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Inspection on 10/05/05 for St Ann`s Residential Home

Also see our care home review for St Ann`s Residential Home for more information

This inspection was carried out on 10th May 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has offered staff access to NVQ training and over 50% of carers in the home have completed NVQ level 3 training, which is a higher level than the level recommended in the National Minimum Standards for Older People. There was a good level of satisfaction with the care provided. The 3 relatives who completed a Relatives/Visitors comment card ticked that they were satisfied with the overall care provided and the 6 residents who completed a comment card ticked that they liked living in the home, that they were well cared for and that staff treated them well. Both care managers ticked that they were satisfied with the overall care provided to their residents and one commented that they were impressed with the level of care provided. Residents who took part in the inspection were satisfied with the care provided and praised the staff. Residents said that they felt safe in the home. The home provides the staff team with support and there was praise from members of staff for the availability of the manager and the proprietor. Support is given on a day-to-day basis and through individual supervision sessions and appraisals. Residents were pleased with the meals served and said that the standard was good. They confirmed that the food met their dietary needs. Residents were involved in drawing up the weekly menus.

What has improved since the last inspection?

Since the last inspection the programme of installing guarded radiators in residents` bedrooms has been completed and new flooring has been provided in all en suite facilities. Building works are almost complete inside the new building at the rear of the property and work has been undertaken in the garden to make this a pleasant facility for residents. There is large patio area, lawn areas, pathway, flower borders and shrubs. The manager has successfully completed the Registered Manager`s Award.

CARE HOMES FOR OLDER PEOPLE St Anns 125 Chalkhill Road Wembley Park Middlesex HA9 9AL Lead Inspector Julie Schofield Announced 9 and 10 May 2005 11.25am and 10.05am 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 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 Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Anns Address 125 Chalkhill Road Wembley Park Middlesex HA9 9AL 020 8908 2033 020 8904 2856 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Captial Investments & Development Ltd Mrs Yetunde Majekodunmi CRH PC 16 Category(ies) of OP 16 registration, with number of places St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10 February 2005 Brief Description of the Service: The home is registered to provide personal care for up to 16 service users. At the time of the inspection there were 12 residents and 4 vacancies. Three of the residents were aged 100 years or more. St Ann’s is situated close to Wembley Park underground station and main bus routes. It is also close to a parade of shops and to a supermarket. At the front of the home there is a large paved area for off street parking. (There are parking restrictions in the road immediately outside the home). Service users are accommodated in bedrooms on both ground and first floors and there are bathing and toilet facilities on both floors. Eight of the bedrooms have en suite facilities. There is a passenger lift connecting ground and first floor. Staff accommodation is situated on the second floor. The office, open plan dining and lounge areas and kitchen are situated on the ground floor and the laundry room is situated on the first floor. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 visits to the home in May 2005 and lasted a total of 8 hours. During the inspection the Inspector had discussions with the manager, the proprietor, members of staff, a visitor and 5 residents. The Inspector would like to thank everyone who took part in the inspection during the 2 visits. The Inspector would also like to acknowledge the comment cards returned to the CSCI 6 residents, 3 relatives, 2 care managers and 2 GPs. A lay visitor spoke to residents in April, preparing them for the inspection and they forwarded a copy of their report to the Inspector. During the inspection staff and care records were inspected and a site visit took place. What the service does well: The home has offered staff access to NVQ training and over 50 of carers in the home have completed NVQ level 3 training, which is a higher level than the level recommended in the National Minimum Standards for Older People. There was a good level of satisfaction with the care provided. The 3 relatives who completed a Relatives/Visitors comment card ticked that they were satisfied with the overall care provided and the 6 residents who completed a comment card ticked that they liked living in the home, that they were well cared for and that staff treated them well. Both care managers ticked that they were satisfied with the overall care provided to their residents and one commented that they were impressed with the level of care provided. Residents who took part in the inspection were satisfied with the care provided and praised the staff. Residents said that they felt safe in the home. The home provides the staff team with support and there was praise from members of staff for the availability of the manager and the proprietor. Support is given on a day-to-day basis and through individual supervision sessions and appraisals. Residents were pleased with the meals served and said that the standard was good. They confirmed that the food met their dietary needs. Residents were involved in drawing up the weekly menus. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The pre-admission procedure needs to include a recorded assessment undertaken by the manager and a visit to the home by the resident (and their representative). By contacting the placing authority the home will encourage regular reviews of the care plan and placement and residents must be given a copy of their care plan. The care plans need to include risk assessments, particularly in respect of the prevention of falls and pressure sores. The health of residents needs to be monitored by keeping a record of the monthly weights of residents. The activities programme should be reviewed and activities arranged that take place both inside and outside the home. There are minor repairs to be completed as part of the ongoing maintenance programme and this is to include the installation of the new washing machine that had been purchased. The recruitment process must ensure that 2 references are obtained for each member of staff. Quality assurance systems for obtaining feedback from residents and their representatives need to be in place. An Immediate Requirements and Feedback form was issued during the inspection on the 9th May. The home needs to keep accurate records of their handling of residents’ personal allowances and to arrange for monies accruing to be deposited in a savings account in the name of the resident. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 7 Recommendations to assist in the development of good working practices include the manager working occasional weekend shifts in the home, information on display regarding the availability of inspection reports and keeping a record on case files of appointments with health care professionals. 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 Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 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 standard(s) 3, 5, 6 The manager of the home needs to demonstrate that they have assessed the prospective resident in order to determine whether the home can meet the needs of the resident. The residents, or their representative, needs to be involved in the choice of home by visiting prior to admission to confirm that the home can meet the needs of the resident. The home does not offer an intermediate care service. EVIDENCE: The case files of 3 residents who have recently been admitted to the home were examined. Two of the residents were admitted on an emergency basis. Information had been received by the home, prior to the admission of the residents. This information included hospital discharge letters, assessment forms and social worker reports. Pre-admission assessment forms, competed by the manager, were absent from the files. There was no evidence on file that the resident or their relative (or advocate) had visited the home, prior to the admission. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9, Residents’ needs are identified in care plans and risk assessments are needed to enable the resident to live as independently as possible. The changing needs of residents are discussed in review meetings and the home needs to have a copy of the minutes as these record any agreed plans of action. Residents’ health care needs are met. The monitoring of health care checks for residents would be assisted by the completion of a record of appointments with health care professionals on each individual case file. Residents are supported by staff to take their medication at the times directed and in the doses prescribed by their GP in order to promote their general health. EVIDENCE: Three case files were examined and each contained a care plan, which was dated. The care plan sets out the action required by staff to meet the goals identified. It covers personal, health and social care needs. Care plans were not signed by the resident, or their representative, and the resident is not provided with a copy. There were monthly evaluations of the care plans on file. Minutes of the initial placement review meetings held for each of the 2 residents who had been recently admitted to the home were on file although the minutes of a subsequent review meeting that took place in April were absent. It was noted in the minutes of one of the review meetings that the St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 11 placing authority was satisfied with the care plan and the 2 care managers who completed a comment card ticked that their resident’s care plan was being followed and reviewed regularly. A further 4 case files were examined and reviews were convened by both the placing authority and the home. On one file the local authority review meeting was overdue. A risk assessment, paying particular attention to the prevention of falls, had not been completed and included on each case file. Although there are no risk assessments on file in respect of developing pressure sores the manager confirmed that none of the residents are suffering from pressure sores. Residents informed the lay visitor that there was good access to doctors, dentists and chiropodists. There was evidence on case files that where necessary referrals were made to the continence adviser and carers have received training in this topic. Appointment cards confirmed appointments with the dentist. Prescriptions for optical services were on file. The manager said that residents have appointments with the chiropodist on a regular basis. A record needs to be kept of health care appointments so that the home can monitor the regularity of appointments and ensure that they are up to date. There was also evidence of access to routine screening e.g. blood tests etc. Risk assessments were on file for residents who self medicate and they are signed by the GP and by the manager. The storage of medication was inspected. Medication was kept securely. The home uses a weekly nomad system and medication had been appropriately administered prior to the inspection. When bottles of medication are opened the date of opening needs to be recorded on the label. Records of the administration of medication were examined and were up to date and complete. The returns book was satisfactorily completed. Members of staff who were responsible for administration had received medication training. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 15 Residents need to be able to take part in a programme of activities inside the home and in activities outside the home, including organised outings, which provide stimulation, interest and enjoyment. While some residents are satisfied with the programme in place there are other residents who are unaware of the activities on offer. Residents should be consulted about the content of the programme. Residents said that they enjoyed the company of their visitors, who were made welcome by the staff when they visited the home. Residents’ nutritional needs are met through the provision of a diet that is wholesome although choice of main dish needs to be between 2 different foods and not between 2 different ways of cooking a food item. Residents would benefit from an up to date monthly record of their weights as this can help to detect health problems. EVIDENCE: Three of the 6 residents who completed a comment card prior to the inspection ticked that the home provided suitable activities, 1 resident ticked that the home sometimes provided suitable activities, 1 resident ticked that the home did not provide suitable activities and 1 resident did not register a comment. During the inspection 2 residents said that there were no activities during the day. Information about daily activities is on display in the lounge area. The manager said that bingo, sing a long sessions, manicures, quizzes etc take place in the home and it was noted that there were board games available in St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 13 the lounge. However the manager said that the programme on the board was not always followed as staff asked residents on the day what they would like to do. A resident confirmed that a member of staff was available to accompany them to the local shops etc. Three relatives who returned a completed Relatives/Visitors comment card confirmed that staff made them welcome when they came to visit the resident and that they could visit the resident in private. The GPs and care managers also confirmed that visits took place in private. The manager said that members of the local churches visit each month to hold a mass and communion. The menu for week commencing the 9th May was examined. The main meal of the day was served at lunchtime and there was a choice of main dish and choice of dessert. However on one day the 2 choices were chicken, but prepared differently and on another day the 2 choices were fish, but prepared differently. Halal meat is served in the home and this meets the religious and cultural needs of an Asian resident and a member of staff confirmed that the cultural needs of an African-Caribbean resident are met. During the inspection 2 residents said that the meals were good and 1 resident said that the food was suitable in view of their health problems. Weight charts were on file for residents. Although they are to be completed on a monthly basis no weights for March or April had been entered on 3 case files. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16, 18 A complaints procedure was in place and residents said that they were able to bring any concerns to the attention of the senior staff. A reminder to relatives and residents is needed to ensure that they are all aware of the procedure and that they have the right to see the inspection reports. Protection of vulnerable adults training for staff and familiarity with the home’s procedure contribute towards the safety of residents. Residents said that they felt safe. EVIDENCE: The home has a complaints procedure, which includes timescales for each stage of the process. It includes details of agencies, including the CSCI, which the complainant may wish to contact. A copy of the policy was on display in the entrance hall. However 1 of the 3 people completing a Relatives/Visitors comment card ticked that they were not aware of the home’s complaints procedure and 2 of the 3 people ticked that they did not have access to a copy of the Inspection reports on the home. One of the 6 residents who completed a comment card prior to the inspection ticked that if they were unhappy with their care they did not know who to speak to. During the inspection residents said that they would talk to the manager if they had a complaint and one resident said that the manager is “very kind and nice and I know she’d listen”. The manager said that no complaints have been recorded since the last announced inspection. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 15 The 6 residents who completed a comment card prior to the inspection ticked that they felt safe living in the home and 1 resident said during the inspection that their family “knew they were safe in here”. The home has a protection of vulnerable adults policy and there is a link with the local authority’s interagency guidelines in the event of abuse. Staff have undertaken protection of vulnerable adults training, either as part of their NVQ studies or on specialised courses (certificates held on staff files). The manager confirmed that no incidents or allegations of abuse have been recorded since the last announced inspection and that the home does not practice restraint. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 25, 26 The home has carried out the repairs identified in previous inspection reports although a number of minor repairs have been identified during this inspection. A weekly maintenance inspection and a maintenance record book would assist in the management of the premises and would ensure that residents enjoy a comfortable and safe environment. Residents are able to enjoy a number of comfortably furnished lounge areas and these meet the individual needs of residents. Residents are able to enjoy a newly landscaped garden area. Residents live in a home where the temperature is within a suitable range, where hot water is available to maintain standards of personal hygiene and where the level of lighting maintains a safe environment. Residents live in a home where standards of cleanliness are good. The newly purchased washing machine needs to replace the machine that is leaking water. EVIDENCE: A site visit took place. It was noted that the cover of the drainage to the shower on the first floor and the ground floor needed to be put back. There were stains on the carpet on the first floor corridors. The extractor fan in the St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 17 en suite of Room 11 was not working. There was a hole in the ceiling and missing tiles in the en suite of Room 12. The bay window area needs repainting in Room 7. All other parts of the home were in a satisfactory state of repair. Work to the exterior of the building has been completed and the building refuse has been removed. Further building works are taking place on the second floor of St Ann’s on the interior. The proprietor said that some minor painting is also taking place in the property. The ramp at the front of the house has been rebuilt and handrails are needed. The ceiling of the office has been repaired and redecorated. The flooring of all ensuites within the home has been replaced with one that is impermeable. The public telephone in the entrance hall is no longer in use although the manager said that a resident could make or receive a telephone call in private, in the office. A suitable stand for the television in the lounge is needed to replace the one covered with Xmas wrapping paper. One of the residents said that although the television in the room was able to receive the BBC channels they were unable to receive the ITV channels. Residents told the lay visitor that they liked the large front room where they can either be together as they choose or be own their own if they would prefer. The garden at the back of the property has been recently landscaped. There is a large patio area with a pathway between the lawn areas. Recently planted flowers and shrubs planted in borders provide a pleasing view for residents and the proprietor said that fencing would complete the work being undertaken to make the garden used by the residents self-contained. The 2 remaining radiators are now guarded and the heating, lighting and hot water systems in the home meet the needs of the residents. The washing machine in the laundry that was in use was leaking water. However a new, commercial quality, washing machine was waiting to be plumbed in. Residents said that the home was clean and that their bedrooms were kept clean. A site visit demonstrated that the home was clean and tidy and free from offensive odours. Staff have undertaken infection control training. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staffing levels are sufficient to respond to the needs of residents. Residents appreciated the support given by the members of staff who have developed their skills and understanding through an NVQ training programme. The home’s recruitment programme includes checks to ensure that the safety of residents is maintained. A lack of 2 satisfactory references for a member of staff compromises this. Staff files demonstrated access to a range of training opportunities, which enable staff to respond appropriately to the individual needs of residents. EVIDENCE: Copies of the rotas for the month of April were received prior to the inspection. They lacked details of the length of the shift. The manager worked Mondays to Fridays, early and late shifts. A domestic and a cook were on duty each day. There were sufficient carers on duty during the day, for the needs of the residents and at night there were 2 carers on waking night duties and staff sleeping in on the premises but on call. During the inspection the rota for the month of May was examined. Staffing levels were maintained. The 3 relatives who completed a Relatives/Visitors comment card ticked that in their opinion, there were always sufficient numbers of staff on duty. Residents said that the staff were “nice” and “kind” and that “they were well looked after”. The manager said that 8 of the 12 carers on the rota have undertaken NVQ level 3 training and there is confirmation that they have satisfactorily completed their training and are awaiting their certificates from the awarding body. In addition 3 of the remaining carers have enrolled on training courses. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 19 Six staff files were examined. Each file contained a completed application form, photographic proof of identity and an enhanced CRB disclosure. Five of the six files contained 2 references. Six staff files were examined and 2 files contained evidence of protection of vulnerable adults training, 3 files contained evidence of diversity and communication training and 2 files contained evidence of breakaway techniques training. There were also induction and foundation training certificates on file. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36, 38 A competent and knowledgeable manager contributes towards the smooth running of a home. Residents’ feedback is a measure of the achievement of a home and also an important quality assurance tool. The home needs to improve ways of obtaining this so that an annual development plan can be drafted. Residents, staff and visitors to the home are supported by valid insurance cover. Accounting systems to protect the financial interests of a resident who is assisted in managing their personal allowance were lacking so an Immediate Requirement and Feedback form was issued. Management support systems for staff were in place to encourage good working practices. Health and safety practices in the home promoted a safe environment for both residents and staff although the provision of mesh screens at the windows in the kitchen remains outstanding. EVIDENCE: St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 21 There was a letter confirming that the manager, a qualified nurse, had successfully completed the Health and Social Care level 4 Registered Manager’s Award training course and was awaiting the certificate from the awarding body. Feedback from residents is obtained during review meetings, individual discussions with residents and, as observed, when residents come into the office to speak with the manager. It was noted that residents’ meetings have not been held lately. Verbal feedback is obtained from relatives during review meetings and the manager said she is available if relatives need to discuss the care of their relative. Client survey forms were last distributed in 2003. The home lacks an annual development plan. A notice regarding the inspection was on display in the entrance hall. A valid certificate of insurance, in the name of a director of the company, for the car used in respect of the business was available for examination. A valid employer’s liability insurance certificate was on display in the entrance hall. It covered the period from 22/4/05 to 21/4/06 and provided cover up to a minimum of £5 million. The manager said that the home assisted only 1 resident with their personal allowance as the remaining residents received assistance, if necessary, from family members. The record of transactions was incomplete and the resident had not signed to acknowledge receipt of money given to him. There was no record of the amount of personal allowance received by the home, on behalf of the resident, nor of the balance accruing. The balance was not kept in a savings account in the name of the resident. An Immediate Requirements and Feedback form was issued during the inspection to remedy these matters. The manager said that individual supervision sessions with staff members take place on a regular basis and there was a supervision contract on file. There was evidence on file of annual appraisals having taken place. Staff praised the support that they received from their manager and from the proprietor. The mesh screens needed to prevent insects from entering the kitchen have not been installed. Of the 6 staff files examined for evidence of training, 2 files contained a first aid certificate, 3 files contained a manual handling certificate, 2 files contained a health and safety certificate (included fire, infection control and COSHH training), 4 files contained an infection control certificate, 4 files contained a food hygiene certificate and 3 files contained medication certificates. There were valid servicing certificates for the fire precautionary systems and equipment and for the portable electrical appliances. There was a valid Landlord’s Gas Safety Record. There was a fire risk assessment and a COSHH assessment. There was evidence that fire drills and fire alarm tests had been carried out on a regular basis. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 x x x x 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 3 1 3 x 2 St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 23 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 OP3 Regulation 14.1 Requirement That the manager of the home carries out an assessment of the resident, prior to admission, to determine and to confirm that the home can meet the needs of the prospective resident. That the resident or their representative visits the home prior to admission to help inform the residents decision regarding the suitability of the home to meet their needs. That the resident is given a copy of their care plan. That the home contacts the placing authority to ensure that the regularity of review meetings is maintained. That a risk assessment, paying particular attention to the prevention of falls, is on each residents case file. That a risk assessment, paying particular attention to the prevention of pressure sores, is on each residents case file. That the monthly record of the individual weights of residents is kept up to date. That the repairs that are needed G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Timescale for action 08 August 2005 and onwards. 2. OP5 14.1 08 August 2005 and onwards. 3. 4. OP7 OP7 15.2 15.2 01 September 2005 01 September 2005 01 October 2005 01 October 2005 01 September 2005 01 October Page 24 5. OP7 13.4 6. OP8 13.3 7. 8. St Anns OP15 OP19 12.1 23.2 Version 1.30 9. 10. OP26 OP29 23.2 19.1 in the shower rooms and in bedrooms 7, 11 and 12 are carried out. That the new washing machine replaces the old machine, which is leaking water. That each staff file contains 2 satisfactory references. That the home seeks feedback from residents about the service received e.g. by the use of annual satisfaction surveys, holding regular residents meetings etc. That a recording system is set up for the handling of personal allowances and that savings accounts are set up in the name of the individual resident. That mesh screens are fitted to the windows in the kitchen to prevent insects entering. (The previous timescale not met). 2005 01 September 2005 01 September 2005 and onwards 01 October 2005 and onwards 11. OP33 24.1 12. OP35 17.2S4.9 13. OP38 16.2 16 May 2005 (recording) 23 May 2005 (accounts) 01 October 2005 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. St Anns Refer to Standard OP7 OP7 OP8 OP9 OP12 OP12 Good Practice Recommendations That the resident signs their care plan. That the home contacts the local authority for a copy of the minutes of the review meeting held in April. That the home keeps a record of all health care appointments so that the regularity of these can be monitored and maintained. That the date of opening is recorded on the label of a bottle or tube of medication. That residents are made aware of the activities offerred in the home. That residents are consulted about the content of the programme of activities on a regular basis and that the G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 25 7. 8. 9. OP12 OP15 OP18 10. OP18 11. 12. 13. 14. 15. OP19 OP 19 OP19 OP27 OP33 decisions are recorded. That the home includes more activities outside the home in its programme of activities. That a choice of food item is offered at a meal e.g. chicken or fish rather than two different chicken dishes. That the manager ensures that resident and their relatives (or representatives) are aware of the homes complaints procedure and gives a copy of this during the admission procedure to the resident and their relative (or representative). That a notice is on display in the entrance hall advising visitors to the home that the inspection reports are available to read. That the manager advises residents that the reports are available to read. That a weekly maintenance inspection takes place and that a maintenance record book is used. That a new stand for the television in the lounge is provided. That all channels on the televisions in the home are in working order. That the manager works occasional weekend shifts in the home to ensure consistency in the quality of care. That the home drafts an annual development plan, which draws on the information obtained through quality assurance systems. St Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 4th Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Anns G62-G11 S17440 St Anns v213688 090505 Stage 4.doc Version 1.30 Page 27 - 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. 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