Inspection on 10/01/07 for St Andrews House, Ashburton

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Andrews House, Ashburton 22/02/06

St Andrews House, Ashburton 27/09/05

St Andrews House, Ashburton 01/02/05

St Andrews House, Ashburton 07/07/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE St Andrews House West Street Ashburton Newton Abbot Devon TQ13 7DU Lead Inspector Michelle Finniear Unannounced Inspection 08:25 10 January 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Andrews House DS0000003810.V305937.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 Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrews House Address West Street Ashburton Newton Abbot Devon TQ13 7DU 01364 653053 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) Mrs Rosemary Christophers Mr Jeremy Christophers, Mr Duncan Christophers Sally Jo Rhodes Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (24) St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include Residents under the age of 65 years. Date of last inspection Brief Description of the Service: St Andrews House is a privately owned care home for older people, some of whom suffer from physical and mental health problems associated with old age. The home is a detached property set in its own walled grounds, consisting of the original rectory with an extension built about eight years ago. The home is well kept and managed by family owners and has a registered manager, who oversees the day-to-day running of the Home. There are two lounge areas and a garden room, which also serves as a dinning area located on the ground floor. There are also some residents bedrooms on this level with the rest being on the first floor, which is accessed via a shaft lift or staircase. All rooms are currently used for single occupancy and most have en-suite facilities. The Home has attractive and well maintained grounds with level access for residents. The Home is situated within a short walk to local shops and amenities. Fees range from £475 to £500 per week. Copies of inspection reports are available within the home in the entrance foyer. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a summary of a cycle of Inspection activity at St Andrews House since the last inspection visit to the home in February 2006. To help CSCI make decisions about the home the owners and manager gave us information in writing about how the home is run; documents submitted since the last inspection were examined along with the records of what was found at the last inspection; A site visit of over 8 hours was carried out with no prior notice being given to the home as to the specific date and timing; discussions were held with the manager and staff on duty; various records were sampled, such as care plans and risk assessments; questionnaires were sent to staff who work at the home and a sample of people who live there; a tour was made of the home and garden; and time was spent with the people who live at the home both individually and in groups observing how they spent the day. 13 completed resident/relative questionnaires were returned and four relatives wrote letters about their experience of the home. Six staff questionnaires were returned. In addition a sample group of residents were selected and their experience of care was ‘tracked’ and followed through records and discussions with staff and management from the early days of their admission to the current date – looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. Time was spent with these residents, and questionnaires were sent to their relatives, general practitioners and care managers where appropriate. This approach hopes to gather as much information about what the experience of living at the home is really like, and make sure that residents views of the home forms the basis of this report. What the service does well: The home provides comfortable and attractive accommodation, with en-suite facilities, accessible level gardens and a choice of communal space in three lounges. Residents have a range of needs, however communal areas are well used during the day, with a variety of activity going on. An excellent menu is prepared with evidence of several choices and healthy eating principles in use, ensuring residents enjoy a varied and nutritious diet. The home has thorough care plans, which reflected well the residents needs and the actual care given by staff. Plans include risk assessments and falls risk St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 6 assessments, which help ensure residents abilities and choices are maximised whilst their safety is maintained. The level of staff training is commendable, and ensures that resident needs are well met. Comments from residents or their relatives included: “I am extremely happy with the standard of care at St Andrews” “My mother has come out of herself since she has been at the home” “I have been impressed with the cleanliness and the friendly, capable staff” and “Having had experience of other care homes, this one exceeds them all in standard of care, commitment to the residents, genuine concern for welfare, standard of food, hygiene, staff training and knowledge of the problems of old people” What has improved since the last inspection? What they could do better: Risk assessments, including water temperatures, must be completed for all hot water outlets in en-suites. This is to protect residents from coming into contact with water temperatures so hot they may scald them. Staff taking messages over the telephone about changes to medication should ask someone else to hear the message as well. This reduces the risks of mistakes. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 7 The home manager should think about providing more activities that meet the individual needs of service users. 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 Andrews House DS0000003810.V305937.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 Andrews House DS0000003810.V305937.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, 6 Quality in this outcome area is Good. Residents and their relatives receive enough information about the home to help them judge if it is the right place for them. The home makes sure they can meet the resident’s needs before offering them a place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a recently updated statement of purpose and a service user guide available, which contains information about the home. The home manager is considering making this available in different formats, (such as on tape), to meet the needs of people referred to the home. A copy of the guide is available in each resident’s room and can be given to prospective residents before they make a decision about whether they wish to move into the home. It also contains a copy of the homes contract, which gives information on how much the home charges and what the resident can expect in return. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 10 On the day of the inspection site visit the records for five residents were seen, which included Pre-admission assessments of the help they required. In some cases these also included assessments made by Social Services. Preadmission assessments like this reduce the risk of residents being moved from home to home, and hopefully ensure that the resident will be compatible with the other people who already live at the home. For the resident it also means they are can feel more confident that the home will be able to meet their needs. Residents wherever possible are offered trial visits. Trial visits are important as they enable the resident to decide whether they feel the home is the right place for them. However it is accepted that this is not always possible, particularly where potential admissions are frail or in hospital. Relatives or other supporters are invited to the home to look at any available accommodation and meet the staff and management. 100 of the residents or their relatives who completed questionnaires before the inspection indicated that they had received sufficient information about the home before deciding to move there. One resident confirmed their family had helped them choose the home. Another said that they had lived locally all their life and had chosen the home as it was “close to the town centre” so that they could walk into town and meet their friends. St Andrews House does not provide intermediate care. This means they do not provide intensive programs of rehabilitation with the aim of returning the resident to their own home. St Andrews House DS0000003810.V305937.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 excellent. Health and personal care needed is assessed, planned and provided appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five resident ‘files’ were examined on the site visit and then discussions were held with the resident or with a staff member about the care they actually received, and the way in which it was delivered. All of the resident files seen contained detailed clear care plans, linked to assessments, which indicated the support that each resident needed, and how it was to be given. Plans were agreed with the resident (which was also evidenced through the quality assurance documentation) and were being reviewed regularly. This means an accurate picture of the residents needs is available. Plans also contained risk assessments which are a way of identifying St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 12 foreseeable risks and minimising them whilst still enabling the person to lead a full life. On arrival at the home for the site visit, staff were receiving a full handover from the manager. This is a meeting between shifts going off and coming on duty, and helps to ensure that information on each person being cared for is passed on and that everyone is aware of which staff are to carry out particular tasks. This helps to minimise care tasks being missed and that for example residents are ready for appointments. Some of the files seen contained in-depth pen pictures of the residents ‘life history’. This can be really important in helping staff to understand the person they are caring for, and in some instances understanding behaviours that may be challenging. Discussions with a staff member about two residents showed they had a clear understanding of the person, their experiences, likes and dislikes and personality. This is commendable. Residents files also contained information on visits from Doctors, chiropodists and district nurses, and medical services arranged. A relative questionnaire confirmed that appointments for health care needs were made and kept, for example for chiropody and flu vaccinations, and this was backed up in discussion with residents. However another relative felt expected to support their relative on these visits. Optical, and dental support is also available from visiting services. Regular blood tests are taken by district nursing staff, but for residents with Diabetes the home is able to manage certain aspects under the supervision of and support from the district nurses. One relative commented of her mothers care that “All her healthcare needs are taken care of – in fact she has recently been unwell and I cannot fault the way she has been looked after”; Another commented that the home was “Proactive in the care of my mother, initiating healthcare, visits to doctors and dentists… attention to medical matters is first class”. Part of a medicine round was observed and discussion was held with the staff member giving out the medication. The home has a new supplying pharmacist, and a new medicine trolley and refrigerator. These help to ensure that medication is kept securely and in appropriate conditions. Staff administering medication receive training in the systems in use, and information is available if staff need to look up the side effects of a medication they are giving out. All medication records seen were being completed to detail the medication that has been given, in stock or returned to the pharmacy. This means that the home is managing residents medication safely. Some residents have a variable prescription for certain medications which may be altered regularly following blood test results. In these circumstances it is recommended that if the home are advised of the new dosage over the telephone they either request a faxed instruction or ask two staff to listen to St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 13 the message, to ensure that it is received correctly. This helps to avoid the risks of an incorrect dosage being given. St Andrews House DS0000003810.V305937.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 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 good. Some areas of practice were excellent. Residents have opportunities to have a say in the running of the home and take part in activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents at St Andrews House vary considerably in their ability and interests. It is acknowledged that it is difficult to provide activities to meet the needs of all these people, and this was evidenced in the returned questionnaires. These showed that some people enjoyed a high level of organised activity within the home and outside. A relative commented that “My mother has come out of herself since she has been at the home and enjoys taking part in all these activities.” Some others who were very frail were said in their questionnaires to not be able to take part in many activities for physical reasons. The home has appointed an activities co-ordinator and discussions were held with the manager on moving towards a more ‘person centred approach’ to providing activity or occupation for residents. This is good practice, and means targeting St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 15 individual activities to meet the likes, preferences, culture and abilities of the people who live there. During this inspection a period of two hours was spent sitting with residents who were not all able to communicate verbally, observing how they spent their time and the quality of contact they had with staff and other people. The results of this demonstrated that staff contact with residents was positive and residents were engaged with and aware of what was going on around them. This can be seen as a sign of well-being. The home has recently appointed a new cook, and service users remained generally complimentary about the meals served. The lunch on the day of this unannounced inspection was roast beef and Yorkshire pudding with fresh vegetables. Dessert was fruit trifle. Comments such as “The food looks and smells freshly cooked; a good variety, with a choice usually. A lot of fresh veg and nicely served” were typical. One service user commented they needed their food to be cut up for them. Kitchen areas seen were clean and clear. St Andrews House DS0000003810.V305937.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 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 good. There is a clear complaints procedure that residents understand, and there are good systems for the protection of residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Andrews House has a clear complaints procedure that is available in the resident guide. The procedure spells out how to make a complaint and that the home will investigate all concerns raised. 100 of residents or their relatives who completed questionnaires indicated that they were clear or usually clear about who they would go to if they were concerned about something at the home or wished to make a complaint, and this was backed up in discussions with residents. Many residents who have some confusion or memory loss may find making a formal complaint difficult, which makes it very important that staff are aware of clues other than verbal ones that indicate that a resident may be unhappy about something. The staff at St Andrews House have received training in the protection of vulnerable adults. This helps to protect residents from being cared for in a way that does not respect their privacy, dignity or rights. Discussions with staff indicated that they had a clear view about the rights of older people. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 17 St Andrews House DS0000003810.V305937.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. Residents live in comfortable and well managed surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour was made of all areas of the home on the site visit. St Andrews house comprises of an old period property with a purpose-built wing attached to the rear. All bedrooms have en-suite facilities of either showers or baths, and there are three separate communal areas for resident use. There are extensive gardens to the rear, and some parking to the front. This means residents have a choice of areas to spend time in. Rooms vary considerably in shape and size, and although there is a chairlift to the period rooms at the front of the property some still have small flights of stairs either within the room or to access the room itself. Plans are in hand to address some areas of this in the near future. In the rear of the property within the purpose-built St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 19 extension there is a passenger lift to access the first-floor rooms. Servicing agreements for both lifts were seen. Some rooms on the first floor have balconies which enable residents to have a small private seating area or place for plants. Several residents had made this area very attractive. All bedrooms have locks fitted to the door to enable residents to lock their room if they so wish, which means they can maintain their privacy if they wish. The Fire Officer and the Environmental health officer visited the home in 2006, and made some recommendations, which the manager confirmed had been attended to with the exception of the clearance of some items in the basement which belonged to the owners. Regular fire drills and practices are carried out at the home, and the home has contracted for external fire training for staff, certificates for which were seen. This helps to ensure that residents are protected as far as possible from the risks of fire. All areas of the home seen on this inspection were clean, warm, odour free and comfortable. The homes laundry is small but centrally located, and plans are in hand to replace the current provision in the near future. Infection control policies, information and practices seen were satisfactory, including for the disposal of clinical waste. An infection control co-ordinator has been appointed to ensure a regular infection control audit is carried out. This is good practice and should help residents to be protected from a risk of cross infection. Environmental risk assessments have been carried out, both for the home and also for the care tasks carried out within it. These risk assessments, regularly updated, review any risks inherent within the environment and detail any measures to be undertaken to remove or reduce the risks to staff and residents. All radiators are said to have been protected, and the home has automatic water temperature protection to areas where residents would bath or shower. However the manager could not confirm that this protection has been extended to residents rooms and wash hand basins. The manager agreed to do an audit of water temperatures in resident en-suites and ensure this is incorporated into the risk assessment with action being taken to ensure service users safety is maintained. This should help to ensure residents are not placed at risk of scalding by coming into contact with too hot water. Residents rooms showed evidence of personalisation, with items of their own furniture, photographs and paintings. This helps people to feel at home. The manager confirmed that they try to keep signs in the building to a minimum to ensure the home still keeps a domestic feel wherever possible. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 20 St Andrews House DS0000003810.V305937.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 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 good. Some areas of practice were excellent. Staff are well trained and experienced. Staffing practices protect service users from being cared for by unsuitable people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the personnel files for four members of staff were seen along with their training records and evidence of appraisals. Staff were invited to complete questionnaires about their employment before the site visit and staff on duty were spoken to during the visit. Discussion was also held with residents about how well the staff meet their needs, and a handover was seen, which showed evidence of how duties are allocated and information communicated between staff. Staff files contained all the required information to show that their recruitment had been undertaken thoroughly. This included the obtaining of references, police checks and evidence of their identity. This helps to ensure that residents are cared for by people who are suitable to work with vulnerable adults. On the day of the site visit a member of staff had been taken ill at the last minute so the care staffing compliment was a little under the usual numbers, St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 22 however care was still delivered in an unhurried way. Some day staff start at 7am to support the night staff in getting up residents who like to be up early. Sufficient domestic staff were also on duty to ensure that the home was kept clean and that meals were prepared. Additional cleaning hours have been provided during the last few months. Staff training has been at a high level during the last year and as well as focussing on core needs such as first aid and moving and handling, the home has spent considerable effort working on such areas as team building and customer service. This should help to ensure staff work well together to support residents. All staff have individual training profiles, there is a training needs analysis for the whole staff group and training plans could be seen for topics booked for the forthcoming year. This is commendable. Staff spoken to showed a clear commitment to the residents at the home and a good understanding of them as individuals, their likes and dislikes, personalities and histories. Staff questionnaires also demonstrated this. One staff member commented “We take great pride in providing a loving ad caring environment for all of our residents”, and another said “The care home provides a very high standard of care for the residents and is a very nice place to work in.”. St Andrews House DS0000003810.V305937.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area was excellent. The home is being well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit time was spent with the manager looking at how management systems at the home are working. This included systems for the management of health and safety and quality assurance. The manager of the home is experienced and well qualified, having achieved an NVQ 4 both in management and care, and the registered managers award, which is a specialist qualification for managing a care home. NVQ’s are a nationally recognised award recognising the competency of a staff member in their work place, and NVQ 4 is a management level award. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 24 Evidence could be seen of comprehensive risk assessments having been undertaken at the home. This included those for the environment, for working practices and for resident activities. Risk assessments are a way of assessing and reducing foreseeable risks. The home manager is however recommended to ensure the risk assessments that have been undertaken for water temperatures to en-suite facilities contain a recording of the water delivery temperatures, and any areas of risk are addressed. This will help to ensure that residents cannot be scalded by coming into contact with hot water. The home has maintenance contracts for all services, and has regular fire tests, drills and instructions. Servicing of the Fire system remains under contract which should mean that residents are protected by well maintained fire equipment and well trained staff. Evidence was seen of employers liability insurance being in place in the front hallway. All windows above the ground floor were said to have restricted width openings; this is to prevent residents from any risks of falling from windows or balconies, but had been raised by some residents in the quality assurance questionnaire as an area some were unhappy with. A programme of hot surface protection has been undertaken, and it is hoped that this will be completed within the next two months. This is to prevent residents from coming into prolonged contact with a hot surface i.e. by falling against a radiator. Safety data sheets could be seen for all cleaning chemicals in use, and the home has six monthly legionella testing. This helps to ensure that water is safe and information is available on chemicals in case of accidental misuse. Staff training in health and safety includes first aid and food hygiene practices, as well as infection control practice. Equipment such as gloves and aprons is available, and the home also uses sterilising hand gels, carried by each staff member, to prevent any risk of cross infection. Information on infection control measures and anti bacterial gel is available at the homes entrance. Moving and handling equipment is serviced regularly, and staff receive training in moving and handling practices. This is to ensure that residents can be moved safely. Staff were observed using this equipment during the site visit and were confident and reassuring to the residents involved. Discussion was held with the manager on the use of wheelchair footrests, as it was noted that they were not always being used during transfers. This presents a risk of residents being injured. The manager confirmed this was at the residents request and additional advice is to be sought on this. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 25 St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 26 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x X 3 St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 27 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 OP25 Regulation 13 (4) Requirement The registered person shall ensure that: (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (Risk assessments must be completed for all hot water outlets in en-suites and any identified action taken to safeguard service users. Water temperatures at these outlets must be taken into account in the risk assessments.) Timescale for action 15/03/07 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 OP9 OP12 Good Practice Recommendations When a variable prescription is altered the staff receiving a verbal instruction should have this confirmed by another staff member. The home manager should consider adopting a more DS0000003810.V305937.R01.S.doc Version 5.2 Page 28 St Andrews House person centred approach to activity and occupation. St Andrews House DS0000003810.V305937.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Andrews House DS0000003810.V305937.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. 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