Inspection on 03/08/06 for St Ann`s Residential Home

This inspection was carried out on 3rd August 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

St Ann`s Residential Home 02/07/07

St Ann`s Residential Home 11/10/05

St Ann`s Residential Home 10/05/05

St Ann`s Residential Home 01/11/04

St Ann`s Residential Home 20/08/04

St Ann`s Residential Home 26/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Ann`s Residential Home 125 Chalkhill Road Wembley Park Middlesex HA9 9AL Lead Inspector Julie Schofield Key Unannounced Inspection 09:40 3rd August 2006 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 Ann`s Residential Home DS0000017440.V291443.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 Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Ann`s Residential Home Address 125 Chalkhill Road Wembley Park Middlesex HA9 9AL 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) 020 8908 2033 020 8904 2856 Capital Investments & Devlp Ltd Post Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 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 10 residents and 6 vacancies, although 2 residents were in hospital. 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 Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Thursday in August. It began at 9.40 am and finished at 4.45 pm. As the acting manager and acting deputy manager were on annual leave the senior carer assisted with the inspection. The Inspector would like to thank her for her assistance. During the inspection a discussion with the proprietor, staff on duty and 5 of the residents took place. The Inspector would like to thank them for participating in the inspection. While the inspection took place records and documents were examined, a site visit was carried out, the serving of the midday meal was observed and care practices were noted. What the service does well: What has improved since the last inspection? Seven statutory requirements were identified during the last inspection of the home and 6 of these have now been met. There was evidence on file that the home has contacted placing authorities to try to ensure that the regularity of review meetings is maintained. The rubbish that had been in the garden has been removed. Records relating to residents’ finances were available for inspection, were accurate and included details of what had been purchased. A machine has been installed in the kitchen to attract and to kill insects that may enter the room. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 6 The garden is now complete and the shrubs, plants and trees that have been planted are starting to take root and to flower. With the groups of seating scattered around the garden and a very large patio area this is now an area for residents to enjoy. What they could do better: That during the pre-admission procedure the home obtains a copy of the placing authority’s care plan and the manager meets the prospective resident and assesses their needs. That the overdue internal review meetings are convened by the home. (This was identified as a statutory requirement previously and remains outstanding). Two review meetings need to take place each year with the home taking responsibility for convening one of these and the placing authority convening the other. When review meetings take place the home needs to ensure that a copy of the minutes of the meeting are kept on file. When the initial 6 week placement meeting takes place the home also needs to ensure that a copy of these minutes are also kept on file. Residents’ files must contain a risk assessment for the prevention of pressure sores and a record of nutritional screening. These must be subject to regular review. Medication records need to be complete with all administrations initialled by the member of staff. The activities programme needs to include the opportunity for activities both inside and outside the home and staffing levels must facilitate this. The complaints procedure requires amending as it still lists the name of the registered manager who left the home in April. All staff need to have training in the protection of vulnerable adults procedures. In respect of the building some minor repairs/replacement are needed and soap and paper towels are needed in each bathroom and shower room. Following the inspection a letter of serious concerns was issued that required the home to have sufficient staffing levels to meet the needs of the residents. It also required the home to carry out the checks necessary to promote the safety and welfare of residents i.e. 2 satisfactory references and an enhanced CRB disclosure. The home was required to inform the CSCI as to how duties were to be allocated amongst staff so that the safety and welfare of residents would be promoted. The rota in the home needs to record the hours to be worked for each member of staff and to record, on a daily basis, the designated member of staff carrying out the sleeping in duties. Staff files must include a record of a completed induction training programme, a staff appraisal and a training profile. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 7 The proprietor needs to appoint a new manager and to forward an application for their registration to the CSCI. A copy of the home’s development plan for 2006 is required. Copies of overdue servicing/checking certificates for systems and equipment in the home must be forwarded to the CSCI. New staff require training in safe working practice topics. The freezer needs defrosting and bags of food items in the freezer need tying securely. 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 Ann`s Residential Home DS0000017440.V291443.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 Ann`s Residential Home DS0000017440.V291443.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): 3, 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is unable to demonstrate that it is able to meet the needs of the resident as pre-admission documentation is incomplete and lacks and assessment by the registered manager EVIDENCE: Two case files of residents who have been admitted to the home within the last 9 months were examined. Both contained an assessment carried out by a social worker from the placing authority, prior to their admission to the home. The files did not contain a copy of the local authority care plan. There was no evidence on file that the registered manager of the home had carried out an assessment or met the resident prior to the resident’s admission to the home. The home does not provide a respite care service. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 10 St Ann`s Residential Home DS0000017440.V291443.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 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although care plans have been drawn up and brief evaluations carried out on a monthly basis the home is unable to demonstrate that changes in the needs of residents are identified and addressed as a system of regular review meetings is lacking. Residents’ health care needs are promoted through access to health care services in the community although risk assessments for tissue viability and nutrition are lacking. Residents’ general health and well-being is encouraged by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP. Records of the administration of medication must be complete. Residents receive assistance with personal care in a manner, which respects their privacy and dignity. EVIDENCE: Four case files were examined. Two files were of residents who had lived in the home for several years and 2 files were for residents who had recently been admitted to the home. Each of the files contained a risk assessment in respect of the prevention of falls. Each contained a care plan although 2 care plans did not have a date and 2 of the care plans had been drawn up in 2004. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 12 Each file contained brief monthly evaluations of the care plan, which were up to date. A statutory requirement was identified during the last inspection that the home carries out an internal review meeting for every resident whose last review meeting was before 01 August 2005. This remains outstanding. There was evidence that the home had requested annual review meetings convened by the placing authority. Although 2 of the files had a letter from the placing authority, convening a meeting, only 1 of the files contained a copy of the minutes of the review meeting. There were no minutes on file in respect of an initial 6-week placement review meeting. Care staff provide assistance with personal care, including oral hygiene. Only 1 of the files examined contained a risk assessment in respect of pressure sores. The senior carer confirmed that at present none of the residents have a pressure sore. There was evidence on the case files of access to the services of the optician, dentist and chiropodist and a resident said that she had regular appointments with the optician and that she had seen the chiropodist 3 weeks ago. There was a record of residents who refused the offer of a flu jab. Letters were on file in respect of out patient appointments and the senior carer said that staff would accompany the resident to the hospital, if required. On the day of the inspection the GP visited the home as a request had been made for the GP to see a resident who had fainted earlier in the morning. One of the files contained evidence of a referral being made to the continence advisor. There was no evidence of a nutritional screening being undertaken although monthly weight charts were available and were up to date. Medication is kept in a locked facility. The home receives weekly dosette boxes, which have been filled by the pharmacist. The box includes a record of administration sheet, which fits under the transparent lid. It was noted that the empty compartments in the boxes were appropriate for the time of day and for the day of the week on which the inspection visit took place. The records of the administration of medication to residents were up to date although initials were missing from the record sheet of a client for one medication round. There is one resident that does not take any medication. It was noted that assistance with personal care was offered in a discreet and tactful manner. One of the senior carers said that it was important to gain the trust of the resident when assisting them to manage continence, as this was such a private matter to the resident. Residents each have their own room and said that they are able to entertain visitors in private. If the resident receives or wishes to make a telephone call in private they may either use the office or use a cordless phone and take this to their own room. It was noted that residents are called by the name that they prefer and one of the residents is using a shortened version of their name, which is the one that family members have used. Residents were spoken to with respect and there was a relaxed and friendly rapport between staff and residents. Residents confirmed that they received the assistance that they needed and they praised the quality of the care given by members of staff. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 13 St Ann`s Residential Home DS0000017440.V291443.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 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities give residents the opportunity for stimulation and enjoyment. A programme, which includes activities outside the home needs to be developed. Residents are encouraged to maintain contact with their families and friends so that their need for fulfilling relationships is met. Residents are encouraged to retain their independent by making decisions and by having their wishes respected. Residents are offered a balanced diet to promote their well-being and the diet respects their cultural needs. EVIDENCE: A discussion took place with residents regarding activities in the home. They said that they sometimes played bingo or cards but on the whole watched television or read books. They said that the television was marvellous. It is a very large wide screen model and has an excellent picture. The proprietor brings books by the author chosen by the resident and during the inspection he asked a resident what book she would next like to have. The senior carer said that some residents like to play dominoes. One resident said that they would like to play scrabble. A resident said that they would like to go out of the home but would need an escort. They said that with only 2 members of staff St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 15 on duty this was not possible. The student on placement in the home was spending time sitting with residents and talking with them. Three residents enjoy spending time in their room and confirmed that they were able to do this without unnecessary intrusion. The home has a policy of welcoming visitors during the day up to 8 pm in the evening. The senior carer said that by this time some of the residents are tired and wish to retire. Residents said that their visitors are made welcome when they come to the home. As residents each have their own room many visits take place in private. Residents have choice in respect of their meals, whether to socialise or to enjoy their own company, whether to take part in activities when these are arranged etc. Most of the residents are assisted by a family manner in managing their financial affairs. Residents are able to bring personal possessions with them to make their rooms more familiar and reflective of their personality. During the inspection a mid day meal was served. It consisted of homemade shepherd’s pie and was served with sprouts. The senior carer said that none of the residents had chosen an alternative dish as this was one of their favourite meals on the menu and a resident confirmed this. Most residents were having apple crumble and custard for their dessert. The meal smelt appetising and the portion size was good. Staff provided discreet assistance with feeding where required. Residents either ate their meal while sitting at the dining table or while sitting in their chair with a small table that fitted across their lap. The senior carer confirmed that although newer members of staff had not completed food hygiene training the more established members of staff had completed their training and that a trained member of staff was on duty each shift to prepare the meal. The menus were examined. There was a separate menu for one resident who has particular needs although it was noted that it contained proteins, carbohydrates and vegetables. Some dishes occur twice on the main menu at lunchtime during the week, when a cooked meal is served. The evening meal consists of a choice of hot or cold light dishes and 2 residents said that they are asked what they would like to have. Residents said that the food was reasonable although 2 residents would like more fresh vegetables included and one resident said that they preferred to have firmer vegetables. One resident said that the 2 sisters that worked in the home were good cooks. One of the members of staff, who was Polish, said that a Polish lunch was offered once a week on the menu. This was an option for the Polish resident and for any other resident who wished to have the meal. St Ann`s Residential Home DS0000017440.V291443.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 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure was in place and residents said that they were able to bring any concerns to the attention of the managers. However the procedure needs to be updated when there are changes in personnel. Although protection of vulnerable adults training for staff and familiarity with the home’s procedure contribute towards providing a safe environment for residents, unsafe recruitment practices put this at risk. All staff must have the opportunity to attend protection of vulnerable adults training. EVIDENCE: A copy of the complaints procedure was on display in the entrance hall of the home and it advised the complainant of their right to contact other agencies if they were not satisfied i.e. the CSCI. Details of the address and telephone number of the local CSCI office were included in the procedure. It was noted that the complaints procedure on display in the hallway included the name of the registered manager who has since left the company. The complaints book was available for inspection. Three residents said that there was some one in the home they could speak to if they had a complaint. The home has a protection of vulnerable adults policy in place and a copy of the local authority interagency guidelines in the office. The senior carer said St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 17 that there have not been any incidents or allegations of abuse recorded since the last inspection and that restraint was not practiced in the home. The senior carer stated that she had received training in adult protection procedures and that other members of staff had also attended the session. However more recently recruited staff had not attended this training. Staff were aware of the whistle blowing procedure. Three of the 8 staff files examined did not contain an enhanced CRB disclosure and a further 3 files contained a disclosure obtained by a previous employer and therefore not valid (see standard 29). St Ann`s Residential Home DS0000017440.V291443.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, 23, 26 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is comfortably furnished and provides a pleasing environment for residents to relax and enjoy. Only a few minor repairs or replacement of items are needed. Residents have the use of an attractive garden in which to relax. Bathing and toilet facilities in the home are sufficient in number and are conveniently located within the home to protect the privacy and dignity of residents. The provision of soap and paper towels needs to be maintained. The privacy of residents is respected by the provision of single bedrooms. Residents live in a home where overall standards of cleanliness are good. In order to maintain safe conditions in the home all staff require training in infection control procedures. EVIDENCE: A site inspection took place. The home was well maintained and comfortably furnished and decorated. It was noted however that the sealant between the St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 19 work surface and the wall in the kitchen was patchy, some bedrooms lacked a lampshade, there was a small tear in the carpet in Room 9 and a new bedside cabinet was needed in Room 4. A fence has been installed at the end of the garden between the garden areas of the home and the new building belonging to the company and used as an office. This gives residents privacy and with access to the new building from a side gate, people working in the office or visiting there do not have to walk through the home or the residents’ garden. The garden is attractively laid out with a large patio area, lawn areas and trees and shrubs. Small areas of seating are set out in different parts of the garden. Residents said that they enjoyed looking into the garden and some residents enjoy sitting outside. A statutory requirement was identified during the last inspection that rubbish is removed from the garden and it was noted that this had been done. Bathing and toilet facilities in the home were inspected. Eight of the sixteen bedrooms have ensuite facilities. There is a bathroom with a toilet and a shower room with a toilet on each floor. There is also a separate toilet on the ground floor. It was noted that the bathroom on the first floor did not contain soap or paper towels. Each resident has their own single bedroom. Each bedroom is a minimum of 10 square metres. Residents said that they had “very nice” rooms. It was noted during the site inspection that all areas seen were clean and tidy and free from offensive odours. A resident said that the home was kept clean and that the bed linen was changed regularly. There is a laundry room on the first floor with 2 washing machines and a tumble drier. Not all staff have undertaken infection control training (see Standard 38). St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 20 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 Overall quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels and recruitment practices do not promote and protect the health, safety and welfare of the residents. NVQ training enhances the quality of care provided to residents and the home has now exceeded the target of 50 of its carers having achieved an NVQ level 2 qualification and for this is commended. Training profiles, staff appraisals and a record of induction training would help develop a staff training programme which can demonstrate that it is designed to meet the needs of the residents. EVIDENCE: As the acting deputy manager and acting manager were on annual leave the senior carer assisted with the inspection. The home asked another carer to report for duty to give the senior carer the time to devote to the inspection. The rota for the month of August was examined. It was only partially completed. Two carers were originally listed on the rota for the day of the inspection and so during the inspection there were 3 carers on duty and there was also a student on placement. Carers are responsible for the catering duties but not the domestic duties as a cleaner is on duty each day. When 8 residents are in the home (2 residents being accommodated were in hospital) 2 members of staff during the day are insufficient to cover caring and catering duties and to supervise a student on placement. At night there are 2 waking members of staff and a pool of 5 sleeping in staff. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 21 A discussion took place with the senior carer regarding progress in meeting NVQ targets for members of staff. The senior carer has completed her level 3 qualification and said that 4 of her colleagues have also completed this. Although she said that a further 3 colleagues had completed their NVQ training she was unsure which level they had obtained. The case file of another member of staff was examined in respect of standard 29 and this member of staff stated on her CV that she had obtained a level 2 qualification. Of the 14 carers listed on the rota over 50 have obtained an NVQ level qualification and the majority of these have obtained an NVQ level 3 qualification. The National Minimum Standards recommends that 50 of carers achieve an NVQ level 2 qualification. One of the senior carers said that she had almost completed her NVQ level 4 training and another senior carer said that she would be starting her level 4 training soon. Eight staff files were examined, including the files of 4 members of staff who have started to work in the home since the beginning of 2006. Three of the 8 files did not contain a CRB disclosure or 2 references. (Open letters addressed to “whom it may concern” are not satisfactory references). A further 2 files did not contain 2 references. Three of the 8 files contained a CRB disclosure that had been obtained by a previous employer. CRB disclosures are not portable and they need to have a disclosure that names St Ann’s as their employer. The staff files of the newly employed staff do not have a record of completion of induction training. Staff files did not include a staff appraisal or training profile. One of these staff described their introduction to the home and how she was introduced to the staff, how she received training in practical tasks, how she was advised to talk to residents and to respect them and how she learnt what support the residents needed on a day-to-day basis. The member of staff said that she had received support in the form of training and gave examples of first aid and manual handling training. She also said that she had discussions with the deputy manager where her progress was reviewed. The senior carer said that staff received more than 3 days training per year. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 22 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 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not enjoy the benefit of living in a care home where there is a registered manager. The development of the service needs to be based on feedback, both verbal and written, from those being cared for and from those acting on their behalf. Financial systems protect the interests of the residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents and all staff require training. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use and overdue servicing and checking needs to be carried out. EVIDENCE: St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 23 The registered manager resigned and at the time of the inspection the post was vacant. A discussion took place with the senior carer in respect of quality assurance systems and how this is used in the development of the service. The last residents’ meeting had been arranged by the registered manager before she left the home in April. Residents also have opportunities to give feedback during 1 to 1 discussions with staff, managers or proprietors. There were 3 annual satisfaction forms that had been completed either by residents (or on their behalf), but not dated. Two were in respect of respite care residents. Relatives can give verbal comments during their visits to the home or complete a questionnaire from a supply kept in the entrance hall, near the visitor’s book. In the past the registered manager had also canvassed the views of placing authorities and professional visitors to the home. An annual development plan for 2006 was not available for inspection. A statutory requirement was identified during the last inspection that records of money kept in safekeeping on behalf of a resident are available for inspection. Statutory requirements were also made that the records are accurate and that they include details of items purchased etc. It was noted that these requirements are now met. The proprietor said that the home only supports 1 resident with their personal allowance. This resident signs each time that they draw money from the money held on their behalf. Accounts are also kept of money left by relatives on behalf of residents. Records were up to date and in sufficient detail to see what items may have been purchased on behalf of a resident. Each record included details of the balance of money remaining. There were 2 rings being held in safekeeping after they were becoming loose on the resident’s fingers. A statutory requirement was identified during the last inspection that the home installs an insect control fitment in the kitchen. It was noted that this has been done. Certificates for the checking and servicing of equipment and systems in the home were examined. There were valid certificates in respect of the fire extinguishers, the fire precautionary system (fire alarms, emergency lighting etc) and the portable electrical appliances. However the Landlord’s Gas Safety Record was dated 7/5/05 and was valid for 1 year. The electrical installation certificate was dated 24/3/00 and was valid for 5 years. The certificate for motor insurance for the company vehicle expired in April 06. A certificate for the passenger lift was unavailable. There were recorded risk assessments for fire and for COSHH. These had been drawn up in 2005. The senior carer said that training in safe working practice topics (lifting and handling and first aid) has taken place recently. There were certificates on file for training in respect of first aid, manual handling, fire safety, infection control and food hygiene. These related to staff that had been in post for some time. When inspecting the kitchen it was noted that the freezer needed defrosting and that bags of food items in the freezer needed to be tied after the initial opening. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 24 St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 X 3 X X 2 STAFFING Standard No Score 27 1 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14.1 Timescale for action That the home receives a copy of 01/09/06 the local authority care plan prior to the resident’s admission to the home. That the manager meets the 01/09/06 resident and carries out an assessment of need prior to the resident’s admission to the home. That the home carries out an 01/10/06 internal review meeting for every resident whose last review meeting was before 01 August 2005. (Previous timescale of 1st March 2006 not met). That 2 review meetings take place each year. One review meeting is convened by the home and the placing authority convenes the other review meeting. The review meetings take place at 6 monthly intervals. That a copy of the minutes of review meetings (internal or convened by the placing authority) is kept on the DS0000017440.V291443.R01.S.doc Requirement 2 OP3 14.1 3 OP7 15.2 4 OP7 15.2 01/10/06 5 OP7 15.2 01/09/06 St Ann`s Residential Home Version 5.2 Page 27 6 OP7 14.2 7 OP8 12.1 8 9 OP9 OP12 13.2 16.2 10 OP16 22.1 resident’s file. That the minutes of the initial 6week review of the placement meeting are kept on the resident’s file. That a risk assessment in respect of pressure sores and nutritional screening is carried out and recorded for each resident. That these are reviewed on a regular basis. That all medication record sheets are up to date and complete. That the programme of activities in the home includes those taking place both inside and outside the home and that staffing levels facilitate this. That the name of the registered manager who has left the company is removed from the complaints procedure on display and new contact details are added. That all staff undertake protection of vulnerable adults training. That the sealant between the work surface and the wall in the kitchen is made good, that all bedrooms have a lampshade, there the tear in the carpet in Room 9 is made good and that a new bedside cabinet is provided in Room 4. That soap and paper towels are provided in each bathroom and shower room. That the rota includes the hours to be worked for all staff in the home. That there are 3 members of staff on duty (which could include a manager) at peak times of the day when between 8 and 11 residents are accommodated in the home. DS0000017440.V291443.R01.S.doc 01/09/06 01/10/06 01/09/06 01/09/06 01/09/06 11 12 OP18 OP19 13.6 16.2 01/11/06 01/10/06 13 14 15 OP21 OP27 OP27 16.2 17.2S4.7 18.1 01/09/06 01/09/06 09/08/06 St Ann`s Residential Home Version 5.2 Page 28 16 OP27 17.2S4.7 17 OP29 12.1 18 OP29 12.1 That the home faxes a copy of an amended staffing rota to the CSCI, which demonstrates this. That one of the pool of sleeping 01/09/06 in staff is designated on the rota, each night, as the member of staff on call. That details of how the duties 09/08/06 will be allocated between staff, as staff without a CRB must not work alone with residents, is faxed to the CSCI That confirmation and evidence 21/08/06 is forwarded to the CSCI that application forms for a CRB disclosure form have been submitted and confirmation that reference requests have been sent as necessary. 01/10/06 19 OP30 18.1 20 21 OP30 OP31 22 OP33 23 24 OP33 OP38 25 OP38 That induction training records are completed for all new members of staff and are kept on their files. 18.1&18.2 That staff appraisals and training profiles are undertaken on an annual basis. 8.1 That the proprietor appoints a manager and that the manager applies to the CSCI for registration. 24.1 That there are systems in place for obtaining written feedback on the quality of the service from residents, relatives, placing authorities and professional visitors to the home. 24.1 That a copy of the annual development plan for 2006 is forwarded to the CSCI. 13.4 That a valid Landlords Gas Safety certificate, valid certificate for the electrical installation, valid certificate for the passenger lift and valid motor insurance certificate are forwarded to the CSCI. 18.1&13.4 That all staff undertake training DS0000017440.V291443.R01.S.doc 01/11/06 01/11/06 01/10/06 01/11/06 25/09/06 01/11/06 Page 29 St Ann`s Residential Home Version 5.2 26 OP38 16.2 in safe working practice topics i.e. manual handling, fire safety, first aid, infection control and food hygiene. That the freezer is defrosted and that bags of food items are tied securely after the initial opening. 01/09/06 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 Refer to Standard OP7 OP7 OP7 OP7 OP12 OP15 OP15 OP15 OP15 OP27 OP35 OP38 Good Practice Recommendations That care plans record the date on which they were drawn up. That care plans are reviewed, updated and amended on an annual basis. That the monthly evaluations of the care plan are more detailed. That the home continues to contact placing authorities when review meetings are due to ensure the continuity of the review process. That scrabble is included in the programme of activities in the home. That all staff working in the home undertake food hygiene training. That more Polish food is included as alternative dishes on the menu. That a wider variety of vegetables are served in the home and that more vegetables are included on the menu. That residents have the option of lightly or well cooked vegetables, according to taste. That unless it is an emergency, the deputy manager and the manager do not take annual leave at the same time. That if a resident is no longer able to wear their rings the rings are given to a relative for safekeeping, if this is what the resident wishes. That the risk assessments in respect of fire and COSHH are reviewed on an annual basis and that the date of the review is recorded on the document. St Ann`s Residential Home DS0000017440.V291443.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth 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. 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