Inspection on 14/03/07 for St Anne`s Rest Home

This inspection was carried out on 14th March 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Anne`s Rest Home 05/08/08

St Anne`s Rest Home 06/02/08

St Anne`s Rest Home 06/02/06

St Anne`s Rest Home 30/03/05

St Anne`s Rest Home 05/08/04

St Anne`s Rest Home 20/02/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Anne`s Rest Home Grange Lane Burghwallis Doncaster DN6 9JL Lead Inspector Matun Wawryk Key Unannounced Inspection 09:00 14th March 2007 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 Rest Home DS0000007964.V314525.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 Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Rest Home Address Grange Lane Burghwallis Doncaster DN6 9JL 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) 01302 700319 01302 708752 NONE Hallam Diocesan Caring Service Gail Nelthorpe Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: St Ann’s Rest Home is situated in the village of Burghwallis to the north of Doncaster, not far from the A1. The hall is a grade 2 listed building with parts dating back to the 11th century. Many original and interesting features remain throughout the building, although the internal layout is not altogether ideal for the provision of residential accommodation for older adults. Bedrooms vary in size and shape and accommodation is provided on a number of levels. The home is set in lovely grounds on the edge of a quiet hamlet. The nearest shops can be found in the next village. The home is owned and managed by the Diocese of Hallam Trust. The home has no specific admission criteria relating to faith of the service users, however a mass is said daily in the internal chapel and the residents have the option of attending. The home is registered to accommodate 30 residents in the category of old age. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager at the home. Information given by the manager indicates the weekly charge is £375.00 per week; there are no additional charges other than those for hairdressing, private chiropody treatment, toiletries, newspapers and magazines etc. More current information about fees and charges can be obtained from the manager. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second key inspection. The visit took place over 1 day in March 2007, Mrs Matun Wawryk regulation inspector carried out the visit. Prior to visiting the home information was gathered from a number of different sources. Questionnaires were sent out to a sample group of residents and staff. Six residents and one member of staff returned a questionnaire. The manager of the home also completed a pre-inspection questionnaire and returned this to the Commission within the given timescale. During the visit the inspector spoke to six residents, three visiting relatives, the area manager, the manager, two care workers and a social work student on placement in the home, to try find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. The inspector also looked around the home and looked at lots of paperwork, including resident care plans, staff training records and other records relating to the running of the home. Information received by the Commission over the last few months was also considered in forming a judgement about the overall standards of care within the home. What the service does well: What has improved since the last inspection? St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 6 More care staff had accessed first aid training. This means staff are able to ensure residents receive appropriate help should they have an accident. More care workers have enrolled to complete a National Vocational Training (NVQ) award to help them develop their skills and knowledge in working with older people. What they could do better: The manager is not always ensuring new residents have their needs assessed prior to admission to the home. It is important that the manager obtains a copy of any needs assessment completed through care management arrangements; in the absence of this the manager must complete an assessment. This is needed to see if the persons need’s can be met in the home. The assessment must be completed before a decision to accept the resident for admission and an offer of a placement is made. The manager also needs to provide new residents with a personalised statement specifically relating to the care and accommodation that they will receive for the fee being paid. Not all residents have an individual care plan that details how staff should care for the person, and in some cases information documented in plans did not reflect the care being provided. It is important that the manager ensures each resident has a care plan detailing all their current care needs and that plans be updated, as the residents need change. This is needed to ensure staff know what care and support people require, when they need it. Staff are not getting formal one to one supervision from the manager and the manager now needs to takes steps to address this. This is important because staff need to be provided with necessary guidance; leadership and support to ensure residents living in the home are safe and well cared for. There has been a noticeable improvement in the provision of safe practice training. However the majority of staff have not had any moving and handling training in the last three years. It is important staff receive this training to ensure the welfare and safety of both residents and the staff. The inspector would like to thank everyone who completed a questionnaire and/or took the time to talk to her during this visit. Your comments and input have been a valuable source of information, which has helped create this report. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 7 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 Anne`s Rest Home DS0000007964.V314525.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 Rest Home DS0000007964.V314525.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): 2 and 3. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Not all prospective residents have their needs fully assessed before they are admitted to the home. The admission process is thorough in so far as staff ensure new residents are made to feel welcome. EVIDENCE: The home has produced a statement of terms and conditions that should be issued to both private and local authority funded residents. Checks on four residents personal files showed two residents been given a statement, however these were old and no fee information was included and one had not been signed by the resident and/or homes manager. The other two residents had not been issued with a statement of terms and conditions. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 10 It is important that each resident knows what they are paying for and any terms of residency. The manager is advised to ensure everyone who is coming to live in the home is given a personalised statement specifically relating to the care, accommodation etc that they will receive for the fee being paid. This should be supplied, at the latest, at the point at which someone takes up residence in the home and should be updated as fees change. Full details about what needs to be included can be found in the revised Care Homes Regulations. The admissions procedure is sufficient to guide staff on the actions to be taken to ensure prospective residents needs are properly assessed and planned for, however this is not followed consistently. Four residents files were looked at, completed needs assessments were in place for two residents. The manager had seen the other two people prior to their admission but had not completed a needs assessment. It is important that in the absence of a professional assessment the manager completes an assessment before a resident is admitted to the home. Failure to this means assurances cannot be given about the homes capacity to meet the needs of the individual. There was nothing to show that residents or their representatives were formally advised that the home could meet their needs, this must now happen for new admissions. Three residents were spoken to about their experience of moving into the home, all three said they had been made to feel welcome, two said they had been given sufficient information about the home. One resident said they had not been given any information about the home. Staff spoken to are able to describe the care needs of residents and had a good understanding of their day-to-day needs. Information given by residents in surveys and face to face meetings indicates they are very satisfied with the care provided to them. One person said ‘ the staff are very good to us, they are kind and we get the care we need.’ Three individuals said ‘we can talk to the staff about any problems we have and they or the manager will make sure our needs are met’. Three relatives spoken to also said are very satisfied with the quality of care provided to their relatives. One relative said ‘it’s a wonderful place’, another one said they care for my mum very well’. Information from the Pre-Inspection Questionnaire completed before the inspection and discussion with the manager, staff and observation on the day indicates that all of the residents are white/British/Irish. The manager said the home is able to support individuals with specific cultural or diverse needs following a needs assessment being completed. And where necessary additional training and guidance would to provided to staff to enable them to be responsive to the resident’s needs. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 11 The home does not provide intermediate care therefore NMS 6 is not applicable. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 12 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 and 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are aware of the residents care needs. However not all residents have a care plan and some plans have not been updated to reflect changes in health and personal care needs. Residents are treated with respect and their right to privacy is promoted and upheld. EVIDENCE: Case Tracking took place for four residents. The methodology used was a physical examination of risk assessments, care plans, discussion with residents and staff, written surveys and direct observation on the day. It was disappointing to note that action had not been taken to address a requirement detailed in the last inspection report concerning a need to ensure care plans are updated when residents needs change. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 13 There are risk assessment tools for mobility, falls, tissue viability, medication, nutrition and general issues in place, however the quality and consistency of information is variable. One resident had a detailed care plan, supported by clear risk assessments and records showed individual plans are being monitored on a regular basis. One resident did not have any care plans or risk assessments despite the fact that daily records identified a significant deterioration in the person’s physical health. This matter was fully discussed with the area manager and manger, both gave an assurance that an immediate review of this person care needs would carried out and supporting care plans and risk assessments would be put in place. Checks on anther residents’ care file also showed an absence of any care plans and risk assessments. One resident had a care plan and supporting risk assessments but some gaps were noted. Records identified the resident has a small pressure sore. Although a care plan for pressure area care was in place this was brief and gave limited information to staff on care support arrangements. For residents at risk of developing pressure sores detailed risk assessments and individual support plans must be put in place. Plans must contain sufficient information to guide staffs practice for example, they should set out in detail tasks staff are expected to carryout, where ‘regular’ positional changes are needed care plans must be specific in terms frequency, manoeuvres and monitoring arrangements It is important that each resident has a care plan(s), supported by detailed risk assessments where needed, to ensure all the residents needs have been identified and to ensure staff know what care needs to given, when its needed. New staff have been recruited and the manager uses agency staff from time to time, these staff are not be able to determine how an individuals care should be provided at the home through reading the residents care file. This could place residents at risk of harm. All the residents are registered with the same GP and the GP visits the home on a fortnightly basis. This is to be commended because these visits ensure residents’ health needs are monitored on an ongoing basis. Residents have access to chiropodists, dentists and optician services with records of visits being written into the residents care file. Residents told the inspector during the visit and also wrote on the surveys that they were satisfied with the standards of care provided, they considered the staff listen to them and always treat them with dignity and respect. One resident said ‘staff always get the GP out if I am feeling unwell’. All the residents spoken to and those who returned a questionnaire said they are satisfied with the level of medical support given to them and this was confirmed in discussions held with three relatives. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 14 Most of the residents spoken said that they are aware of their care plans but had no interest in reading them. Records indicate that some reviews of care plans have carried out although a number still need to be completed. The home uses a Monitored Dosage medication system and information from the pre inspection questionnaire and discussion with the manager indicates staff responsible for medication administration have received appropriate training. Medication records and systems are generally satisfactory although some improvement is needed. Checks on a sample of medication administration records (MAR) identified a small number of omissions and this raises questions about whether medication has been given. One resident has been prescribed a ‘patch’ for pain relief. Staff are not always ensuring the patch is applied at the same time each day. It is important that this now happens and the residents care plan should be changed to include this information. Staff are occasionally handwriting medication onto the MAR sheets (transcribing), but are not following best practice. In some cases staff are not always recording amounts of medication received or brought forward. The inspector advised the manager to ensure two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct and that quantities of medication, including balances where appropriate are recorded on the MAR to ensure an accurate audit trail. As a matter of good practice the inspector advises that patient information leaflets of medication supplied be obtained from the dispensing chemist and that these be kept in the medication cupboard. This will provide staff with up to date information on medication prescribed for each resident. The manager is also advised to put in place a staff signature list of staff authorised to administer medication. Comments from residents and relatives show people are very satisfied with the care and support offered by the staff. Four residents said they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. One person said ‘ the staff are very good to us, they are kind and we get the care we need.’ Another person said ‘I can talk to the staff about any problems I have and they or the manager will make sure my needs are met.’ ‘I can go to bed when I want and staff don’t get me up too early.’ St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 15 It was possible to see many examples of residents being treated with privacy and dignity throughout the day. Staff do not enter bedrooms without knocking and seeking permission, and the majority of residents have keys to their doors and routinely lock them. Residents see their visitors and health care professionals in private, and are asked for their preferred form of address on admission. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 16 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 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents were seen to experience a full life with opportunities to take part in varied activities and residents are encouraged to make decisions and choices about this that matter to them. The meals in this home offer both choice and variety. EVIDENCE: There is a positive approach to activities, and the manager employs a part – time person to co-ordinate activities for residents. A wide range of internal recreational and social activities are arranged, including outside entertainers, craft sessions, exercises classes, bingo and sing a longs. Regular meetings with residents are held, this means residents have an opportunity to discuss what happens in the home and are encouraged to make suggestions about how things can be improved. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 17 A religious commitment is not a pre-requisite for prospective residents, and the home’s admission policy is non-denominational but there is emphasis on fulfilling the spiritual needs of residents. A catholic service is held every day at 11:00am in the chapel where communion is given (except Tuesdays, when it is at 6:00pm), and an Anglican service is held on the first Wednesday of every month for other residents. The home has an open visiting policy, and contact with family and friends is encouraged. Three visiting relatives were spoken to, one said ‘the home provides absolutely brilliant care”, and the other two spoke very highly about the standards of care. Relatives described the staff as ‘lovely’ ‘caring’ and ‘approachable’. Relatives said they are made welcome when visiting the home and confirmed they are encouraged to visit at any time. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 18 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 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents can be confident that their concerns will be listened to and acted upon. Procedures are in place to ensure a proper response to any suspicions or allegations of abuse. EVIDENCE: The Commission has not received any complaints about the home since the last inspection carried out in February 2006 and the manager stated no complaints have been made. A complaints procedure was in place and staff spoken to said they had no complaints about the home and felt confident to raise issues of concern if they arose with the manager. Four of the six residents spoken to confirmed that they knew who to report concerns or complaints to, and this was also confirmed in discussions with three visiting relatives. Residents spoken to said they felt ‘safe’ in the home. Information from the Pre-Inspection Questionnaire and discussion with the manager indicates the home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, management of challenging behaviours and management of residents money and financial affairs. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 19 When asked about abuse, what it was and what they would do if they suspected or saw or suspected any abuse staff stated that they would report it to the manager or senior care worker. Training records evidenced that the majority of staff have had adult protection training St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 20 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, 25 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean and comfortable, but a number of areas in the home require redecoration and refurbishment. EVIDENCE: All areas of the home were clean and tidy; although some cobwebs were seen in high-level areas. Five of the residents who returned a questionnaire said the home was always kept clean. One resident said the home needed redecoration. One relative commented that the home was not as clean as it used to be and said some areas needed redecoration. The last inspection report noted that work has been carried out over the years to box in old piping and to fit radiator guards to protect residents. Inevitably because of the age of the building there are still signs of exposed heating piping at different heights in different parts of the home that still need to be St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 21 modified. The manager should continue where possible to ensure old pipe work is lagged to protect resident’s safety especially where residents are in close proximity to the piping. The sash windows are old and some are in need of repair. Staff are aware of the potential health and safety risks these present to residents. The manger stated staff are vigilant about this and try and educate the residents to the dangers of trying to open/close the windows themselves. At the last inspection a requirement was made to fit thermostats to radiators in some residents bedrooms to enable them to regulate the temperature of their rooms. This remains an outstanding requirement and action must now be taken to address this. All bedrooms seen were clean and tidy, but some require redecoration and some carpets need cleaning or replacing. Residents spoken to stated they are happy with their rooms and many people had furnished their bedrooms with a range of personal items, some even bringing in items of furniture to reflect their own individual choice and taste. It is essential the manager produces a maintenance and renewal of the fabric and redecoration plan for the home to show how and when essential redecoration and refurbishment work will be completed. The inspector did not observe any wedged doors, this was an issue identified in the last inspection report. The fire risk assessment for the home has only been partially completed, the manager must now ensure the assessment is fully completed and if necessary should have this checked by a competent person. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 22 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 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There are sufficient number of staff on duty to enable residents needs to be met and residents are safeguarded by the homes staff recruitment practices. Improvement is need in safe practice training to ensure the health and welfare of staff and residents EVIDENCE: The roles and responsibilities of staff are clearly defined and in discussion with the inspector staff demonstrated understanding of the management and reporting structures for the home. On the day of the inspection there were twenty-two residents living in the home. Inspection of the duty rota and discussion with the manager indicated four staff are on duty in the morning, three in the afternoon and two staff at night. All of the staff spoken to said there is sufficient numbers of staff on duty at any one time to enable resident needs to be met. The home has a commitment to National Vocational Qualification (NVQ) training and a number of staff have already successfully achieved NVQ level 2 or above and a number of other staff have enrolled to complete an award. The manager stated that the homes induction programme meets the criteria set by Skill for Care Staff. The inspector was unable to verify this because the St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 23 manager was unable to show the inspector any completed induction records for new starters. Annual appraisals for staff are out of date and it is important that the manager takes action to address this. It is important annual appraisals are kept up to date to ensure the homes training plans and priorities reflect the training needs of the staff team. A recruitment and selection policy and procedure is in place, which the manager follows when appointing new members of staff. Checks of two staff files showed Protection of Vulnerable Adult register checks, police (Criminal Records Bureau) checks, written references, health checks and past work histories are obtained and satisfactory before the individual starts work. An equal opportunities policy and procedure is in place and feedback from the manager, staff and information in personnel and training records showed the procedure is followed when employing new staff and throughout the homes working practices and staffs access to training. A training plan to incorporate mandatory training and updates was in place. However records indicated most of care staff have not been provided with moving and handling training, despite this being detailed as a requirement in the last inspection report. This training must now be provided to ensure the health and safety of both residents and staff. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 24 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, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The process of managing the home is open, but some systems and working practices need to improve to ensure residents and staff benefit from a well run home that ensures their welfare and safety. Formal arrangements are in place, which support and encourage resident and staff consultation and participation in the running of the home. EVIDENCE: The manager Mrs Gail Nelthorpe has now completed the registration process with the Commission and is in the process of completing a recognised management and care qualification. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 25 Residents and staff are very complimentary about the management arrangements for the home and how it is run. All the residents able to express an opinion said the manager is kind and friendly. Staff confirmed that moral is good and commented that there is a good team approach to care delivery at the home. Evidence from staff interviews indicates the staff consider the manager and deputy manager to be approachable. Staff said the manager take issues raised seriously and takes prompt action to resolve matters where needed. Since the last inspection the manager has fully implemented a new quality assurance system, which includes regular audits and surveys to residents, their families, staff and relevant stakeholders for example; social services staff. On completion a report together with action points is developed. Outcomes of quality monitoring arrangements are discussed at resident meetings and information is also made available in the home. The inspector was told that a copy of the most recent quality development report for the home has been sent to the Commission Sheffield office. The home does not manage the finances of residents but keeps safe a small amount of personal allowance for several, usually deposited by relatives. This is accessible to residents as required. No progress has been achieved regarding full implementation of a formal programme of staff supervision, despite this being identified as a requirement in the last inspection report. Records and staff interviews established the manager is not providing staff with structured one to one support. It is important that the manager now takes steps to address this. This is important because staff need to be provided with necessary feedback on their performance, guidance; leadership and support to ensure residents living in the home are safe and well cared for. The manager ensures individual records are secure and staff are aware of the importance of maintaining confidentiality. However some improvement in this area is needed. A number of records required by regulation are missing and/or are not up to date for example; needs assessments for new residents, care plans, risk assessments and supervision records. It is important that the manager now takes steps to address these matters. Checks on a sample of care records identified the manager was not always completing a regulation 37 notice to advise the Commission of matters relating to residents for example when they are admitted to hospital. This must now happen to meet legal requirements. Information in the provider information questionnaire indicates that a current insurance certificate is in place as are current maintenance certificates for the gas systems, the fixed electrical systems, the passenger lift, bath hoists and mobile hoist. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 26 As detailed on page 22 of this report the fire risk assessment for the home has only be partially completed, the manager must now ensure the assessment is fully completed and if necessary should have this checked by a competent person. Bedrails had been fitted to one resident’s bed, however the resident kept trying to climb over them and on one occasion caught his arm in the rail as a result of this they were removed. There was no evidence to show staff had completed a bedrail risk assessment prior to before fitting the rails. Because of the potential dangers posed by improper use of bedrails it is essential bedrail risk assessments are completed, in line with guidance issued by the Medical Devices Agency before they are used. Records and staff interviews showed significant progress has been made in provision and take up of safe practice training for example, fire safety, health and safety and first aid. However no progress has been made to ensure staff are provided with moving and handling training. Failure to provide this training places both staff and residents at risk of harm. This remains an outstanding requirement from the last inspection and action must now be taken to address this. St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 27 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 2 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 2 2 St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 28 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 OP2 Regulation 5 (1) (b) Requirement Timescale for action 30/04/07 2 OP3 14(a)(b) 2(a) The registered person must ensure each resident be given a personalised statement specifically relating to the care, accommodation etc that they will receive for the fee being paid. This should be supplied, at the latest, at the point at which someone takes up residence in the home. It is important that this fee information is widely available at an early stage to support people to make informed choices. Further information about this can be found in the revised Care Homes Regulations The registered person must 31/03/07 obtain a copy of the care management needs assessment for prospective residents. In the absence of a professional assessment the manager must complete an assessment. This is needed to ensure the home is able to meet the needs of the individual. Details about what needs to be included in any assessment can be found in National Minimum Standard 3 of the Care homes Regulations DS0000007964.V314525.R01.S.doc Version 5.2 St Anne`s Rest Home Page 29 3 OP7 15 4 OP7 15 5 OP7 15 6 OP8 OP7 13 The registered person must ensure that plans of care are updated to maintain the health personal and social care needs of residents. Timescale of 28.2.06 not met. The registered person must ensure that annual reviews of residents are carried out. Timescale of 28/02/06 not met. The registered person must ensure each resident has a care plan(s). The plan(s) must detail all the identified needs of the resident together with specific details about what care needs to be provided by staff. This is needed to ensure staff know what care needs to be provided and when. The registered person must ensure care plans are supported by clear and detailed risk assessments for example; for moving and handling, pressure area care and nutrition. The assessments must detail what the precise risk is, together with detailed information about what action staff must take to eliminate or minimise any identified risks. These must be subject to regular monitoring and must be updated, as the residents need change. This is needed to ensure resident’s heath needs have been assessed and adequately planned for. The registered person must develop a pressure area care plan, support by a clear risk assessment for resident A. These must contain sufficient information to guide staff practice for example, they should set out in detail tasks staff are expected to carryout for DS0000007964.V314525.R01.S.doc 30/04/07 30/06/07 15/04/07 31/03/07 7 OP8 13 31/03/07 St Anne`s Rest Home Version 5.2 Page 30 that individual e.g. where ‘regular’ positional changes are advised care plans must be more specific in terms frequency, manoeuvres and monitoring arrangements. This is needed to ensure residents get the care they need, when they need it. 8 OP9 13(2) Sch 3 (i) The registered person must ensure that full and accurate records are kept of all medicines received and administered in the home. This is needed to ensure the health and welfare of residents. The registered person must ensure that all staff receive moving and handling training. This is needed to ensure staff know how to move and handle residents safely. The registered person must ensure that staff receive supervision at least 6 times per year. Timescale of 28.2.06 not met. The registered person must ensure Regulation 37 notices are produced. A copy must be kept in the home and another one must be sent to the Commission. Full details of the circumstances under which a notice must be produced can be found on the Commissions website. The registered person must ensure that a risk assessment is made out for the resident living in close proximity to the second floor fire escape door. Timescale of 28.2.06 not met. The registered manager must produce a maintenance and renewal of the fabric and redecoration of the premises plan for the home to show how DS0000007964.V314525.R01.S.doc 31/03/07 10 OP30 OP38 18 30/04/07 11 OP36 18 31/05/07 12 OP37 37 31/03/07 13 OP19 OP38 23 31/07/07 14 OP19 13,23 31/05/07 St Anne`s Rest Home Version 5.2 Page 31 15 OP38 23 (4)(a) and when essential redecoration and refurbishment work will be completed. The registered person must complete the fire assessment for the home and ensure this is available at all times. 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The registered person should ensure a second member of staff should witness all hand written annotations on Medication Administration Record charts. The registered person should ensure all staff are provided with an annual appraisal. These are needed to ensure the homes training plans and priorities meet the needs of the whole staff team. 2 OP30 St Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Anne`s Rest Home DS0000007964.V314525.R01.S.doc Version 5.2 Page 33 - 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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