Inspection on 31/01/07 for St Bennetts Care Home

This inspection was carried out on 31st January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Bennetts Care Home 18/11/08

St Bennetts Care Home 28/11/07

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 Keith Charlton Key Unannounced Inspection 09:30 31st January 2007 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.V311280.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.V311280.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.V311280.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. 19/12/05 Date of last inspection Brief Description of the Service: This is a refurbished home, centrally located 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 £411 to £425 - this information was provided prior to the inspection. There are additional costs for individual expenditure such as hairdressing, newspapers and chiropody. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting four service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The home’s Acting Manager was not on duty, so the Senior Care Assistant in charge assisted with the inspection process. Planning for the Inspection included assessing notifications of significant events sent to the Commission for Social Care Inspection and correspondence between the Registered Provider and the Commission for Social Care Inspection. There has been one complaint regarding the service since the last inspection received by the Commission for Social Care Inspection, and the previous Registered Manager properly investigated this with no evidence found to substantiate the allegation. The Inspection took place between 9.30 and 15.50 and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspectors spoke with nine service users, the Registered Provider, and four members of staff. The inspection was concluded the following day with the Acting Manager. What the service does well: Service users said that staff were friendly and helpful towards them, reported that staff welcome visitors and they thought some of the food provided to them was good. Staff were observed to be friendly towards service users. Service users generally spoke positively about the activities arranged by staff, which provided interest and stimulation for them. Staff thought they were valued in their performance of their jobs and staff meetings are held to ensure the service is tailored to meet service users needs. The Acting Manager has a positive attitude in seeking to improve the care standards in the service and was receptive to ideas as how to improve the service for service users. Facilities have been improved and there is ongoing redecoration of facilities. Staff understand how to act if abuse occurs or is suspected. If service users complain the Registered Manager has taken up issues and resolved them. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 6 Facilities are kept in a generally clean and tidy condition. What has improved since the last inspection? What they could do better: Staff must always be aware of service users care needs; this would include ensuring a full assessment of needs on admission, Care Plans need to have full details of the care requirements of service users regarding Risk Assessments so that the proper care is always given and service users Health and Safety is protected, and staff need to be aware of all the Care Plans. Care Plans need to contain the past life history of service users if service users/their representatives agree to supply this information. This helps staff see service users as people with a valued past and assists in talking with them. Medical services need to be swiftly alerted where a service user has an injury. The Registered Provider needs to ensure that the welfare of service users is protected at all times, as there were staff without statutory without up to date checks, which meant service users were exposed to staff who may have posed a risk to them if they had criminal convictions or cautions. The Commission for Social Care Inspection has issued an Immediate Requirements Notice for the Registered Provider to rectify this situation. Staffing levels need to be reviewed as care staff have domestic duties which take them away from essential care tasks (there is only domestic support five days a week, not seven), especially with more dependant service users in the home which need the support of two staff. Staff training on relevant care topics needs to be carried out in order to equip staff to meet service users needs. Service users safety needs to be protected so that: staff are always carrying out medication procedures properly and they receive full training on all essential care issues. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 7 The staff, particularly those doing maintenance tasks, should have health and safety training to make sure that they and the residents are safe. Infection control needs to be tightened by ensuring soap is available in all toilets. Cleaning substances must always be kept secure to protect service users from harm. Staff should have regular fire safety training and fire drills to make sure that they know what they should do if there was a fire to keep the residents and themselves safe. The health and safety records for fire alarm tests and hot water temperatures could have more detail as to which areas had been tested. This would show that all taps and fire points had been checked. Providing signs to facilities would assist service users who have dementia, in that they can identify facilities clearly. A number of areas of the home have been repainted and this needs to continue – e.g. chipped skirting and paintwork still needs to be attended to on skirting, pipes and doorways where required, and the toilet (W.C. F), where there are signs of damp that need to be eradicated. It is recommended that the Manager have the responsibility for managing maintenance issues so these can be swiftly met and full Health and Safety systems put into place. For reasons of staff recruitment and welfare it is continues to be a recommendation that new staff do not have to pay for their own Criminal Records Bureau checks. 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 Bennetts Care Home DS0000006381.V311280.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.V311280.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): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process is managed so that service uses receive a satisfactory assessment, thereby ensuring that their main health and welfare needs are being met, though this needs to be extended to include all known needs so service users receive a more individual service. EVIDENCE: Service users said that they could visit the home prior to their admission to give them a good idea of what services the home has and whether they would like living there. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 10 The staff spoken with said that they usually knew what the resident’s needs were before they were admitted to the home. Service users told the inspector that they had a visit from a member of staff from the home before they were admitted. There was evidence of the assessment undertaken by the Manager available on the residents files examined though this was of a limited nature, as it did not outline all service users needs. The Acting Manager was asked to incorporate all issues contained in the National Minimum Standard for future assessments. A trial period of stay is offered to all prospective residents and to discuss how individual care needs can be met. The home does not offer intermediate treatment facilities. St Bennetts Care Home DS0000006381.V311280.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not fully describe identified care needs; this has the potential for omissions in care occurring. Medical services are not always swiftly referred to which means necessary treatment is not always swiftly provided. Medication is not always suitably and safely managed to protect the safety and welfare of service users. EVIDENCE: A service user said her Care Plan had been discussed with her. Care Plans cover all aspects of the national standard regarding health, personal and social care needs e.g. behaviour, skin care, speech, hygiene, medication, medical checks, food preferences, risk assessments on health and safety issues etc. However there were some sections that were not detailed, e.g. last dental appointment, the frequency of chiropody visits etc. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 12 The Acting Manager said that they would be reviewed and this information added. Plans are usually reviewed monthly, though not always. Currently there are no personal histories of service users or their daily living preferences. The Acting Manager said these would be followed up and added to give staff more information as to the needs and wishes of service users so as to provide more individual care. Risk assessments were not always available, e.g. where some service users were at risk of falls. Where they were they were set out within a risk assessment framework though these were not detailed and need to be reviewed so that they state the specific risk and how it needs to be managed. Care Plans did not clearly set out medical checks, e.g. service users with poor vision did not have information as to when they last had optical checks/appointments with consultants as to their condition, dental needs as regards routine dental checks were not stated, whether the service user needed a chiropodist was not stated and there was no information regarding daily living wishes. The Acting Manager said these issues would be followed up. Service users said that staff would call the doctor if they were not well and they made medical appointments for their regular health checks. However there was one instance whereby a service user had a fall and the GP had not been called for four days. The Acting Manager agreed that this was not acceptable and would follow it up with staff to ensure this does not occur in the future. Accident records were viewed which showed that medical services were called if there had been injuries following falls. However this was not the case if service users had bruising. The Acting Manager said that this policy is being reviewed, as there is a danger that fractures may not be noticed and treated in a swift manner. Service users said staff were friendly. The inspectors observed that this was the case whenever staff talked to or assisted service users. The visitors the inspectors spoke with said they thought the staff were caring and friendly and did a very good job. The Acting Manager confirmed that only senior staff and other trained care staff issue medication and have undertaken medication training. Two gaps were noted in medication record sheets though in general medication sheets were well completed. It was observed by the inspectors that the medication trolley was left unattended for up to five minutes when issuing medication to service users, which poses a danger in that anyone could take this medication and this be potentially dangerous to health. Controlled medication is held in a separate trolley with records kept. However it was not kept in an approved and secure cabinet. The Acting Manager said these issues were noted and would be acted upon. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 13 Service users were seen to be encouraged to take their medication is a friendly and supportive way. St Bennetts Care Home DS0000006381.V311280.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to lead a full lifestyle and can exercise choice. Food was said to be of good quality, particularly with the recent changes asked for by service users. EVIDENCE: Service users and staff said that there were no rules apart from smoking confined to a designated room. If someone wanted to have a lie in or go to bed late then this would be their choice. There is an opt out choice if service users do not wish to join in activities and some service users stay in their bedrooms all day if they wish. Service users said that there were now going to be enough activities as the Acting Manager had a recent meeting with them and there were always going to be activities in the afternoon, which they welcomed. The service users meeting records supported this view. Service users said they would like more St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 15 outings and this is to be organised. The Acting Manager showed the inspector information as to an arranged outing in December 2006 that service users were given the opportunity of going to. One service user is still able to use his mobility scooter to use local facilities, which helps him to retain his independence. Another service user said she walks around the garden three times a day so as to give her the exercise and fresh air she wants. A Comment Card from a relative said that the garden needed attention to make it look more attractive. The Registered Provider said that he planned to do this by planting shrubs and flowers this year. The Acting Manager said she is looking into providing specific training to staff so as to provide relevant activities for service users with dementia, and that service users are currently having memory boxes filled with important items of interest and used to discuss events from the past, so as to provide more stimulation. A service user showed the inspector one of these and said she liked looking at the things in it as it reminded her of happy events from the past. The Acting Manager said service users and relatives are able to take part in Residents Meetings, which are to be held every three months. Minutes of meetings evidenced this meeting as taking place. One service user who stayed in her room did not have many activities though enjoyed staff coming in and talking to her. However she did not always have her glasses nearby so she could not read or do quizzes. Another service user had poor eyesight and said she liked reading in the past. The Acting Manager said she may benefit from having talking books, and said these issues would be followed up. Both service users and relatives stated that visitors are always welcomed to the home by staff and no one reported any restrictions. There was general satisfaction expressed regarding the food in that service users said it was good. The recent service users meeting raised issues regarding the food and service users said that these were being put into place, which was evidenced by the minutes of these meetings. Menus were inspected and found to have two choices for the main meal and included the vegetables served. The inspectors tasted the food, which was of satisfactory flavour. Food records were in place though some were not dated. St Bennetts Care Home DS0000006381.V311280.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident their concerns will be acted upon and staff know how to protect them from abuse. EVIDENCE: Service users and relatives said that they thought that if they had any concerns then the Acting Manager would follow these up with proper action taken. Staff were asked what they would do in case of abuse and were aware of the proper steps to take regarding reporting this to outside agencies if not properly handled by the Management. The Complaints Procedure is satisfactory and gives the complainant the opportunity to go to the Commission for Social Care Inspection at the initial stage, as per the National Minimum Standard. Care staff spoken with by an inspector were aware of the full procedure regarding of which Agencies to contact if the in house arrangement failed. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 17 The homes records were inspected and complaints were recorded with proper follow up action taken by Management when service users/relatives have presented concerns. There have been two complaints regarding the service since the last inspection. There was no evidence to support one complaint. Management took action on the other complaint to ensure proper welfare of a service user. St Bennetts Care Home DS0000006381.V311280.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Facilities are seen to be comfortable by service users and are currently undergoing improvement. Facilities need to be signed to assist service users with dementia, and infection control must always be implemented. Odour control is generally good. EVIDENCE: Service users said they were satisfied with their rooms, which the inspectors observed to be personalised with items of resident’s furniture, pictures and photographs in them. They said that the home was kept clean and tidy. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 19 The inspector saw that this was the case with only one bedroom needing hovering, as there was talcum powder on the floor. A number of facility issues have been attended to - e.g. communal carpets in the lounge/dining room and chipped paintwork on skirting in certain areas of the home. The front of the home has been painted and looks attractive. However the rubbish seen accumulated in the front garden area detracted this positive appearance. The Registered Provider was asked if this could be picked up as needed, as it does not present a good picture of the home or a pleasant vista for service users to look out. The back garden looked bare and uninviting. The Registered Provider said this is to be upgraded so that it will look attractive this year. A number of areas of the home are in still in need of repainting – chipped skirting, pipes and doorways, and a toilet (WC F) where there are also signs of damp that need to be eradicated. The Registered Provider said that he has now employed a maintenance person who can quickly attend to issues as needed and he was in the process of repainting areas of the home that needed it. The inspector saw that a curtain track in a bedroom was hanging down and that a handle on a window was broken with a sharp surface left exposed which was a Health and Safety risk to service users. The Acting Manager said this would be swiftly followed up. It was noted that there was minimal sound insulation for the office as conversations from the next door bedroom could be freely heard in the office and visa versa. This constitutes a breach of confidentiality and privacy and needs to be addressed. The Acting Manager said she would follow this up. It was also noted that the Acting Manager does not manage maintenance issues – this is recommended so that Health and Safety issues receive swift attention. There were a number of toilets without working soap dispensers or liquid soap dispensers in them, which means there was a danger of cross infection. The Acting Manager said this would be followed up. A service user expressed a wish to move rooms, as there was only a view of a wall from her bedroom window. The Acting Manager said she would follow this up. St Bennetts Care Home DS0000006381.V311280.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not maintained to a level to meet all service users needs. Recruitment procedures need to be in place to meet service users needs and properly protect them. Staff training systems need to be put into place to ensure that there are properly trained staff. EVIDENCE: There were comments received that there were not always enough staff on duty to be able to do all the tasks needed to run the home, and on occasion staff took a long time to answer call bells. The Acting Manager said this had already been brought to her attention and she had taken action to ensure that this is not the case in future. One Comment Card from a relative said that only having one domestic was not sufficient to keep all areas clean. The staffing rota appeared to demonstrate sufficient care staff on duty in the day, evening and night time. For all day time/evening periods there are at least four care staff with two care staff awake on night duty. However care staff have to do domestic tasks – stripping beds, general laundry tasks etc, as St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 21 there is no laundry worker and one domestic worker, five days a week with no domestic worker on duty at weekends. There was also a comment that there was no domestic worker on duty for over ten days over the last Christmas period. Staffing needs to be reviewed to ensure that service users are properly protected and their needs are met, especially with a number of service users with dementia or needing the assistance of two staff. Staff said there had been minimal training in the last twelve months, which was confirmed by the Acting Manager, who said she is currently arranging more training. There was also evidence of proper induction training for new staff that the Acting Manager showed the inspector. The Acting Manager was recommended to extend the current Training Matrix to identify key issues that staff need training in (to quickly access who needs training in any relevant issues) – e.g. first aid, challenging behaviour, moving and handling, health and safety, medication, dementia, training on service users conditions – stroke care, diabetes, parkinsons disease etc. Staff said they had been encouraged to undertake National Vocational Qualification level 2 training and the Registered Manager stated that the National Minimum Standard regarding of 50 of care staff with National Vocational Qualification level 2 would be met in the future as she had a plan to achieve this. Recruitment records were inspected and found in some areas to be poor with up to date Criminal Records Bureau /Protection of Vulnerable Adults checks not in place when staff commenced employment, and a written reference from a relative of one of the staff, which does not provide an independent judgement. An Immediate Requirements Notice was served for this to be quickly rectified by the Registered Provider. St Bennetts Care Home DS0000006381.V311280.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of service users. EVIDENCE: Service users, staff and relatives said that they thought the Acting Manager ran the home well and that she was approachable and thoughtful. There was evidence on staff records that staff are beginning to be appropriately supervised and supported, with recent staff appraisals carried out by the Acting Manager. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 23 Staff Meetings have been held and were recorded though there have been minimal meetings in the past year. The Acting Manager said she planned to have more meetings to support staff and ensure practice issues were regularly discussed. Evidence of a Quality Assurance system could not be found by the Acting Manager, who said that this would be organised for 2007. A summary of the outcome is needed with the results included in the Statement of Purpose to inform prospective and current service users. There is a Health and Safety folder with Risk Assessments for safe working practices though other Risk Assessments for safe working practices were missing, e.g. use of ladders, any work needed regarding the lift, the need for window restrictors etc. The Acting Manager is to check this issue with the Environmental Health Officer so that it comprehensively covers all workplace risks. There was also a note on file that a hoist may not have been serviced since 9/8/05, over a year ago. The Acting Manager said this would be followed up. An inspector found that the cleaning trolley and cleaning cupboard with potentially dangerous substances on display was left unattended. The Acting Manager said this would be followed up with appropriate training provided. Service user monies records were generally found to be properly kept with running balances, though two signatures were not always recorded so that transactions are properly witnessed. The Acting Manager said this would be followed up. Staff members were asked the fire procedure and found to be aware of what steps to take place in the event of a fire. There was a note in the file that the outside fire escape steps were slippery when wet – the Acting Manager said she would follow this up to see it has been rectified. System testing was on the required schedule for emergency lighting, though not always for weekly fire bell testing (the last recorded test was on 8/1/07, over three weeks ago), and fire drills, as there had not been a required three monthly fire drill since 31/8/06, five months previously. There was a fire risk assessment on file, which the Acting Manager said she would review. The hot water temperature was checked in a bathroom and found to be 45c; the National Minimum Standard is 43c, the Acting Manager said that hot water temperature checks would be regularly carried out in the future, as there was evidence on file of hot water temperature checks carried out, though not at regular intervals. St Bennetts Care Home DS0000006381.V311280.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 2 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 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 3 1 X X X X X X 1 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X 3 X 1 St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 Requirement Care Plans need to be reviewed to ensure they fully meet the care needs of service users, including Risk Assessments to ensure their Health and Safety. There must always be referral to medical authorities in a swift manner when service users are injured. Medication systems must be in place to ensure medication security. A number of areas of the home are still in need of repainting (This was stated in the last Inspection Report and the timescale for action is overdue). Systems need to be put into place to ensure Infection Control at all times. Staffing levels need to be reviewed and increased to ensure that service users needs are met at all times. DS0000006381.V311280.R01.S.doc Timescale for action 01/04/07 2. OP8 13 01/02/07 3. OP9 12 01/02/07 4. OP19 23 01/04/07 5. OP26 12 01/02/07 6. OP27 18 01/03/07 St Bennetts Care Home Version 5.2 Page 26 7. OP29 19 Statutory staffing checks must be in place before staff commence employment. Further staff training is needed on a number of care issues (This was stated in the last Inspection Report and the timescale for action is overdue). The Health and Safety systems in the home must protect the welfare of service users from harm. This includes proper fire systems being in place, proper servicing of equipment and protection from dangerous substances. 01/02/07 8. OP30 18 01/08/07 9. OP38 13 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP3 OP19 OP27 Good Practice Recommendations The Assessment form need to be more detailed to ensure all service users needs are met. Facilities need to be signed to help orientate service users with disabilities. For reasons of staff recruitment it is strongly recommended that new staff do not have to pay for their own Criminal Records Bureau checks. St Bennetts Care Home DS0000006381.V311280.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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