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Inspection on 19/05/05 for St Anthonys Residential Home

Also see our care home review for St Anthonys Residential Home for more information

This inspection was carried out on 19th May 2005.

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

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

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

What the care home does well

Prospective residents are given clear information about the home and are invited to visit the home before they decide whether they would like to live there. All of the residents met during the inspection expressed their satisfaction in respect of the service provided at St Anthonys. One resident said " We are very well looked after here. This is the next best thing to your own home, I think it would be difficult to find anywhere better, it`s a lovely home". Residents are invited to regular meetings to discuss the service provided at the home. One resident said "We do have group meetings if we have any suggestions". Residents were well supported by the care staff to meet their health, welfare and personal care needs and these needs are kept under review. Residents value making decisions regarding their daily lives. One resident said "It`s free and easy here, we can go to bed whatever time we like". Residents are also encouraged to participate in the writing and reviewing of their care plans. St Anthonys provides an attractive, homely, clean and safe environment for residents to live in. There is a wide variety of activities on offer for the residents to participate in should they choose. One resident said " I really enjoyed the piano and accordion player as he played all of the old tunes that I had forgotten". Meals provided at the home are nutritious and wholesome and there is always a choice of food available. One resident said " The food here is very nice and they give you something else if you don`t like what`s on the menu". The home does not use agency or temporary staff and this ensures that continuity of care is achieved. In addition staff have received training relevant to their job roles.

What has improved since the last inspection?

Staff responsible for the administration of medication had received appropriate training to ensure that residents are given their medication in a safe manner.

What the care home could do better:

A second reference had not been obtained in respect of a member of staff who had commenced employment at the home recently and this lapse in following procedures may potentially pose a risk to residents` safety. A risk assessment must be undertaken in respect of a resident who had chosen to self administer their own medication and should ensure that the medication is stored safely for the residents to use as prescribed. The complaints procedure must be amended to ensure that all residents have access to the correct information of how to complain should the need arise. A mechanical washer was not available for the hygienic cleaning of commode pots and this may pose a risk to staffs` health and safety. A number of staff worked an excessive amount of hours per week by choice and action must be taken to reduce this from happening regularly.

CARE HOMES FOR OLDER PEOPLE St Anthonys Residential Home 126 Sutton Road Erdington Birmingham B23 5TJ Lead Inspector Amanda Lyndon Unannounced 19 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Anthonys Residential Home Address 126 Sutton Road Erdington Birmingham B23 5TJ 0121 373 7900 0121 382 7911 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Tim Kelly Mrs Isabel Smith Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number of places St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Seventeen service users who are over 65 years of age and fall within the category of old age. 2. One named person under the age of 65 years of age at the time of admission can be accommodated and cared for in this home. Date of last inspection 23 November 2004 Brief Description of the Service: St Anthony’s residential home offers residential care for eighteen older people. The home is a large detached two-storey property, which has been extensively renovated, extended and decorated to a high standard and it is situated close to local amenities and public transport. The home provides a total of fifteen bedrooms consisting of twelve single and three double bedrooms, situated on both the ground and first floors. There is an attractive dining room and two lounges and a dedicated smoking area. The rooms are all suitably furnished and equipped to meet the current needs of the occupants. The décor throughout the home is suitable and homely. All bedrooms and communal rooms have access to a call system. Whilst none of the bedrooms have ensuite facilities there are ample assisted bathing and toilet facilities to meet the needs of the current residents. The home has a vertical lift to assist access to the first floor. There is limited parking at the front of the house. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by one Inspector and the Registered Manager and Deputy Manager assisted the Inspector throughout. There were eighteen residents living at the home on the day of the inspection, and one of these people had gone on holiday. Information was gathered from speaking with the residents, visitors and staff, observing the care staff perform their duties, examining care and medication records and undertaking a tour of the premises. What the service does well: Prospective residents are given clear information about the home and are invited to visit the home before they decide whether they would like to live there. All of the residents met during the inspection expressed their satisfaction in respect of the service provided at St Anthonys. One resident said “ We are very well looked after here. This is the next best thing to your own home, I think it would be difficult to find anywhere better, it’s a lovely home”. Residents are invited to regular meetings to discuss the service provided at the home. One resident said “We do have group meetings if we have any suggestions”. Residents were well supported by the care staff to meet their health, welfare and personal care needs and these needs are kept under review. Residents value making decisions regarding their daily lives. One resident said “It’s free and easy here, we can go to bed whatever time we like”. Residents are also encouraged to participate in the writing and reviewing of their care plans. St Anthonys provides an attractive, homely, clean and safe environment for residents to live in. There is a wide variety of activities on offer for the residents to participate in should they choose. One resident said “ I really enjoyed the piano and accordion player as he played all of the old tunes that I had forgotten”. Meals provided at the home are nutritious and wholesome and there is always a choice of food available. One resident said “ The food here is very nice and they give you something else if you don’t like what’s on the menu”. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 6 The home does not use agency or temporary staff and this ensures that continuity of care is achieved. In addition staff have received training relevant to their job roles. What has improved since the last inspection? What they could do better: 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 Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 The admission and assessment processes and information ensure that residents are comprehensive, enabling residents to make a choice about whether or not they may wish to live in the home. Residents know before admission that the home can meet their care needs through the assessment process. Residents are issued with a contract to ensure that they are informed of the terms and conditions of their stay at the home. EVIDENCE: The service user guide had been amended since the previous inspection and included all information required by Regulations. Each resident is issued with a statement of terms and conditions of residency and this is signed by the resident and included information about the trial and notice periods offered by the home, however this did not include detail of the room number to be occupied. Prospective residents are assessed prior to coming to live at the home using a comprehensive pre admission assessment document and are invited to spend St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 9 the day at St Anthonys and share a meal with other residents prior to living at the home with a twenty eight day trial period. The home is registered for older people, and a number of residents accommodated had additional medical care needs including diabetes, “stroke” and wound care needs. The home evidenced that they were able to meet these additional needs with the support of visiting Health Care Professionals. Residents are reassessed should their care needs change in order to ensure that the home could continue to meet their needs. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11 Residents health, welfare and personal care needs are met with the additional support of visiting Health Care Professionals and written documentation in respect of this is good. Arrangements for the management of medication is generally good with clear and comprehensive procedures being in place to ensure residents’ medication needs are met in a safe manner. Residents are supported in a respectful manner by the staff working at the home and this ensures that the residents’ dignity and self esteem are maintained. EVIDENCE: On admission to the home, assessments are undertaken of residents’ care needs and care plans are derived from these assessments and these included the residents’ personal preferences in respect of their care and daily lives. In addition residents are involved with the writing of and the monthly reviewing of the care plans. Personal risk assessments had been undertaken including the risks of falls and nutrition and moving and handling, however these did not include detail of the action to be taken should a resident fall. A detailed daily report was kept in respect of each resident and this included information about how the individual had spent their day. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 11 Residents were weighed regularly and pressure relieving equipment was obtained from the District Nursing team. The home had established a good rapport with visiting Healthcare Professionals, for example, District Nurses, Continence Advisors and Speech Therapists and there was evidence that the care staff refer to the resident’s General Practitioner as required for medical advice and to ensure that the resident’s health care needs were met. One resident said “ We are very well looked after here. This is the next best thing to your own home, I think it would be difficult to find anywhere better, it’s a lovely home”. Another resident said “ I wouldn’t have dared having a bath on my own in my own home, the staff help me have a bath here and I feel safe ”. Residents appeared to be well supported by staff to choose clothing that was appropriate for the time of year and their hair was neat and styled. In general a safe system for the management of medication was in place at the home, all designated staff responsible for the administration of medication had undertaken appropriate accredited training, and robust procedures were in place for the receiving, storage, administration and disposal of drugs. One resident had chosen to self administer their own medication and a risk assessment had not been undertaken in respect of this and not all prescription creams were dated on opening and discarded after twenty eight days. It is recommended that controlled medication guidelines are adhered to in respect of Oramorph medication. A written record of quantities of medication received into the home were maintained with the exception of antibiotics and these must be recorded to ensure that accurate medication audits are undertaken. Appropriate locks were not available on all bedroom doors, however these are being fitted as and when the bedrooms become vacant to ensure that all residents coming to live at the home have the option of whether to lock their bedroom doors. Residents’ privacy is maintained, for example, lockable storage facilities are available in all bedrooms and residents have the option of having a private telephone line in their bedrooms. Staff were interacting appropriately and respectfully with residents. Staff had not received training in respect of death and dying. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 & 15 The home provides well organised, varied social and recreational activities that meet the expectations of the residents and provide interest and pleasure. Residents are able to exercise their choice over their daily lives and the activities that they choose to participate in which promotes their independence and individuality. Meals provided at the home are well balanced, nutritious and meet any special dietary requirements and a choice of food is always available. EVIDENCE: There was a wide range of activities on offer both inside and outside of the home for the residents to participate in should they choose. One resident said “ I really enjoyed the piano and accordion player as he played all of the old tunes that I had forgotten”. A record of activities was not maintained and this must identify the residents that participated in each activity and whether the activity was a success. A hairdresser visits weekly and Holy Communion is available at the home. Residents can go outside of the home on their own if they choose, however, risk assessments in respect of this had not been undertaken. One resident said “It’s free and easy here we can go to bed whatever time we like”. Residents’ bedrooms contained personal possessions that reflected their individual tastes. There was an option of two home cooked meals available at lunchtime. A daily record of food eaten by each resident was maintained and this identified that a St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 13 well balanced diet of wholesome food was available at the home and the residents were always offered a choice. One resident said “ The food here is very nice and they give you something else if you don’t like what’s on the menu”. The dining tables were laid attractively and appropriately and staff were respectfully assisting residents with their meal as required. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The written information in respect of the complaint procedure did not include all of the relevant information and this may potentially prevent residents from reporting their concerns to the relevant people. A robust adult protection procedure was in place, however staff had not had training in respect of this which may potentially put residents at risk. EVIDENCE: There was a complaints procedure on display in the home, however this had not been amended since the previous inspection and did not include either the contact details of the Commission or that the complainant could inform the Commission of their concerns at any stage of the complaint process. A complaints log or “grumbles” book had not been implemented, however a record of small concerns from residents in respect of the building was available within the minutes of the residents’ meetings and there was evidence that these had been addressed to the satisfaction of the residents. The home had not recorded any formal complaints since the previous year. One resident said “ The Manager is very fair and always encourages us to say if we are not happy about anything”. A comprehensive adult protection procedure was available and this incorporated Birmingham Multi Agency Guidelines, however staff had not received training in respect of the protection of vulnerable adults. Criminal record bureau clearance had been obtained for all staff working at the home. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24, 25 & 26 St Anthonys provides a clean, homely and comfortable environment to live, in which residents are safe, relaxed and secure. The home does not have a hygienic system for the cleaning of used commode pots and this may pose a health and safety risk to staff. EVIDENCE: The internal environment was homely in style and floor coverings, furniture and fittings were of a high quality. The external grounds of the home were well maintained and attractive with tubs of plants and flowers. A programme of redecoration was in place on the day of the inspection and plans are in place to replace carpets and bedroom curtains in the home. There was a large television and video/music system in the larger lounge for residents’ use. The large dining room was decorated to a high standard. Hand rails were available near to all communal toilet facilities and raised toilet seats were fitted. The home had sufficient assisted bathing and toilet facilities for residents’ use. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 16 A number of bedrooms had low windows which meant that residents could look outside of the home in the comfort of their bedrooms. One resident said “ I would prefer a ground floor room and I have been informed that I can have the next one that is available. There is a lift here that I can use until I have a ground floor room”. A weekly audit of hot water outlet temperatures is undertaken and the record of this identified that the water temperatures were within safe limits. Window restrictors had been fitted to all windows in the home. The temperature within the home was comfortable on the day of the inspection and guards had been fitted to radiators. The home was found to be clean and fresh on the day of the inspection and hygienic hand washing facilities were available in the home. An effective and hygienic laundry service for residents’ clothing and bed linen was in place and clinical waste awaiting collection was stored appropriately and securely. The majority of residents living at the home chose to use commodes in their bedrooms and the used commode pots were cleaned manually by the care staff and this may pose a health & safety risk. The Registered Provider must forward an action plan to CSCI in respect of purchasing a mechanical commode pot disinfector for staff use. The Registered Manager must devise and implement an infection control procedure in respect of the manual cleansing of commode pots in the interim until specific equipment is available for staff use. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The home has an appropriate skill mix and allocated numbers of staff over the full day and night to offer good consistent standards of care to meet the assessed needs of the residents. Recruitment procedures had improved since the previous inspection, however further improvements in respect of this are still required to protect residents’ safety. EVIDENCE: Ancillary support is available to the care staff on duty on a daily basis in the form of a cook and a cleaner. A senior member of staff provides on call support to the person in charge of the shift and the person responsible for this is indicated on the staffing rota. The staffing rotas identified that a number of staff continued to work excessive hours per week at the home on a long term basis, and remedial action must be taken to reduce this. The Registered Manager stated that the home had not used temporary or agency staff. One resident said “ The staff are wonderful, I couldn’t wish for better, they are very supportive, patient and understanding”. Staff files contained the majority of information required by Regulations, with the exception of a second reference in respect of a staff member who had recently commenced employment at the home. Health declarations and evidence of entitlements to work were available if required and in addition each staff member is issued with a job description. A staff member who had recently commenced employment at the home had undertaken a basic induction, however a written record of this was not St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 18 available. Other staff had completed a comprehensive induction that was compliant with TOPSS. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 The Registered Manager has a good knowledge of working within her job role and this ensures that a good standard of service is provided at the home. The systems for resident consultation are good and there is evidence that the residents’ views sought are acted upon. Staff are trained and supervised in the majority of health and safety issues to ensure that the residents’ safety and welfare is protected and equipment used at the home is maintained as required. EVIDENCE: The Registered Manager has had much experience of working with older people and holds a NVQ Level 4 qualification in management and NVQ Assessors qualification, however has not commenced working towards the Registered Managers’ Award. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 20 Residents and staff meetings are undertaken regularly and the minutes of these were available. One resident said “We do have group meetings if we have any suggestions”. A formal system for quality assurance had recently commenced at the home and this is being undertaken by an external source. The home does not manage the finances of any residents and the majority of residents are supported in this area by their families. In addition, the home does not hold any money for residents and individuals are invoiced for hairdressing and chiropody services. The system of formal staff supervision and appraisal was up to date. Health and safety checks in respect of the gas boiler, gas appliances, passenger lift, bath hoisting equipment, fire fighting equipment and portable electrical appliances were maintained as required. Staff had received training in health and safety issues for example, first aid, fire safety, moving and handling and basic food hygiene, however training was required in health and safety. Fire drills are undertaken weekly, however, a written record of this was not kept. Risk assessments in respect of fire safety had been undertaken, however, these were due to be reviewed and updated. A resident had sustained bruising following a fall and although the resident had been reviewed by their General Practitioner and an accident record had been completed, the home had failed to inform the Commission of this. The home must inform the Commission of all accidents and incidents that affect the health, safety and welfare of residents as per Regulation 37. Audits of accidents involving residents living at the home were undertaken, however the accident book did not comply with the Data Protection Act 1998 guidelines. Bed safety rails must not be used without bed safety rail protectors to prevent the risk of entrapment injuries being sustained by the residents. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 3 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 3 3 x 3 3 x 2 St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 17 Requirement The room number to be occupied must be included in the residents statement of terms and conditions of residency (timescale of 23 April 2005 not met) Moving and handling risk assessments must include detail of the action to be taken should a resident falll Prescription creams must be dated on opening and discarded after twenty eight days. Timescale for action 19 August 2005 2. 7 13(5) 19 July 2005 20 May 2005 3. 9 13(2) 4. 9 13(2) (4)(b) The Registered Manager received this in the form of an immediate requirement A risk assessment must be 26 May undertaken for any resident who 2005 chooses to self administer their own medication. (timescale of 30 March 2005 not met) The Registered Manager received this in the form of an immediate requirement A written record of all medication 01 July received into the home must be 2005 Version 1.30 Page 23 5. 9 13(2) St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc maintained. 6. 12 16(2)(m)( n) A record of activities must be maintained and this must identify the residents that participated in each activity and whether the activity was a success. Risk assessments must be written in respect of residents that choose to go outside of the home on their own. (timescale of 23 March 2005 not met) The complaints procedure must be amended to include the contact details of the Commission and inform the complainant that they can inform the Commission of their concerns at any stage of the complaint process. The Registered Manager must arrange training for staff in respect of the protection of vulnerable adults. 01 August 2005 7. 14 13(4)(b) 15 July 2005 8. 16 22(1) 31 July 2005 9. 18 13(6) 18(1)(c )(i) 01 September 2005 10. 26 13(3) 16(2)(j) (timescale 0f 23 April 2005 not met) The Registered Provider must 31 July forward an action plan to CSCI in 2005 respect of purchasing a mechanical commode pot disinfector for staff use. The Registered Manager must devise and implement an infection control procedure in respect of the manual cleansing of commode pots in the interim until specific equipment is available for staff use. (previous immediate requirement timescale of 25 November 2004 not met) Remedial action must be taken 11. 27 18(1)(a) 2 June Page 24 St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 13(4)(c ) to reduce the number of excessive hours worked by staff per week on a long term basis. 2005 12. 29 13(6) 19 The Registered Manager received this in the form of an immediate requirement Two satisfactory written 2 June 2005 references must be obtained in respect of all staff members prior to commencing employment at the home, one being from the current or most recent employer. (previous immediate requirement timescale of 30 November 2004 not met) The Registered Manager received this in the form of an immediate requirement A written record of staff inductions must be available on staff files. Mandatory staff training in respect of health and safety must be arranged. (Previous immediate requirement timescale of 23 January 2005 not met) The Registered Manager received this in the form of an immediate requirement The fire risk assessments must 19 August be reviewed and updated. 2005 (timescale of 23 March 2005 not met) The home must inform the Commission of all accidents and incidents that affect the health, safety and welfare of residents as per Regulations. The Registered Manager received this in the form of an immediate 13. 14. 30 38 18(1)(c )(i)(2) 18(1)(c )(i) 19 July 2005 19 August 2005 15. 38 23(4)(a) 16. 38 37 19 May 2005 St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 25 requirement 17. 38 13(4)(b)(c Bed safety rails must not be ) used without bed safety rail protectors. 19 May 2005 18. 38 17 The Registered Manager received this in the form of an immediate requirement Accident records must comply 01 August with Data Protection Act 1998 2005 guidelines. 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 9 11 16 31 Good Practice Recommendations It is recommended that controlled medication guidelines are adhered to in respect of Oramorph medication. Training for staff in respect of death and dying should be arranged. A complaints log and grumbles book should be available. The Registered Manager should work towards the Registered Managers Award. St Anthonys Residential Home E54 S16780 V229593 St Anthonys 190505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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