CARE HOMES FOR OLDER PEOPLE
St Agnes 31/33 Silverbirch Road Erdington Birmingham West Midlands B24 0AR Lead Inspector
Jill Brown Unannounced Inspection 7th December 2006 08:40 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.V323679.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.V323679.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 *** 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.V323679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th June 2006 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 £322 and £346 per week this is dependent on whether rooms are shared or single and en suite. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors carried out an unannounced inspection on a day in December. The inspection took place over 7 hours and looked at most of the 38 standards. During the inspection the inspectors looked at three residents care files and three staff employment files. Further records of accidents, medication administration, complaints and comments were looked at. A tour of the building was undertaken and records of the maintenance and inspection of services such as the gas and electrical services. During the inspection three residents were talked to. The inspection report also includes information collected about the home’s performance since the last key inspection, which took place in June 2006. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The commission had received no complaints since the last inspection. What the service does well:
The care records showed that residents had an assessment of needs before admission and this included a visit to the home and often the home manager visited the prospective resident in hospital. A number of residents thought their relatives assisted with arranging the placement at the home. All residents had an up to date care plan. The care plans were clear and contained good information about how staff were to meet residents needs. The care plans were near care staff giving the care for reference. Daily records showed that where a concern about a resident’s health was raised this was followed up quickly. Health checks such as flu vaccinations regular checks on residents’ weights were routinely undertaken. Residents thought that staff were helpful and one resident said that staff joked with them and that made them feel happy. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 6 Residents were able to move around the home freely residents that wanted could receive their care and spend time in their bedrooms. Visitors were welcome in the home. What has improved since the last inspection? What they could do better:
The home whilst providing service user guides and having a statement of purpose could improve the availability of these. A pack of information including the service user guide available before a resident’s admission would assist
St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 7 residents with whether or not to come to the home. The Statement of Purpose needed to be more readily available and have all the amendments in place. The home’s contract needed to be updated to show accurate fees and the change of fees must be communicated to residents and their representatives at the time the fee changes. Residents and or their representatives need to be advised at the time of admission that the home can meet their needs. One resident had a mental health issue in the past and the home need to consider determining the signs the resident may display to show that their mental is deteriorating. Medication storage could be improved for medicines that are kept in a fridge by recording the present maximum and minimum temperatures to ensure that medicines are kept well. The home needed to ensure that medication given was always recorded and that the numbers of medicines in the home were auditable. The home still needs to improve activities for residents and keep better records of activities that residents have enjoyed and time spent with residents that find it difficult to join in group activities. Residents were not as satisfied with the food as on previous occasions. There had been a change in the staffing of the kitchen temporarily and this may not be sufficient to ensure that residents’ preferences were always met. The dining room was subject to draughts and was cold on the day of the inspection and the food was not as hot as needed. The warmth of food was also raised in meetings with residents. The home must ensure that all staff comply with infection control measures at all times and that items such as nailbrushes must be removed from the staff toilet. The home had employed a number of staff that had worked with them through an employment agency. However they had not ensured that the full employment checks required were completed before the staff were employed by the home. This does not protect residents. Whilst the training of staff had improved the home could not always show that staff had completed the mandatory training in a timely way. Supervision of staff still needed improving. The manager has yet to apply to be the registered manager for the home through the Commission and complete the training recommended to the position although she has the required experience. The home had improved on the audits of the service but this needs to be collected together with residents, relatives and professional opinions to form a quality assurance system that results in a yearly improvement plan. The home had a recent inspection from the West Midlands Fire Service and had a number of requirements as a result. These must be completed without undue
St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 8 delay. The home had two windows that were not restricted adequately and this could be a potential risk to residents. 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.V323679.R01.S.doc Version 5.2 Page 9 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.V323679.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The information available to residents and their representatives needed to improve to ensure that residents were able to make an informed decision about choosing the home and their rights in form of a contract were protected. The information collected about residents had improved and detailed residents needs, routines and preferences and this helps in meeting residents needs. EVIDENCE: The residents spoken to could not remember whether they had received information prior to admission. These residents had short-term memory difficulties. One resident said ‘I think I had a brochure.’ Another said that they came here by recommendation. A number of service user guides were found in bedrooms. The Statement of purpose had been updated but a full statement of purpose with the amendments in place was not found. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 11 The contracts showing the terms and conditions of residents stay were generally available on the care files these denoted the fee that residents needed to pay. The manager thought that these had not been updated. Residents spoken to were not able to say how much they paid to be in the home most saying that their relative managed this on their behalf one stating that they had ‘no idea.’ Care files showed that residents were having an assessment by the home before admission and these assessments ensured that residents were not admitted outside of their category of registration or the home’s ability to care for residents and this is an improvement. It was clear from records that the manager had visited prospective residents in hospital before admission though residents found this hard to remember. A number said that their relatives sorted this out for them. One resident said that they had visited three homes and chose this home. The home recorded information about how to communicate with residents that had some impairment and details about the residents’ ethnic origin and religion was noted on their care files. This information helps to ensure that care is given in the way appropriate to the individual resident. The information collected prior to a resident being admitted was good. Information was added to with a format on what the home had learned about the resident found on the care file and this is good practice. A resident with a specific health condition had information about that health condition in their file for staff to read. Risk assessments about the provision of alcohol and medication were not looked at on this occasion. The home has yet to supply a letter to residents or their families to say that the home can meet the resident’s needs before admission. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had continued improving on the care planning, monitoring of residents’ health needs since the previous inspection. These arrangements were now good. The home needed to ensure that medication administration procedures were always followed to ensure that medications could always be accounted for. Residents thought that they were treated well and staff were seen to treat residents well. EVIDENCE: Care plans remained improved from the previous inspection. The care files were well organised and information was easy to find and this assists care staff to give good care. The care plans showed how care was to be given for example one plan said ‘bath on request male carer only’. The home had a summary of the care plan and this acted as a quick check to the care a specific resident needed. Care plans were reviewed on a monthly basis and where
St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 13 appropriate these detailed changes in the residents’ health and abilities and this was an improvement on previous inspections. The home had records of reviews that were undertaken with social services and family members where these occurred. One review said that the resident was happy with their placement, liking the room, the home and had voluntarily stopped smoking. The family stated that the resident had significantly improved in health since being at the home. The home had improved its risk assessments; a number of risk assessments for moving and handling, skin care and falls were seen. A moving and handling assessment seen was appropriate to the needs of the resident and the bedroom had appropriate equipment to ensure that the transfer of the resident to bed, into a chair and so on could be managed well. One risk assessment was seen for a mental health issue this could be enhanced by information on triggers to show when and if the resident’s mental health begins to deteriorate. The home was able to show that they follow up health concerns of residents. There were records of outpatient appointments being made and kept. There were also signs that the home had gone further with encouraging specialist assessments and referrals to be made. Residents had received a flu vaccination where they had consented. Residents were being weighed routinely and where concerns were raised arrangements were made to improve the resident’s nutrition and for monitoring of weights to be done more often. The home showed that they were using more monitoring charts for food intake and fluid intake. The home was also monitoring those residents that were unable to use a call alarm throughout the night. Daily records were improving and it was clear that health concerns were followed up once they were raised. The home was looking at accidents in the home and an analysis of these accidents was taking place on a monthly basis and this had remained improved from the previous inspection. Residents looked well and well presented except for their hair, a number of residents needed the services of a hairdresser. The manager stated that she had delayed the hairdresser coming so that the residents had their hair done for Christmas an extra visit by the hairdresser would have been more appropriate. Medication records for five residents were looked at. All residents had a photograph with their medication record and this acted as a check that the right medication was given to residents. Generally medication was stored appropriately. However the medicines fridge did not have a record of the daily current, maximum and minimum temperature and this can mean that medication is stored outside the temperatures that it is licensed for. Creams
St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 14 and eye drops were dated at the time they were opened and this means that the home can keep a check that they have not become contaminated by being open too long. One cream was not being administered as often as the prescription stated. The home had a signature list for staff that give out medication however one signature was missing on this record. One medication had not been supplied this time by the pharmacy but there was no carry over of the medication still in stock on the medicine administration record (MAR). This means that it was not possible to audit this medication. A medication was prescribed as 1 or 2 tablets when needed but the record did not state whether one or two had been given. There were a number of gaps on the MAR and a number of medications did not tally with the records. Residents were happy with the care they received. One resident thought that the staff joked with them and this made them feel happy. Staff spoke to residents appropriately. Staff assisted residents well at meal times. One resident had instructions on the wall of how to use the call alarm to maintain his independence. Residents said of the help they received ‘the staff are pretty good,’ ‘the ladies help a lot.’ ‘I am happy here.’ St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The homes arrangements for activities and meal provision needed to be improved in response to comments made by residents. The arrangements for visitors and for residents to have freedom of movement and how care was delivered were improving. EVIDENCE: The home had started to collect information about residents’ lives before coming into the home and was beginning to look at previous interests. It was clear however that activities had not been improved since the last inspection. A number of residents meetings had raised this as an issue and the manager stated that whilst some activities were being undertaken recording of this was not good and there was no one at present to drive the home’s minibus. Residents spoken to did not think that they had enough activities provided. A number of residents have dementia and records of their activities were not always written. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 16 There were no undue restrictions on visitors in the home. It was clear that the home was trying to increase contact with residents’ families and letters were found on a resident’s file. The home has begun to record discussions with relatives to ensure that there is some continuity between shifts of staff. The home has begun record concerns raised with them. Residents were able to receive care where they wanted. A number of residents spend time in their bedrooms rather than in the communal lounges. Residents whilst encouraged to come downstairs for meals can have meals in their room if it is safe for them to do so. Residents that were at risk spending time alone in their room have risk assessments and monitoring charts to ensure their continued well-being. The inspectors joined residents for the main meal at lunchtime. The main cook had not been at the home for some time and a number of comments had been made about the food to the inspectors and in the residents meetings. Comments received were about the lack of cooked breakfasts however records showed that residents did have a hot option at breakfast most days more recently and a residents meeting said that these were being enjoyed. Sometimes the meal was not hot enough and this was true on the day of the inspection. The inspectors found that the main dining room was cold and a number of residents complained about draughts from the large window and the kitchen area and this may affect the heat of food. One resident said that they didn’t like the quality of the faggots. Other residents thought the food fair, or good. All agreed that they liked cooked breakfasts when these were on offer. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had improved their arrangements for recording concerns and complaints and needed to move to showing that these concerns result in improvements in the home. The home had made improvements in their policies, procedures and training of staff to protect residents. EVIDENCE: The Commission have received no complaints about the home since the last inspection. The home has begun to record complaints and concerns that they receive. The home had registered a complaint from a relative about the personal hygiene needs of a resident not being met. The home responded appropriately by requesting an assessment from the continence advisor, checking for urinary infections and gaining advice from the district nurses. The home had also started collecting together concerns and showing how they had responded to these concerns. Examples of these were a missing item of clothing, horlicks not being offered to residents on a night and a stain on a carpet. The home had started to put issues raised by residents in residents meetings in this concern book. This collection of concerns should assist the
St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 18 home in determining areas of the homes performance that need improvement and set targets for their annual plan. The home had a complaint procedure that needed some review. Residents spoken to were not aware of the complaints information due their health difficulties. One resident seemed to have some anxiety about raising concerns but this appeared to be connected with their life history. One resident spoken to spoke warmly of the manager and when asked about raising concerns said ‘I love her.’ The small group meetings of residents appear to be a useful way of collecting residents’ opinions. The home has an adult protection procedure and submitted a restraint procedure that protects the rights of residents. The home has not had any adult protection issues since the last inspection. The staff files looked at showed that the majority of care staff had some adult protection awareness training and this needs extending to all staff. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 19 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): 19,21,22,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and fresh and the environment for residents continued to improve. Further improvements in assisted bathing facilities, changes to prevent flooring becoming damaged would make this a homely and comfortable place for residents to live. Improvements were needed in the staff adherence to infection control policies to ensure that residents were not at increased risk of cross infection. EVIDENCE: A tour was undertaken of the home taking in most of the residents’ bedrooms and communal bathing areas the following was found. The home was clean and fresh and the redecoration of bedrooms was continuing. A number of rooms had new flooring and this had improved the odour in these rooms. A number of beds and canter-lever tables had caused problems with some of the
St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 20 non-slip vinyl flooring and solutions must be sought for this not to continue and the existing repaired. Canter-lever tables may not be appropriate for a number of residents and these can be moved if not in use. The second floor bathroom had yet to be adapted to be useful to residents. The home had reduced the number of rooms that were to be used as shared rooms. To adjust the certificate and the fees to the Commission the home must apply for a variation to the certificate. There were a number of aids available and in use with certain residents such as hoist, propad mattresses and cushions to prevent pressure areas developing, pads to prevent residents falling out of bed and so on. The home had undertaken risk assessments of residents’ ability to use the raised toilets in some of the en suites. The home whilst having reasonable infection control measures needed to ensure that staff adhered to them. Staff were found not to remove gloves and aprons in the toilets before walking residents to their seats and a nailbrush was found in the staff toilets. The homes training matrix and staff records did not show that care staff had received training in infection control. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing the kitchen were not consistent and resulted in dissatisfaction with the meals provided. Recruitment practices needed to be improved to ensure that residents’ safety is paramount. Training of staff was not given in a timely way across all required areas and this could lead to poor practices in the home. EVIDENCE: Three staff files were looked at for recruitment and employment practices. The staffing rotas showed that whilst the care staff maintained much at existing levels the absence of the cook had not been adequately provided for and this must be attended to without undue delay. The home has yet to reach the standard of 50 of staff with an NVQ2 in care or equivalent but was approaching this figure. Staff that are appointed complete an application form, have references and appropriate checks from the Criminal Records Bureau and the Protection of Vulnerable Adults list. However a number of these checks were not completed
St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 22 in a timely way. A number of staff had been appointed as permanent staff having worked with the home as agency staff and checks had been completed subsequent to their permanent employment at the home. This means that the home could potentially employ someone that is no longer safe to work with vulnerable people. The home had a matrix of staff training but this had not been updated since September 2006. It showed that a number of staff had not had the basic required training to provide care, however the majority of care staff had up to date moving and handling, adult protection, fire safety and food handling there were considerable gaps in first aid and dementia care. Infection control and health and safety were not represented on the matrix. Although induction of staff took place this was not given as recommended by the Skills For Care organisation. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements of the management in the home needed to be improved. Training for the manager, collection of staff and professional views and supervision were not sufficient and these lacks affect the homes ability to provide a good improving service for residents. The homes attention to health and safety had improved but consistency was needed in some areas to ensure that is maintained. EVIDENCE: The manager has yet to undertake the ‘fit person process’ with the Commission to become a Registered Manager. She is required also to undertake essential training to complement her experience for this role. She St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 24 has undertaken the same training in dementia and moving and handling with the staff at the home. There was no quality assurance mechanism in place, the home had been involved with an organisation providing this but had stopped this. The home stated that they were arranging this with another company. The registered person and company secretary do visit the home regularly and reports are made of some of these visits. The Commission had received a report of a monthly visit in more recent months. The home had started collecting views of residents in small meetings of groups of residents. This had been effective having managed to get views from 14 residents in these small meetings. The home need to show how these views can be responded to as part of their quality assurance and annual review. The home stated that they do not hold finances for residents and invoice residents that have hair and chiropody services. These invoices usually go to the relatives. The home was not achieving the required number of supervisions of staff needed. The home manager was concentrating on care planning, reviews and resident consultations but needs to build in staff supervision with these processes as this will ensure that staff performance. The home had devised a gender and intimate care policy and this was an improvement on the previous inspection. The home had ensured that new residents had photographs available and this was a requirement of the previous inspection. The home had completed a number of general risk assessments that apply to all residents for example a risk assessment was written about the heat wave in the summer and how to maintain the well-being of residents through this. The home has the routine inspection and maintenance and inspection of the services such as gas and electric equipment and supply. Window restraints in two rooms were not ensuring that the window could not be open more than 6 inches and this could expose residents to risk. The home had a visit by the Food Safety Department in June 2006 and they inspected the kitchen, fridges and so on. Requirements were made about the flooring in the kitchen and this had been replaced by this inspection. The home had appropriate records of fire safety tests, maintenance and inspection and had reviewed their fire risk assessment however an inspection by the West Midlands Fire Service subsequent to this inspection made requirements and the home will need to inform the Commission how they intend to comply with these requirements. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 25 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 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 3 2 X 2 3 X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4(2) Requirement Timescale for action 31/01/07 2. OP2 5(1)(c) 3. OP3 13(4)(c) 14(1)(d) An up dated full copy of the homes statement of purpose must be available for residents and or their representatives. The home must ensure that the 31/01/07 contract outlining terms and conditions for residents is reviewed routinely and residents informed when the fees increase. Risk assessments for alcohol 31/01/07 must include information on the effect of alcohol on any medication taken by the resident and any agreed limit or supply of alcohol. (Not inspected on this occasion) The manager must write to the resident advising them having regard to the assessment that the home can meet their needs. (Outstanding since 31/07/06) Residents that have a mental health condition must have information on signs or triggers on their care plan that alert staff that the resident’s condition is deteriorating. All medication must be given as
DS0000016757.V323679.R01.S.doc 4. OP7 13(4)(c) 15(1) 31/01/07 5.
St Agnes OP9 13(2) 31/01/07
Page 27 Version 5.2 stated on the MAR or a reason why not recorded. Fridge temperatures must be recorded to ensure medication stay within their product licences. Medication that remains in stock at the end of a month’s medication administration record (MAR) must be carried forward to the next MAR. Variable dose medication must have recorded the amount of medication given at each administration. All residents must be provided 31/01/07 with appropriate activities and an activities programme must be devised. The home must ensure that all residents with dementia have access to activities and record must be kept what activities individual residents have taken part in. This remained outstanding since 30/12/05.and 31/07/06 Arrangements must be made to review the meals provided in the home. Food must always be served at an adequate temperature in a dining room free from draughts. The home must demonstrate that improvements are made in line with residents’ views. All staff must receive adult protection training. Outstanding since 31/05/05 and 28/02/06. This requirement was partly met. The garden path must be cleared of weeds and overgrown plants
DS0000016757.V323679.R01.S.doc 6. OP12 16(2)(n) 7. OP15 16(2)(i) 31/01/07 8. 9. OP15 OP18 16(2)(i) 13(6) 31/01/07 31/03/07 10.
St Agnes OP19 23(2)(o) 31/01/07
Page 28 Version 5.2 to ensure safe access for residents. (Not inspected on this occasion) Solutions must be sought to prevent the ripping of the vinyl flooring with equipment. The 2nd floor bathroom must be made fit for use by residents. Outstanding since 11/11/04, 28/02/06 and 30/09/06. Staff must adhere to infection control procedures. The home must ensure that the ancillary staffing is appropriate to the needs of the residents and adequate provision is made during the cook’s absence. The home must ensure that all staff have appropriate checks and references before commencing employment with the home. The home must ensure that all training is of an appropriate standard to meet the Skills for Care requirements for induction and mandatory training. Outstanding since 15/12/05 and 31/08/06. The manager and homeowner must ensure that any staff working in the home have the required up to date training. Outstanding since 31/07/06 The home must ensure that appropriate manager is consistently in place and this person undertakes the fit person process. Outstanding since 28/02/06 and 31/07/06. The Homes manager must have the NVQ4 in care and the NVQ4 in management or equivalent. (Date of 31/12/06 not expired) A quality assurance system must be put in place that reflects the
DS0000016757.V323679.R01.S.doc 11. OP21 23(2)(j) 31/03/07 12. 13. OP26 OP27 13(3) 18(1)(a) (b) 31/01/07 31/01/07 14. OP29 13(4)(c) 15/01/07 15. OP30 18(1)(c) 28/02/07 16. OP30 13(4)(c) 26/02/07 17. OP31 9 31/01/07 18. OP31 9 31/05/07 19.
St Agnes OP33 24 30/04/07
Page 29 Version 5.2 20. OP36 18(2) views of all stakeholders and results in an annual report and action plan. All staff must receive supervision (1:1 recorded) by 23/06/06 And A programme of a year’s one to one supervision must be sent to the Commission 31/03/07 21. OP38 13(3) 22. 23. OP38 OP38 13(4)(c) 23(4) All care staff must have recorded supervision for no less than six times a year. Outstanding since 20/01/04 an 31/01/06 and 23/06/06 COSHH must be kept in a locked 31/01/07 cupboard and separate to foodstuffs. (This was not inspected on this occasion and this requirement was brought forward.) Windows must be restricted to 4- 31/01/07 6 inches to protect residents. The home must advise the 31/01/07 Commission of how they intend to comply with the requirements made by the West Midlands Fire Service. 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 OP28 Good Practice Recommendations It is recommended that the home devise a plan of how they increase the number of NVQ2 trained staff and maintain this level. St Agnes DS0000016757.V323679.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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
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