CARE HOMES FOR OLDER PEOPLE
St Anne`s Rest Home Grange Lane Burghwallis Doncaster DN6 9JL Lead Inspector
Marina Warwicker Key Unannounced Inspection 5th August 2008 09:30 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.V367893.R02.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.V367893.R02.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 700 319 01302 708 752 NONE www.stannesresthome.org.uk Hallam Diocesan Caring Service None in post 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.V367893.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th February 2008 Brief Description of the Service: St Ann’s Rest Home is situated in the village of Burghwallis to the north of Doncaster. The home is a grade 2 listed building with parts dating back to the 11th century. Many original and interesting features remain throughout the building. Bedrooms vary in size and shape and accommodation is provided on a number of levels. There is a passenger lift and a chair lift to the different levels. The home is set in large 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. However, a Mass is said daily and the residents have the option of attending. The home is registered to accommodate 30 residents needing personal care and support. Information about the home can be found in the statement of purpose and the service user guide. These documents are available from the manager. The manager said that the weekly charge was £416.00 and that there were no additional charges other than those for hairdressing, private chiropody treatment, toiletries, newspapers and magazines. St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An inspection of this residential home was carried out on Tuesday 5th August 2008. We visited the home between 10 am and 6 pm. Eleven people who use the service were consulted on the day. We also spoke with all the staff who were on duty. We spoke to people using the service and the staff to get an insight into the quality of life and the standard of care and dignity given to the people. We also looked at the quality of food and activities provided at the home for people. The premise was inspected, which included bedrooms of people using the service, the communal areas and the service areas such as the kitchen and the laundry. The private areas were accessed with the permission of the people and/or the staff at the home so that we respected the people’s wishes. Samples of records such as the care plans, staff recruitment and training files were checked. We would like to thank the people who live at St Annes, the staff and the temporary manager for their contribution towards this process. What the service does well: What has improved since the last inspection?
A temporary manager has been appointed from an agency to be in charge of the day-to-day running of the home. However, this person is employed to work only two to three days a week. Therefore it has been impossible for the temporary manager to offer continuity, support and leadership to make lasting progress.
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 6 The care staff said that they had received training in the use of the revised care plan format by the temporary manager. They were pleased to receive help to improve their documentation which some felt was overdue. The present needs of the individuals are reflected in their care plans so that the staff are able to deliver the correct health, personal and social care. The care plans have been reviewed and most people have been involved in the decisions. The three care plans we checked had documentation of identified needs of the persons together with specific details about what care is to be provided by staff. The decisions about the care had been based on the risk assessments completed by the staff. The temporary manager has ensured that all staff have received supervision. This is to be ongoing and to be completed at least every two months. The staff responded positively to having 1:1 time to discuss issues with the temporary manager. The deputy manager had organised a fire risk assessment of the whole building and the management are working through the action plan. However, progress has been slow. The staff are confident to access the appropriate primary health care teams to receive advice and support. Records of people’s interests, preferences and the activities each person had taken part in have been maintained. Documentary evidence of staff attending training in dealing with allegations of abuse or neglect was available for checking. Following the last inspection the management had provided a hoist for moving & handling of people. Most parts of the home were clean and free from offensive odours. The staff complement on duty had improved so that the people are able to receive appropriate care. The temporary manager had reviewed the recruitment procedure and has updated the documentation according to current employment law. What they could do better:
The management must make available an up to date service user guide for the people using the service and those who wish to move into the home. So that based on the information people will be able to make their decision about the provision of service at St Annes.
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 7 No one must be admitted to the home without confirmation that the home is suitable to meet the identified needs of the individual. Following admission the management must carry out regular reviews so that changes in the individuals behaviour could be identified and appropriate care settings could be found. The care staff must follow care plans and take every opportunity to promote the health and wellbeing of the older person. The people must be encouraged to sit out of bed as part of the daily routine by using appropriate aids. The management must ensure person centred care is delivered at the home. The management must produce an up to date programme for the maintenance, essential redecoration, renovation and refurbishment work to be completed to ensure that the home is safe and comfortable for the people who live there. Previous timescales: 31/05/07,12/04/08. A programme was submitted to the Commission for Social Care Inspection on 11/04/08 by the management. However, very little progress has been made since then. The communal areas must be accessible to people and the furnishings of communal rooms must be domestic in character and of good quality. The carpets in some of the bedrooms the bedrooms and parts of the corridors, which smelt of stale urine, must be replaced. The carpet in one of the bedrooms, which caused a tripping hazard, must be attended to without delay. The dining room must have call buzzers and emergency lighting so that the people are able to safely use the facilities. The management must ensure that the staff use the appropriate facilities to control the spread of infection. The sluicing facilities must be reinstated. Staff must be issued with a contract or Terms and conditions of their employment so that their employment is legally binding and they have rights. This has been an ongoing requirement. Timescale was 25/03/08, 11/04/08. No progress had been made on the day of the visit. The lack of a full time manager is hindering progress, continuity of leadership, monitoring of care and support for the staff. Therefore the home is in need of a competent manager to carry out the day-to-day running and be accountable for 24 hours and 7 days a week. The requirements made following the fire risk assessment in May 2008 by the fire safety authorities must be completed without delay. The management have taken interim measures to ensure that the people are safe and not at risk of tripping or falling over when accessing all parts of the communal and private areas. These arrangements need to be reviewed.
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 8 The lack of progress in some areas by the Diocese of Hallam management team to comply with the ongoing requirements will result in the Commission for Social Care Inspection taking enforcement action to improve the health, safety and wellbeing of the people living and working at St Annes. We therefore urge you to take appropriate actions without delay. 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 Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 9 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.V367893.R02.S.doc Version 5.2 Page 10 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): 1,3&5 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The people who wish to use the service have access to a copy of the service user guide, which is in need of update. Therefore people are unable to make an informed decision about the suitability of St Annes. New admissions are accepted only on the basis of an independent assessment by the placing authority. The care manager and the staff from the home come to an agreement that the identified care needs will be met for the person moving into St Annes. EVIDENCE: Three people’s individual files were checked. The staff on duty were consulted and people living at the home were spoken with. It was evident that the people have had needs assessments completed by the social service care managers. The senior staff from the home had also carried out assessments before people
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 11 moved into the home. The three files checked had copies of needs assessments by the placing authorities. However, we identified a person who had moved in recently whose identified needs require further monitoring. The temporary manager was made aware of this on the day of the Key Inspection. The service user guide is old and does not reflect the present arrangements. It needs to have the following information so that the people are kept up to date. • The description of the services provided, • Specification of the individual accommodation, • The facilities available to them including any special needs or interests catered for, • The views of the people who live at the home, • The management structure with names, • The name of the registered manager, • The relevant qualifications and skills of the workforce St Anne`s Rest Home DS0000007964.V367893.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Some people are involved in decisions about their lives and the staff show respect and treat them with dignity so that the people using the service feel secure and happy at the home. The health and personal care and support the people receive on the whole reflect their specific needs. EVIDENCE: Three care plans were checked and three care staff and five people using the service were consulted to check this outcome area. We also observed the delivery of care and spent time with the people using the service chatting to them. The health, personal and social care needs were set out in the individual plans of care. There were risk assessments with appropriate interventions either to minimise the risk or to deal with it. The care plans had been reviewed and there was evidence to indicate that relatives were informed of any changes to the care if there was a need.
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 13 On the day of the site visit a person was left with a plastic apron on in the lounge after breakfast. It was removed when we informed the staff. During mealtimes those people who had difficulty handling a serviette were given a white or a blue plastic apron to wear. The staff used these aprons when delivering personal care or when serving food to the people. This practice is unsatisfactory, as these aprons were not fit for the purpose. The people should be offered a different form of protection. Some people had food stained sticky hands when they left the dining room after meals. This is due to staff not offering them wipes. This was discussed with the care staff on the day of the visit. It was noted that some staff were very attentive and helped those who needed extra support. During the tour of the premise we noted a person in bed at around midday. On further inquiry the staff said that the person was reluctant to sit out and did not like being hoisted. Therefore she was nursed in bed all day. The staff accepted that sitting out helps the person with changing of position and pressure area care. It was evident that the care staff were not being supervised. This is one of the examples where the lack of a full time manager is having an adverse effect on the people using the service. The people’s health care needs were looked after with the help of the community nurse and the general practitioner. The staff said that they contacted the district nurse if they needed help. The care staff who had completed medication training were allowed to administer and manage people’s medicines. The medicine administration records of three people were checked and they were satisfactory. The staff had recorded the reason why each medication had been prescribed and some of the common side effects. This is good practice and the staff were commended for this. The staff said that there had not been any training or support from the supplying pharmacist and wished the management would facilitate this. The last pharmacy audit was completed during June 2007. This finding was passed on to the temporary manager. The people using the service said that they received their medication from the staff and that they were happy with this arrangement. St Anne`s Rest Home DS0000007964.V367893.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The people who use services are able to make choices about their life style, and be supported by the care staff to maintain their independence. Social, cultural and recreational activities meet individual’s expectations. EVIDENCE: Seven people using the service and four staff were consulted and records were checked. The people said that they were given opportunities by the staff to exercise choice in relation to what time they woke up, when they ate their meals and what they wanted to do all day. One person said, “I like when X is on duty since she knows what I like and there is a special bond between us. The others are good too.” Another two people said, “I like going out. The other day staff took us out on a mystery tour and we loved it. They should do more of this.” “We have entertainment in the home and we thoroughly enjoy the activities.” There was a request for more outings and for the inclusion of the people using wheelchairs. The staff said that the minibus, which belonged to St Annes, did not have facilities for wheelchairs. On the day of our visit three people told us that they were looking forward to the afternoon when they were expecting an activity organiser. However this
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 15 person did not turn up and the staff did not know why this had happened and carried on with their jobs. There was no one to find out why the activities entertainer had not arrived. The people using the service enjoyed mealtimes. They were offered a choice of meals and if anyone wanted to have both they were able to do so. On the day of our site visit the deputy manager was standing in for the cook. She is an experienced cook and I had lunch at the home. The food served was appealing and tasty. I observed the people asking for extra helpings and enjoying the meal. Discreet assistance was offered by the staff to those who needed encouragement and coaxing to eat. Four people commented on how much they enjoyed the meals and that they could have a hot drink anytime if they asked the staff. St Anne`s Rest Home DS0000007964.V367893.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17&18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service are able to express their concerns and have access to a complaints procedure. The people are protected from abuse, and have their rights protected by the staff who are trained and competent. EVIDENCE: The people using the service said that they spoke with the staff if they were not happy or if they had any concerns. They also assured us that the staff were very caring and respectful and therefore if there were to be any complaints it is usually due to misunderstanding and this would be sorted out between them. One person said, “I have nothing to complain about. Staff are very kind and caring.” The staff kept a record of any formal complaints. The deputy manager had handled formal complaints and kept records of the action taken. Two people said that they were able to go out and visit their friends and the staff helped them with organising the transport. The same two people said that they were able to cast their votes during general and local elections with the help of care staff. The staff we spoke with had attended safeguarding adults training and were confident about what they should do if they were to witness any incidents.
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 17 The people using the service said that they were well looked after by the staff and that they were in no doubt that the staff would protect them and take proper action if any unusual incidents happened at the home to any one of them. St Anne`s Rest Home DS0000007964.V367893.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,25&26 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the building makes it difficult for the people who use the service to live in a safe and comfortable environment. The lack of maintenance, refurbishment, replacement of furniture and fittings contribute to the tired, less attractive looking interior and difficulty in accessing parts of the home. EVIDENCE: A tour of the premise was carried out which included the bedrooms and the communal areas of the home. Permission was gained before entering peoples’ bedrooms. The following were some of our findings on the day. • Generally the home looked clean. • There was no buzzer system in the dining room for the staff or the people to summon help.
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 19 • • • • • • • • • • • • • There was a lack of emergency lighting in the dining area. The uneven flooring between the two dining areas was hazardous. It needed attention to avoid slips and falls. Three bedrooms smelt of stale urine. Several carpets needed replacing. One of the bedroom carpets was uneven putting the person at risk of tripping over. The bedrooms, which were not in use, were used as storerooms. Some rooms were filled with clutter (i.e. unwanted items of furniture and fittings) making these areas a fire risk. There was a lack of designated storage facilities. The handy person was seen carrying out the day-to-day maintenance. However, the programme of routine maintenance, renewal of fabric, update of the premise and decoration of the building was not available at the home. Therefore no records were available for inspection. The temporary manager explained that this was being managed by one of the members of the Hallam Diocesan management team. To maintain transparency and to keep the staff involved in the progress the management needed to make such information available to at least the senior staff members of the home. The fire safety inspection had taken place and there were records of the work carried out so far in order to comply. Progress has been slow. The interim measure taken to avoid people tripping over steps is not proving effective. Since the signs were coming detached and in some instance people are put at risk of tripping. This was discussed with the staff on the day of the visit. One of the bedrooms where the person was nursed in bed did not have disposable hand towels for the staff to dry their hands before leaving the room. There were implications for the control of infection since staff were using the same hand towel belonging to the person to dry their hands each time. In this room the waste bin did not have any bin liner to contain the waste. This is yet another example of the lack of staff supervision. The sluicing room had a machine, which had not been used for sometime, and the staff said that they had requested for it to be repaired. The management had taken no action so far. Not all bedrooms had en-suite. For convenience people were using commodes especially at night time therefore the home needed to have sluicing facilities as part of promoting hygiene and infection control. St Anne`s Rest Home DS0000007964.V367893.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The staff working at the home on the whole are trained, skilled and in sufficient numbers to support the people who use the service thereby support the smooth running of the service. EVIDENCE: Four staff were interviewed and three staff recruitment files were checked with the help of the temporary manager. The files were in good order and contained the necessary information with regards to recruitment of staff. There was a lack of staff contracts in the staff files. Further comments have been made later on in this report. During the interview the care staff said that had either achieved NVQ level 2 in care or had enrolled to work towards it. The domestic staff were too taking on NVQ training. The staff said that they appreciated the input from the temporary manager but they were anxious that this arrangement was only a stopgap and wanted to know the long term plans for the home management. The staff said that there was a lack of communication from the Hallam Diocese management.
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 21 On the day of our inspection the staff complement was adequate but there was no manager around to give them support and guidance. The temporary manager had been invited to work very part time therefore there was a lack of supervision and leadership. Some of the findings highlight the lack of leadership and supervision of staff. The staff training records evidenced that all staff had attended the mandatory trainings. These are moving & handling, health & safety, infection control, fire safety, first aid and safeguarding adults. St Anne`s Rest Home DS0000007964.V367893.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The management of St Annes is reliant upon the calibre of staff working at the home. The lack of a registered manager is unsettling for staff and the people using the service. The temporary manager is employed on a very part time basis and therefore the day-to-day leadership and running of the service is left to the staff at the home, which is unsatisfactory. EVIDENCE: The manager’s position became vacant in May this year and the Hallam Diocese management team appointed a temporary manager from an agency. She is employed to work two to three days a week. She has helped the staff improve record keeping and has organised training and supervision. Systems have also been introduced to monitor the quality of service. These were in the
St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 23 form of staff self-monitoring and analysing the feedback from the meetings with residents, relatives and staff. The staff said that they have had supervisions and appraisals. There were records of these for inspection. The following comments were received from some of the staff and the people using the service. “It was overdue for a reality check. We were left to run this place without any support. At least now Y has come in to give us some guidance.” “I don’t know who the manager is. I am satisfied with the care staff. The manager is for them, not for me I hope!” “We needed someone from outside to look at our paperwork and give us feedback. Y has done that and she has also given us basic training on record keeping. We needed someone like Y to be our permanent manager.” “How long is this support going to last? Once your report comes out we will be forgotten again.” The people using the service said that the staff were a good team and they did not receive the support from ‘above’. They said that the home could do with refurbishing and bringing up to the 21st century. They also made comments about the use of ‘yellow & black’ tapes to warn people of danger. One person said it felt like the bus station not someone’s home. The temporary manager had convened staff, residents and relatives meetings to update them. Copies of the minutes of the meetings were available to us. The staff commented that they had not yet received payment for the overtime they worked to cover for the lack of staff last December (2007). Although one of the members of the management team assured us after our last Key Inspection that this would be rectified, it is still outstanding. They said that such action confirmed the lack of care by the management for the staff working at the home. They also said that they had not received any Terms and conditions of employment from the management and had not had any contact with the members of the Hallam Diocese management team to let them know what was happening to the home. The staff would welcome a meeting with the management as part of their forthcoming staff meeting. St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 x 3 x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 x 3 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 2 x x x 4 x 2 St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 25 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 OP5 Regulation 14 Requirement No one must be admitted to the home without confirmation that the home was suitable to meet the identified needs of the individual. However, if the individual’s needs change then reviews must take place and appropriate placement must be sought. The care staff must follow care plans and take every opportunity to promote the health and wellbeing of the older person. The people must be encouraged to sit out of bed as part of the daily routine by using appropriate aids. The responsible individual must produce an up to date programme for the maintenance, essential redecoration, renovation and refurbishment work to be completed to ensure that the home is safe and comfortable for the people who live there. Previous timescales: 31/05/07,12/04/08 A programme was submitted to the Commission for Social Care
DS0000007964.V367893.R02.S.doc Timescale for action 22/09/08 2. OP8 13,14 22/09/08 3. OP19 13,23 22/09/08 St Anne`s Rest Home Version 5.2 Page 26 4. OP20 23 5. OP24 13,23 6. OP25 13,16 7. OP26 12,13 8. OP31 8, 12 9. OP38 23 Inspection on 11/04/08 by the management. However, very little progress has been made since then. The communal areas must be accessible to people and the furnishings of communal rooms must be domestic in character and of good quality. The carpets in the bedrooms, which smelt of stale urine, must be replaced. The carpet, which was uneven, must be attended to. The dining room must have call buzzers and emergency lighting so that the people are able to safely use the facilities. The management must ensure that the staff use the appropriate facilities to control the spread of infection. Bedrooms must have hand washing and drying facilities. The sluicing facilities must be reinstated. The lack of a full time manager has highlighted lack of staff supervision and gaps in the service delivery. Therefore the management must ensure that a full time manager is appointed in charge of the day-to-day running of the home. The requirements made following the fire risk assessment by the fire safety authorities must be completed. 09/12/08 29/09/08 29/09/08 22/09/08 29/09/08 22/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 27 No. Refer to Standard Good Practice Recommendations St Anne`s Rest Home DS0000007964.V367893.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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
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