CARE HOMES FOR OLDER PEOPLE
St Agnes 31/33 Silverbirch Road Erdington Birmingham West Midlands B24 0AR Lead Inspector
Jill Brown Key Unannounced Inspection 8th June 2006 09:30 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.V299070.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.V299070.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 F/P 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 Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th November 2005 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. St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors Jill Brown and Lisa Evitts visited the home on a day in June and completed an unannounced inspection in just over 9 hours. The home had some legal action taken since the last visit and has had some additional visits on these short falls. These visits were about care planning, moving and handling of residents, and training of staff in moving and handling and dementia care. During the inspection 4 residents were spoken to and all the residents in the two dining rooms were observed during the lunchtime when the inspectors joined residents for lunch. Four residents case records were looked at and medication records were also checked. Two staff above the manager and owner were talked to and three staff records were looked at. A tour of the building was completed and records of visits from the West Midlands Fire Service and the Food Safety department were also checked. The home charges between £322 and £346 per week this is dependent on whether rooms are shared or single and en suite. What the service does well:
The residents spoken to said that the care they receive was good. One resident said ‘the staff here are nice and helpful.’ Care plans were available for needs and risks identified at assessment. Residents appeared to be appropriately dressed and had their hygiene needs met. Staff knew ways in which they could keep residents’ dignity whilst giving personal care. Residents that needed assistance to eat were assisted in a sensitive and appropriate way. The food provided was appropriate to the needs of the residents. Residents in the home have a choice about where their care is provided. Several residents choose to spend time in their bedrooms and food is provided for them there although they are encouraged to join with the other residents. St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 6 The staffing levels in the home were appropriate and although the home has had to use agency staff to maintain this they are trying to keep with the same agency. The home has a good handover process between day and night staff that ensures the care of residents remains consistent. What has improved since the last inspection? What they could do better:
Whilst the assessment of residents has improved there is a need to reduce the number of assessment forms to ensure that information kept is the same on each document. Assessments need to be signed and dated. Risk assessments on identified risks were not always in place on admission and a risk assessment for a resident that drinks alcohol needed to show what the risks were with the medication he was on. Care plans sometimes were not updated with important information and parts of care plans were not reviewed monthly as required. There were a number of medication administration problems that meant it was not possible to know if the amount of medication was correct in a number of cases. Routine safeguards were not always in place such as photograph of the resident and two signatures for handwritten records. These lacks could potentially mean that errors could be made.
St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 7 The home could not show which residents had joined in what activity. Many of the residents are not able to join in group activities and there was no record of individual time spent with them. Residents’ views were not being collected. As the majority of the residents were not able to remember how they have been cared for, the home needs to collect comments made at the time. In this way they can shape the care to match what the individual resident likes. The home had not always ensured that they kept a record of conversations with staffs ex employers and could not always show that they had the appropriate references before they employed staff. The home has concentrated training on the areas identified at previous inspections. However the home must ensure that all staff have the required training at appropriate time including induction that meets the Skills for Care guidance. To do this the home must pull together a chart of all the staff training and the date that the staff member has attended so that effective planning for gaps in training can be met. This includes the relevant training for the manager and application to the Commission to become the Registered Manager. The Manager was not ensuring that staff were having supervision at least 6 times a year. The home has undertaken a lot of work on the home and is working to an improvement plan. The following items need to be added to the plan. The garden paths must be cleared of weeds and plants to ensure that residents can walk around safely. The handrails must be replaced with new. A number of the toilets are very high and the home must ensure residents can safely use these and bedrooms must be kept to a reasonable temperature. The home needs to improve its management of quality assurance and provide the Commission with a yearly report and plan of improvements it intends to make based on the views it collects. The home was ensuring that maintenance and inspection of equipment and services such as Gas, electrical wiring and so on. However they needed to review the Fire risk assessment to make it was still correct. Ensure that Fire drills were undertaken in a timely way and ensure a building risk assessment was completed. 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. St Agnes DS0000016757.V299070.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.V299070.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 at least once during a 12 month period. 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 home has improved on ensuring that staff are aware of the needs of the residents. Risks to and needs of residents must be recorded consistently and in a timely way to ensure needs are met. EVIDENCE: The home had updated a statement of purpose and sent this to the Commission, this has been amended subsequently, and a full updated version must be sent to the Commission. The home charges between £322 and £346 per week this is dependent on whether rooms are shared or single and en suite. Residents had contracts with the home but a number were not completed. A large number of residents have a three-way contract between the home, Social Care and Health and the resident (or their representative).
St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 10 The home was recording resident’s details on more than one form prior to admission. This duplication could allow for inconsistency of information and mistakes could arise. For example one resident’s first assessment form said that the resident was allergic to penicillin and on the second it was not mentioned. There was an increased link between needs identified in the assessment and the care plan and this was an improvement. The home was not writing to the residents or their representatives stating that following their assessment the home could meet the resident’s needs. Assessments and risk assessments were completed but these were not always in a timely way. A risk assessment about a resident’s consumption of alcohol did not have information on whether medication should be given if the resident had been drinking, or if there was an agreed limit of alcohol. It was not clear what type of the resident preferred and what alcohol was kept at the home if any for the resident. A number of key forms such as nutritional assessment forms and skin health assessments (Waterlow) were not completed on a number of files and the review of these assessment were not always timely. Residents recently admitted into the home met the criteria for admission. It was clear that staff interviewed had knowledge about the care of residents. Recent training in dementia and moving and handling were seen to be more effective than previously. The name of staff that did the assessment was not recorded and this is important if there are later any questions about information recorded. St Agnes DS0000016757.V299070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has made major improvements in its care planning process attention to updating and reviewing would improve these further and ensure that residents have good consistent care. Medication needed improvement to ensure that the potential for error is lessened and that residents’ safety is assured. Residents were happy with how staff approached them and staff knew how to ensure that residents’ personal needs were attended to sensitively. EVIDENCE: All residents had a care plan; one seen was not completed in a timely way. The care plans were a major improvement on plans seen at previous inspections. Daily records showed that some parts of some records had not been updated for example one plan had not been updated about a health condition another did not state care provided by a relative. One daily record stated that a resident had a red bottom but no actions to be taken were noted in the care
St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 12 plan. Sections of the care plan were reviewed at different times and this meant that some parts of plans had not been reviewed monthly as required. The care given to residents was improved. Residents were assisted to get up and move in an appropriate way. Staff were able to talk about communication with residents with little or no speech due to dementia. Residents appeared to have their personal hygiene needs met and were appropriately dressed. Residents that were not eating much did not have recorded the amount that they ate and this needs to be done to ensure good nutritional care. Accidents were recorded and there was improvement in the reporting of these accidents to the Commission. The home has a good handover procedure looking at all the care needs of the residents from day to night staff and night staff to day staff. The home manager had undertaken an analysis of falls starting in December 2005; this is good practice because it assists the home in looking at minimising risks to residents. The home ensured that at the handover of the night staff to the day staff there was a full check made of the needs of residents and clear handover information was given. None of the residents was receiving assistance from the district nurse team on pressure area care at the time of the inspection. It was clear where necessary residents had contact with health professionals. A resident needed a referral to an occupational therapist to see if a more appropriate chair could be provided. Although photographs of residents were usually kept with the Medication Administration Records (MAR) a number of these were missing. These photographs assist staff to ensure that medication is given to the right resident. An audit trail was not possible on two residents’ medication because the medication had not been counted in and recorded on the MAR. A number of the MAR were handwritten when they should now be printed by the pharmacy. This led to poor detail on the MAR; there was a lack of signatures. Medication was not given such as Senna without a record of why it had been omitted. Medication, such as eye drops, was not dated when opened but were stored in a fridge. Fridge temperatures were not taken and this could mean that medication is being stored at temperatures outside the product license. The management of medication was not as good as at previous inspections. Staff were able to discuss ways in which they maintain the privacy and dignity of the person. Residents said that ‘the staff here are nice and helpful.’ ‘Its very good’ ‘its hard losing your independence though.’ St Agnes DS0000016757.V299070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for choice, visiting relatives and friends and meals were good and this enhances residents lives. The arrangements for activities needed improvement and evidence kept of how residents with communication difficulties had time with staff. EVIDENCE: The home ensured that they recorded the interests of residents on their assessment form on admission. There was a programme of events for the week but this included use of the minibus and this hadn’t yet been available. Individual residents were having some details of social activities but these were not specific enough to measure whether residents were getting one to one time with staff if they couldn’t join in activities. Daily records said that residents joined in activities but didn’t mention what activity this was. The home needs to keep information so that they can arrange more of the activities that residents like. Residents spoken to thought that they could have friends and relatives visit when they wanted.
St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 14 The home ensures that residents that wish can receive care in their room. This includes meals. There was a choice of food available for residents. Residents spoken to said that they could get up and go to bed when they want. The residents spoken to thought that staff responded well then they needed help. Many residents were unable to clearly remember aspects of their care but seemed happy and not distressed. The choice of meal was either fish in sauce, battered cod, or quiche with mash potatoes and mushy peas or salad. This was outlined in the planned menu. Residents were assisted appropriately to eat if help was needed. One resident could have used a plate guard to stop food spilling off the plate but all other residents that needed had appropriate aids. St Agnes DS0000016757.V299070.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home had arrangements for formal complaints this process was not enough for residents that have difficulties complaining. The home needs to ensure that all staff have some training in adult protection to ensure residents are safe at all times. EVIDENCE: The manager was unable to locate the complaints book at the inspection and states there have been no complaints since the last inspection. The Commission has received no complaints. The home has an appropriate complaint procedure. Although the home has a formal process for complaints it still has not improved on systems to collect residents views so it can improve the service it provides. This must be undertaken in differing ways to ensure the quality of care continues to improve. The home has a restraints policy, which does not contain detail on more usual restraints on older people such as reclining chairs, bed rail, medication and locked front doors and this must be reflected in the homes policy and procedure. A number of the home’s staff have not had adult protection training and this important for staff to ensure they understand their individual responsibility in the protection of residents. St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment has improved; further improvements are necessary to ensure the comfort and well-being of residents. EVIDENCE: An improvement plan was in place for the refurbishment of the home and was being worked through. The floor covering has been changed in several rooms and corridors since the last inspection and some redecoration has taken place. The home is looking to change some shared rooms into singles and the Commission will make the adjustments to the home’s certificate if notified formally about this. The garden of the home is large and generally well maintained. The paths however must be cleared of weeds especially at the rear of the garden. The rails around the patio were rotting and the home had plans for these to be replaced.
St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 17 The lounges were well decorated and clean. A second floor bathroom still needs to be upgraded to meet the needs of residents in that area. The home stated that they were hoping to make this into an accessible shower area. One bath board needed replacement because it was cracked. A number of the toilets in the home have been raised and this may pose risks to residents that are not tall and account of this must be made in the residents risk assessment. An external assessment of the water supply stated that the home needed to take remedial action on the water supply to ensure that the water was within safe limits and unused pipes were sealed off. The home was unable at that point to provide evidence of this work being completed. A number of aids were evident in the home and these were appropriately maintained and in use with specific residents. A small number of bedrooms still have odour control issues, which was not general to the home. The management of the cleaning and the odour of the rooms must be addressed to make the rooms pleasant for the occupying resident. The inspection took place on hot day and a couple of the bedrooms were exceptionally warm and the home must ensure that measures are put in place so that rooms are not too hot or cold. St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The records of the arrangements for the induction and training of staff need to be kept in a way that shows where shortfalls may be. There was a number of shortfalls in training and this does not assure the safety of residents. EVIDENCE: The home supplied a staffing rota this showed the member of staff in charge of the shift and the roles of the staff on duty as required. Three staff provide care to residents from 7 am until 8 pm and an extra member of care staff is available between 7 am until 11am, which is identified as a busy time. The home has had a number of staff shortages and has used agency staff recently these tend to be from the same agency to ensure consistency of care. About 42 of staff have achieved the NVQ2 in care and the home must ensure that this maintain the standard of 50 The home ensures that prospective staff complete an application form, a Protection of Vulnerable Adults (POVA) check is completed and returned prior to staff being employed and a Criminal Records Bureau check applied for. There is some proof of identity kept on staff files. Details are not kept of conversations with previous employers or verbal references. References were not always received prior to staff being employed. A health reference was not completed on one file.
St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 19 Induction training had commenced on one member of staff and this must continue and cover the Skills for Care induction guidance. The home is taking remedial action to ensure staff have all the mandatory training required and specific training request by the Commission. The home must keep a matrix of staffs attendance on courses so that update training can be provided in a timely fashion. The home was making staff sign to say that they would make staff pay back training if they leave within three years. The owners should revise this policy in line with their responsibility to provide training appropriate to the work staff are required to perform, the standard that staff must have the equivalent of three days paid training a year and an individual training and development plan. The home were not ensuring that agency staff had in date training on moving and handling fire safety and so on prior to working in the home and this could affect the safety of residents. St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 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 residents, staff, professional and staff 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 has improved but consistency is 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.V299070.R01.S.doc Version 5.2 Page 21 has undertaken the same training in dementia and moving and handling with the staff at the home. The home had not conducted any residents’ meetings because a large number of residents would have difficulty expressing a view in such a way. The home did not have other methods of collecting views. 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 requirement for these reports to be monthly was not quite met. 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 manager was not ensuring that supervisions of staff were being undertaken on a routine basis and was unlikely to achieve the six times a year required. This does not ensure that staff are able to discuss issues of care in a confidential way and that staff performance is managed in a consistent way. The home had yet to develop a cross gender and intimate care policy and procedure. The home employs both female and male care staff and cares for both male and female residents. The home did not have photographs of some residents and this can potentially cause risks to residents. The home’s fire risk assessment and emergency plan had not had its yearly review and update. Fire drills had been completed recently but this was not always falling within the six months. All fire maintenance and inspection checks had been completed. The home had appropriate documents for the safety of Gas and the electrical wiring of the building. The home must ensure a building risk assessment is completed. St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 22 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 2 3 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X X 2 2 STAFFING Standard No Score 27 3 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.V299070.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP1 OP2 Regulation 4(2) 5(1)(c) Requirement Timescale for action 31/07/06 3 OP3 13(4)(c) 14(1)(a) An up dated copy of the homes statement of purpose must be sent to the Commission. The home must ensure that the 31/07/06 contract outlining terms and conditions for residents is completed for all residents that it admits. 09/06/06 The home must not admit residents without an assessment and risk being in place. Care plans must be written within 5 days and risk plans especially for moving & handling and specialist care on day of admission. All assessments must be dated and contain the name of the person undertaking the assessment. Risk assessments for alcohol must include information on the effect of alcohol on any medication taken by the resident and any agreed limit or supply of alcohol. The manager must write to the resident advising them having 4 OP3 13(4)(c) 14(1)(d) 31/07/06 St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 24 5 6 OP7 OP7 15(2)(b) 15 7 OP7 15(2)(c) 8 OP8 12(1)(a) 13(1)(b) 9 OP8 12(1)(a) 17(2) 13(2) 10 OP9 regard to the assessment that the home can meet their needs. All residents’ plans must reflect the up to date position in relation to a service users health needs. All care plans must be completed in a timely way and must include any care that is agreed to be given by a relative. All care plans must be reviewed on a monthly basis with a note stating whether the care plan has been changed or not. Monitoring charts must be used and reviewed regularly for all residents whose condition demands this such as: - fluid intake, behaviour and so on. (This remains outstanding since 31/05/05 and 31/12/05) Health issues raised in daily records must be followed up and the action and outcome recorded. All medication must be counted on delivery to the home and the number placed on the MAR. The MAR must be printed wherever possible and where hand written two signatures are needed to ensure the accurate recording. All medication must be given as stated on the MAR or a reason why not recorded. All eye drops must have a date of opening recorded. Fridge temperatures must be recorded to ensure medication stay within their product licences. The home must ensure that all residents with dementia have access to activities and record
DS0000016757.V299070.R01.S.doc 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 11 OP12 16(2)(n) 31/07/06 St Agnes Version 5.2 Page 25 12 OP16 22(8) 13 OP18 13(7) 14 OP18 13(6) 15 OP19 23(2)(o) 16 OP21 23(2)(j) 17 OP21 23(2)(j) must be kept what activities individual residents have taken part in. This remained outstanding since 30/12/05. The home must keep a clear record of grumbles and complaints including whether the complaint was substantiated and any action taken. This remained outstanding since 30/12/05. The home must devise an appropriate restraint policy. Outstanding since 10/02/04 and 30/12/05. All staff must receive adult protection training. Outstanding since 31/05/05 and 28/02/06. The garden path must be cleared of weeds and overgrown plants to ensure safe access for residents. The 2nd floor bathroom must be made fit for use by residents. Outstanding since 11/11/04 and 28/02/06. And plans made for it meet the needs of the residents in that area. A number of the toilets in the home were raised and risk assessments for residents that use these must be undertaken. One bath board must be replaced. Evidence of the home undertaking work on the water as outlined by Nant must be sent to the Commission The home must ensure that all bedrooms remain at a comfortable temperature. Outstanding since 30/12/05. The home must devise a procedure to ensure odour in the
DS0000016757.V299070.R01.S.doc 31/07/06 31/08/06 30/09/06 31/07/06 30/09/06 31/07/06 18 OP25 13(4)(c) 23/06/06 19 OP25 23(2)(p) 31/07/06 20
St Agnes OP26 13(3) 31/07/06
Page 26 Version 5.2 21 OP29 13(4)(c) home is kept to a minimum and monitor adherence to this. Outstanding since 31/05/05 and 30/12/05. The home must ensure they keep records of any verbal references or conversations with ex-employers of staff and receive these references prior to employment. All staff must sign a health declaration. 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. The home must supply the Commission with a matrix of staff attendance on mandatory courses, NVQ2 and specialist courses. The manager and homeowner must ensure that any agency staff working in the home have the required up to date training. The home must ensure that appropriate manager is consistently in place and this person undertakes the fit person process. Outstanding since 28/02/06. The Homes manager must have the NVQ4 in care and the NVQ4 in management or equivalent. The home must investigate strategies to gain the opinions of service users and that these have affected how the service is delivered. Outstanding since 21/12/03 and 28/02/06. The homeowner must ensure that a representative of the company visit the home not less than once a month and provide
DS0000016757.V299070.R01.S.doc 23/06/06 22 OP30 18(1)(c) 31/08/06 23 OP30 18(1)(c) 23/06/06 24 OP30 13(4)(c) 31/07/06 25 OP31 9 31/07/06 26 27 OP31 OP32 9 12(3) 31/12/06 31/07/06 28 OP33 26 31/07/06 St Agnes Version 5.2 Page 27 29 OP33 24 30 OP36 18(2) the Commission with a report of their findings. A quality assurance system must be put in place that reflects the 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 All care staff must have recorded supervision for no less than six times a year. Outstanding since 20/01/04 an 31/01/06. A cross gender and intimate care policy must be written. Outstanding since 31/05/05 and 28/02/06. Photographs must be available for each resident a week after admission. Risk assessments for building, must be undertaken. Outstanding since 30/06/05 and 30/12/05. COSHH must be kept in a locked cupboard and separate to foodstuffs. (This was not inspected on this occasion and this requirement was brought forward.) The homes fire risk assessment and emergency plan must be reviewed. Fire drill must be carried out no less often than six monthly. 31/08/06 23/06/06 31 OP37 17(2) 31/08/06 32 33 OP37 OP38 Sch 3 (2) 13(4)(c) 09/06/06 31/07/06 34 OP38 13(3) 31/07/06 35 36 OP38 OP38 23(4)(c) (v) 23(4)(e) 31/07/06 31/07/06 St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 28 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 2 Refer to Standard OP8 OP28 Good Practice Recommendations It is recommended that one resident be referred to the Occupational therapist about an appropriate chair. It is recommended that the home devise a plan of how they increase the number of NVQ2 trained staff and maintain this level. It is strongly recommended that the home review its policy of insisting that staff work for three years to pay back any training. 3 OP30 St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Agnes DS0000016757.V299070.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
