line with the recommendations of the environmental health department. This requirement was raised at the last visit and has been partially met. The manager must ensure all service users are provided with s a written contract/statement of terms and conditions that reflect all the information as stated in standard two. The manager must ensure that no service user moves into the home without having had his/her needs assessed and been assured that these will be met as described in standard three. The manager must ensure that care assessments/plans are reflective of service users needs DS0000012360.V289183.R02.S.doc Timescale for action 15/09/06 2 OP2 5 15/09/06 3 OP3 14(1) 15/09/06 4 OP7 15(1) 13,12,14 15/09/06 East Cosham House Version 5.2 Page 28 and identify behaviours that may challenge and how staff are to deal with this. These must also be based on the outcomes of adequate assessment, especially for manual handling, continence and nutrition. 5 OP9 13,17(1) a The manager must ensure the 15/09/06 staff have access to The Royal Pharmaceutical society Guidelines, a controlled drug log and a policy for the crushing of medication and an up to date drug reference. Consultation must take place 15/09/06 with the Public health Nurse regarding the homes infection control procedures, and address the toilet without a hand washbasin. Staff must be provided with the necessary information so as to prevent the risk of infection. The staff must only be employed 14/06/06 after all the necessary information detailed in Schedule two has been secured and is found to be satisfactory. The process for the audit of the 15/09/06 homes standards must be developed as well as the development for regulation 26 reports. Audit must be continuous and monitor the National Minimum Standards and seek the opinions of all stakeholders and persons who have dealings with the home. 15/09/06 The homes policies and procedures must be reviewed and demonstrate current best practice and the staff must be provided with up to date guidance/magazines or references to support dementia care in care homes. The manager must ensure that 15/09/06 DS0000012360.V289183.R02.S.doc Version 5.2 Page 29 6 OP26 13,16, 7 OP29 OP18 Schedule 2 8 OP33 24 9 OP33 10,12 10 OP38 13 East Cosham House service users are not placed at risk by hot water and must ensure that the homes water system is free from Legionella. Regular recorded checks of the water must be undertaken and the homes written and practiced bathing procedure reviewed in line with safe practice. 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. Good Practice Recommendations It is recommended that dementia mapping be introduced to the home. OP12 East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 East Cosham House DS0000012360.V289183.R02.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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