Inspection on 28/11/07 for St Bennetts Care Home

This inspection was carried out on 28th November 2007.

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

The inspector 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 Bennetts Care Home 18/11/08

St Bennetts Care Home 31/01/07

St Bennetts Care Home 19/12/05

St Bennetts Care Home 26/07/05

St Bennetts Care Home 22/02/05

St Bennetts Care Home 15/07/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

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

CARE HOMES FOR OLDER PEOPLE St Bennetts Care Home 346-348 London Road Leicester Leicestershire LE2 2PL Lead Inspector Susan Lewis Unannounced Inspection 10:00 28 November 2007 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 Bennetts Care Home DS0000006381.V344136.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 Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Bennetts Care Home Address 346-348 London Road Leicester Leicestershire LE2 2PL 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) 0116 2745959 Mr M A Mapara Vacant Care Home 27 Category(ies) of Dementia - over 65 years of age (10), Learning registration, with number disability over 65 years of age (10), Old age, not of places falling within any other category (27), Sensory Impairment over 65 years of age (10) St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person to be admitted to the Home in category SI(E) when there are 10 persons in total of this category already accommodated in the Home. No person to be admitted to the Home in category DE(E) when there are 10 persons in total of this category already accommodated in the Home. 31st January 2007 Date of last inspection Brief Description of the Service: This is a centrally located service on the London Road of Leicester, which offers a service to older people. The location is convenient for transport links. There are 3 lounges and 1 dining room on the ground floor. A large number of bedrooms are well over the National Minimum Standards size requirements. There are a majority of single bedrooms. Service users have a ramped way to the rear garden and a patio where they can sit. The weekly fees range from £290 to £525. There are additional costs for individual expenditure such as hairdressing, newspapers and chiropody. The most recent report is available in the manager’s office. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 10 hours including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. We were unable to effectively understand and communicate with some of the people living at the home, therefore some judgements in this report are drawn from our observation of staff and resident interactions. Two members of staff and one set of relatives were spoken with as part of this inspection. In addition the views of two other residents who were not part of the “case tracking” were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. Relatives interviewed said they were given a information about the home, and had seen an inspection report on the internet. The registration document was reviewed as part of this inspection visit and any changes will be made to ensure it complies with all legislation. What the service does well: The acting manager assesses all prospective residents to ensure that the staff have the skills and experience to meet the persons needs. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 6 The staff are good at recognising when residents need help from other Health care professionals to improve their health and well being. Activities are provided that are varied and meet the needs and abilities of all the residents. Residents are able to have control over how they want to live their life and about the activities within the home. Meals are served in pleasant dining area; residents get a choice of nutritious meals. Residents who need assistance do so in a discreet manner. The home is well maintained and a clean and safe place for residents to live. Complaints are documented, investigated and complainants are responded to, ensuring that their concerns are addressed. Residents feel safe and relatives are able to feel confident that their loved ones are treated well and are safe from harm. There are enough staff to meet the needs of the residents at the home, they receive regular training and over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care What has improved since the last inspection? Care plans are being reviewed regularly to ensure that they remain up to date and meet residents needs. Where residents have medical needs they are referred to health care professionals promptly to ensure their needs are fully addressed. The provider has started a programme of refurbishment and large areas of the home are being repainted. The garden in currently undergoing a complete relandscaping and will be ready for the summer 2008. Systems are now in place to ensure that infection control within the home is maintained and residents are protected as much as possible from potential infection. Staffing levels are being maintained to meet residents needs and maintain their safety. Robust recruitment now takes place on all staff who come to work at the home to make sure they are suitable to work with vulnerable people. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 7 The acting manager is improving the training for all staff to ensure that their mandatory training is kept up to date and so residents are c\red for by knowledgeable staff. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Bennetts Care Home DS0000006381.V344136.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 Bennetts Care Home DS0000006381.V344136.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 and 6 Quality in this outcome area is good. Admissions to the home only take place if the manager is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Residents and their relatives are given sufficient information to make an informed decision about moving to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed as part of this inspection and each showed that assessments were carried out either by the manager or the Community Care Assessment carried out by the social worker were also obtained. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 10 The assessment informed the care plan and staff spoken with said that they had enough information to help settle a new resident in and what their needs were. The pre inspection information provided by the acting manager said that she visited all prospective residents and ensured that the service was able to meet the needs of the residents. Residents spoken with said that staff were very friendly and had help them settle in when they arrived and relatives spoken with confirmed this. Relatives also said that the manager had given them information about the home to help them make a decision as well as encouraging them to visit. Intermediate care is not provided in this service St Bennetts Care Home DS0000006381.V344136.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. Each resident has a care plan, but practice of involving residents in the development and review of the plan is variable. Residents have access to health care services that meet their assessed needs both within the home and in the local community. The home has a medication policy which is accessible to staff, however there are gaps in recording which may place residents at risk. There is some evidence that staff do not always treat residents in a way, which respects their privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of the “case tracked” residents were inspected to make sure that they contain enough detail about people’s needs to properly guide staff. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 12 Each plan included a copy of the responsibilities of the key worker, a statement of purpose and the resident’s rights. The acting manager was introducing a new care plan system and some provided good information others were still under construction. Where residents had specialist care needs these were detailed and showed who had been involved in different care plans and who could be consulted for further advice. Staff spoken with said that they found the plans useful and gave them clear information about how to provide care and support. Residents spoken with said that staff did talk to them about their care but did not know specifically what a care plan was. Residents knew they had a key worker and what that person did to help them. Relatives said that they had been consulted with in the creation of the care plan and felt the manager had a good understanding of their loved ones needs. However none of the care plans viewed showed any evidence that residents or their relatives were involved in the creation or review of the plan. A requirement was made at the last inspection to ensure that care plans were reviewed evidence was seen on care plans to shows that this is now being done regularly. Comments received from residents said that ‘staff are very good if there is anything you need the staff get it for you’. ‘Staff know how to care for me and I don’t have any problems with getting the help I need’. All residents said that they see a doctor if they need to and staff knew to seek medical help if a resident was unwell or had injured themselves. Evidence was seen in diary notes of liaison with GPs and district nurses regarding different residents medical needs, including where residents were assessed as being at risk of pressure ulcers. A requirement was made to ensure referrals to medical authorities are done in a swift manner when service users are injured. From evidence from diary notes and residents spoken with this is now being done. Residents had their weight monitored regularly and there was evidence in care plans of liaison with GP and dietician where residents lost weight to ensure action was taken to maintain their nutritional intake. The storage of medication is secure although the trolley is not secured to the wall even though there is the ability to do this. This would make it more secure than it currently is. The records of ordering and receipt of medication are satisfactory. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 13 Staff were observed during a medication round to ensure that each medicine is visibly taken before signing. The Medication Administration Record showed evidence of several gaps, which had not been explained by staff. This could place the person at some risk of ill health. The controlled drugs register and cupboard contents corresponded ensuring that this medication is administered and stored according to the relevant guidelines. There was a bottle of Buttercup Syrup in the medication trolley this is classed as a Homely remedy but it was not labelled as to whom it was for. There was no medication administration record to check what dosage they had been given. There was a homely remedies policy that was not being followed and there is potential that residents could be at risk of ill health. There was also some other prescribed medication that did not have the prescription label on to identify who it was for, again there is potential that a resident may not receive the medication they are prescribed. Not all handwritten entries on the records sheets are signed and countersigned and there is a potential that errors can occur when information is transferred over from one document to another. A requirement was made to put medication systems in place to ensure medication security. Training has taken place and staff spoken with said they felt that medication practice had improved. This requirement is met. Staff were observed throughout the day interacting with residents in a positive manner. Where a resident had a tendency to get up through their meal staff would gently redirect them to their seat and positively encourage them to remain seated whilst they ate their meal. Staff spoken with understood what they needed to do to ensure that residents privacy and dignity was maintained and residents spoken with said that staff were kind and polite and knocked on the bedroom door before entering. However, during the course of the inspection visit a member of staff took a resident to the toilet and left the door open whilst the residents used the facilities. This does not promote a resident’s privacy and dignity. This was brought to the provider’s attention who said he would deal with it. St Bennetts Care Home DS0000006381.V344136.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 and 15 Quality in this outcome area is good. Residents are able to enjoy a full and stimulating life style with a variety of options to choose from. The menu is varied, balanced and nutritious with choices provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with said that the home offered plenty of activities and that an activities organiser was employed who arranged different things like painting card games and dominoes. Staff spoken with also said that activities were arranged and these were varied depending on the ability and gender of the resident. For example female residents were seen having their nails painted by staff and male residents were seen taking part in games of dominoes. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 15 Care plans indicated residents likes and dislikes as well as their preferred time for getting up and going to bed residents spoken with said that they felt they had control over their lives and could choose how they spent their time. One resident who had an electric wheelchair was able to visit local shops and another was supported to go to the pub with staff. Where possible residents were supported to attend activities outside the service such as attending a day service and going to church. This was confirmed in discussion with residents. Residents were able to choose where they ate their meals and one resident said that they were able to have breakfast in bed, which they liked. The pre inspection information stated that residents are encouraged to be vocal and state what they want. Residents spoken with confirmed that there is a residents meeting where they are asked about the service and what they want improving. All residents spoken with said that they had been able to bring in personal items to their bedroom. This was also noted during the partial tour of the building. Visitors were seen throughout the day and residents spoken with said that their visitors were always made welcome and that they were able to visit any time. Visitors spoken with confirmed that they were made to feel welcome when they visited. The midday meal was observed and residents spoken with said that they enjoyed the meals had a choice and were given plenty to eat. Although one resident commented that they didn’t get enough vegetables. The dining room was a pleasant light and spacious area, staff were observed assisting residents who needed help to eat their meal in a discreet and polite manner. Menus were recorded and information was available regarding residents nutritional needs to inform the cook when preparing menus. Staff spoken with were aware of dietary needs such as diabetes or those needing a soft diet. St Bennetts Care Home DS0000006381.V344136.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 and 18 Quality in this outcome area is good. Residents and their relatives understand how to make a complaint and are confident that it will be dealt with. Although staff have not received safeguarding adults training they understand what their responsibilities are to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission received an anonymous complaint regarding this service concerning a theft. This was discussed with the registered provider who explained what action had been taken and what the outcome was. This matter is considered resolved. The manager has received two complaints since the last inspection one had been dealt with according to the service’s procedure and one was still pending. There is a complaint policy, which is displayed in the service, and residents spoken with were aware of this and knew who to speak to. Staff spoken with said that they understood the importance of supporting residents to complain and knew what their responsibility was in passing on information to the manager or the provider. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 17 From pre inspection information is states that the acting manager and provider are available at all times to deal with complaints. All staff residents and visitors spoken with felt confident that the acting manager or provider would deal with any complaints. Residents spoken with said that they felt safe in the home and that staff treated them well. Visitors spoken with said they felt confident to leave their loved one in the home and felt they were safe. There is up to date information on safeguarding adults available in the office and staff spoken with had been given leaflets about recognising abuse but no specific training. In discussion with staff they understood what abuse was including restraint and what they must do if they witness it including passing information over about the manager or provider. St Bennetts Care Home DS0000006381.V344136.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 and 26 Quality in this outcome area is good. The home has a well-maintained environment and is a pleasant, safe place to live. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the tour of the building there was evidence that improvements in the environment are slowly being made. All bedrooms are to be redecorated and there only 5 left to do. These are done in negotiation with the residents to minimise disruption. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 19 There was evidence that bathrooms are being redecorated and a damp area that was identified at the last inspection has been treated and is now awaiting retiling. There is a maintenance person employed who is slowing working his way round the home repainting corridors this is mainly done in the evenings and weekends to minimise disruption to residents. A maintenance plan was seen to show what improvements are planned for the rest of the financial year. A requirement was made at the last inspection to ensure that a number of areas of the home that needed repainting has either been done or in the process of being done. The garden is currently being completely renovated and will include accessible walkways for residents in wheelchairs as well as wheelchair height flower beds again to support those residents who are wheelchair users who also want to garden. From plans seen this will be an excellent resource for residents to use in the warmer weather. The home was clean throughout and the provider said that carpets are shampooed as and when they were needed. New carpets were in evidence in parts of the service such as the dining room with new carpets planned for other parts of the home later on in the financial year. Residents spoken with confirmed that their bedrooms were kept clean and tidy. One resident said she didn’t think her ornaments were moved when the cleaner dusted. Continence pads were stored in the open in all toilets and bathrooms in discussion with the provider it was pointed out that this did not promote residents privacy and dignity the provider said that he would have cupboards made to store them more discreetly. The service provides a separate smoke room with a suitable extractor fan to minimise the smell of smoke migrating to the other parts of the service. Only liquid soap and paper towels were found in toilets and the requirement made at the last inspection to put systems in place to ensure Infection Control at all times has been met. The Laundry was in a completely separate building and did not require soiled laundry to taken through areas where meals were prepared or eaten. Staff were aware of what policies and procedures were for infection control and staff were observed throughout the day following these procedures. St Bennetts Care Home DS0000006381.V344136.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 and 30 Quality in this outcome area is good. The recruitment of good quality carers is seen as integral to the delivery of an excellent service. The acting manager sees induction and any probationary period as being an extension of recruitment. The acting manager ensures that all staff within the organisation receives relevant training that is focussed on improving outcomes for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Through observation during the inspection visit four care staff were seen on duty including one senior carer. The manager was on annual leave but the provider was available to staff should they need anything. Staff rotas were available to show how many staff were on shift and in what role. Pre inspection information from the acting manager also stated that four staff were on shift in the morning and afternoon. Residents spoken with said that staff were available when they needed help and were friendly and polite. Staff spoken with said they felt there was usually St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 21 enough on each shift but it could become busy if a member of staff rang in sick and was not replaced. A requirement was made at the last inspection to ensure that staffing levels are reviewed and increased to ensure that service users needs are met at all times. From evidence seen this has been met. From pre inspection information provided by the acting manager it states that all the senior carers have either National Vocational Qualification (NVQ) level 2 or 3 in care. Staff have NVQ or above and further 8 are working towards NVQ 2 or above this will mean that on completion 100 of staff will have their NVQ 2 or above ensuring they are competent to care for the residents. A requirement was made at the last inspection to ensure that statutory staffing checks are in place before staff commence employment. Staff files were checked and found to have all relevant checks are now completed prior to someone starting work. This requirement is met. From pre inspection information the acting manager stated that induction starts immediately a member of staff starts work at the service. Staff spoken with confirmed that this is the case. They were also given opportunity to spend some time in the home prior to starting on a shift to meet residents and talk with them and for the manager and others to see if they fit in within the service. The pre inspection information stated that this was seen as part of the recruitment process and that staff were not given a contract until all parties felt they were suitable to work in the service. Staff spoken with confirmed that they had been involved with a variety of training including Dementia Awareness M&H and Fire training as well as Health and Safety. Staff spoken with said that they felt access to training was promoted. Pre inspection information provided by the acting manager indicated the training programme that all staff will have up to date mandatory training as well as Food hygiene and team building. A requirement was set at the last inspection to ensure further staff training is needed on a number of care issues Evidence provided showed that this was being addressed. However there is no mention of safeguarding of adults training and as staff spoken with said they have not received this it would indicate this is an area that needs addressing. St Bennetts Care Home DS0000006381.V344136.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 and 38 Quality in this outcome area is adequate. The acting manager has the required experience and is a caring and approachable person. The acting manager is resident focused and runs the service in the best interests of residents. The acting manager is not registered as fit to be a manager with the Commission. Staff and residents health and safety is supported ad promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 23 The acting manager is a qualified nurse and there is evidence from training records that she is continuing to update own knowledge with a view to providing good care to residents. She was praised by the staff, residents and relatives who all said she was kind, approachable and supportive. As yet the acting manager is not registered with the Commission as a ‘fit person’ to run a care service and has been in post for over a year. The acting manager must submit an application to register to cease committing an offence against the Care Standards Act 2000 or face possible prosecution. There is a quality audit system in place but as yet not in use. In discussion with the provider questionnaires are due to be sent out soon. The acting manager runs a residents meeting where residents are given opportunity to voice their opinion about the service and what they want. The acting manager states in the pre inspection information that she has an open door policy and welcomes comments from outside agencies such as District Nurses, GPs and social services to inform how care is provided in the service. Although some notifications have been sent to the Commission regarding incidents and deaths within the service not all incidents that fall under the regulation have been provided thereby failing to ensure that a full picture of what is happening to residents is given. The arrangements in respect of residents’ finances were checked to ensure their interests are being protected. The records all tallied with the amounts held on the premises and there were receipts for expenditure indicating the arrangements are well organised. The records of Health and Safety servicing and checks were inspected to ensure that residents’ are properly protected. These were all up to date and well recorded. Most staff have completed their statutory training courses and they confirmed that their health and safety is promoted and protected by the provision of training and equipment. St Bennetts Care Home DS0000006381.V344136.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 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 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 St Bennetts Care Home DS0000006381.V344136.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 OP7 Regulation 15(1) Requirement Timescale for action 01/02/08 2 OP9 13(2) 19(1) Residents should be involved in the creation and review of care plans to ensure that the plan reflects how they want to receive their care. The management of medication 01/02/08 must improve as follows: The Medication Administration Record must be fully completed. If any medication is not given there must be an explanation for the omission. This is to ensure that residents get their medication as prescribed by their Doctor. Medication must be suitably labelled including Homely remedies and recorded as to whom they are to be taken by and in what quantity to minimise risk of mal administration. Staff must respond to residents in an appropriate way and with respect for their dignity The staff must attend training on the Safeguarding Adults DS0000006381.V344136.R01.S.doc 3 OP10 12 01/02/08 4 OP30 13(6) 01/03/08 St Bennetts Care Home Version 5.2 Page 26 5 OP31 9(1) 6 OP33 7 OP38 Section 11 CSA 2000 24(1)(b) The quality assurance system & (2) must be used to review the service and developing an action plan that informs any improvement in the service. 37 All incidents which fall within this Regulation must be notified in writing to the Commission without delay to enable monitoring of the service provided to residents procedures to ensure they know about their reporting responsibilities in terms of protecting residents The acting manager must be registered as a fit person to manage a care home. 01/02/08 01/03/08 01/03/08 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 3 Refer to Standard OP9 OP9 OP26 Good Practice Recommendations Hand written entries in Medication Administration Records should be signed and countersigned to minimise risk of errors. Use the chain to secure the medication trolley to the wall. Continence pads should be stored more discreetly in bathrooms. St Bennetts Care Home DS0000006381.V344136.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Bennetts Care Home DS0000006381.V344136.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!