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Inspection on 05/06/07 for St Bartholomews Court Nursing Home

Also see our care home review for St Bartholomews Court Nursing Home for more information

This inspection was carried out on 5th June 2007.

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

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

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

The home has the needs of residents at the forefront of service delivery. The home prides itself in encouraging feedback and involvement from residents, relatives and families. This is done through regular residents meetings, relatives` get togethers and on the visits to the home by visitors, families.Families and visitors are encouraged to discuss the needs of their cared for residents at any time. One family said they are encouraged to ask anything they want and discuss any worries or problems they may be experiencing. All residents spoken with said they liked living in the home and were complimentary about the staff. Care staff were described as `very good`. One visitor said they were very happy with the care their relative received. Residents were encouraged to personalise and decorate their bedrooms to reflect their lifestyle. All residents spoken with said that they were well cared for and had no complaints. The Commission for Social Care Inspection had received no complaints. St Bartholomews provides a consistent staff team, which is well supported by the management team. The atmosphere of the home is relaxed and friendly. Residents spoke positively about the food and were pleased with the choice and variety on offer. Residents said they "can eat what they want "and "if you fancy something different you just need to let the cook know and they will make it for you".

What has improved since the last inspection?

The quality of recording in care plans has improved and now includes the recording of specialist needs. Staff have developed the recording of the social history which provides additional information about residents which further assists staff to have an insight into their past lives and preferences. A number of bedrooms have been re-painted to give them a fresh and clean appearance. Residents said the home is always cleaning and decorating somewhere. Some bedrooms have had new carpets fitted to further enhance the appearance of the bedrooms.

What the care home could do better:

The home continues in its efforts to provide a good quality care service to residents that are accommodated there. Relatives, friends and visitors who took part in the inspection process were all more than happy with the care, the staff and management of the home.The medication administration needs to be improved upon to ensure that staff are signing when they give out medication and do not handle medicines when they are administered.

CARE HOMES FOR OLDER PEOPLE St Bartholomews Court Nursing Home Woodfield Road Roby Huyton Merseyside L36 4PJ Lead Inspector Mrs Kath Oldham Unannounced Inspection 5th June 2007 08:20 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 Bartholomews Court Nursing Home DS0000005469.V334745.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 Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Bartholomews Court Nursing Home Address Woodfield Road Roby Huyton Merseyside L36 4PJ 0151 480 9997 0151 480 5505 saintbarts@btconnect.com 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) St Helens & Knowsley Caring Association Mrs Elaine Marie Allison Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (47), Terminally ill (3) of places St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents to Include up to 47 (OP) and up to 3 (TI) Residents to include up to 14 (OP) for rehabilitation, 5 of which may be aged 50 - 65 The service should at all times have a suitably qualified and experienced manager who has been approved by the CSCI Date of last inspection Brief Description of the Service: St Bartholomew’s is a purpose built Nursing Home. It provides nursing care for the long-term needs of 47 elderly people. It has three bedrooms set aside for people who require palliative care during the last stages of life. St. Bartholomew’s also has an agreement with the Local Authority to admit people from hospitalwho require rehabilitation care so that they eventually may return to their own homes. The home currently has fourteen beds set aside for this purpose and has a dedicated staff team to provide support. The service is a non-profit making organisation and has registered charity status. St. Bartholomew’s is situated in a quiet residential area of Roby-with-Huyton, Merseyside. It has landscaped gardens, which are accessible to everyone. All areas of the home are adapted to meet the needs of those residents who use wheel chairs. The home has two large dining rooms and separate lounges which benefit from a loop system for those who have hearing impairments. A local shopping centre can be accessed by a short bus ride or car journey. The home has a statement of purpose and service user guide, which were reported to be given to people living at the home or their families. The fees for staying at the home were reported to be between £484 and £500 per week St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place on 5th June 2007 commencing at 8.20am. The home was not told beforehand of the visit. All key inspection standards were assessed at the visit and information was gathered by observing care practices and talking with people who live at the home, management and other members of the staff team. Time was also spent looking at a selection of records including those about the care provided to a number of people who use the service. Time was spent on the inspection speaking to residents, visitors and friends, observing staff practice and routines and in discussion with the manager. The requirement and recommendations of past inspections were also monitored to see how the home had developed. The focus of this inspection was predominantly how residents felt about living at the home and their views and opinions of life within a residential care setting. Comment cards were given to residents and posted to a selection of visitors and families. Additional comment cards were sent out to doctors and health and social care staff that visit the home to ensure anyone who wanted to comment on the service had that opportunity. Comments received from residents on the inspection, their relatives and visitors and from comment cards are included in this report. Lunch was taken with residents and a partial inspection of the premises was undertaken. Verbal feedback was given on conclusion of the site visit to the manager and deputy. What the service does well: The home has the needs of residents at the forefront of service delivery. The home prides itself in encouraging feedback and involvement from residents, relatives and families. This is done through regular residents meetings, relatives’ get togethers and on the visits to the home by visitors, families. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 6 Families and visitors are encouraged to discuss the needs of their cared for residents at any time. One family said they are encouraged to ask anything they want and discuss any worries or problems they may be experiencing. All residents spoken with said they liked living in the home and were complimentary about the staff. Care staff were described as ‘very good’. One visitor said they were very happy with the care their relative received. Residents were encouraged to personalise and decorate their bedrooms to reflect their lifestyle. All residents spoken with said that they were well cared for and had no complaints. The Commission for Social Care Inspection had received no complaints. St Bartholomews provides a consistent staff team, which is well supported by the management team. The atmosphere of the home is relaxed and friendly. Residents spoke positively about the food and were pleased with the choice and variety on offer. Residents said they “can eat what they want “and “if you fancy something different you just need to let the cook know and they will make it for you”. What has improved since the last inspection? What they could do better: The home continues in its efforts to provide a good quality care service to residents that are accommodated there. Relatives, friends and visitors who took part in the inspection process were all more than happy with the care, the staff and management of the home. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 7 The medication administration needs to be improved upon to ensure that staff are signing when they give out medication and do not handle medicines when they are administered. 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 Bartholomews Court Nursing Home DS0000005469.V334745.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 Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process ensured prospective residents needs could be met. Sufficient information is provided to help people make a choice. EVIDENCE: Residents said that although they couldn’t always recall if they had paperwork telling them about the home before they came to stay they had seen books and brochures whilst at the home. One resident said she couldn’t honestly remember as she was very poorly when she came into the home. Another resident said that her family looked round a couple of homes and choose St Bartholomew’s for her. A further resident said the doctor had recommended the home to her. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 10 The manager undertakes an assessment for all residents who are coming into the home on long-term care. Assessments for intermediate care are undertaken by the primary care trust. The manager said that she sees these residents on admission and makes a judgement about the care and support and confirms through observation and the paperwork in place that the residents needs can be met by the home. An assessment had been undertaken for each person receiving long term care before they came into the home. Some people are able to come to the home for a trial visit before making the decision to move there and this is encouraged, where possible. Staff said they get to know about the needs of new residents by reading their care plans and by talking with them and their visitors. Staff were knowledgeable about the residents they were caring for. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff work in partnership with other professionals to ensure that people’s health care needs are met. Medication practices of some staff are not completely safe. EVIDENCE: All the residents had a care plan which contained information, including risk assessments, to assist the care workers in providing individual care for the residents. The detail in the care plan was, in some cases, minimal and on other occasions was not reflective of the care needs of residents or what was being provided to them. Each resident risk assessments was associated to their health e.g. nutritional risk assessments, pressure sore risk assessments and falls risk assessments. Records showed that residents had been helped to access health care services, such as dentists, opticians and podiatrists. Several residents said that staff were quick to call in the nurse if they were not well and one visitor said she St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 12 was kept informed if there were changes to her relative’s health. Three residents were identified as suffering from pressure sores. Appropriate equipment was being used to help promote healing and one of these residents was viewed in bed, appearing comfortable and well cared for. A requirement was made following the last inspection that staff should record all pressure ulcers. Clear recordings were found within the plans therefore this requirement was met. Although the wounds had been mapped the records for these were not up to date. Information provided to CSCI on the 19 July 2007 for resident”A” confirms that the last date of photographing resident “A” wounds took place on 3 May 2007. This means that it cannot be confirmed by the records how the wound has progressed since 3 May 2007.This is reliant upon Staff confirming that healing was taking place. All residents and relatives confirmed that staff respected their dignity and privacy and were kind and patient. All felt that staff have the necessary skills to look after them well. A large number of residents bedroom doors are kept open when they are sleeping this does not promote their dignity or privacy, however, records provided to CSCI on 19 July 2007 for two residents showed that entries had been made the day after the inspection that these two residents had chosen to have their bedroom doors left open. All the people living at the home who were spoken to said that staff were polite and respectful. Comments included “Staff are very nice, very kind” and “staff are lovely”. Interaction between staff and people living at the home was professional but also friendly and relaxed. People seemed happy, content and “at home”. A relative commented, Every time we visit our relative, they are always clean, well dressed, happy and content. Staff work very hard indeed to provide the care and support they need, we are very grateful to them all”. One relative spoken to said they ‘had peace of mind’ that their relative was being cared for properly. The relative said the person was always presentable, with attention to hair, nails, clothing and bedding Although there were procedures for the administration of medication in place, these were not followed in relation to the completion of the medication administration records. The Mar for three residents were looked at and did not contain a signature to say their medication had been given to them. One member of staff was seen signing the Mar before they gave the medication to residents, the consequences of this practice could be that if residents refuse their medication the records would not be accurate. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 13 One member of staff was observed taking medication out of the blister pack, placing it into her hand then putting it into a pot before giving it to a resident This could lead to cross infection St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ daily life in cluding meals and and social activities are catered for. EVIDENCE: The residents spoken with were happy with the leisure activities provided both at the home and out in the community. Resident meetings, which took place regularly, gave the residents the opportunity to express their views and opinions. The home employ two part time designated activities organisers. A relative commented, “We are extremely thankful that there are organised activities within the daily routine for the residents. (My relative) is rarely at a loss and due to interaction with other residents in communal lounges. Individual celebrations are shared-birthdays. The staff organising the activities provide a great variety of physical, wheelchair activities, creative ideas that appeal to all interests. These include crosswords, bingo, xmas craft ideas, St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 15 physical exercises. Everyone is encouraged to achieve their fullest possible potential, providing stimulation and interest to our cared for relative.” Daily records provided little information about how each resident had spent their day or how their social care needs had been met, although a separate record was kept of group activities that had taken place, which listed events such as social evenings, video afternoons, quizzes, card games, movement to music, information about people’s interests and preferences was contained in the files One resident said there was “always something going on” at the home and she joined in with everything. The home have a key worker system but staff described this as mainly a practical role in terms of helping residents to keep their wardrobes tidy and ensuring they have enough toiletries. Routines appeared to be flexible and residents said they were able to get up and go to bed as they wished. Several residents said they went out regularly with relatives, and visitors said they were made welcome at the home. Residents said they could have a cooked breakfast if they wished. Menus were displayed on boards within the dining room stating the choice of meals for the day. Residents had brought up the idea of having menus on the tables at the residents meeting, which the manager said she was going to arrange. Staff were heard asking residents what choices they wanted. Examination of the menus showed that a nutritious and varied diet was provided by the home. All the people spoken with said that the food was good and should they not like what was on the menu they would be given an alternative. Soft diets for some residents were prepared and presented appropriately and staff helped those people who needed assistance discreetly. However on one occasion a member of staff was observed assisting a resident with the meal standing at the side of them, which is not best practice. A further resident brought up an occasion where she was supported with feeding and the carer left her and another staff member assisted her in between doing other things. This did not assist the residents’ enjoyment of the meal and is discourteous. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that complaints are dealt with appropriately and are protected from abuse or exploitation EVIDENCE: A record is maintained of complaints received from residents, their families, relatives, visitors or staff. The investigation and outcome of the complaint is clearly recorded. One resident said they were happy at the home and they have periodic meetings from time to time when their opinions and views are discussed. Another resident said the staff ask their opinions daily in conversation or if they try anything new or different there feedback is requested and acted upon. A relative in response to the question, “ Do you know how to make a complaint about the care provided by the home” responded, “Never needed to and do not anticipate ever needing to, but the office staff are always very helpful with any queries we may have”. Adult protection and whistle blowing policies were in place. Staff were aware of these procedures and their responsibility in reporting any such event. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 17 They demonstrated a good knowledge of how abuse may present and action they would be required to take should they suspect any instances of abuse. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and well maintained, bedrooms were personalised and furnishings, fittings and equipment were in a good condition. EVIDENCE: The inspector looked round the home and viewed a number of residents’ bedrooms. All were clean and were in the main furnished by residents themselves. Those seen had been personalised and residents appeared to take a pride in their bedrooms and their belongings. One resident said it had meant so much to her bringing her furniture, ornaments and personal items and she felt it had helped her settle at the home along with the support and care provided by staff. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 19 A number of bedrooms have been repainted and looked fresh and clean Residents said they were warm and comfortable and had everything they could possibly need in their rooms. There are two lounges and separate dining rooms and two quiet lounges, which residents were seen to use at different times of the day. All corridors and communal areas were nicely decorated and well maintained. The home smelt pleasant and all areas viewed were clean and tidy. Domestic routines keep the environment clean, with adequate numbers of staff to keep the home odour free. Toilets or combined toilets and bathrooms are situated close to lounges and residents’ bedrooms. Infection control procedures are in place at the care home. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff were skilled and trained to meet the needs of the residents. The residents were kept safe through procedures and staff training. EVIDENCE: Residents, relatives and staff spoken to all said that there were enough staff working at the home. Staff said that agency staff were called in when staff were sick or on holiday, although the home did not require a lot of agency cover. Examination of the staff duty rotas and observation at the time of the visit showed that numbers of staff were satisfactory to meet the needs of the people living at the home. Several staff had worked for many years in the home with the continuity of care benefiting the residents. Rotas are managed well with, additional staff on duty at peak times of the day. Staff personnel files were examined. Those seen contained all the information and documents needed to ensure that the necessary checks had been made before they started work at the home. Files also contained records of staff training. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 21 75 of staff at the home have a NVQ level 2 or above which means they have the knowledge and understanding in care which should benefit residents. All residents comments throughout the inspection were positive regarding the care, treatment and respect they received from staff. One relative said, “ They (the staff) are always cheerful and friendly”. Staff said they received regular training and updates in techniques and felt that this benefited the residents at the home. Food hygiene, mental health, adult protection, dementia and health and safety training being some of the topics staff have received training in. Staff said they felt supported in their roles by the manager and worked well as a team. A relative said, “The staff have a firm, but friendly, kind and helpful manner”. In addition a relative said, “ Staff are always friendly and helpful towards all the residents. Our cared for resident has a degree of independence, which she is able to use within the home, as well as ask for help or support in other situations”. Staff meetings are arranged and provide staff with an opportunity to influence and be included in the development of the home. Notes are kept of the meetings. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home are generally effective, promoting an environment in which residents and staff may air their views and influence the care provided EVIDENCE: The manager has nursing qualifications and keeps up to date with techniques and development of care through the attendance to additional training and through research. A representative from the company should, in line with regulations visit the home once a month and undertake specific tasks to check that the home is being managed appropriately. The reports of these visits have not been St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 23 completed monthly. These need to be done and a copy kept at the home available for examination by the Commission. Formal staff supervision and annual appraisal took place on a regular basis and was recorded. Staff were observed to be working using safe working practices and staff said they had enough equipment, such as hoists and resources such as gloves, aprons, wipes, etc., to undertake their jobs safely. Weekly checks had been made of the building and equipment in respect of fire prevention and health and safety. Records showed that fire drills had been held regularly. This training assists in the knowledge of staff and informs them of what they should do in an emergency situation. During the inspection no obvious risks to the health and safety of the residents were observed. A fire risk assessment has been undertaken which had been passed to the fire authority to make sure it is what is required. Accident reports are completed for all accidents, incidents and occurrences, which are maintained on file. An analysis of these events should be undertaken in an attempt to safeguard residents and minimise the risk of injury or harm. Risk assessments are recorded and staff discuss and advice residents about what they may do to minimise the risk when carrying out particular tasks. Maintenance checks are undertaken and contractors contacted to ensure equipment is working correctly. St Bartholomews Court Nursing Home DS0000005469.V334745.R01.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement Medication must be signed for on administration to the people living at the home and regular checks to the medication administration records are made to identify any omissions and the reasons for these. Timescale for action 05/06/07 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 2 3 4 5 Refer to Standard OP7 OP7 OP8 OP9 OP9 Good Practice Recommendations The care plans need to contain sufficient detail to fully inform staff about residents needs and abilities. Consideration needs to be given to the training of staff in the understanding the role of a key worker. Wound mapping tools and photographic evidence should be kept up to date to evidence healing or deterioration of wounds. Staff should not handle medication to reduce the risk of cross infection. Staff with responsibility for medication administration DS0000005469.V334745.R01.S.doc Version 5.2 Page 26 St Bartholomews Court Nursing Home 6 OP31 should be assessed regularly to ensure they are following the correct procedures. The formal unannounced visit by a representative of the company needs to be undertaken monthly, and a monthly report produced. An analysis of accidents that occur could be undertaken to safeguard, and minimise the risk of injury or harm to residents. 7 OP38 St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Bartholomews Court Nursing Home DS0000005469.V334745.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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