Inspection on 17/08/07 for Sceats Memorial Home

This inspection was carried out on 17th August 2007.

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

Sceats Memorial Home 12/08/09

Sceats Memorial Home 18/02/09

Sceats Memorial Home 16/01/08

Sceats Memorial Home 06/09/06

Sceats Memorial Home 15/11/05

Sceats Memorial Home 03/03/05

Sceats Memorial Home 18/06/04

Sceats Memorial Home 19/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Sceats Memorial Home 1-3 Kenilworth Avenue Gloucester Glos GL2 0QJ Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 11:45 17 & 20th August 2007 th 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 Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sceats Memorial Home Address 1-3 Kenilworth Avenue Gloucester Glos GL2 0QJ 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) 01452 303429 Sceats Memorial Housing Association Limited Mrs Iris Anne Burton Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: Sceats is a Care Home, which provides personal care to the older person. It is situated in a residential area on the outskirts of Gloucester City. It offers accommodation over two floors in two, extended Victorian houses. Bedrooms are single and have wash hand basins. Communal toilets and bathrooms are near to all bedrooms and main communal rooms. There are two lounges, one dining room and a sunroom on the front of the property. The building is accessible by wheelchair; the first floors are reached by stair lifts, but some bedrooms are not easily accessed unless the individual is confidently mobile and advice would need to be sought from the Registered Manager as to which bedrooms are affected. The home has a copy of their Statement of Purpose on display in the main entrance hall and all service users in the home have a copy of their Service Users Guide. The fee range for this home is £320 to £388.60 per week and extras include hairdressing, newspapers and chiropody. This information was given to the inspector after the inspection. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this site visit over two days in August 2007. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Registered Manager was available for one day of the inspection. A total of 27 standards were inspected. A number of people who use the service were spoken to and visitors to ascertain their views on the care and services provided. The comments received from people who use the service during the inspection all indicated they are very happy living at the home. One visitor said they were happy with the care their relative was receiving. The Registered Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. Seven requirements have not been complied with since the last inspection. On this occasion the timescales have been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead the Commission for Social Care Inspection to consider enforcement action to secure compliance. What the service does well: The home has a team of staff that work hard to maintain the quality of the lives for people who use the service. All comments received about the staff were very complimentary. The Registered Manager and Deputy Manager have worked at the home for a number of years resulting in continuity for staff and service users. The dietary needs of people who use the service are well catered for with a balanced and varied selection of food available that meets their tastes and choices. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 7 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 Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, & 6 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has some pre-admission processes in place, however these are not always followed which could potentially place people at risk of being inappropriately placed. EVIDENCE: The home’s terms and conditions were examined. The home needs to add two statements to meet new Care Home Regulations that came into force last September. This relates to how any services not included in the fees can be accessed and paid for and if this would be any different if the person was funded by another source other than himself or herself. Copies of the home’s terms and conditions were seen in one person’s records. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 9 The pre-admission assessments of two recently admitted people were examined. One assessment had not been completed in full, signed or dated by the member of staff completing it. The Registered Manager said they also gave an assessment form to the family to complete. Information was seen from other sources to include an assessment of needs completed by Community and Adult Care Directorate (CACD). This included information about their care needs. It was evident that the pre-admission assessment completed in full for one person had not identified their specific care needs as they have a tendency to wander which could place them at risk and the home had not fully investigated their medical diagnosis for which the home is not registered. When accepting new people into the home the Registered Manager must fully investigate any diagnosis and review this in line with the staffing levels and layout of the home. The other person’s assessment was detailed and was dated and signed by the member of care staff completing it. This person had minimal care needs. The Registered Manager said the procedure for admissions to the home is to invite the person to spend a couple of hours at the home and a member of care staff completes the assessment of needs. Both people could not recall if they visited the home before moving in. They also ask CACD for any information if appropriate. On the day of admission or the next day another assessment is undertaken and this provides care staff with more information and this becomes their ongoing assessment of need. The home is still not writing to people to confirm that following the assessment their needs can be met. Another person who uses the service said they moved in last November and were made to feel very welcome by the staff and other people who use the service. Intermediate care is not provided. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are not always having their health and personal care needs identified and met by the staff. However the principles of respect, dignity and privacy are mostly put into practice. EVIDENCE: The care of three people who use the service was examined in detail. This included examining care records, speaking to care staff and the person who uses the service where able. All three people had an assessment of need that contained individual details about each person. From this it appeared that only certain care needs had care plans devised but not all. For example people who need help with personal hygiene had care plans for bathing but not for what help is needed for washing and dressing. All three had front sheets with personal details about them and a photograph. All had evidence of monthly reviews but care plans were not in place for all identified needs and other care plans had not been updated with current care needs, despite the monthly Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 11 review. Daily records contained information about changes in their condition, but again this was not transferred to the care plans. Two people have limited appetite and the possibility of reduced fluid intake but neither person had a fluid or food record chart. These two people spend all day in bed but no care plan or record chart was in place to demonstrate care staff are changing their position. One person has started to ‘wander’ around the home especially at night as detailed in their daily records, however no care plans or risk assessment was in place. The home must maintain detailed records about this so that if health professionals become involved in their care they will have information about their condition. One person had a fall which involved them becoming trapped by a chair next to their bed, despite this the chair remains in place. The home must review this to ensure this person will not be at risk again. All three people who use the service had falls risk assessments in place and moving and handling assessments, however one was not completed and when people have been identified as ‘high risk’ no care plans had been devised. People spoken with confirmed they have access to health professionals to include the GP, Chiropodist and Community nurses. Community nurses were visiting people who use the service during the inspection. The home’s Annual Quality Assurance Assessment (AQAA) says they have now found a Dentist that will visit the home. Medication systems used by the home were examined. Records were seen of medication received into the home, administered (in the majority of cases) and where needed returned to the local pharmacy. The storage arrangements for medication have not changed since the last inspection. The medication trolley stored in the dining room is not secured to the wall therefore medication must not be stored in there, however medication was found in this trolley when it was not being used to administer medications. A risk assessment was required to be undertaken to ensure the systems used by the home were safe. There was no evidence seen that this has taken place. One person said they are able to self-medicate their own medication and have a locked draw in their room for this to be stored. However the home has not undertaken a risk assessment or completed a consent form with this person. Medication Administration Records (MAR) were examined, it was found that prescribed creams are being ordered but there is no recorded evidence these are being used, as the MAR sheets are not being signed. This was also the case for people who use inhalers. Not all medication that is in boxes is dated on opening. Hand written entries were checked and signed by a second member of staff. Care plans were not always in place for people who require ‘prn’ medication. A specimen signature and initials list is stored in the main office. Following the key inspection last year the Commission for Social Care Inspection pharmacist visited the home due to some concerns with controlled Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 12 medication. They suggested some areas for the home to implement to reduce any errors when using controlled medication. Two people were receiving controlled medication, the liquid morphine had not been dated on opening. It was last used in July 07 and was still in the home. This was also the same for the tablet morphine that was being used by one person. If not in use these medications must be returned to the pharmacy. Otherwise the records were all correct. Policies and procedures were not checked at this inspection. The Registered Manager said the MAR sheets are audited but no records are maintained of this. Staff confirmed they could not administer medication unless they have undertaken training. People spoken to confirmed the staff treat them with respect and dignity. This includes staff knocking on their door before entering their room and addressing them with their preferred choice of address. The home’s AQAA has a statement in it that says “people are invited to the office to discuss their bathing routines”. This statement makes the impression that the home is institutional and not peoples’ home. We would expect the bathing arrangements to be discussed with people in the privacy of their room whilst reviewing their care records with them. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their life style and participate in activities that meet their individual expectations and preferences. EVIDENCE: The home does not have a structured activities programme but care staff record what activities they undertake each day. People who use the service said that a number of different activities take place and the care staff tries to encourage as many people of different abilities to join in. Two people said the home has a religious service each month that people can choose whether they attend or not. The hairdresser visits weekly and if able a number of people said they go outside for a walk. One person has a green house where the staff take them each day to look after the vegetables they are growing there. The home is able to use the vegetables for their meals. No activities took place during the second day of the inspection. However a number of people were enjoying sitting in the sun lounge and talking to each other. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 14 Visitors to the home and people who use the service said that visiting is not restricted. A number of visitors were seen during the inspection. Several people are able to attend day centres. A number of rooms belonging to people who use the service were seen and people confirmed they could bring in their own furniture and belongings. People said they are able to make choices about their daily lives. This includes if they join in activities, what time they get up within limits of the home and where to eat their meals. Since the last inspection the home has a new chef. The home operates on a four weekly menu rotation that was devised prior to the chef starting at the home. An alternative is always offered at lunchtime as the home has vegetarians and alternatives are offered at teatime. The chef said they are able to cater for people who require a therapeutic diet. People said they could have a cooked breakfast each morning if they wish to. Lunchtime was observed and found to be a very social event The Manager working in the home on that day has lunch with the people who use the service. People are offered assistance discreetly. The inspector tried the meals on both days of the inspection and found it to be well cooked and very enjoyable. One person said they are able to have alcohol with their meal if they wish. Baskets of fruit are now left on the table for people to help themselves. People who use the service all complimented the food provided by the home. The kitchen was inspected but not in detail and the chef provided evidence that health and safety checks are undertaken. Records of food need to be kept in detail and this is discussed in Management and Administration Standards. The Chef said he is up to date with his training. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns and have access to a complaints procedure, however the arrangements the home has in place for protecting people from abuse or harm potentially places them at risk. EVIDENCE: The home has investigated two complaints since the last inspection and records were seen of these. People who use the service said they would go to the Registered Manager if they had any complaints and they said they could discuss any concerns with the Registered Manager at their residents meetings. A copy of the complaints procedure is displayed in the front hall in the Statement of Purpose. All staff except new staff has completed the distance learning training in abuse. The Registered Manager teaches this training. The home must now ensure all new staff have this training. This training incorporates policies for whistle blowing and abuse and mentions in general terms who to contact if there is a suspicion of abuse or if it has taken place; however the home does not have any local information about who to contact and they have not undertaken the training provided by the local council. This could potentially Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 16 place people who use the service at risk and it is important that the staff and especially the management of the home know the local reporting procedures. Two members of staff that have started at the home since the last inspection did not have Criminal Records Bureau Disclosures (CRB) and POVA checks completed on them prior to starting at the home. This places people who use the service at risk. The home has not referred any members of staff to the POVA list. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service live in a home that is comfortable but the lack of redecoration does not make for a pleasing and pleasant environment. Poor infection procedures place people at risk of cross infection. EVIDENCE: A tour of parts the environment took pace with a number of people’s rooms seen. No maintenance issues were found at this inspection. The Deputy Manager said that rooms are redecorated when they become vacant. The home does not have a redecoration programme in place for the communal areas, as it is noticeable that in places the décor is tired and this has been the case for the last two inspections. Also it has previously been noticed that the bathrooms were ‘institutional’ looking as they were all white. Since the last inspection the home have applied transfers to the tiles but have not Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 18 redecorated. Whilst the lack of redecoration does not pose a risk to people who use the service it does not make for a pleasing or pleasant place for people to live. The home has plans in place to review the communal area. The television picture in one of the lounges is poor and the Registered Manager said they have had this looked into and they need to consider having new aerials. The environment is not purpose built, as it is two houses joined together and has several areas where steps need to be negotiated. Chair lifts are provided to the upstairs floor, as the home does not have a lift. One person spoken with said she is pleased that the home has male and female toilets. People said they are happy with the cleanliness of the home and confirmed they have their rooms cleaned frequently. Protective clothing is available for staff when required. It was noticed that one person is being cared for in their room due to an infection, however the home has taped a black bin liner outside the room for staff and visitors to place their gloves and aprons. This is very poor practice as there is a risk of infection the home must have a bin with a lid on and check with the local Health Protection Agency about how to dispose of this waste. Bins were also found not to have lids in some toilets, which again can place people at risk. The home has a machine to dispose of incontinence pads. The laundry area was examined and it was found to be clean and tidy and organised. The care staff in the home manage the laundry. The washing machine has a sluicing programme. People who use the service said they are happy with the laundry system used. In one person’s room it was noticed that chemicals used for cleaning were on the side and not locked away. This places people who use the service at risk especially as one person is prone to wandering. This must be addressed. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is confident that the number of staff on duty meets the needs of the people who use the service. However the lack of suitable training and poor recruitment practices potentially places people at risk. EVIDENCE: Duty rotas for care and ancillary staff were examined and the Registered Manager said no changes have been made to the numbers of staff on duty except at the moment they have one member of care staff who is supernumerary to the numbers as they are on an employment scheme. The Registered Manager and other members of the management team are extra to the staffing numbers when they are on duty and one of these is always on call. The home is using agency staff at the moment to cover both care and cooking tasks. The home is confident that the staffing numbers are able to meet the need of people who use the service. Care staff spoken with had an understanding of the care needs of the people whose care was examined in detail. People who use the service all praised the staff in the home and said they are always helpful and friendly. However a comment was received that at times Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 20 some members of staff do not always speak to people who use the service in a respectful way. A number of staff spoken with said they enjoy working at the home as several had been there for a number of years. Staff also said they have a good team spirit. A visitor to the home said they were very happy with the care their relative was receiving. The home has two care staff with NVQ 2 training and four working towards this award. Two members of care staff are undertaking the NVQ 3 training. Four personnel files of staff appointed since the last inspection were examined. One personnel file had no application form; therefore they would be unable to explore any gaps in employment, no written references and no evidence that a Criminal Records Bureau Disclosure (CRB) and POVA check had taken place. This member of staff is working in the home. The second personnel file contained all the required checks. The remaining two personnel files contained all the required checks except they did not have a CRB and POVA checks as the home had used the previous ones from other employment. This is unacceptable and places people who use the service at risk and must be rectified immediately. One member of staff has a criminal record, which they had shared with the home, however the home had not explored this with the member of staff or completed a risk assessment. The home uses an outside training company for their induction training, which enables the staff to use this towards gaining their NVQ training. The records for one member of staff stated they did their induction training about six months after starting work at the home. Another member of staff who undertakes both care and domestic tasks started at the home in December 2006 and to date has not started induction training. The home was not able to provide any evidence that they provide induction training pertinent to the home and the recently appointed chef also has not had any induction training. The home had no evidence that new members of staff are appointed an experienced member of staff to supervise them during their induction programme. There were gaps in the training of staff as the member of staff who started at the home in December 2006 has not undertaken training in moving and handling, food hygiene, infection control or first aid. Another member of staff who had previously undertaken care work has had no training since being at the home. Another member of staff who started in July 2006 has had no moving and handling, infection control or first aid training. The home has a number of people who use the service with a diagnosis of dementia but no training has been provided for staff in this area. The home has obtained a hoist to assist with moving and handling but to date staff have not been trained to use it. This needs to be addressed. The Registered Manager said fire training has been completed for all staff. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, however the lack of an effective quality assurance system and shortfalls in the service not being identified places people who use the service at risk. EVIDENCE: There have been no changes to the management of the home since the last inspection. The Registered Manager has the NVQ 4 training. The Commission is concerned about the number of requirements issued at this inspection and that have been carried over since the last inspection. The Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 22 home must work towards addressing the shortfalls identified as they place people who use the service at risk. People who use the service and a visitor to the home said they could approach the Registered Manager if they had any concerns. The majority of staff spoken with also said they could discuss any concerns with the Registered Manager and other members of the management team. The home has meetings for people who use the service and the last one was recently. One person who attended that meeting said they could discuss any concern they had with the Registered Manager and minutes of these were seen. The last staff meeting was in September 2006 but the home has handovers at each shift. A small number of questionnaires were seen but these had not been collated. The home should consider doing this at least yearly and send them out to relatives and other visitors to the home. The home should also collate the results and display them in the home. Regulation 26 visits are taking place and a copy is sent to the Commission. At the last inspection and this inspection monitoring systems used were discussed as these are taking place but records are still not being maintained. Accident records are not audited but the Deputy Manager said the Registered Manager looks them. Evidence was seen that some policies and procedures are reviewed yearly but the home is not always reviewing them in line with any new legislation. The home must devise a quality assurance procedure to ensure the home is run in the best interests of the people who use the service. The home stores and manages monies for a number of people who use the service. A small number of these were randomly selected and checked. Two peoples’ records were incorrect (no money was found to be missing) and the third was correct. The home said members of the management team check them. Consideration should be given to the home getting two members of staff to sign money in and out for safety reasons. Records for staff supervision were checked and it was noticed that a number of care staff have not received any. The records indicated that a member of night staff that started working at the home in December 2000 had only one supervision session in and that was September 2006. The home’s Annual Quality Assurance Assessment says this is an area they have improved on. Other members of staff were also not receiving sessions and this includes night staff. This must be addressed. The home needs to maintain detailed food records as well as the menus. This includes people who use the service who have an alternative to the menu or anyone on a therapeutic diet. Records were examined for maintenance checks and servicing of equipment. No records were seen for checking of the boilers. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 23 The homes fire risk assessment was last reviewed in June 2006 but it contained minimal information and the evacuation procedure needs to be reviewed in line with the latest legislation. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 24 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 X 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 X 2 2 2 2 Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation Requirement Timescale for action 30/11/07 2. OP3 3. OP7 5(1bc&bd) The registered person must update their Service Users Guide to include the information in relation to fees as described in this Regulation. This is to ensure that people who use the service have all the information about the service available to them. 14(1)(d) The registered person must confirm in writing to proposed service users that having regard to their assessment the home is suitable for the purpose of meeting their needs. This requirement remains outstanding since the last inspection. 15 The registered person must ensure that people who use the service have care plans in place for all identified needs. This will ensure that care staff have all information available to them so they can meet their needs. 15 30/11/07 30/10/07 4. OP7 The registered person must 30/10/07 ensure that any change to a person’s condition is documented DS0000016573.V337159.R01.S.doc Version 5.2 Page 26 Sceats Memorial Home 5. OP7 13(4c) 6. OP9 13(2) 7. 8. OP9 OP9 13(2) 13(2) in their care plan. This requirement remains outstanding since the last inspection. The registered person must devise a detailed risk assessment for the person who wanders around the home to ensure any risk are identified and where able eliminated. The registered person must ensure that a risk assessment is carried out to determine if the procedure they use to transport medication to rooms not accessible by the trolley is safe. This requirement remains outstanding since the last inspection. The registered person must ensure that medication is stored securely at all times. The registered person must ensure that people who use the service who wish to selfmedicate have a risk assessment completed that is kept under review. The registered person must ensure that people who use the service have care plans in place for medication that is ‘prn’ or ‘as and when required’. This will ensure all staff follows the same procedure. The registered person must ensure that all staff are aware of the local procedures for reporting suspicions of abuse or actually abuse. This is to ensure that people who use the service are not put at further risk. The registered person must ensure that the infection control procedures they have in place for the person with the identified infection do not place other DS0000016573.V337159.R01.S.doc 30/09/07 30/09/07 20/08/07 30/09/07 9. OP9 13(2) 30/09/07 10. OP18 13(6) 30/11/07 11. OP26 13(3) 20/08/07 Sceats Memorial Home Version 5.2 Page 27 12. OP26 13(4a) 13. OP29 7,9,19.Sc h 2 (5) 14. OP29 19 & Sch 2 15. OP30 18 1(c)(i) 16. OP30 18(2) people at risk. The home must provide a bin with a lid to place items worn by staff and visitors. The home must also check with the local Health protection Agency about how to dispose of this safely. The registered person must ensure that any chemicals used in the home are stored safely to prevent people who use the service from being put at risk. The registered person is required to ensure that two written references are obtained when employing new staff, before they commence employment. This requirement remains outstanding since the last inspection. The registered person must obtain the following pre employment checks: A full employment history, together with a satisfactory written explanation of any gaps in employment. Criminal Records Disclosure (including where applicable a POVA check). This requirement remains outstanding since the last inspection. The registered person must ensure that all new staff receive structured induction training. This requirement remains outstanding since the last inspection. The registered person must ensure that for the duration of the new workers induction training: a member of staff (the staff member) is appropriately qualified and experienced, is appointed to supervise the new worker; DS0000016573.V337159.R01.S.doc 20/08/07 30/10/07 30/10/07 30/10/07 30/10/07 Sceats Memorial Home Version 5.2 Page 28 17. OP30 18 18. OP33 24(1) 19. OP36 18(2a) 20. OP37 Schedule 4(13) as far as is practicable, the staff member is on duty at the same time as the new worker; and the new worker does not escort any service user away from the care home premises unless accompanied by the staff member. This requirement remains outstanding since the last inspection. The registered person must ensure that staff receives training pertinent to the needs of the people who use the service. This is to ensure the needs of the people are met. (This relates to dementia training, moving and handling, infection control and food hygiene). The registered person must devise a quality assurance system to ensure the home is run in the best interests of the people who use the service. The registered person must ensure that all staff are supervised to ensure the needs of the people who use the service are being met by competent staff. The registered person must ensure that detailed food records are maintained to provide evidence that people who use the service are receiving a nutritious and wholesome diet. 30/12/07 30/11/07 30/11/07 30/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 29 No. 1. Refer to Standard OP3 Good Practice Recommendations The home should complete their pre-admission assessments in full and date and sign them. The home should then review this with any other information available and investigate further any medical diagnosis. Once this is done the home needs to consider all factors before accepting any people into the home. People who have limited oral intake should have fluid and food record charts in place. The home should purchase a lockable box to transport medication to the areas in the home that is not accessible to the trolley. The home should audit the Medication Administration Records as part of their quality assurance systems and maintain records of this. All staff in the home should attend the half training provided by the local council about the ‘Alerters’ guide. The management team should attend the days training provided by the council in relation to enhanced adult protection training. Continue with redecoration to the home including the Appliances room. Make bathrooms less institutional in appearance and plan to replace the strip light in bedroom 4. This recommendation has been repeated for the last two inspections. 2. 3. OP7 OP9 4. OP9 5. 6. 7. OP18 OP18 OP19 Sceats Memorial Home DS0000016573.V337159.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sceats Memorial Home DS0000016573.V337159.R01.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. 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