Inspection on 30/04/07 for St Andrews House Nursing Home

This inspection was carried out on 30th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Andrews House Nursing Home 19/01/06

St Andrews House Nursing Home 06/07/05

St Andrews House Nursing Home 17/11/04

St Andrews House Nursing Home 28/06/04

Similar services:

Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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

CARE HOME ADULTS 18-65 St Andrews House Nursing Home 37 Rainhall Road Barnoldswick Lancashire BB18 5DR Lead Inspector Mrs Marie Matthews Key Unannounced Inspection 30th April 2007 10:00 St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 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 Nursing Home DS0000022474.V333126.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 Adults 18-65. 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 Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrews House Nursing Home Address 37 Rainhall Road Barnoldswick Lancashire BB18 5DR 01282 816701 01282 816508 standrefitzpa@btconnect.com 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) Oakfoil Limited Ms Jean Harriet Shaw Care Home 24 Category(ies) of Physical disability (24), Physical disability over registration, with number 65 years of age (3) of places St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing will be in accordance with the Notice issued on 9th November 1998 19th January 2006 Date of last inspection Brief Description of the Service: St Andrews House is a large detached property located in the centre of Barnoldswick. It is registered to provide both nursing and personal care for twenty-four people who are physically disabled. Both men and women live in the home. The majority of rooms are single and all bar two include en-suite toilet and hand basin. There are three shared rooms that also have en-suite facilities. All rooms meet the minimum size requirement to allow people who use a wheelchair to be accommodated. There is a passenger lift to the first floor. The home is well provided with communal space. This includes a small gym and hydro pool that is open five days a week and managed by the physiotherapist and physiotherapy aide. There is limited outdoor space with a small garden area to the front of the building and a patio to the rear. However Barnoldswick is well adapted to the use of wheelchairs with many pavements being wheelchair friendly and local shops and facilities being easily accessible. Information about the services offered by the home is provided in the form of a service user guide and is available, with a summary of the most recent inspection report, to existing and prospective residents and their relatives. On the day of the inspection the weekly fees ranged from £529.00 to £1006.00. Items not included in the fee include newspapers, toiletries, hairdressing, private chiropody and dental fees. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection, including a visit to the home, took place on 30th April 2007. The inspection process included looking at records, a tour of the home, discussions with the registered provider, registered manager, two staff and four residents who lived in the home. Information was also included from survey forms filled in by eight visitors and by fifteen residents. The inspection also looked at things that should have been done since the last visit and a number of areas that affect people’s lives. There were nineteen residents living in the home on the day of the inspection. What the service does well: People said they were given enough information about the home and this helped them to make a choice as to whether the home was the right place for them. The home collected detailed information about prospective residents before they were admitted to ensure their needs and aspirations could be met. The individual plans contained detailed information about the support that people needed and preferred and included assessments of any risks to their safety. Each resident had a designated key worker to assist them with personal tasks and were encouraged to make decisions and choices about their care. Residents said staff listened to and supported them and they said they were able ‘to do what they wanted’. Residents participated in all aspects of life in the home including meetings, individual and group discussion and satisfaction surveys. They were able to take responsible risks and had been involved in discussion about those risks. Residents were provided with and supported to take part in a range of suitable activities that were suited to their diverse social and physical needs. Families and friends were welcomed into the home, could visit in any area of the home and would be invited to stay for meals. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 6 Privacy was respected in a number of ways; staff were seen knocking on doors and waiting for permission to enter, one room had a doorbell in place and others had ‘please knock’ or ‘do not enter’ notices. The meals were varied and nutritious and alternative meals were offered; it was clear from records and discussions with residents that they had been involved in decisions about menus. The staff group was balanced to allow residents to choose male or female staff of various ages to assist them with personal care. The complaints procedure was clear and people knew how to make a complaint and said that staff ‘listened’ to them. A record had been maintained which showed that complaints and concerns were dealt with appropriately and within the agreed timescales. One resident said ‘I told the staff and things were sorted out’. The home was comfortable, safe, bright, clean and homely and met people’s individual needs; a range of technical aids and equipment were available to help them to maintain their mobility and independence. The home had a qualified physiotherapist, physiotherapy aides and qualified nursing and care staff; there was also a gym and therapy pool to ensure resident’s specialised needs were met. Staff were competent and qualified and sufficient in numbers to meet resident’s diverse needs. People’s views and opinions were sought about whether the home was meeting their needs and expectations. It was clear people felt they were involved in decisions about the home and kept informed about important matters. Records showed the home was safe and people’s health, safety and welfare had been protected. What has improved since the last inspection? What they could do better: Healthcare needs were regularly assessed and action to be taken to meet those needs had been recorded in the individual plans; however staff needed to ensure, where appropriate, that the plans included full details in respect of care. Minor additions were needed to the medication policies and procedures to ensure staff had clear and safe guidance in all aspects of this area. Some St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 7 aspects of medication record keeping needed to be improved to ensure resident’s medicines were managed safely. The home had procedures for safeguarding adults but these did not give staff clear, specific guidance regarding whom to refer incidents to; failure to follow procedures could put residents at risk. It was clear that areas of the home had been improved although there was no plan to support further improvements; the registered manager was advised that a regular audit of all areas of the home should be completed to help identify areas requiring attention. Recruitment records showed that the home had not consistently followed a safe recruitment procedure and this could put residents at risk of being cared for by unsuitable people. There was no evidence that residents were involved in decisions about whether new staff would be suitable to care for them. Policies and procedures had been reviewed and updated although there were no formal systems in place to monitor whether staff were following policies and procedures in their daily work. 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 Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents had the information they needed to make an informed choice about where to live. The home had obtained detailed assessment information about residents, prior to admission, to ensure their needs and aspirations could be met. EVIDENCE: Information about the home was provided in the form of a service user guide. The service user guide was made available to residents and their families and friends and displayed in the entrance at wheelchair height. The service user guide was not yet available in any other format suitable for people with disabilities. Residents said they were given enough information about the home and this helped them to make a choice as to whether the home could meet their needs. There had been one resident admitted since the last inspection. The home had collected detailed information about them before they were admitted; this ensured their needs and aspirations could be met. An individual care plan had been developed from the assessment information and had taken into account the views and opinions of other relevant people to ensure all aspects of the residents needs were recorded. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans were developed from assessment information and contained detailed information about personal, social and healthcare needs; this ensured staff were aware of how to meet the resident’s needs. The home was good at involving residents or their representatives in decision making about all aspects of their lives in the home. EVIDENCE: Three individual plans were looked at in detail. The plans had been generated from a detailed assessment and included information about all areas of the residents life with evidence that the individual, their family, friends or advocate had been involved in the development, update and regular review of the plan. The plan was not yet available in any other format but was available to the individual. Each resident had a designated key worker to assist them with personal tasks and there was evidence of advocacy support recorded on the plan. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 11 Residents said they were encouraged to make decisions and choices about their care and that staff listened to them. They said they were able ‘to do what they wanted’. There was evidence to support a number of residents had access and support from external advocates and there were records to support choices had been given. Residents participated in all aspects of life in the home including meetings, individual and group discussion and satisfaction surveys although they had not been involved in the interview and selection of new staff (see standard 34). Any restrictions on choice and freedom had been fully discussed and documented in the plan. Risk assessments were in place to minimise any risk of harm to people. Residents were able to take responsible risks and had been involved in discussion about those risks. The use of bed rails was fully documented but there was no evidence to support this had been discussed with residents and their relatives. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home ensured everyone had access to and were supported to participate in a range of appropriate leisure activities that met their diverse social and personal needs. The home promoted resident’s independence, choice and decision-making. Meals were nutritious and varied and alternatives had been offered to ensure everyone received a healthy diet. EVIDENCE: From observation and talking to residents it was clear that every effort was made to help them to take part in a range of suitable activities that were suited to their diverse social and physical needs. The activity person had designed a range of vocational training to support residents to learn and develop their skills; support was given either in small groups of residents with similar interests or individually for those who were unable to and preferred not to participate in group activities. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 13 A number of residents were planning to go on holiday during the summer months and one said ‘I am really looking forward to it’. Two residents said ‘there is always something going on’. One visitor said there had been more activities arranged for people since the new manager started. Information about local facilities and activities was displayed on the notice board to enable residents to become more involved in the local community. A number of residents were well known in the local community. Residents were supported with their right to vote and were able to vote by post or helped to visit the polling station. Families and friends were welcomed into the home, could visit in any area of the home and would be invited to stay for meals. One visitor commented ’I used to visit every day and was always made welcome’. One resident said he was able to maintain contact with his friends and staff gave him the support he needed. Privacy was respected in a number of ways; staff were seen knocking on doors and waiting for permission to enter, one room had a doorbell in place and others had ‘please knock’ or ‘do not enter’ notices. Residents would open their own mail or would be supported by their key worker; preferred names and nicknames were recorded on the individual plans and were used by staff. Staff chatted with residents and visitors to the home in a friendly manner and there was a relaxed friendly atmosphere. The menus did not detail a choice menu however records supported that alternatives meals were provided at each mealtime. Residents said they enjoyed the food and could dine in the dining room or in other areas of the home. The meals were varied and nutritious and it was clear from records and discussions with residents that they had been involved in decisions about menus. Nutritional needs were regularly reviewed and dieticians had been consulted if someone was thought to be nutritionally at risk. Staff were seen assisting and supporting residents at mealtimes when needed. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The individual plans contained enough information to ensure staff were able to meet resident’s personal and healthcare needs. Medication policies and procedures did not fully provide staff with safe guidance and staff had not consistently followed procedures and this could put residents at risk. EVIDENCE: Three individual plans were looked at in detail. The plans contained detailed information about the personal support that residents needed and preferred and included assessments of any risks to their safety. The plans included information about how residents were moved and transferred ensuring safety was maintained and a range of technical aids and equipment were available to help them to maintain their independence. The home had a qualified physiotherapist, physiotherapy aides and qualified nursing and care staff to ensure resident’s specialised needs were met; the home also had a gym with therapy pool. The staff group was balanced to allow residents to choose male or female staff of various ages to assist them with St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 15 personal care. Residents said that routines were flexible and staff gave them assistance and support; one lady said she had been able to stay in bed until mid morning and this had been respected by staff another said she could choose what to wear and regular shopping trips were arranged to purchase new clothing. Healthcare needs were regularly assessed and action to be taken by staff to meet those needs had been recorded in the individual plans; however staff needed to ensure, where appropriate, that the plans included full details in respect of care of enteral ‘PEG’ sites to ensure resident’s needs would be met. There were records of contact with GP’s and other healthcare professionals that showed that resident’s physical and emotional needs were considered. One lady confirmed that the doctor had been called and she had been visited in the privacy of her room. Medication management policies and procedures were clear and detailed; however minor additions were needed to ensure staff had clear and safe guidance in all aspects of this area including covert administration, PRN or when required medication and management of non-prescribed medication. Records were clear although it was recommended that two signatures were obtained to record medicines for disposal to ensure there was no mishandling and also that application of prescribed creams must always be recorded to show that residents were receiving the correct treatment. A number of residents were having medications ‘when required’ or ‘PRN’ but there was no clear procedures or instructions to help staff to make an appropriate and safe decision. Staff were reminded that any handwritten charts must be witnessed by a second person to ensure the correct prescribing information was recorded. Appropriate signage and link chains were used where oxygen was stored and storage areas were secure and safe. Residents had given their permission for staff to manage their medication and risk assessments were seen for one resident who wished to manage his own medication; however the assessments needed to detail how he would be supported to manage his medicines safely. Any reviews of medication by the persons GP were recorded and regular monitoring visits by a pharmacist had been carried out to support staff to provide safe management of medicines. There was no evidence that regular management checks were in place to monitor staff compliance with policies and procedures (see standard 40). St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People knew how to make a complaint and felt they would be listened to and their concerns acted upon. The home had adult protection procedures but these did not provide staff with the appropriate guidance to ensure residents were protected from harm. EVIDENCE: The complaints procedure was clear and people knew how to make a complaint; resident’s said that staff ‘listened’ to them. A record had been maintained which showed that complaints and concerns were dealt with appropriately and within the agreed timescales. One resident said ‘I told the staff and things were sorted out’. The complaints procedure was not yet available in a number of formats that would be appropriate for everyone in the home to use. The home had procedures for Safeguarding Adults but these did not give staff clear, specific guidance regarding whom to refer incidents to; failure to follow procedures could put residents at risk. Some staff had received adult protection training that would help to keep residents safe from harm and two staff were spoken to and were aware of how to recognise abuse and what action to take. All staff had to read the adult protection procedures as part of their induction although regular updates in the area of protection should be arranged to increase staff awareness and understanding in this area. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 17 There were procedures to support staff with managing verbal and physical aggression and managing resident’s finances. Financial records were looked at and showed that the home followed safe procedures to protect resident’s finances although it was recommended that records were regularly audited to ensure staff protection (see standard 40). St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was safe, clean, comfortable and well maintained; however records did not support that further improvements were planned to develop the home and provide a more pleasant place for residents to live. EVIDENCE: The home was comfortable, safe, bright, clean and homely and met resident’s individual needs. Disabled access and adaptations and equipment were provided to assist residents with mobility and independence. Bedrooms had en-suite facilities and were pleasant, comfortable and homely; residents said they were happy with their rooms and had brought in personal items. One lady said she had been consulted about the décor and had chosen the furniture and wallpaper; rooms had been decorated with consideration for the individual persons needs and preference. Only one bedroom was shared and this was with the agreement of the residents concerned. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 19 Bathrooms and toilets were fitted with appropriate aids and adaptations to meet resident’s needs. One person reported that there had been a problem with the supply of hot water to the shower but the registered manager was aware of this and the matter was being resolved with the water services. The communal areas were clean and bright although the conservatory was still in need of blinds as the temperature was very hot in the sunshine. It was clear that areas of the home had been improved although there was no plan to support further improvements; the registered manager was advised that a regular audit of all areas of the home should be completed to help identify areas requiring attention. Residents and visitors to the home said the home was always bright, clean and odour free; new equipment had been purchased recently to help staff to reduce the risk of infection. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team were experienced, well supported, competent and provided in sufficient numbers to meet resident’s needs. Safe recruitment procedures had not consistently been followed and this could put residents at risk. EVIDENCE: The training plan supported that staff were competent and qualified to meet resident’s diverse needs and that a range of training had been provided to develop and maintain staff skills and to ensure people were safe. It was recommended that staff received equal opportunities, race equality and disability equality training although some of this was covered briefly in the policies and procedures. Staff confirmed they received supervision, appraisal and support from senior staff and records were maintained of one to one sessions to help identify training and development needs; appraisals had been completed annually. Staff meetings were held regularly and staff said they were able to voice their opinions and felt they would be listened to. Staff duty rotas were clear and showed staff were provided in sufficient numbers to meet resident’s needs; there was a low use of temporary staff which ensured residents received care from staff who were aware of their St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 21 needs. Staff said ‘we work well together’. The home employed a qualified physiotherapist and aides to meet resident’s rehabilitation needs and male and female staff, of various ages, were employed to reflect the ages, cultures and genders of residents who lived in the home. Three staff employment files were looked at. Records showed that the home had not consistently followed a safe recruitment procedure as not all the required checks had been obtained prior to employment and this could put residents at risk. Photographs, as a means of identification, were not included on all files. There was no evidence that residents were involved in decisions about whether new staff would be suitable to care for them. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from a well managed home and their health, safety and welfare was promoted and protected. People were involved in decisions about how the home was run. EVIDENCE: The registered manager is Jean Shaw. Ms Shaw is a registered nurse with experience to manage the home; she is undertaking the registered manager award that will support her with the management aspects of her role. Residents and visitors made positive comments regarding her contribution to the home. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 23 The home had achieved the Investors In People award; this was a recognised quality assurance system that measured whether the home was meeting some of its aims and objectives. The home obtained people’s views and opinions by regular satisfaction surveys, group meetings or individual meetings. From comment card information and discussion with people it was clear they felt they were involved in decisions about the home and kept informed about important matters. Policies and procedures had been reviewed and updated although there were no formal systems in place to monitor whether staff were following policies and procedures in their daily work. Records showed the home was safe and people’s health, safety and welfare had been protected. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 2 X 3 X St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? 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 YA18 Regulation 15 Requirement Details regarding any nursing care provided, particularly with regard to care of PEG sites, must be specified in the individual plan. A record must be kept of all medicines administered including creams. The safeguarding adults procedure must be reviewed to provide staff with clear and specific guidance regarding whom to refer incidents to. The registered person must operate a thorough recruitment procedure and ensure all checks are completed and recorded in full prior to employment. Timescale of 01/02/06 not met. Timescale for action 25/06/07 2. 3. YA20 YA23 13 13 25/06/07 25/06/07 4. YA34 29 25/06/07 St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 26 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. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Refer to Standard YA9 YA20 YA20 YA20 YA20 YA20 YA23 YA24 YA24 YA34 YA34 YA37 YA40 Good Practice Recommendations The use of bed rails should be discussed with the resident or their representative and recorded in detail on the individual plan. Medication policies and procedures should include procedures for PRN medication, management of nonprescribed medication and covert administration. The recording of medicines awaiting disposal should be improved to ensure no mishandling occurs. All handwritten medicines records should be doublechecked and counter signed. All medicines prescribed as “when required” or, as a “variable dose” should have a clear written protocol to ensure they are given correctly. The risk assessment to support self-administration of medicines should be developed in line with the procedure and to indicate safe monitoring and review processes. Staff should be provided with regular updates in the area of adult protection. The home should undertake regular audits of all areas of and develop a planned maintenance and renewal programme to support ongoing improvements. The registered person should consider fitting suitable blinds in the conservatory. Photographs, as a means of identification, should be provided for each member of staff. Residents should be encouraged to participate in the interview and selection of new staff. The registered manager should obtain a recognised management qualification. The registered manager should develop systems to regularly monitor staff compliance with policies and procedures particularly with individual plans, medicine management and financial records. St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 2nd Floor Unit 1 Tustin Court Port Way Preston Lancashire PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Andrews House Nursing Home DS0000022474.V333126.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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