Inspection on 28/06/06 for St Benet`s Court

This inspection was carried out on 28th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 13/12/07

St Benet`s Court 01/03/07

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 Benets Court 32 College Road Newton Abbot Devon TQ12 1EQ Lead Inspector Clare Medlock Unannounced Inspection 28th June 2006 10:00 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 Benets Court DS0000067041.V296857.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 Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Benets 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 337083 Mrs Nicola Rogers Mr Guy Perring Rogers, Ms Michelle Anne Stepney 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 Benets Court DS0000067041.V296857.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 October 2006 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, overlooking Decoy Woodland and nature reserve. The home is within easy reach of the town centre and all 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. Two passenger lifts, one stair lift grab rails and ramps offer freedom of movement for disabled Service Users. A nurse call system covers all rooms and the gardens. There are terraced gardens with secluded seating areas and a waterfall accessible to all Service users with 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. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced at 3pm the day before it took place. This was to ensure the new Provider was available for the first inspection. The Inspection took place on Wednesday 26th June 2006. It consisted of a full tour of the building, speaking with residents, relatives, staff and the Providers. Records, Care Plans and other documents were inspected. All food provided on the day of inspection was sampled. Five resident questionnaires were received and two from relatives. What the service does well: The home continues to provide a high standard of accommodation, which is well-maintained, personalised to reflect residents likes and dislikes. The home is extremely clean and has a welcoming entrance and atmosphere. Residents are able to wear their own clothes, be called by their chosen name and bring personal items to decorate their rooms. The home provide a stable level of staff. Nursing care provided at the home is generally good. Staff at the home access a range of services including; General Practitioner, District Nurse, Out patient appointments as well as NHS Services. The home has many adaptations to help Residents keep as independent as possible and ensure they are able to access all parts of the building. The attractive very well maintained garden area is used more frequently by Residents during the recent fine weather. The home provides a good choice of menu to residents with a range of needs, including special diets such as a vegan diet. The food purchased is of good quality with fresh fruit and vegetables used routinely in cooking. The staff assist residents to eat a well presented meal, using specialist equipment such as plate guards and special cups. The kitchen is clean and tidy and staff are aware of the need for good hygiene, with movement restricted in the kitchen to limit the chance of food contamination. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Many improvements have been commenced or planned. Some have been completed. If these improvements continue it is anticipated that the quality of care at the home should continue to increase. As a matter of urgency, The Provider must ensure the Trained nurses are aware of their professional responsibilities regarding the safe keeping, administration and recording of medicines. This will ensure residents are not at risk of receiving the wrong dosage of medicines and do not miss medicines just because the home have run out. Trained nurses must be aware they are not allowed to change prescriptions and must record any changes in prescriptions and obtain signatures from the General Practitioner. The Care Plans must also be kept up to date and reflect the care that is given. An changes in care must be written in care plans in a away that they are easy to follow. The Provider must listen to the residents and respond with the reintroduction of a formal varied activities programme to meet their needs and provide stimulation. The Provider is aware of the need for changes at the home to make sure the National Minimum Standards are met. They must continue with the planned programmes of improvements which include introduction of the organisation documents which will improve the admission process, care planning system, staff induction, appraisal and supervision and records of professional visits. The Provider must also continue with the planned training programme to make sure staff have the skills and knowledge to perform their roles. Residents need to remain safe at all times. This can be done by ensuring all staff receive POVA (Protection of Vulnerable adults) training and by ensuring all staff know how to report any allegations correctly and have the local contact details to hand should this occur. The Provider must also continue with the quality assurance programme and act on any issues raised by Residents or their families. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 7 Feedback regarding vegetarian and vegan meals should also be listened to and acted upon to ensure all residents are satisfied with the meals provided. The Provider must also continue to act upon Recommendations set prior to the sale of the home. These are to include covering all radiators and considering reducing the triple occupancy of some rooms. 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 Benets Court DS0000067041.V296857.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 Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents, families and Representatives are given sufficient information to decide whether Pinehurst is the right place for them to be. Staff obtain adequate information on residents to ensure they are able to care for the residents. EVIDENCE: There has been a change of ownership since the last inspection. Inspection Confirmed that the home have introduced a new Statement of Purpose and Service User Guide which contain all the information required. Residents spoken to said their relatives made the final decision to come to the home as admission was from hospital and a trial visit was not appropriate. One resident said his son had looked at many homes and decided St Benet’s was the right place for them. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 10 Three contracts were inspected for this inspection. These are new contracts due to the change of ownership. These appeared to be clear and contained all information necessary. A blank specimen contract is sent to all new prospective Residents. Discussion with the Provider confirmed that the pre admission document is in the process of being changed with a new document introduced. Inspection of this documents confirmed that a detailed needs assessment will be carried out. Residents spoken to said they were visited by the Provider in hospital before they were admitted which was lovely and meant they had a familiar face when they came to the home. Examination of Care Plans confirmed that staff obtain a detailed history of each resident prior to admission to ensure they are able to meet their needs. Staff spoken to in the home confirmed they did not have any resident with cultural differences but confirmed that if this was the case they would find out as much information prior to the admission. Staff spoken to said some staff were from overseas and this meant staff having to understand and teach staff different ways of caring for residents and local phrases used. Residents spoken to said they were encouraged to visit their usual church and were provided with vegetarian and vegan food options if requested. St Benets Court DS0000067041.V296857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service Judgement: The residents’ health care needs are met in some ways but not others. Residents’ plans of care do not always reflect the care that has been given. The residents feel they are treated with respect and their privacy is upheld. The homes policies and procedures for dealing with medicines place residents at risk of harm. EVIDENCE: Quality in this outcome area is currently poor, however should the Manager implement changes stated at this inspection this rating should increase. Observation, Records and discussion with the Manager confirmed that staff at the home access services from heath care professionals. These include General Practitioners, physiotherapist, Speech and language therapists, and continence specialist. Records confirmed that these services are arranged within the home or within the local community. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 12 Three services users files were inspected. These held a range of information, including care plans, initial assessments and ongoing assessments were examined. The files showed details of residents past history and ongoing care that was not always reflected in the care plans and documents generally were not well completed or recorded in any detail. In a similar way the ongoing daily records of the care provided by staff to residents showed care being delivered but this was not reflected in the individual care plans. The Provider was aware that the current system of recording needs to be improved and was able to produce the format for a new system which if well completed would address these issues. It is important to ensure care plans and records of residents care are well completed so that staff had consistent information about the care needs of residents and how they are cared for, so that resident’s needs are fully met. Residents spoken to consistently said that they felt well cared for, that staff helped them care for themselves or helped them to obtain outside professional help for example from there Doctor. The members of care staff spoken too were able to give a detailed description of the care needs of residents and said that they felt confident in providing care to residents. The homes medication administration system is a pre packed blister pack system that the local pharmacy delivers with some additional boxed or liquid medicines. The storage area of the medicines were, clean, tidy and secure and the systems for the collection and disposal of medicines were well managed. The recording of medication was on the whole well completed, however there were repeated staff signing to say that they did not give medications because they had run out of supplies. Four MAR sheets showed that staff had run out of medication for 15,7,8 and 24 days with no staff acting on this. Members of staff spoken too clearly understood the importance of the accurate recording of the administration of medicines and had knowledge of how the system worked, but explained poor communication with General Practitioner and Pharmacy. Poor recording puts residents potential at risk from harm and reflects badly on the Registered nurses and shows that the nurses are not following the Nursing Midwifery Council Code of Practice for the administration of medicines. Most importantly it also places residents at great risk and means they do not always receive prescribed medication. A Controlled Drug Prescription label had also been changed. Records were not clear as to why this had been done. Eventually, the Registered Nurse spoke with the General Practitioner who confirmed that the dosage had been changed with a member of staff who has since left the home. This poor recording has the potential to place residents at home and reflects on the Registered Nurses within the home. These poor practices must be addressed as a matter of high priority. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 13 Five Resident questionnaires were received regarding this service. All five stated that residents feel they always receive the care and medical support they need. One comment was made that staff at St Benets have made the resident better. Two relative questionnaires said that they are always kept up to date with changes in care and consulted about plans of care. Thank you cards received stated ‘We appreciated the care and nursing you gave. The decision to place was a difficult one but you, as the staff helped us through it on a daily basis.’ And ‘We thank you very much indeed for all you did and for keeping our spirits up when we visited. The cups of tea were also a help!’ A Tour of the building confirmed that residents are well cared for with the finer details of care given. Residents who were being cared for in bed appeared pain free, clean and relaxed. Staff were seen to knock on resident doors prior to entering and called residents by their chosen term of address. Residents seen were wearing their own clothes and said the staff wash them and return them promptly. Residents said they receive their post unopened and felt that the staff are very kind and caring. Residents spoken to said staff help them as much as they need but ‘do not take over’. Residents said staff understood their routines and allowed them to get up when they chose. One resident said she likes to go to bed late and get up late and staff have organised their routine to make sure this happens. St Benets Court DS0000067041.V296857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service . Judgement: Residents are dissatisfied with the social aspect of the home and find they do not have activities that match their preferences. The residents receive a wholesome balanced diet in a choice of venue either in the homes dining room or in their own private rooms. EVIDENCE: Quality in this outcome area is currently poor, however should the Manager implement changes stated at this inspection this rating should increase. Staff at St Benets try to be to be flexible and attempts to provide a service which is as individual as possible, by using its staff and resources effectively. Staff stated that new routines have been introduced where day staff come on duty earlier and give breakfasts to ensure residents receive this meal hot. Staff spoken to said this works well. One resident said this seems to mean night staff are less rushed. Observation confirmed that the home works to open visiting arrangements and residents know they can entertain their family and friends in their own room or if they prefer they can use community areas of the home to talk to visitors. Visitors spoken to on the day of inspection said they felt welcomed by staff at the home. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 15 Complaints have been received in the last three months regarding the food. Two of these complaints were not substantiated. The larder was well stocked and the freezers full. Observation confirmed that new storage systems had been introduced which provide safe methods of storing larger amounts of food. All food seen in the cupboard was good quality branded produce. Residents said the quality of the meat has improved and said they thought a new supplier had been sourced. Fresh fruit and vegetables were available and staff said that in the afternoon residents are offered home made cakes or freshly sliced fruit portions. All meals were sampled on the day of inspection. Pureed food was hot flavoursome and attractively presented. The Meal of the day was roast chicken and fresh vegetables. The vegetarian/vegan option was red pepper stuffed with savoury rice. All meals seen leaving the kitchen were well presented and meets the dietary needs of residents. Nine residents were asked whether they were enjoying lunch. All replied yes. Eight of the nine stated they had plenty to eat and one said she wanted more. This was arranged. Comments included: ‘The meat is lovely and tender’ ‘Nice’ ‘Lovely Roast potatoes thank you’ and ‘Wonderful’. One resident stated that she was aware that FLORA had replaced butter for cooking purposes and sandwiches because it was healthier, but stated that butter was still available if it was specifically requested. The cook is experienced, and has a list of residents preferences. Observation confirmed that a set four week menu is followed but that this is changed with the seasons. Observation confirmed the chef has obtained a book on cooking for diabetics to ensure home produced food matched their dietary needs. This action should be commended. Observation confirmed that staff help those residents who need help when eating and are sensitive in their approach. Residents are able to choose to eat in their own room if they wish. Regular drinks and snacks are available. Discussion with residents and staff confirmed mid morning coffee is served with a selection of biscuits, followed by a two course lunch and fresh fruit and homemade cakes in the afternoon with tea. Supper is served and followed later with cheese and biscuits for those who want a pre bed time snack with their hot drink. Discussion with residents confirmed that there is plenty to eat and more can be requested. Residents with vegetarian/vegan diets stated that the menu is inconsistent. Sometimes it is full of flavour and sometimes this is very bland. Feedback was given to the chef who gave assurances that he would look at this. The overwhelming feedback from residents and relatives at the inspection and from questionnaires received from two relatives and five residents was that the social aspect and activities had dramatically reduced since the departure of the activities coordinator. Residents stated that they had not been consulted or listened to regarding the choice of daily activity. One resident said they are ‘bored stupid’ in the afternoons. One resident stated that they do not have any mental stimulation and are limited what they can do on their own. Staff said that a relative has been in to give a talk but that residents do need more activities arranged. Two comments on the Relatives questionnaires stated that their ‘only concern is about the lack of extra activities’ and ‘Residents just sit and look at each other and have nothing to look forward to as all outings have been cancelled’ Discussion with the Provider confirmed they know the residents miss these activities and that steps are being taken to address this. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 16 St Benets Court DS0000067041.V296857.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents feel able to complain knowing the manager will act on them appropriately. Residents are potentially at risk because of staff lack of awareness and training in adult Protection issues. EVIDENCE: St Benets has a complaints procedure that meets the National Minimum Standards and Regulations. The complaints procedure is available within the Home, Statement of Purpose and Service User Guide. Two relative questionnaires stated that they knew who to complain to but had not needed to make a complaint. Residents spoken to said they had never had to make a complaint but minor ‘niggles’ are sorted out straight away. The Commission for Social Care Inspection have received three complaints since the last inspection. One was investigated by the Commission for Social Care Inspection through an unannounced inspection and found to be unsubstantiated. Another was received and the complainant wanted the issues to be looked at during this inspection, and the third was investigated by the Provider and followed up at this inspection. The investigation performed was in depth and provided detail to dispute the claims in the complaint. The home have new policies and procedures regarding protection of residents. These have not yet been read by all staff. Within the policy it is clear when incidents need external input and who to refer the incident to. Links with external agencies are St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 18 satisfactory and include CSCI, police and adult protection teams. During the inspection the Provider gave an example where a concern had been referred to the Adult Protection Team. Discussion with staff confirmed that they would speak with on of the corporate directors if an allegation of abuse was made. All staff spoken to knew how to contact them. However, staff were unaware of who to report to locally if directors were not available. Staff also explained the action they would take if an allegation was received. These actions may affect any investigation the Police or Adult Protection Team would possibly stop. The Provider was aware of the correct action and stated that she would address this as a matter of urgency until POVA (Protection of Vulnerable Adults)training had been organised. All residents spoken to said they felt safe at the home and that all staff were kind, gentle and caring. St Benets Court DS0000067041.V296857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to the service. Judgement: St Benets is a well maintained home which provides a homely place for residents to live. EVIDENCE: St Benets provides a homely atmosphere, it has a rolling programme to improve the decoration, fixtures and fittings. Radiators remain at the home which are not guaranteed low surface temperature. Discussion with the Provider confirmed there is a plan to cover these. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. There are a number of single rooms, a few double and triple rooms, some of these have en-suite facilities, but some of the residents say that they knew when they chose St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 20 the home that they would have to share. screens provided for privacy. Residents have the choice to bring small personal items of furniture into the home. All the homes fixtures and fittings meet the needs of the residents and can be changed if their needs change. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. All Residents spoken to said the home is always clean, warm, well lit and comfortable. There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. Although there is sufficient number of bath and shower rooms but not all are regularly used. Residents spoken to said they have set bath days where they enjoy the larger assisted bathrooms. A Tour of the building confirmed that the home is generally clean and tidy, and there have been no outbreaks of infection. Hygiene equipment is available with evidence that staff wear gloves and aprons when providing personal care. The Laundry is well equipped with sluice cycle washing machines which reduce the risk of infection. Residents say that the clothes are washed well and returned promptly unless they do not have labels when there is sometimes a delay. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The New recruitment procedure and planned staff induction and training programmes will begin to protect residents as they are introduced. EVIDENCE: Residents are generally satisfied that the care they receive and that staff are able to deliver their care needs. Off Duty Records confirmed that Staffing numbers have been changed to reflect the busier times of the day. Staff stated that new routines have been introduced where day staff come on duty earlier and give breakfasts to ensure residents receive this meal hot. Staff spoken to said this works well. One resident said this seems to mean night staff are less rushed. The Provider stated that as an organisation they are aware of the importance for training and produced a plan to show that, over time this will be provided. All staff spoken to were clear regarding their roles and what is expected of them. One member of staff said morale had improved and now they needed to work more as a team to make sure residents have their needs met. The Provider explained the recruitment procedure. Three staff files recruited by the New Manager were inspected on this occasion. These confirmed that all information required had been obtained and Criminal Records Bureau/POVA St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 22 (Protection of Vulnerable Adults) checks performed. No concerns regarding this process were identified. The Provider explained that the induction process will also be changing at the home to ensure detailed records will be kept and old processes incorporated. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38. Quality in this outcome area is currently adequate. This judgement has been made using available evidence including a visit to the service. Judgement: The Provider has an awareness of what improvements are needed at St Benets. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected in some areas but not others. EVIDENCE: The Provider has the necessary experience to run St Benets. The Provider demonstrated a clear understanding of the National Minimum Standards and is working hard to introduce changes at the home which will ensure these standards can be met. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 24 The home have had a change of ownership which was unannounced to residents and staff alike until the sale had been completed. Feedback received confirmed that this caused distress, uncertainty and disruption for residents, relatives and staff alike. Discussion with residents, staff, records and meeting minutes confirm that the Provider is working hard to answer questions, respond to complaints and concerns. Staff spoken to said morale has improved and this is having an impact on residents. One resident said staff grumble less now and seem happier. One resident said ‘laughter is in the air again’. Staff said the Provider has introduced new ways of working which were difficult at first but ‘make sense for the residents’. Residents also aid the Providers were lovely and often popped their heads round the door to check things were OK. Records confirmed that the home have a new Manager who will be starting at the home in the near future. Staff spoken to said a couple of staff meetings have been held. Meeting minutes and records also confirmed that relatives and residents have been asked whether they are happy with the service provided in response to the recent complaints received. The Provider confirmed that some staff have been out of date with their mandatory training. Records and action plans confirmed that this has been arranged and a system organised to show all staff will have received training. The Provider also stated that supervision and appraisals have also not been kept up to date but this will recommence with the arrival of the new manager. A Statement of Purpose produced at the inspection explains the aims and objectives of the service. The Provider explained what systems are to be introduced to monitor practice and compliance with the homes plans, policies and procedures. Service Records were produced to show that gas services, electrical appliances, lifts, hoists, assisted baths and fire equipment is maintained and services. Waste Management and drug disposal is also done safely through external contactors. Records were seen of these agreements. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. It is aware of the areas where they need to make improvements and has an action plan for undertaking the work. This included radiator covers and staff training. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 25 The registered person produced business plans and financial viability evidence for Registration with the Commission for Social Care Inspection. in April. Insurance cover certificates were available at the home. Residents spoken to have the opportunity to manage their own money if they wish, but chose to allow relatives to manage this. The Majority of records were well maintained and secure. Staff files were stored in locked facilities and resident care plans stored within the office. St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 26 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 3 3 2 3 2 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 3 2 St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 27 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(2) Requirement Timescale for action 01/12/06 2 OP9 18(4) 3 OP12 16 (2m&n) The Provider must ensure all Registered Nurses safely manage the medication system. This must include: o The follow up any omissions of medication o Correct recording of medication o Two signatures on any hand written changes or entries on the MAR sheet o Ensuring staff do not change prescription labels especially on controlled drugs. o Any changes in medication must be clearly recorded by General Practitioner. The Provider must issue all 01/12/06 Registered Nurses with the Nursing Midwifery Council publications including Code of Practice and Administration of medicines and record keeping The Provider must consult with 01/12/06 residents about their preference regarding activities and make suitable arrangements to facilitate these DS0000067041.V296857.R01.S.doc Version 5.2 St Benets Court Page 28 4 OP18 13(6) The Provider must protect Residents from abuse. This must include: o Ensuring all staff receive appropriate POVA Training Timescale:01/01/07 01/08/06 5 OP25 13(4a) 6 OP38 18(1ci) Until this is done and afterwards this must also include ensuring: o All Staff are aware of the correct reporting procedure and what to do if a Provider is not available o Ensuring staff have contact details of who to contact and what to do, should an allegation be received. The Provider must continue with 01/07/07 the planned programme of covering radiators, ensuring risk assessments have been performed in the meantime. The Provider must continue with 01/07/07 the planned training programme to show all staff have received training in all mandatory training (Moving and Handling, First Aid, Infection Control, food hygiene and fire safety) 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 OP3 OP7 Good Practice Recommendations The Provider should continue to introduce the pre admission assessment record Continue as planned to update documents including care plans and assessments to ensure they: o Reflect the care that is provided. o Can show changes in care o Can show when Residents have been seen by DS0000067041.V296857.R01.S.doc Version 5.2 Page 29 St Benets Court healthcare professionals and what decision has been made regarding change of care or prescription. 3 4. 5. OP9 OP15 OP23 The Provider should consider performing an audit on the management of the medication system The Chef should obtain feedback regarding the vegetarian and vegan food option and make any changes necessary. Existing recommendation, Continue as planned to reduce the number of shared spaces from three bedded rooms to two bedded rooms. (Carried over from last inspection) Existing recommendation, not inspected on this visit. Continue as planned the extension of the homes induction. (Carried over from last inspection) The Provider should continue with the quality assurance programme. Existing recommendation, not inspected on this visit. Continue as planned with the appraisal system. (Carried over from last inspection) 6. OP30 7 8. OP33 OP36 St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Benets Court DS0000067041.V296857.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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