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Inspection on 28/10/05 for Richmond Mews Nursing Home

Also see our care home review for Richmond Mews Nursing Home for more information

This inspection was carried out on 28th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Most of the standards inspected on this occasion were fully met. It was quite clear that the service aims to meet its stated purpose at all times and the staff commitment to the service user needs is satisfactory. Over the two days of inspection, the premises were clean, tidy and comfortable. Interaction between staff and service users was respectful and friendly. On the whole, staff were approachable, interested in the service users, motivated and committed. The home provides all necessary equipment to meet the service users` physical needs and ensures that they have access to all primary and specialist health care as needed. The establishment ensures safe working practices for all service users, staff and visitors to the home by having in place all the relevant safety checks, services and inspections as well as risk assessments that minimize risk from potential or actual hazards.

What has improved since the last inspection?

Some requirements were made during the last inspection. Given the time scales, the home has responded very well and met all except for one of the six requirements made. The one that was not met is still well within its time frame. The contracts had been amended to meet the specified requirements and where possible service users were now signing the documents. All areas that were highlighted in the last inspection as needing risk assessments have now been carried out. Water temperatures have now been readjusted to meet the required safe temperatures and all open bins have now been replaced with lidded bins in the interests of infection control.

What the care home could do better:

Some areas were found lacking during the course of this inspection. Requirements and recommendations have been made accordingly. The first one was that of medication where some creams were not labelled and dated on the day of opening. On some remedies there was no indication as to who the medication was intended. There was evidence to show that there was one member of staff who had not received a full induction and more staff stated that they did not have regular supervision, the unit that supervision records were requested was unable to produce these. Finally, there were two fire extinguishers had not been tested for nearly two years, in the interests of safety, a requirement was made for these to be tested.

CARE HOME ADULTS 18-65 Richmond Mews Nursing Home Richmond Terrace Shelton Stoke-on-Trent Staffordshire ST1 4ND Lead Inspector Lorraine Mavengere Announced Inspection 10:00 28 October 2005 Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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 Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Richmond Mews Nursing Home Address Richmond Terrace Shelton Stoke-on-Trent Staffordshire ST1 4ND 01782 263387 01782 209800 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) Richmond Care Homes Limited Angela B Warrilow Care Home 48 Category(ies) of Learning disability (48) registration, with number of places Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. LD aged 18-60 years on admission Date of last inspection 3 August 2005 Brief Description of the Service: Richmond Mews consists of eight flats that surround a central courtyard as well as an annexe that is situated across the road and away from the main building. Each flat is self-contained in that they each can accommodate between one and eight service users, have their own kitchen, bathrooms, lounges and dining room. All of the flats have single bedrooms with six of those having en-suite facilities. The home has a central laundry.Each flat, apart from flat eight, provides both nursing and personal care for young people who have a learning disability. Flat eight provides personal care and support. The service users may also have varying degrees of behavioural problems or a physical disability. Each flat has its own enclosed garden area. There is a car park to the side of the property.Richmond Mews is situated within a residential area of Stoke on Trent that is close to Hanley town centre and all local amenities.Service users are able to access day facilities at Regent College, part of the Richmond Care Homes Ltd. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The size and layout of Richmond Mews meant that the inspection was span over two inspection days in order to adequately cover all relevant standards. During the inspection, many staff and service users were spoken to. It was difficult to get opinions from a lot of the service users due to their communication needs but some were able to give feedback. Information for this inspection was gathered through close examination of records, the home’s practices, staff and service user feedback, case tracking, direct and indirect observations and the pre inspection questionnaire that was completed by the registered manager. In total, 21 standards were inspected. These were the remainder of those that were not assessed during the unannounced inspection that took place earlier on this year. What the service does well: What has improved since the last inspection? Some requirements were made during the last inspection. Given the time scales, the home has responded very well and met all except for one of the six requirements made. The one that was not met is still well within its time frame. The contracts had been amended to meet the specified requirements and where possible service users were now signing the documents. All areas that were highlighted in the last inspection as needing risk assessments have now been carried out. Water temperatures have now been readjusted to meet the required safe temperatures and all open bins have now been replaced with lidded bins in the interests of infection control. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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 Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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): Standards Not Assessed on this occasion. These standards were fully assessed during the last inspection and were fully met with the exception of standard five that had minor shortfalls. EVIDENCE: During this inspection, the requirement made in the last inspection for all the areas specified in standard 5.2 to be included in the service user contract has now been fully met. Where possible, the registered manager facilitates for service users or their representatives to sign their contracts. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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): 7, 8, 10 Service users’ rights to make decisions about their own lives is respected, that right is only ever restricted when a risk has been identified and the appropriate risk assessments have been put in place. Service users are facilitated in as much as possible to take part in the daily running of the home. Information concerning service users is handled in accordance with the home’s policy and is in line with the Data Protection Act 1998. EVIDENCE: Records seen during the inspection showed that the care plans had information on how each individual expresses choice and makes decisions. This is an extremely necessary part of the care documentation given the communication difficulties faced by some of the residents of Richmond Mews. Although none of the relatives were spoken to during the inspection, staff were able to confirm that some service users are facilitated in making choices about their lives and relatives are invited to help in this process. Some of the staff spoken to stated that the home does not carry out service user meetings for all the residents due to the limited nature of their communication. Those that are able to Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 10 benefit from the meetings do participate in them. The care plans seen demonstrated that service users were fully consulted about their daily lives. Staff spoken to showed knowledge on service users likes, dislikes and preferences. Observed practice showed that the home endeavours, as far as possible, to promote participation from the service users in the running of the home. Staff were seen using verbal and non verbal communication to facilitate participation. On the whole, discussions with various members of staff highlighted that due to the service users limited communication, it was extremely difficult for them to fully participate in the running of the home and in the making of major decisions in some of the flats. There some service users who are fully capable of participating in the running of the home. These service users were spoken to and were indeed very expressive about their experience of being at Richmond Mews. In fact the inspector had tried on a number of occasions to speak to this particular group of service users but they had been otherwise engaged in their daily routines and hobbies. The inspector finally caught up with them just as they were about to leave for the gym. It was quite evident from discussions with this group that they pretty much dictate what happens within their living space. This is supported by staff through provision of necessary information to enable them to make informed decisions. The home has a comprehensive policy on confidentiality that was seen during the inspection, the home’s current practices are in line with this. All confidential records are stored and maintained in accordance with the Data Protection Act 1998. Service users are given information within their service users guide about the home’s policy on confidentiality. The registered manager also confirmed that this is also explained verbally to them. The home also has an Access to Records policy. It is stated within this policy that service users have the right to access any information held by the home about them. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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): 12, 16, 17 Service users access training and education, and/ or take part in valued and fulfilling activities. The home’s daily routines support and promote independence. All restriction are agreed in the individual care plan and serve to uphold the safety and well being of the service users. Services users are offered a healthy and varied diet that is in line with their preferences and dietary needs. EVIDENCE: Records show that the residents of Richmond Mews access a variety of day time training/ educational and recreational facilities depending on their assessed needs and preferences. Some service users access a near by day centre, others attend college while others do a mixture of both. Some of the service users spoken to stated that they incorporate their leisure and recreational interests into their daily living. This particular group were going to be attending a gym session that afternoon. The home also offers trips out and individualised activities where this has been assessed as necessary. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 12 Some of the residents are only able to go out on a one to one basis- this too is facilitated. Observed practice showed that staff only enter service users’ bedrooms and bathrooms after knocking first. They only entered with the service users’ permission. Discussions with the registered manager confirmed that service users are offered keys but not all of them have the capacity to use them. This is highlighted in their care records. Observed practice also showed staff interacting with service users and taking time to understand their needs. Service users were seen to decide whether they wanted to be in company or whether they wanted to be on their own. A number of the service users at Richmond Mews are restricted in the areas that they can access within the home. Discussions with the registered manager confirmed that the restrictions were as a result of assessed risk and was in the best interests of the service users. The manager also confirmed that those who are able do take part in the household tasks can do so, this is specified in their care plan. Menus seen showed that the home provides nutritional, wholesome, balanced and varied meals. The inspector had the opportunity to share lunch with the service users in flat 2 and was also able to observe breakfast on the Monday morning. Both these meals showed that service users are offered choices and are assisted in a respectful and unhurried manner. Records show that the home caters for soft diets and gluten free diets. Various staff spoken to stated that service users on special diets are risk assessed accordingly. The menu plans have a nutritional checklist attached to them. Staff explained that the purpose of these checklists is to ensure that all the food groups are included in the meals. Records also show that provision is made for the five a day portions of fruit and vegetables. The home has a Food Safety and Hygiene policy in each flat. A Food Hazard Analysis was also seen in flat 2. This covered the purchasing of food, storage, preparation and cooking. The home takes and records fridge and freezer temperatures daily. Staff spoken to stated that food shopping is done weekly and foods checked for use by dates regularly. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 13 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 The individual support that is provided is sensitive and flexible. Service users receive personal support in the way they prefer and require. Service users have access to all primary healthcare facilities as well as any specialist services as required. All health needs are therefore adequately catered for. The service users health needs are met and their welfare is safeguarded by the home’s policies and procedures. First aid and administration of medication are all carried out to a satisfactory level with minor shortfalls that prevent this standard being fully met. EVIDENCE: Observations and examination of records during the inspection show that personal care needs are recorded in individual care plans and service users’ privacy is respected. Service users’ wishes regarding gender preference is not recorded in every care plan. Discussions with the registered manager confirmed that service users are provided with the adequate equipment to help maximize their independence as assessed. Records show that service users receive additional, specialist support and advice as needed. Staff spoken to stated that in as far as possible, service users are encouraged to choose their Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 14 own clothes. All service users are provided with guidance and support with regards to personal hygiene. The care files for a number of service users were seen during the inspection. The care files each contained a clear written health plan that covered all areas specified in standard 19.2. Records seen showed that the home keeps documentation of all illnesses, injuries and accidents. The service users spoken to stated that they could get guidance, support and advice about health and personal care issues. It was evident from discussions with the manager and records seen that service users have access to all primary health care facilities such as the dentist, opticians and general practitioner. The registered manager confirmed that referrals would be made for specialist services as required. All health care plans contained in them a comprehensive medical history form and a health action plan covering physical health problems, mobility, eye sight, hearing, foot care, dental care, continence, breast awareness, cervical screening, testicular health and other health issues. The health action plan that is currently in place is service user friendly and is in appropriate formats. The health plans had in them a pressure sore risk assessment and weight charts as well as nutritional needs. Records seen indicate that a number staff have had training in first aid. There is an adequate supply of first aid boxes and first aid equipment within the home. These were seen during the inspection. The home’s policy is that only qualified staff administer medication and they have had the relevant training for this. The process of receipt, storage, administration and disposal of medicines were assessed during the inspection. These were assessed alongside and in accordance with the home’s policy for the medication. The findings were as follows: • All receipt of medication was appropriately recorded. • All medication is stored safely in a locked facility. • There was a cleaning and temperature chart for each medication cabinet in the home. • Some creams that were in the medication cabinets were not dated when opened. This does not give an indication as to how long the cream has been opened for. Creams have limited shelf lives and must be disposed of accordingly. The registered manager must ensure that creams are dated on the day of opening and disposed of accordingly. • Records show that qualified staff are trained appropriately to administer medication. • The home has a medication fridge for all the flats, temperatures for these are recorded appropriately. • Some antiseptic cream was seen in the medication fridge. The antiseptic cream had evidently been used or was in use. It was disturbing to note that the antiseptic cream was not labelled with the name of the service user it was intended for, neither was is dated to indicate the day of opening. The registered manager must ensure that all remedies indicate the name of the service user for whom they are intended. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 15 • • The home’s policy on medicines was seen during the inspection. The policy is robust and covers all the required areas. In flat two, there was some KY gel, again this was not labelled. The member of staff spoken to stated that it was used for administering enemas. The KY gel must be labelled too. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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 Service users are provided with clear information on how to make a complaint with contact details of other relevant agencies should they wish to use these. As a result, service users are certain that their grievances will be dealt with in a timely fashion. The home’s policies and practices protect service users from abuse, neglect and self harm. EVIDENCE: The home has a comprehensive policy and procedure on Complaints. The complaints log was seen. This showed that one complaint has been made since the last inspection. The complaint record showed that this was dealt with in an appropriate and timely fashion. The complaints procedure is made widely available to service users and significant others. The Commission for Social Care Inspection has not received any letters or phone calls of complaint about the home. All service users spoken to stated that they knew how to complain and felt that their grievances would be resolved fairly and promptly. The home has in place a robust policy for responding to suspicion or evidence of abuse. The Abuse policy and the Whistle blowing policy give clear guidance on what should be done in the case of alleged or actual abuse. Staff spoken to illustrated an understanding of adult protection issues and some of them confirmed that they had attended the training. In the past year there have been to allegations of abuse made in the home. After thorough investigations, the allegations were unfounded. The home does not have the local authority adult protection policies. It is recommended that the home has in place the local authority adult protection policies in order that the home’s own policies and procedures fall in line with these. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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): These standards were not assessed on this occasion. These standards were assessed during the last inspection, four of them were fully met and three had some shortfalls which have either been addressed or are in the process of being addressed as stated by the registered manager. EVIDENCE: Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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, 33, 34, 35, 36 Staff have the competencies and qualities to required to meet the service users needs. The home has a sufficient number of staff with complimentary skills and experience to meet the service users’ needs. The establishment’s policies and practices on recruitment serve to protect the safety and well being of service users. This standard had minor shortfalls. The home’s training programmes are in line the Sector Skills Council workforce training targets and ensures that the staff are able to fulfil the aims of the home and the service users changing needs. Staff do not entirely receive the supervision that they need to carry out their jobs and meet the stated purpose of the home. EVIDENCE: Observed practice showed that staff respect service users and are approachable, interested, motivated and committed. These qualities also came through very strongly during staff interviews. Staff spoken to demonstrated that they have an understanding of the service user group that they work with. Many of the staff who work in the establishment have either got their NVQ2 or Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 19 above or are registered to do their NVQ2. This was made evident in records seen. Rotas show that the home is well equipped with sufficient numbers of staff to meet the service user needs. Staffing ratios vary from flat to flat and depend on service user needs in any given flat. The home has a large number of staff given the size of establishment. Eight members of staff have so far left employment at the home this year but more have been recruited to fill the vacancies. The registered manager told the inspector that there were 68 care staff and 13 qualified nurses in total. The staff team reflects the culture and gender composition of service users. A sample of ten staff files were examined for assessing the recruitment standard. The files showed that on the whole, files did have two references, CRB checks, and a statement of terms and conditions. A few of the files had relevant information missing such as references and NMC PIN confirmation. The Human resources manager spoken to stated that information was omitted in error and not because staff did not have their NMC registration. The registered manager must ensure that all required recruitment information is on record. It was also noted that some files did not have two forms of identification. It is recommended that all staff files have two forms of identification. The Human Resources manager spoken to confirmed that all staff were provided with the General Social Care Council code of conduct. Records showed that most staff receive a comprehensive induction programme. The programme outline was seen during the inspection and it covers all relevant and required areas. Two members of staff who were spoken to stated that they had not received an induction. Records verified that their induction packs had not been completed. The registered manager must ensure that all staff are given an induction on commencing employment. The home has a training and development plan which allows all staff to receive mandatory and additional training on a rolling programme. Records showed that all training is linked to the home’s stated purpose and aims to serve the best interests of the service users. The home has a supervision policy in place. Records showed that ten qualified nurses had attended a training course on supervision. No supervision records were seen on this occasion as the member of staff asked stated that the new format was in the process of being implemented and would therefore not show the required six supervisions per year. One member of staff spoken to stated that she had not received supervision since commencing employment in August this year. This not acceptable. Supervision must be carried out at least six times per year. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 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, 41, 42 The registered manager is competent, qualified and experienced to run the home. Service users therefore benefit from a well run home. The home has effective quality assurance and quality monitoring systems that are based on seeking the views of service users and all concerned parties. Service users are therefore confident that their views direct the development of the home. The home holds all records as required by regulation for the protection of service users and the effective running of the home. On the whole, the establishment protects and promotes the health, safety and welfare of service users. This standard was met with very minor shortfalls. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 21 EVIDENCE: The registered manager confirmed that she has many years management experience in the care field. She is a qualified registered nurse and has just completed her RMA and awaiting the certificate for this. The manager’s overall responsibilities are laid out in her job description. The registered manager confirmed that she undertakes periodic training and development to maintain and update her knowledge and skills. This was evidenced in the training schedules and confirmed by the manager herself. Observations and discussions with the registered manager indicate that good practice is being developed in obtaining views on the quality of the service provided, from service users and others who come in contact with the home. At the time of inspection the home had a satisfactory quality assurance and quality monitoring system in place. Satisfaction surveys had been undertaken with service users, their families and other stakeholders. As well as this, the home carries out various audits. For example, a full environment audit was carried out in July 2005, a medication audit has also been carried out quite recently by the pharmacist, and the home routinely carries out its regulation 33 visits and filters these through to the Commission for Social Care Inspection. The registered manager confirmed that the findings from the audits and surveys is used to develop the service and plan for any changes that must be considered to improve service user care. Each flat has a lockable filing cabinet where all confidential records about the service users are kept. Staff spoken to showed an understanding of the importance of maintaining service users’ confidentiality. The registered manager confirmed that service users are informed of their right t access the records held by the home about them. This is further supported in the home’s policy for access to records. The home also has a policy on confidentiality. It was noted during the examination of documentation that all records are kept and maintained in accordance with the Data Protection Act 1998. Training schedules seen show that staff are trained in all the relevant safe working practices such as manual handling, fire training, first aid, food hygiene and infection control. These are mostly as part of the mandatory training. Staff spoken to demonstrated knowledge on these safe working practices and said that they utilise them on a daily basis as applicable. It was quite clear during the tour of the premises that each flat had safe storage for hazardous substances. Records showed that boilers are regularly serviced by a CORGI registered contractor. Water temperatures are tested weekly. The water temperatures taken on the day show a reading of 43 degrees celcius or very close. Although a fire inspection has not been carried out recently, records show that fire extinguishers are serviced annually and fire alarms are tested weekly. The establishment is divided into eight zones for the purposes of fire Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 22 safety. Each zone is tested weekly to ensure the fire alarms are working. The emergency lighting is tested monthly and fire training is carried out annually on a rolling programme. The premises have 32 fire extinguishers in total and a fire blanket in each and every kitchen. It was noted that two of the fire extinguishers had not been serviced for about two years. The registered manager must ensure that all fire extinguishers are serviced in accordance to the home’s policy. The registered manager confirmed that the testing of portable electrical appliances is done annually. The home carries relevant policies and procedures that support safe working practices. Each of these policies and procedures is supported by a risk assessment for the home. The home has individual risk assessments for the service users and is also in the process of formulating generic risk assessments that cover all areas of general risk within the home. Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X x LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Richmond Mews Nursing Home Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 3 2 x DS0000026961.V252515.R01.S.doc Version 5.0 Page 24 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. 2. 3. 4. 5. 6. Standard YA20 YA20 YA34 YA35 YA36 YA42 Regulation 12(4) Requirement Timescale for action 31/10/05 31/10/05 31/12/05 31/10/05 31/01/06 30/11/05 All creams must be dated on the day of opening and disposed of accordingly. 12(4) All remedies must indicate the name of the service user for whom they are intended. Schedule 2 All required recruitment information must be on record. 18(1)©(i)(ii) All staff must be given an induction on commencement of employment. 18(2) Supervision must be carried out at least six times a year. 13(4)(b)(c) All fire extinguishers must be serviced in accordance with the home’s policy and the safety of service users. 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 YA34 Good Practice Recommendations It is recommended that all staff files contain in them some forms of identification. DS0000026961.V252515.R01.S.doc Version 5.0 Page 25 Richmond Mews Nursing Home Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Richmond Mews Nursing Home DS0000026961.V252515.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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