Inspection on 25/06/08 for St Agnes

This inspection was carried out on 25th June 2008.

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

Other inspections for this house

St Agnes 18/07/07

St Agnes 07/12/06

St Agnes 08/06/06

St Agnes 09/11/05

St Agnes 05/05/05

St Agnes 04/11/04

St Agnes 24/05/04

St Agnes 09/12/03

St Agnes 21/10/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Agnes 31/33 Silverbirch Road Erdington Birmingham West Midlands B24 0AR Lead Inspector Karen Thompson Unannounced Inspection 25th June 2008 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Agnes Address 31/33 Silverbirch Road Erdington Birmingham West Midlands B24 0AR 0121 350 4212 0121 350 4212 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) Residential Care Limited Manager post vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2007 Brief Description of the Service: St. Agnes was originally two large three storey, Victorian style houses. These have been converted and extended to provide a care home for a maximum of 25 older people. The home is situated in a residential area between the Wylde Green and Erdington shopping areas in a road directly off the Sutton Road. Both the shopping areas and the centre of Birmingham are accessible by public transport. The bedrooms are spread over the three floors of the building and are a mix of singles and doubles, some with en suite facilities. The home has a lift to the upper floors however access to some of the bedrooms on each floor requires service users to negotiate some steps. On the ground floor are three lounges, a dining room with the main kitchen leading off, a small laundry and an office. Assisted bathing or showering facilities are available on the ground and first floors and there are ample toilets throughout the home. There is level access into the home and off road parking for a few cars at the front of the home. There is a very large, well-maintained and pleasant garden to the rear. The home charges between £338 and £358 per week this is dependent on whether rooms are shared or single and en suite. Theses charges do not include extras such as newspapers, toiletries and outings. Residents will be expected to pay additional costs for these. For up to date fee information the public are advised to contact the home. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. This was an inspection, which was carried out over a two-day period. The first day of the inspection visit was unannounced and for the second day of the visit the Care Manager was given short notice of our intention to complete the inspection visit. The focus of inspection undertaken by us is about outcomes for people who live in the home and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirement, minimum standards of practice and focuses on aspects of service provision that need further development. The inspection commenced at 11:00am on the first day and the home/provider did not know that we were coming on this day. The manager was present for the duration of the inspection. Information used in the report was gathered from a number of sources: a questionnaire (AQAA Annual Quality Assurance Assessment) was completed before the inspection by the management team of the home. During the inspection a tour of the building was undertaken, records and documents were examined about the management of the home, conversation with managerial and care staff and a number residents took place. Direct and indirect observation was also used to inform the inspection process. At the time of the inspection fifteen people were living at the home. Three residents who live in the home were ‘case tracked’ which involves establishing individuals experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on the outcomes of their lives including their health. Tracking people’s care helps us understand the experience of people who use the service. The home was asked to forward questionnaires to a randomly selected number of residents, relatives and health professionals on the first day of the inspection visit. Comments from residents’ spoken to during the inspection have been incorporated into the report, along with comments from staff working at the home. The inspectors would like to thank the residents, relatives, management and staff for their hospitality throughout this inspection St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Care Manager has identified that they would like to develop activities further and include more outings. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 7 The Care Manager has also identified the type of quality assurance system that they wish to set up in the home and was in the process of implementing the system with the help of an external training organization. Staff supervision needs to occur more frequently to ensure staff are given the skills and support to meet residents’ needs. Residents contracts and terms and conditions of residency must be reviewed so that they show clear information about who will be responsible for paying residents fees, the role and responsibility of the registered provider and the rights and obligations of each resident. Record keeping and systems for maintenance and servicing of equipment need to be reviewed to ensure equipment used in the home is in good working order. Staff must take part in a fire drill twice a year to provide them with the practical skills and knowledge to protect and maintain residents and their safety if a fire did occur in the home. Money received into the home and held on the residents behalf must be recorded to demonstrate that this has occurred. Further work is required on the Service Users Guide to ensure residents have all the necessary information required for them to make choices. The presentation and practice of pureeing meals must be reviewed to ensure residents experience the unique flavour of each item of food. The Complaints policy and procedure needs to be reviewed and amended so residents and or their representative know how long to expect an investigation to take and when they will receive a response. Staff training and development needs to be reviewed to ascertain whether it is fully meeting residents needs. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Agnes DS0000016757.V367356.R01.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 St Agnes DS0000016757.V367356.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2.3.4.5.6 Quality in this outcome area is good Information about the service or facilities has recently been updated further work is required to ensure all information given to residents is comprehensive. Residents’ needs are assessed before they move in so they can be confident their needs will be met upon moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Service Users Guide and Statement of Purpose, which they were in the process of reviewing at the time of the inspection. The Service Users Guide was seen on the second day of the inspection visit and was looked at in detail. Although the Service Users Guide is a comprehensive document, it will need to include the range of fees the home charges in order to meet the current legislation. The Service User Guide contained most of the information St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 10 required by legistlation with the exception of fees. The home should at this revision stage of the guide like to consider whether it is in an accessible format to all the residents, such as large font, plain English and including sufficient information about the facilities available. Residents contracts and terms and conditions of residency also need to be reviewed so that they show clearly who is responsible for payment of the fees, the roles and responsibility of the registered provider and the rights and obligations of the residents themselves. The home provides care for people who require long term or respite care. People are encouraged to visit the home before moving in to view facilities, meet staff and other people who live there in order to sample what it would be like to live there. At this time it also enables staff to undertake an assessment of the person’s needs to determine if they are able to meet them appropriately. On inspection of the records of some people who had moved into the home recently it was found that staff had completed a good assessment. This process ensures the person is happy to move into the home and that staff are able to meet their needs. In addition, there is a trial period of one month, which provides further opportunity to discuss whether the person would like to continue living there and if their care needs were being met or any changes that are required. Residents confirmed that they and or their relatives had been invited to visit the home prior to deciding to live there. Prospective residents of the home receive a letter confirming that the home can meet their needs. The home does not provide intermediate care facilities. St Agnes DS0000016757.V367356.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9 Quality in this outcome area is good. There are good systems in place to ensure peoples health and personal care needs are met. The medication system is well managed ensuring people receive medication that is prescribed for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ files were seen as part of the case tracking process. This is a document that is developed by staff following an assessment of individual needs. It outlines what they can do independently, the activities residents require assistance with and the actions staff need to provide in order to support them. The care plans contained risk assessments, which were linked into the care planning strategies to meet residents’ needs. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 12 The home could demonstrate that it routinely assessed residents for risk of falls, malnutrition and developing pressure sores. Residents’ lifestyle and background was recorded so that staff were aware of the individuals needs, choice and preferences. Staff were also able to demonstrate a good understanding of residents needs and how these were to be met through an individualized approach to care. For example some residents required items of clothing to be washed in a particular manner and staff were carrying out these wishes. The home is supported in its care of the residents by the G.P, district nursing service and other visiting professionals. Residents also benefit from regular visits off the optician, dentist and chiropodist. Whilst care planning was of a good standard on the whole one anomaly was identified. One resident was observed eating a pureed meal at lunchtime, which they appeared to be enjoying. Staff confirmed that it was only the lunchtime meal, which was pureed for this resident. This particular residents care plan could not demonstrate the reasoning for such actions by the staff. This was discussed with the Care Manager and whilst the manager acknowledged it there had been some concerns these had not been recorded to demonstrate any consultation, patterns or trends. The pureed meal presentation is discussed in daily life and social activities section of the report. The home is supported in its care of the residents by the G.P, district nursing service and other visiting professionals. Residents also benefit from regular visits off the optician, dentist and chiropodist. The medication system in the home consisted of a blister and box system with printed Medication Administration Record (MAR) charts being supplied by the dispensing pharmacist on a monthly basis. The home had copies of the original prescription (FP10) for repeated medication, so they were able to check the prescribed medication against the MAR charts when it entered the home. Medication is stored correctly and adequate stocks maintained which ensures a robust system for ordering medication. This ensures residents always have access to their medication and their health and well being is maintained. There were good systems in place to audit varying dosage medication to monitor and maintain the health needs of residents. A fridge is used for some medication, and the temperature recorded daily. It is recommended that the home purchases a digital thermometer so that maximum, minimum and current temperatures be recorded to ensure any medications stored within the fridge are stored correctly within the manufactures guidance at all times. On inspection of the medication for the current month it was found that all audits were correct and discussion with staff demonstrated they had a good knowledge of the medication available. No residents in the home were self-medicating at the time of the inspection. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 13 St Agnes DS0000016757.V367356.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Quality in this outcome area is good There are no rigid routines and visitors could visit at times that suited them enabling residents to maintain contact with them. Activities need to be reviewed in the home to ensure they are tailored to residents’ need, preference and frequency. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents confirmed they were able to go out with relatives and that family and friends visited them. Residents’ bedrooms were personalised with their own possessions, providing a more comfortable and homely environment. Residents confirmed that there were no restrictions on getting up or going to bed. The home provides the opportunity for people to follow their own religion ensuring their religious needs are met. Six of the fifteen residents are Roman St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 15 Catholic and Mass is conducted on a regular basis for these residents with other residents invited to attend. A representative from the Anglican community also attends the home on a regular basis. Activities have been discussed with the residents and some were occurring. Those staff spoken to felt that more activities were needed to meet the needs of the residents. The Care Manager stated a new game had been purchased for residents to play inside and a volunteer did visit the home every Monday to do craft-type activities with the residents. External activities were not occurring on a regular basis, and this will need to be reviewed to ensure all residents’ social needs are meet. There are two dining areas within the home, which were pleasant in appearance. The tables were laid appropriately and the meals were presented well with one exception. All residents are offered a choice at each mealtime. The main lunchtime meal on the first day of inspection was chicken, potatoes and vegetables. Residents were also offered an alternative to this meal. The home does cater for alternative cultural dietary needs and this was observed on the first day of the visit to the home. Residents were served individually and choices were prompted and acknowledged. One resident was observed eating a pureed meal, however good practice would dictate that each individual item is pureed and presented separate as opposed to the home’s present practice of pureeing the whole meal together. This means the individual factor of each constituent part of the meal is lost. This matter was discussed with the Care Manager. Drinks and snacks are available to residents at any time of the day. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is adequate There are systems in place so that residents are protected from harm further work however is required to ensure these are comprehensive and fully protect residents rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a written policies and procedures for complaints which have been reviewed recently by the Care Manager but does not fully meet the standard as it has no timescale in which the processes will be completed and it refers to the National Care Standards Commission, which no longer exists. The Commission has received no complaints about the home and the service it provides to residents. The Care Manager stated that the home had also received no complaints in the past twelve months. The Care Manager does have a “grumbles book” for residents and relatives to write in if they have any matters that they feel do not warrant a formal complaint. The Care Manager stated there had been one grumble and concerns raised in this matter had led to changes in practice to meet residents’ needs. The adult protection procedures and policy remain unchanged since the last inspection. Approximately 80 of staff have received training in Adult St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 17 Protection. Staff knowledge about safeguarding issues was good and staff demonstrated a zero tolerance to any form of abuse. All staff need to have adult protection training and the home has training planned for October 2008. Whilst staff at the home are waiting for this to occur a number of methods can be used to ensure all staff have a good understanding of safeguarding such as briefing and supervision. The Care Manager has been on a training day for Mental Capacity Act awareness. All staff need to receive training in this area. The home appears to be meeting residents rights well, but will need to review its systems and daily practice of obtaining consent for accommodation, care and treatment decisions in line with the Mental Capacity Act Code of Practice. St Agnes DS0000016757.V367356.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19.21. 26 Quality in this outcome area is adequate Residents live in a homely and comfortable environment where they are happy and secure and their privacy is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a detached three storey building with off road parking for visitors. The exterior would benefit form some work to improve its appearance. During the inspection it was observed and noted that the home made improvements to the front garden and entrance. There are extensive gardens to the rear of the home and it was observed that gardeners had been working to maintain this pleasant space and reducing some of the spring growth. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 19 Accommodation is provided for twenty residents over the three floors of the home. Shared spaces consist of two lounges of which one is a lounge diner and one separate dining room. The home does not employ cleaning staff on a daily basis, a cleaning company is supplied three times a week to clean the home. This arrangement work well but may need to be reviewed once the home is running at full occupancy to ensure that the current standard of cleanliness is maintained. There are bathing facilities on all three floors however the bathing facilities on the middle floor were either not working or not suitable for residents needs. The assisted hydraulic bath seat on the middle floor on the first day of the inspection was not working and also the water had been disconnected, as a new thermostatic valve was needed to regulate the water temperature. On the second day of the inspection visit, work had been completed to fit the hydraulic seat but the plumber was still waiting for the thermostatic valve and the water remained disconnected. . Whilst waiting for this work to be completed residents’ dignity needs are being compromised by the need to travel to different areas of the home for bathing. Gloves and aprons were freely available to staff. Not all toilets and washing facilities visited had liquid soap or paper towels available for staff to wash their hands on the first day of the visit. Paper towels and liquid soap needs to be available to reduce the risk of cross infection to residents. One issue of cleanliness was discussed with the deputy manager during the tour of the home. Some residents have their washing done individually by one designated member of staff. This demonstrated the homes approach to meeting individual needs and choice. On the first day of the inspection the sluice pot disinfector was observed to be not working. The laundry is a small area, the walls and floors are not impermeable or easily cleaned. However the home does have good systems in place for laundering of residents clothing. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27. 28.29. 30 Quality in this outcome area is adequate. Staff are employed in sufficient numbers to meet the needs of residents. Whilst staff demonstrated knowledge and skills in a number of areas there are some shortfalls, which will need to be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection there were adequate staff on duty to meet residents needs. The Care Manager stated that the home had two staff on duty throughout the day with this being increased to three of a morning to ensure residents’ needs are met. All of the current staff group have either completed an NVQ 2 in care or are in the process of doing so. This training improves staff knowledge and skills and leads to improved outcomes for residents living at the home. There have been no new members of staff since the last inspection. The manager stated that all staff have been Criminal Records Bureau checked. One staff file was sampled, which demonstrated a robust recruitment procedure St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 21 had occurred along with an induction programme to present job description within the home. Staff training has lapsed in a number of areas and the training matrix needs to be updated to reflect all training that has taken place. The home has employed the services of an outside trainer and a number of training courses have been booked for the forthcoming year. All staff need to attend these sessions as the one staff file demonstrated that yearly mandatory training was not always occurring for all staff. As well as ensuring mandatory training needs are met the home needs to look at specialist training in relation to residents needs such as dementia, diabetes etc. This will improve staff knowledge and improve outcomes for residents living at the home. Staff training was identified by one health professional as a way in which the home could improve the service it provided to residents. They did however also state that the home provided “ caring environment for frail elderly” St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 22 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. 33.35. 36.38. Quality in this outcome area is adequate The home had systems in place to support the management and running of the home however these are not operating consistently or operating effectively which could place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s manager is not currently registered with us. She has a number of years experience working in a managerial position and is currently undertaking the Registered Managers Award. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 23 The home has made no measurable progress had been made in the past twelve months in implementing the Quality Assurance System. There have only been two residents meetings in the first six months of the year. It is vital that the quality assurance system is fully implemented so that the service can be monitored effectively and residents’ needs anticipated and met. Staff spoken to during the inspection were enthusiastic about their job. They felt they worked well together. Staff had a good knowledge of the residents’ individual care needs, which ensures their needs are met. Supervision has not been occurring for staff on a regular basis and was not found to be occurring six times a year. Prior to the inspection an Annual Quality Assurance Assessment was completed. The document was returned to us on time and gave us information about the home, staff, residents and the improvements over the past year. It also gave us information about the plans and areas of development for the future. The management team have had to deal with a number of issues that have meant they have not always been able to adhered to their plans or vision for the home. It is vital that they make improvements in areas that they have already identified as requiring attention to ensure residents’ needs are fully met. Residents have metal safes available in their bedrooms for safekeeping of valuables. The Care Manager stated that the home did not manage personal money for any of the resident living at the home. During the inspection it was found that relatives do hand over money to the manager for hairdressing and chiropody. This money therefore is accepted into the home for safekeeping, and records must therefore be kept to demonstrate receipt and payment so that this money can be audited. Health and safety maintenance checks had been undertaken in the home. Maintenance checks were completed on the fire system and equipment so that people are safe in the event of a fire occurring. Fire drills are occurring in the home and these do involve an evacuation with residents taking part. The frequency of Fire drills needs to increase to ensure that all staff participate in a fire drill twice a year. The call bell system had recently been serviced and two were found not to be working. The Care manager stated they had carried out a risk assessment for the two residents this would impact on and would forward a certificate to the Commission to demonstrate when the work had been completed to mend the problem. The manager was unable to locate evidence at the time of the inspection to demonstrate hoist safety checks had been carried out again and the Commission was informed a certificate would be forwarded to us. The lift insurance safety check certificate had expired at the time of the inspection though the Care Manager stated it had been arranged for the check to be carried out in the next week. This certificate would then be forwarded to the Commission. St Agnes DS0000016757.V367356.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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 2 X 2 St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP35 Regulation 13 Requirement Timescale for action 30/08/08 2 OP38 24(4) (e) 3 OP38 23(2)(c) 4 OP38 23(2)© The home must implement a financial records for money it hold on residents’ behalf to be able to demonstrate that this money is safeguarded and accounted for. All staff must receive fire drill 30/11/08 training twice a year to protect and promote theirs and residents well being in the event of a fire. Certificates of testing and 30/08/08 worthiness must be in place to demonstrate that the hoist has been serviced as required by law on a yearly basis so that residents’ safety is maintained. The lift must have an annual 30/08/08 insurance check carried out so that residents’ safety is maintained. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard OP1 Good Practice Recommendations The home’s Service User Guide must be in a format accessible to residents and include the range of fees charged by the home. The Service Users Guide must then be given to all residents living at the home. Residents’ contracts need to show them who is responsible for paying their fees, the role and responsibility of the registered provider and their rights and obligations as residents. (Recommendation carried forward from previous inspection report July 07) All residents needs must be assessed, documented and plan of care put in place to ensure they are the residents health and well being is being effectively monitored The home should carry out an audit of residents’ social needs and put in plans to meet these, to ensure residents live a meaningful and stimulating life. The practice of pureeing individual items of food should take place to ensure residents experience the unique favour of each item of food. The Complaints procedure should be amended so that complainant is aware of the anticipated time it will take to investigate their concerns. Reference to the National Care Standards Commission should be replace with the Commission for Social Care inspection to avoid any unnecessary confusion or frustration. It is recommended that the home obtains the Dept of Health booklet on the Mental Capacity Act for Residential Care published July 2007 Staff should receive briefing and supervision in safeguarding procedures to ensure they all have a comprehensive understanding of their role in protecting vulnerable adults As the home increases the number of residents it cares for the manager must review the domestic assistance to ensure that the home remains clean and odour free. (Recommendation carried forward from previous inspection report July 07) Assisted bathing facilities on the middle floor are in working order so as not to impact on the privacy and dignity of residents residing on that floor. Paper towels are available in all areas of the home where staff are likely to wash their hands. The pot disinfector is repaired swiftly. Individual training needs are identified and a development DS0000016757.V367356.R01.S.doc Version 5.2 Page 27 2. OP2 3 4 5 6 OP7 OP12 OP15 OP16 7 8 OP18 OP18 9 OP19 10 11 12 13 St Agnes OP21 OP26 OP26 OP30 14 OP31 plan is put in place to address these needs. The manager should consider applying for registration with the CSCI. (Recommendation carried forward from previous inspection report July 07) The home needs to be able to demonstrate that it is acting in the best interests of residents. (Recommendation carried forward from previous inspection report July 07) The manager needs to further develop systems for ensuring that all staff have regular supervision. (Recommendation carried forward from previous inspection report July 07) 15 OP33 16 OP36 St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Agnes DS0000016757.V367356.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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