Inspection on 20/11/06 for St Anne`s Residential Home

This inspection was carried out on 20th November 2006.

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

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

Other inspections for this house

St Anne`s Residential Home 16/05/08

St Anne`s Residential Home 17/05/07

St Anne`s Residential Home 15/11/05

St Anne`s Residential Home 22/06/05

St Anne`s Residential Home 18/01/05

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

CARE HOMES FOR OLDER PEOPLE St Anne`s Residential Home St Anne`s Residential Home Clifton Deddington Banbury Oxfordshire OX15 0PA Lead Inspector Kate Harrison Unannounced Inspection 20th November 2006 09:00 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 Anne`s Residential Home DS0000062413.V321036.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 Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Residential Home Address St Anne`s Residential Home Clifton Deddington Banbury Oxfordshire OX15 0PA 0796 8490068 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) ruralcareltd@aol.com Mr Prashant Brahmbhatt Janet Margaret Collier Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: St Annes care home is situated in the village of Clifton, near Deddington on the edge of the Cotswolds. The property is a most attractive old stone built cottage, which has been extended. St Annes was first registered as a care home in 1987 and is today home to 21 older people who suffer from forms of memory loss, Alzheimers and other types of dementia. Accommodation is provided in single and double rooms on two floors. All rooms have en-suite facilities. The communal spaces are well laid out and provide comfortable homely areas for all to enjoy. The grounds are most attractive and have a walk way which service users are able access and is a safe secure area St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.30 hours and was in the service for 7.5 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the home since the last inspection. The inspector saw all areas of the home and looked at records and documents relating to the care of the residents. The inspector asked the views of the residents, relatives and health and social care professionals about the home through questionnaires (comment cards) that the Commission had sent out. Ten relatives and one GP surgery replied to the Commission’s comment cards and their views are reflected in this report. Most residents were not able to complete the Commissions comment cards and five relatives completed them on behalf on their resident relatives. It was difficult to carry out in depth interviews with residents during the inspection visit due to the residents’ dementia, but the inspector had meaningful conversations with several residents on the day. The registered manager was not in the home on the day, but the deputy manager was available and provided valuable help. From the evidence seen the inspector considers that it is not certain that this home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. This is because evidence was available to show that some residents are not effectively listened to, and their needs are not met in a systematic way. Several requirements and recommendations are made in this report to help St Anne’s provide an improved service for people with dementia, and the Commission sent a letter to the home following the inspection visit regarding the immediate action that had to be taken. What the service does well: The home welcomes relatives and includes them in the planning of care. Admission procedures are good, and one relative who replied to the Commission’s comment card said that staff members try very hard to make the residents feel at home. Food is good, and the staff are caring and kind. The home provides a secure environment for the residents. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager needs to make sure that the residents have access to the health care they need at all times, and needs to improve staff training, so that skilled staff are available to meet the needs of all the residents with dementia. A more ‘person centred’ approach to dementia care would improve life for the residents. For example, information from the residents’ life stories needs to be used in a meaningful way to help the team to understand each resident better and to reduce residents’ anxiety associated with dementia. The manager needs to consult dementia organisations to advise on how the activities could be developed to include the best practice person centred approach to dementia, as this will help residents feel less anxious. An up to date activities programme needs to be produced and well displayed so that residents and relatives are kept informed of the available activities, and the programme needs to include activities planned for the times when the activities coordinator is not in the home. The home’s nutritional risk assessment is outdated and needs to be updated so that the current nutritional state of the residents can be known. The carers’ daily report at times contains information that could be used to improve the care planning for individuals, but the information is not transferred into the care plans. The manager needs to give the care staff easy access to the care plans, as this will help to improve care. The manager must review how medications are managed at the home and must review staff training regarding medication, so that residents receive medication as prescribed. All the medication arriving at the home is not recorded as received, and this must be done to comply with legislation. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 7 The home’s medication policy and procedure should be revised to include the relevant guidelines from the Royal Pharmaceutical Society and to meet the Care Standards Regulations. The manager should organise breakfast time so that sufficient time is allowed between breakfast and lunch for residents to be able to eat well at both meals. The manager needs to consult dementia organisations regarding best practice in helping residents access the home’s complaints procedure. The home needs to make sure that relatives have easy access to the complaints procedure ‘Management of Complaints’ so that they can act on behalf of their resident relatives behalf, and the complaints procedure needs to include the Commission’s local telephone number. The procedure needs to be amended to show that complainants have the right to contact the Commission at any time, and not only when the home is unable to satisfactorily resolve issues. All the complaints need to be recorded, and the action taken by the registered person in response to the complaints also need to be recorded. A system needs to be in place so that the cleaning and updating of the home’s fixtures and fittings are regularly carried out. A risk assessment needs to be carried out in the laundry to make sure that staff can safely work in the building, and staff members need to have easy access to the hand washbasin in the laundry to prevent the spread of infection. Not all the information required by law about staff working at the home is available, and the home must make sure that all the information and documents are available. The provider needs to provide reports to the registered manager about his monthly quality visits to the service, and needs to show the results of the annual quality questionaires to relatives to the Commission. 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 Anne`s Residential Home DS0000062413.V321036.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 Anne`s Residential Home DS0000062413.V321036.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. good. Quality in this outcome area is This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager usually carries out the pre-admission assessment, to determine that the individual’s needs can be met at the home. Individual files seen show that pre-admission assessments are carried out, and that all the necessary information is available from care managers if appropriate before carrying out the pre-admission assessment. Residents are admitted for a trial period and care plans are in place for all the residents. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor, because the health and welfare needs of residents are not well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector assessed two residents’ care plans and followed up the care provided. Risk assessments are carried out to provide information for care planning. The home’s nutritional risk assessment is outdated and does not include the resident’s body mass index. The home has acquired the catering manual associated with the Malnutrition Universal Screening Tool (MUST), but is not using the MUST to assess the nutritional state of the residents. The MUST includes the resident’s body mass index and provides evidenced based information about residents’ nutritional state, and should be used to assess the nutritional state of the residents. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 11 One resident admitted three weeks previously had no falls risk assessment or nutritional risk assessment completed, so it is not clear that residents’ care needs are taken seriously. One resident’s GP was concerned about a possible lack of protein in her/his diet, but this concern was not included as part of the care plan and did not prompt a review of the resident’s nutritional assessment. One resident told the inspector several times during the day about severe anxiety and a strong wish to self-harm, but the care plans and daily report did not mention the issues or include any information for staff, and staff members were noted not to be effectively addressing these issues. After discussion the deputy manager agreed to address the issue by involving appropriate professionals and by giving clear information for staff members to help care effectively for the resident. The registered manager must at all times make proper provision for the care and treatment of residents, The daily report at times contains useful information added by the care staff that is not used to improve the care planning, and this should be addressed. The care plans are kept in a separate area of the home to the daily report, away from the care staff, and the registered manager should consider how best to give the care staff easy access to the care plans, so that the care staff will be as involved in the care planning process as they are in the daily report writing. Some resident’s files contained information about residents’ life stories, but other valuable relevant information known to staff is not always recorded or used for the benefit of the resident. Best practice in caring for people with dementia shows that information from life stories is very valuable in helping people cope with dementia, and the home should take this into account. Information from life stories should be used to help the care team to care for the residents, and to reduce anxiety. The registered manager should consider developing a more person centred approach to dementia care. All the medication arriving at the home is not recorded as received, and this must be done to comply with legislation. Medicine hand written on one resident’s medication administration chart was not available at the home, and it was not clear that the medication had been prescribed for that resident. Prescription medication was found in a resident’s medication box but there was no record that the medication was prescribed for that resident, and the medication did not have the name of any resident on it. The registered manager must review how medications are managed at the home and must review staff training regarding medication, so that residents receive medication as prescribed. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 12 The home’s medication policy and procedure should be revised to include the relevant guidelines from the Royal Pharmaceutical Society and to meet the Care Standards Regulations. A notice on a board in a public place in the home described some residents as ‘feeders’ and others as ‘self feeders’ and the deputy manager told the inspector that this referred to residents who needed help with eating, and to those who are able to eat without help. The deputy manager agreed that this was not a dignified way of referring to residents and removed the notice. Staff members were noted to address residents in a courteous manner, and to knock on residents’ bedroom doors before entering. The majority of relatives responding to the Commission’s comment cards said that their relatives ‘always’ got the care and support they needed. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s activities organiser works part time with those residents who take part in communal activities and the results of the collages and painting activities are displayed in the home. Other entertainers come to the home on a monthly basis and outings are organised for the residents who can go. Relatives who responded to the Commission’s comment cards said that activities were ‘usually’ or ‘sometimes’ organised that the residents could take part in. The activities plan on display in the home was dated for a week in June 06, and listed activities for three of the days that week. There was no evidence to show that a recommendation about the provision of activities at the last inspection visit had been acted on, and this recommendation remains. An up to date activities programme should be produced and well displayed so that residents and relatives are kept informed of the available activities. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 14 As St Anne’s provides care for people with dementia it is good practice to link the individual activities provided with the life stories of the residents, so that the residents can find meaning in their daily lives. The registered manager should consider consulting dementia organisations to advise on how the activities could be developed to include the best practice person centred approach to dementia, as this approach will benefit the residents. Visitors can visit the home at all reasonable times and the home’s policy on visitors is part of the service user’s guide. None of the residents are able to manage their own financial affairs and relatives and care managers manage on behalf of the individuals. The home’s chef is enthusiastic about providing high quality food to the residents, and residents enjoyed lunch on the day of the inspection visit. Food is purchased locally where possible, and a good choice is available for supper each day. One resident who was unable to eat without help was left with breakfast in the lounge for twenty minutes before a carer came to help. The deputy explained that the resident was given time to eat independently before help was offered, but by this time it was late in the morning, and only two and a half hours before lunchtime finished. The registered manager should organise breakfast time so that sufficient time is allowed between breakfast and lunch for residents to be able to eat well at both meals. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is poor. This is because the home’s complaints procedure does not meet the regulation, and it is not clear that the home takes proper action to help residents with dementia and their relatives to make complaints. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of relatives who replied to the Commission’s comment cards said that they knew how to make a complaint, but some said that they did not. The home’s complaints procedure was not easily visible in the home. It is unlikely that the majority of residents would be able to complain on their own behalf, so it is very important that relatives know how to deal with complaints and concerns. The registered manager should make sure that relatives have easy access to the complaints procedure so that they can act on behalf of their resident relatives. Some residents may have the capacity to make a complaint on their own behalf, and the registered manager should consult dementia organisations regarding best practice in helping residents access the home’s complaints procedure. The home’s complaints procedure ‘Management of Complaints’ does not include the Commissions local telephone number, and this must be included to meet legislation, and to give relatives and residents all the information they need. The registered manager should also amend the procedure to show that St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 16 complainants have the right to contact the Commission at any time, and not only when the home is unable to satisfactorily resolve issues. The home’s record of complaints shows that no complaints have been recorded since 2003, and the registered manager must record all complaints made, and must record the action taken by the registered person in response to the complaints. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is poor, because the environment of the laundry presents a health and safety hazard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s communal areas provide variety and are complimented by a good garden for residents to enjoy. The décor is generally in need of improving; the dining room carpet is worn, and in the assisted bathroom the wall covering is peeling, the paintwork is dirty, and the washbasin taps are encrusted with lime scale. Although there is a book for staff to record items that need attention from the maintenance staff member, the registered manager should develop a system so that the cleaning and updating of the home’s fixtures and fittings are regularly carried out. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 18 The home’s laundry is situated away from the main building. A private contractor manages most of the home’s laundry, and only residents’ personal items of clothing are laundered on the site. Several cardboard boxes were stored in the laundry, and several containers and a plugged in electric cable to the machines was stretched across the staff access to the washbasin. This presents a safety hazard for staff, and makes it difficult for staff to safely wash their hands. The laundry has no ceiling fitted to separate the corrugated roof from the work area, and this allows dust and insects into the laundry. Other items such as uncovered pillows were also stored in the laundry, and are at risk of contamination. A risk assessment regarding health and safety must be carried out in the laundry to make sure that staff can safely work in the building, and that fire and electrocution hazards are minimised. The registered manager should make sure that staff can easily access the hand washbasin to prevent the spread of infection, and for the health of the residents items used by the residents should not be stored in the laundry. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This is because not enough staff have sufficient skills to care for older people with dementia, and because the home’s recruitment procedure does not meet the legislation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of relatives who responded to the Commission’s comment cards said that there were always sufficient numbers of staff on duty, and on the day of the inspection visit there was a good mixture of carers, housekeeping and kitchen staff for the 21 residents. Five care staff members have completed the NVQ Level 2 training, and four more are in the process of training. At present this means that the home does not meet the National Minimum Standard of 50 trained care staff, although when the four carers complete the current course the standard will be met. The induction programme for new staff members meets the Skills for Care standard, though the inspector was not able to see an induction workbook in progress. Half of the staff members have done or are in the process of doing dementia awareness training, but from the evidence seen on the day of the visit staff were not effectively addressing the needs of one resident with dementia. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 20 As the home has a category to care for older people with dementia, the expectation from the Commission is that sufficient staff will have the skills to care for the residents. The registered manager must consider how to improve dementia training, so that skilled staff members are available to meet the needs of all the residents with dementia. Three staff files were seen to assess the home’s recruitment procedure. One file did not contain a photograph of the staff member, and a Standard Criminal Record Bureau (CRB) clearance was obtained, instead of Enhanced clearance, as the member of staff saw residents alone. The inspector understood that the member of staff carries an identity card with a photograph, but a photograph must be on file to meet the legislation regarding documentation. One file for a member of staff working at the home for three weeks contained no references or proof of any CRB clearance, and the registered manager confirmed that appropriate action was taken the following day. The registered person must make sure that all the information and documents specified in regulation 19 and Schedule 2 are available. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. This is because the risks to the health and safety of residents and staff are not well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager works part time and is a registered nurse and has managed the home for the past year. Serious issues regarding the health and safety of the residents have come to light during this inspection visit and need the attention of the registered manager and the provider. The inspector did not receive enough information about the home’s quality assurance system to be sure that relatives and other stakeholders are consulted regularly about the quality of care provided. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 22 The responsible individual must supply a recent annual quality assurance report showing consultation with relatives about reviewing and improving the quality of care provided at the home, and must provide reular reports to the registered manager about his monthly quality visits to the service. No petty cash is kept on behalf of the residents. Weekly alarm testing and other regular fire safety checks are recorded, and the home’s fire marshal intends to ask the local fire officer to review the home’s fire risk assessment. This is necessary particularly to make sure that the hazards noted in the laundry are addressed. The registered manager is in the process of setting up a Health and Safety committee with responsibility for health and safety matters at the home, so that the risks to the safety of staff and residents are minimised. St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12 Requirement The registered manager must at all times make proper provision for the care and treatment of all the residents through access to appropriate health professionals at the appropriate time. The registered manager must review how medications are managed at the home. The registered manager must review staff training regarding medication. All medication received into the home from any source must be recorded as received. The home’s complaints procedure ‘Management of Complaints’ must include the Commissions local telephone number. The registered manager must record all complaints made, and record the action taken by the registered person in response to the complaints. A risk assessment regarding health and safety must be carried out in the laundry to make sure that staff can safely DS0000062413.V321036.R01.S.doc Timescale for action 30/12/06 2 3 4 5 OP9 OP9 OP9 OP16 13 13 13 22 30/12/06 30/12/06 30/11/06 31/12/06 6 OP16 17 Schedule 4 23 15/12/06 7 OP26 15/12/06 St Anne`s Residential Home Version 5.2 Page 25 8 OP30 18 9 OP29 19 10 OP33 24 11 OP33 26 work in the building. The registered manager must consider how to improve dementia training, so that skilled staff members are available to meet the needs of all the residents with dementia. The registered provider must make sure that all the information and documents specified in regulation 19 and Schedule 2 regarding persons working at the home is available. The registered provider must supply to the Commission a recent quality assurance report including the views of relatives, about reviewing and improving the quality of care provided at the home. The provider must provide reports to the registered manager about his monthly quality visits to the service. 31/12/06 30/12/06 31/12/06 31/12/06 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 Refer to Standard OP7 OP7 OP8 OP8 OP9 Good Practice Recommendations The registered manager should seek advice on how to develop a more person centred approach to dementia care at the home. The registered manager should consider how best to give the care staff easy access to the care plans. The registered manager should consider using the Malnutrition Universal Screening Tool to assess the nutritional condition of all the residents. Information from life stories should be used to help the care team to care for the residents. The home’s medication policies and procedure should be revised to include the relevant guidelines from the Royal DS0000062413.V321036.R01.S.doc Version 5.2 Page 26 St Anne`s Residential Home 6 7 OP12 OP12 Pharmaceutical Society and to meet the Care Standards Regulations. The registered manager should consider how activities could be provided on the days when the activities coordinator is not in the home. The registered manager should consider consulting dementia organisations to advise on how the provision of activities could be developed to include the best practice person centred approach to dementia. An up to date activities programme should be produced and well displayed so that residents and relatives are kept informed of the available activities. The registered manager should organise breakfast time so that sufficient time is allowed between breakfast and lunch for residents to be able to eat well at both meals. The registered manager should make sure that relatives have easy access to the complaints procedure so that they can act on behalf of their resident relatives. The registered manager should amend the complaints procedure to show that complainants have the right to contact the Commission at any time, and not only when the home is unable to satisfactorily resolve issues. The registered manager should consult dementia organisations regarding best practice in helping residents access the home’s complaints procedure. The registered manager should develop a system so that the cleaning and updating of the home’s fixtures and fittings are regularly carried out. The registered manager should make sure that staff could easily access the hand washbasin in the laundry to prevent the spread of infection. Items used by the residents should not be stored in the laundry, as they may become contaminated by infection. 8 OP12 9 OP15 10 OP16 11 OP16 12 OP16 13 14 15 OP19 OP26 OP26 St Anne`s Residential Home DS0000062413.V321036.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Anne`s Residential Home DS0000062413.V321036.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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