Inspection on 13/12/07 for St Benet`s Court

This inspection was carried out on 13th December 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.

Other inspections for this house

St Benet`s Court 09/03/09

St Benet`s Court 01/03/07

St Benet`s Court 28/06/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Benet`s Court 32 College Road Newton Abbot Devon TQ12 1EQ Lead Inspector Andy Towse Unannounced Inspection 01:32 12 and 13 . December 2007 th th 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 Benet`s Court DS0000067041.V353676.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 Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Benet`s Court Address 32 College Road Newton Abbot Devon TQ12 1EQ 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) 01626 354069 01626 354069 NB - RIs home address is logged under former addresses Mrs Nicola Jayne Rogers Mr Guy Perring Rogers, Ms Michelle Ann Stepney ** Post Vacant *** Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability over 65 years of age of places (40) St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate 40 service users in the category of Physical Disability, over the age of 65 years The home can accommodate 40 service users in the category of Old Age 1st March 2007 Date of last inspection Brief Description of the Service: St Benets, is a large Victorian house situated on the southern slopes of Wolborough Hill Newton Abbot. It overlooks the attractive Decoy Woodland and nature reserve. The home is within a short drive from the town centre and local amenities including British Rail mainline station and direct access to the A38. St Benets offers en-suite facilities in the majority of the single and shared rooms. Residents are assisted moving around the home by the two passenger lifts, one stair lift, grab rails and ramps which offer freedom of movement for disabled Service Users. A nurse call system covers all rooms and the gardens. There are well maintained terraced gardens with secluded seating areas and a waterfall accessible to service users. The garden has views over the Devon countryside. The home caters for physically disabled Service Users and has a registered nurse on duty at all times, a range of equipment is available to help meet Service Users needs. Copies of previous inspection reports are available at the home to visitors and those who reside there. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that the people who use this service experience an adequate quality service. This was an unannounced inspection. It took place over a period of two days. Prior to the inspection surveys were forwarded to members of staff and those who use the service and also social services and healthcare professionals involved with the home. The inspection comprised a tour of the premises and examination of records kept at the home, including care plans. There was also discussion with visiting relatives, staff and those who live at the home as well as senior staff, two of the providers and others belonging to the staff group. What the service does well: The home operates an admissions procedure which includes encouraging prospective residents or their relatives to visit the home in order that they can make an informed choice about living there. The home stands in well maintained pleasant gardens, complete with water feature, which are accessible to those who live in the home. The home has a good system to safeguard any money held on behalf of those who live in the home. There is an ongoing system of quality assurance which will enable the provider to develop the service by taking into consideration the perceptions of those who live there. Records show that the home is maintained in a way which protects the health, safety and wellbeing of those who live and work there. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home needs to ensure that care plans are up to date and that information and advice from healthcare professionals and relevant others is transferred to the care plans so that it can guide care staff in offering the appropriate care to those living at the home. The home needs to ensure that its recruitment procedure is robust and protects those who live in the home. If staff are to commence work prior to receipt of police checks they should at least have a check carried out which confirms that they have not been placed on the Protection of Vulnerable Adults (POVA) register. All staff records should contain the necessary documents, for example two references, as required by the Care Standards Regulations. Whilst staff have signed contracts relating to supervision, there is no evidence that staff receive supervision. It would benefit staff if they received regular formal supervision. The home is currently run by a staff member who works in the capacity of a matron. She is however not registered. In order to comply with requirements of the Care Standards Act it is necessary that the provider put forward someone who can be registered to run the nursing home. Please contact the provider for advice of actions taken in response to this St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 7 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 Benet`s Court DS0000067041.V353676.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 Benet`s Court DS0000067041.V353676.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, 5 and 6 Quality in this outcome area is good. The home operates an admissions procedure which ensures that people are only admitted following assessment and that they are free to visit the home and look around as part of the process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of three people who live at the home were case tracked. Their files showed that on a prospective resident’s first contact with the home, his/her details are recorded on a ‘Room Enquiry Form.’ This comprised a short resume of the person’s needs. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 10 One record which was being case tracked showed that the matron of the home visited the person who was in hospital and completed a ‘Pre-Assessment Form’. This form contained information about why the person needed nursing care and what their needs were relating to mobility, feeding, diet and personal hygiene. This form had been signed by both the matron and a relative of the prospective resident who had assisted in its compilation. Another file contained a ‘Pre-Assessment Form’ which had been completed a day prior to admission by one of the providers in the absence of the matron. A further file contained a ‘Room Enquiry Form’ compiled by the matron and an assessment carried out by the matron three days prior to the person’s admission to the home. Files were also seen to contain further information, such as care plans drawn up by Social Services Departments, and assessments carried out by healthcare professionals such as speech therapists, which gave the senior staff further information upon which to decide whether the home could meet the needs of prospective residents. The provider said that two of the relatives of the people whose files had been examined had visited the home as part of the admissions process. The relative of the third confirmed that he/she had visited the home. Other relatives spoken to during the inspection said that they had also visited the home to see if it met the needs of the person thinking about moving in there. Copies of the home’s Statement of Purpose and Service User guide were displayed in the entrance hall of the home, making them available to anyone visiting the home. The home does not offer intermediate care. St Benet`s Court DS0000067041.V353676.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 and 10 Quality in this outcome area is adequate. Whilst all those living at the home have care plans there is a lack of consistency in transferring information supplied by healthcare professionals and relatives onto the care plans. Reviews of care plans do not always take into account changes in the needs of the people to whom they refer. Whilst most staff were able to give good accounts of how to ensure a persons privacy and dignity was respected, this is an area where improvements could be made. Those living at the home are protected by the home’s medication procedures. This judgement has been made using available evidence including a visit to this service. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 12 EVIDENCE: The files of three people who live at the home were case tracked. All files contained care plans. These contained various assessments, such as the ‘Waterlow’ assessment for pressure sores. All files contained a risk assessment for the room the person was occupying and also regarding aspects of their daily lives, such as the use of cot sides. There were also assessments carried out by professionals such as Speech and Language Therapists. There was an inconsistency in transferring recommendations made in assessments into care plans. In one instance the ‘Waterlow’ assessment was neither signed nor dated. In another the recommendations made in a Speech and Language Therapy assessment that a person should have, ‘normal fluid with support—no spouts or straws please’ had not been included in the care plan, nor was it carried out in practice. A relative’s comments that a person should not be given fresh fruit for health reasons had also not been included in the care plan. The issue of care plans and risk assessments not being updated was also referred to in survey responses from some professionals involved with the home. Other records inspected showed that information regarding nutritional screening and care of pressure sores had been incorporated into the care plans and daily records showed that appropriate action was being taken in accordance with what was contained in the care plans. All files contained forms relating to whether relatives wanted either locks fitted to bedroom doors or involvement in care plan reviews. This gave people the opportunity to participate in developing their care plans. The home has care plans, separate booklets in bedrooms and also different books where other issues are recorded. This makes it very difficult to ascertain, with any level of ease, what care is being provided. The matron informed said that she is currently discussing with healthcare professionals the possible implementation of a new care plan format. Prior to the inspection there was a recent investigation regarding care practices within the home. In this instance, although entries on a care plan recorded that it had been reviewed, these consecutive entries confirming that there had been no change in the person’s needs when in fact the daily records were St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 13 confirming quite important deterioration in the person’s well being. These should have been mentioned in the review notes and the care plan should have been amended to reflect both the changes in the person’s needs. The home operates to a corporate medication policy used by other homes within the Court Group. Medication was observed being dispensed. All medication dispensed on the day of the inspection was seen to be recorded appropriately. In instances where people refused their medication, records reflected this. Medication is kept securely in a locked cabinet which is secured to a wall. Controlled drugs are kept appropriately. Their administration is recorded. Entries are double signed and an error in recording stock was seen to have been noticed corrected. Where creams are used, a record is kept of when the tube is opened and all seen were within their expiry date. There is a separate fridge in which medication which needs a cool environment is kept. Records are kept of the fridge’s temperature. There is a record kept of medication which is disposed of. This is signed by the pharmacist. During the inspection several relatives and friends of those living at the home were seen to be visiting. In conversation all said that they were able to visit at any time and that the home made them welcome. Those spoken to said that they were spoken to with respect. Staff were seen usually to knock on bedroom doors before entering and in the instance when this was seen not to have occurred the staff member concerned did apologise immediately. During the inspection a person was having his/her bloods taken. This occurred in the lounge of the home. Although other residents were having a meal in the other room, the door was left open and this did not seem to be respecting the privacy of this person. In discussion most staff gave good examples of how they ensured that the privacy and dignity of those in the home, was respected. These examples included ensuring that screens were used in double bedrooms, people being dressed according to their wishes, the right to ask for what they wanted and if they were unable to do so, their family being consulted, choice of what day they took a bath and the right, if possible, to choose the gender of the staff who would assist them especially in relation to personal care. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 14 Whilst most of the rooms have an ensuite facility, there are other wcs and bathrooms around the premises. One wc was seen not to have a lockable door and neither had two bathrooms. In order that those living at the home are given privacy and dignity all bathrooms and toilet doors should be lockable. The home has several shared rooms. In instances where rooms are shared, the home has several mobile screens which can be used to ensure the privacy of those occupying these rooms. In discussion staff confirmed using these in order to protect the privacy and dignity of those who live at the home. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Those living at the home have access to various activities, can have visitors when they wish and generally have meals which they enjoy and which take into account their individual likes and dislikes. Visitors are welcome to visit the home at any time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Benet’s Nursing Home is adjacent Wolborough Court and this allows the people who live at St Benet’s the opportunity to join in activities arranged for people who live at Wolborough Court. At the inspection of Wolborough Court people from St Benet’s were seen there watching a performance by a theatre group. Inspection of activities available over the Christmas period showed community involvement with various local choirs visiting the home as well as St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 16 Christmas based activities, such as card writing and assisting in decorating he home. Some of the activities arranged over the Christmas period had been arranged following in Residents’ Meeting in October 2007 when people had been asked what activities they would like to be involved in over Christmas. Usually people who live at St Benet’s have in-house activities arranged such as quizzes, and games which include large floor dominoes, bingo and a croquet style game. Throughout the duration of the inspection visitors were seen coming and going. People who live at the home confirmed that they could have visitors whenever they wanted and the visitors themselves said that they were welcome to visit at any time. The home intends to involve the relatives more in the future, with invites to attend forthcoming Residents’ Meetings. Currently relatives are invited to attend functions at the home. In response to the survey forwarded to people who live in the home prior to the inspection, most responded that they ‘usually’ like the food available in the home. We spoke with the chef who showed us the rotating four week menu offered by the home. The chef was able to show separate meals in the freezer which he could offer as an alternative to the main menu if requested. There was also a list, in the kitchen, of different people’s likes and dislikes. Meal times were observed to be relaxed, with staff offering support to those requiring it. A staff member was observed sat with a resident, talking with her, and encouraging and assisting her to eat at a pace suitable to her needs. The dining area is small, however, it is sufficient as several people prefer to dine in their rooms. Apparently under previous ownership an even smaller room was used as the dining room, and the current owners moved the dining room to its present location to make a larger and more pleasant dining area for those living in the home. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate . People living at the home were aware of who to complain to and were confident in the management of the home to deal with complaints. Whilst the home ensures that staff receive training relating to the Protection of Vulnerable Adults, discussion with staff did not confirm that they had the knowledge to adequately protect people should abuse occur. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Benets has a written complaints procedure. Copies of the procedure are available within the home ensuring that both visitors and those living at the home are aware of its existence. Responses from those who live in the home, contained in the surveys confirmed that generally they knew how to make a complaint. In discussion during the inspection, people said that they would talk to the matron if they St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 18 were not happy at the home. One commented that the matron was ‘easy to talk to’. Since the last inspection the Commission for Social Care Inspection has been involved in a complaint investigation. This highlighted issues regarding poor care planning procedures and is still ongoing. Records showed that staff receive training regarding the Protection of Vulnerable Adults. We spoke with five members of staff about what constituted abuse and what action they would take if they suspected that it was happening. Three of the staff gave competent responses, however, with regard to the remaining two staff, one was unable to give examples of what constituted abuse, although did say upon further questioning that they had had training relating to the Protection of Vulnerable Adults and another was unsure about what action to take if they suspected abuse was occurring. Inspection of staff records also showed that the home’s recruitment procedure was not always as robust as it should have been and could therefore potentially put those living in the home at risk from abuse. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Those who live in St Benet’s benefit from the ongoing refurbishment in a home which has a good standard of hygiene and cleanliness and meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the inspection a tour of the premises was carried out. St Benets is situated in a residential area of Newton Abbot. It is a detached, older type property situated in grounds shared by another home owned by the same proprietors. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 20 There is evidence of ongoing refurbishment, which includes furniture replacement and redecoration as referred to in the home’s annual quality assurance assessment (AQAA). Examples of this were new carpets in both the main and small lounges and both rooms having been redecorated. Whilst some rooms did not have lockable furniture, those bedrooms which had been refurbished were seen to have had lockable furniture installed, and gradually as all rooms are refurbished, all would have this facility. Whilst most rooms have an ensuite facility, which afford those living there the privacy of use of their own toilet, it was seen that not all bathrooms and wcs in the home were lockable. The carpet in the main hallway and stairs was seen to be showing signs of wear and we were told by the providers that these were scheduled for replacement. The kitchen is also scheduled for refurbishment during 2008. Whilst most bedrooms have covered radiators some do not. This was discussed with the provider who said in instances where radiator covers were not provided, furniture was put in front of them to safeguard the occupants of the room. Furnishings, pictures and ornaments in bedrooms showed that those who occupied them had personalised them in a manner of their choosing. All bedrooms had call systems which were made accessible to the rooms’ occupants. All areas of the home are accessible to those who live there, through either the use of the two passenger lifts or by use of the stairs. There is currently a chair lift on the main staircase. We were informed that those living at St Benets were safeguarded by thermostatic mixer valves having been put on all baths and wash hand basins within the home. The laundry area comprises two sections. One within the main building where ironing and sorting of clothes takes place, the other, in structures external to the main building where washing and drying machines were situated on an impermeable floor in rooms with easily washable walls. There was a good standard of hygiene and cleanliness throughout the home. This was commented upon favourably in the surveys returned by those who live at St Benet’s. Externally the home has pleasant and well maintained garden areas, complete with water feature and good views of the surrounding countryside. The gardens are easily accessible by those who live in the home. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 21 St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Those who live at the home benefit from having levels of staffing which meet their needs. Staff benefit from an induction course and the availability of ongoing training. Whilst it appears that staff at the home now have police checks, the recruitment procedure has not been robust enough to ensure the safety of those who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rotas showing staffing levels were inspected and there was discussion with staff and management about staffing levels. There is a registered nurse on duty at all times. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 23 Staff files were inspected to both look at staff training and also the home’s recruitment process. On the days of the inspection staffing levels appeared to meet the needs of those who live at the home. These observations were confirmed during discussions with staff who considered the staffing levels appropriate and also from surveys returned by people who live at the home. The latter showing general satisfaction with the availability of staff to meet their needs. Inspection of staff files shows that all staff participate in an induction programme. There is also a separate induction programme for staff with nursing responsibilities. All staff at the home have access to training offered by a person employed by the Court Group to undertake staff training. This person offers staff training on all mandatory subjects, which include, the Protection of Vulnerable Adults, Moving and Handling and Food Hygiene. Staff sign to say that they have read the home’s policies and procedures. To ensure the safety of those who live in the home it is required that before staff commence work, the home checks that their names have not been placed on the Protection of Vulnerable Adults (POVA) register. If someone’s name has been placed on this register this is because they have been found unfit to work with vulnerable adults and would therefore be unsuitable to work in a care or nursing home. In addition to this a police check should have been carried out and two written references received confirming the suitability of a person to work in a care home. The file of one staff member showed that they had been employed for nearly two months before the results of a police check were received and another had transferred from another registered home, within the Court Group, and the management of the home had not realised that the police check was not transferable. Another file only contained one reference. This means that the home has not always followed a recruitment procedure which ensures the safety of those who live in the home. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. In order for the home to have an appropriate management structure the providers should ensure that the home is run by a registered manager. Those who live in the home benefit from ongoing audits of the quality of care which enables their views to be used to develop the service. People are safeguarded by the home’s financial policies and procedures. Staff would benefit from regular supervision. Those living in the home are safeguarded by regular testing and servicing of equipment and installations. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 25 This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst the home has a senior staff member occupying the position of matron, this person has not been put forward to the Commission for Care Standards Inspec1tion (CSCI) for registration. Therefore there is no registered person in charge of this home. The providers say that it is their intention to put forward the person currently occupying the role of matron, for registration and say that they have obtained the necessary forms to commence this process. The matron has been running the home, and is a qualified nurse. One of the directors is regularly at the home and is supportive of the matron. St Benet’s operates a Quality Assurance System. A form requesting the views and comments of people living at the home is attached to the contracts of people newly admitted to the home. An audit was also completed in January 2007, prior to the home’s last key inspection. Details of it’s findings were attached to the home’s Statement of Purpose. The provider is currently conducting a new audit and has given out forms to people who have been recently admitted to the home. This is an ongoing procedure and as yet only two responses have been received. Whilst the providers encourage those who live at the home to manage their own finances or let their relatives oversee or take responsibility for this there are occasions where the home has to hold monies on their behalf. When this occurs, the monies were seen to be kept securely, with access restricted to two designated people. All monetary transactions recorded and wherever possible receipts retained. We were informed that those for whom the records were kept could have access to them at any time. Inspecting staff files revealed that they contained signed supervision contracts, however, even though some of these contracts had been signed in July 2007, there was no evidence that supervision had been carried out. Discussion with staff confirmed that supervision was not regularly carried out. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 26 The provider reported in the annual quality assurance assessment that full health and safety inspections are carried out every three months. Examination of records within the home showed that hoists and lifting equipment was serviced regularly as were the passenger lifts. There had been recent testing of portable electrical appliances and a fire risk assessment of the premises had been carried out. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 x X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 14 (2) Requirement The registered person shall ensure that the assessment of a service user’s needs is kept under review and revised at any time when it is necessary to do so having regard to any change of circumstances. In order to ensure the safety of those who live in the home, those in charge must obtain the documents listed in schedule 2, paragraphs 1-7. Timescale for action 31/03/08 2 OP29 19(1)(b) 29/02/08 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 Refer to Standard OP10 OP31 Good Practice Recommendations Whilst most staff were able to give examples of how to safeguard the privacy and dignity of those at the home, this is an area which could be improved upon. The registered provider should appoint an individual to be registered as manager of the nursing home. DS0000067041.V353676.R01.S.doc Version 5.2 Page 29 St Benet`s Court 3 OP36 The manager should ensure staff receive regular supervision in accordance with the supervision contracts in their files. St Benet`s Court DS0000067041.V353676.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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