Inspection on 02/02/06 for St Catherine`s Residential Home

This inspection was carried out on 2nd February 2006.

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 Catherine`s Residential Home 28/10/08

St Catherine`s Residential Home 11/07/07

St Catherine`s Residential Home 01/06/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE St Catherine`s Residential Home 326/328 Boldmere Road Boldmere Sutton Coldfield West Midlands B73 5EU Lead Inspector Brenda O`Neill Unannounced Inspection 2nd February 2006 09:30 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 DS0000064065.V280506.R01.S.doc Version 5.1 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. DS0000064065.V280506.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Catherine`s Residential Home Address 326/328 Boldmere Road Boldmere Sutton Coldfield West Midlands B73 5EU 0121 377 8178 0121 382 8953 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) Ms Pearl Goss Ms Pearl Goss Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places DS0000064065.V280506.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Provide assisted bathing/showering facilities in ground and first floors within eighteen months of registration. Any of the four rooms used for double occupancy must be in excess of 16sqm so each occupant has adequate space for furniture and belongings. Extend the nurse call system into all bathing, toilet and showering facilities within six months of registration. Fit bedroom door locks (which are suited) within twelve months of registration. Provide all items of furniture as detailed within the National Minimum Standards within twelve months of registration. In addition to the manager and ancillary staff a minimum of three care staff must be on duty each morning, two care staff during afternoons and evenings and two care staff on night duty (one on waking duty and one sleeping in). 29th September 2005 Date of last inspection Brief Description of the Service: St Catherine’s is a large detached Victorian property that is situated on the Boldmere Road, Sutton Coldfield. It is within easy reach of shops and local facilities. The home is registered to provide accommodation to 22 residents for reasons of old age. Accommodation is provided over three floors in a mixture of single and double rooms, some of which have en-suite facilities, and a shaft lift gives access to the first floor and second floors. Communal accommodation consists of a lounge, dining room and a conservatory that looks out onto an enclosed wellmaintained garden. The home has one assisted bathroom on the top floor of the home, a bathroom and shower room on the first floor and two bathrooms on the ground floor, only the toilet facilities are used in these rooms by the residents due to accessibility difficulties. The home also has office space, staff room, laundry and kitchen which are all located on the ground floor. There is adequate parking to the front of the property with ramped access to side entrances. DS0000064065.V280506.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day in February 2006 and was the second of the two statutory visits for the home for 2005/2006. To get a full overview of all the standards assessed this report should be read in conjunction with the report written after the inspection on September 29th 2005. During this visit a partial tour of the premises was undertaken, two resident and two staff files were sampled as well as other care and health and safety documentation. The inspector spoke with the owner/manager, two members of staff and briefly to three residents. The inspecting pharmacist also visited the home unannounced on February 7th 2006 to assess the medication system. What the service does well: What has improved since the last inspection? Numerous improvements had been made at the home since the last inspection which had halved the number of requirements made following the last inspection. The statement of purpose and service user guide for the home had been updated ensuring prospective residents had all the information they required to make an informed choice as to whether the home could meet their needs. All residents were being issued with contracts which detailed the terms and conditions of their stay at the home. The care plans for the residents had been much improved and detailed all the needs of the residents and how they were to be met. DS0000064065.V280506.R01.S.doc Version 5.1 Page 6 The medicine management had significantly improved and now reached the required standard. There was recorded evidence that some consultation had taken place with the residents as to what activities they wished to be available to them and about the food on offer at the home. Action was being taken as a result of this and there was evidence that a greater range of activities were being offered to the residents on a more regular basis. The safety of the residents had improved: The manager had been liaising with the fire officer in relation to the requirements at his last visit and the vast majority of these had been met and the practice of wedging fire doors open had stopped. The flooring that was a tripping hazard had been addressed. The issues around hygiene and infection control that were raised at the last inspection had been met. The manager had undertaken a thorough premises risk assessment to highlight any shortfalls. The dining room had been redecorated and had new chairs which enhanced the comfort of the residents. 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. DS0000064065.V280506.R01.S.doc Version 5.1 Page 7 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 DS0000064065.V280506.R01.S.doc Version 5.1 Page 8 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, 5 There was adequate information available for any prospective residents to be able to make an informed decision about whether the home could meet their needs. Assessments needed to be undertaken on any prospective residents prior to admission to the home to ensure their needs were known and could be met by staff. Prospective residents were able to visit the home prior to admission and were issued with a contract at the point of admission. EVIDENCE: The statement of purpose and service user guide for the home had been updated by the new owner/manager and apart from some minor amendments the documents included all the relevant information. It was recommended that all the residents in the home were issued with an updated copy of the service user guide. Two residents’ files were sampled, both had been admitted by the current manager. Both files included copies of the assessments undertaken by the staff at the home. The assessment documentation included all the required areas and was quite comprehensive however one had been completed after the admission of the resident. It was important that the assessment of any DS0000064065.V280506.R01.S.doc Version 5.1 Page 9 prospective residents’ needs was done prior to admission to the home so that staff were aware of the needs before admission and able to make an informed decision as to whether the home could meet them. There was evidence that prospective residents were able to visit the home prior to admission. Both of the residents whose files were sampled had been issued with a contract that detailed all the necessary information about the terms and conditions of their stay at the home. DS0000064065.V280506.R01.S.doc Version 5.1 Page 10 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 Care plans were well detailed and included all the needs of the residents and how they were to be met by staff. Risk assessments for the residents needed to be further developed to ensure any risks were identified and minimised. The health care needs of the residents were being met. The systems for medicine management have improved since the last inspection. Clear comprehensive arrangements had been installed to ensure service users medication needs are met. EVIDENCE: Two residents’ files were sampled and both included up to date care plans. The system for care planning had been improved since the last inspection and the plans included some very good detail of the needs of the individual residents and how staff were to meet the needs. The care plans covered a vast area of topics including, personal care, medical needs, dietary requirements, mental health, mobility and social needs. There was clear detail of what the residents were able to do for themselves, their likes, dislikes and preferences, where they needed staff assistance and what that assistance was. One of the files sampled included a booklet entitled assessment for good care planning which included numerous risk assessments including, nutritional and DS0000064065.V280506.R01.S.doc Version 5.1 Page 11 tissue viability screenings and falls assessments. The other file did not include any risk assessments at all. Both residents also needed to have manual handling risk assessments that detailed the actions to be taken by staff in the event of a fall. The daily records sampled were well detailed in respect of the residents’ general welfare and evidenced that the personal care needs were being met and any health care needs were being identified, followed up and monitored. Visits made by health care professionals were recorded separately from the daily records which made them easy to track. All audits undertaken demonstrated that the medicines had been administered as prescribed. Robust systems had been installed to check the prescriptions and the dispensed medicines into the home. Good stock rotation of medicine was evident. The new owner was keen to improve practice further and new policies had been drafted. Some staff had received accredited training in the safe handling of medicines. Residents appeared to be treated with respect and their right to privacy was generally upheld. Residents were addressed appropriately by staff and all were suitably attired. Medical consultations took place in the privacy of the residents’ bedrooms. Residents could meet with their visitors in the privacy of their bedrooms or one of the quieter areas of the home. There was a telephone for the use of the residents which did allow for some privacy when making or receiving telephone calls as it was in an area that was not in constant use however privacy would be further enhanced if it could be relocated to an area where residents would never be overheard. All the bedrooms had a lockable facility for the use of the residents but the bedroom doors did not have locks fitted. At the time of the inspection the manager/owner was obtaining some quotes for this work to be carried out as this is one of the conditions of registration and will further enhance the privacy of the residents. DS0000064065.V280506.R01.S.doc Version 5.1 Page 12 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, 14 There had been some consultation about residents’ preferred leisure activities and there were activities on offer for those residents who wished to take part. Residents were helped to exercise choice and control over their lives. EVIDENCE: There did not appear to be any rigid rules or routines in the home. Residents were seen to wander freely around the home, spend time quietly in their rooms and sit chatting. During the course of the inspection a church service took place in the conservatory for those who wished to attend and staff facilitated a game of bingo. There was recorded evidence that some consultation had taken place with the residents as to what activities they wished to be available to them and about the food on offer at the home. Activities on offer included dominoes, reminiscence, exercise, card games, bingo and sing-a-longs. There had also been parties in the home for a 100th birthday and for Christmas. The new care planning system included the preferred leisure time activities of the residents. The manager was very committed to on going consultation with the residents and ensuring action was taken in response. Residents were being helped to exercise choice and control over their lives wherever possible. There was evidence in their care plans of where they were able to make to choices and that these were to be offered, there was DS0000064065.V280506.R01.S.doc Version 5.1 Page 13 documented evidence of residents choosing to have their meals in their rooms and that this was not an issue and evidence that residents had been consulted about their likes, dislikes and preferences. Residents appeared to be able to get up and go to bed and go out with friends or relatives when they wished. Residents were encouraged to personalise their rooms to their choosing and evidence of their personal possessions were seen during the tour of the home. The manager stated that the requirement made at the previous inspection in relation to keeping food records had been met. The records for these were not sampled however the pro forma being used was and it was found to be appropriate. DS0000064065.V280506.R01.S.doc Version 5.1 Page 14 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 The complaint procedure needed to be amended to ensure complainants were aware they could refer a complaint to the CSCI at any point. To ensure the protection of the residents staff needed to undertake further training in adult protection. EVIDENCE: There was a complaint procedure for the home and it was included in the service user guide. The procedure needed to be amended to ensure that any complainant was aware they could refer a complaint to the CSCI at any point. There had been no complaints lodged at the home or with the CSCI. There were policies and procedures on site for adult protection and whistle blowing. These were thorough and up to date. It was strongly recommended that the manager obtained a copy of the multi agency guidelines for adult protection to complement these. There were also policies and procedures on site for restraint and handling aggression. Staff had received some training in adult protection issues that had been organised by the previous manager however this was only one and a quarter hours in duration and it was difficult to know what would have been covered in this period of time. The manager was advised she should arrange further training for staff that was in more depth. DS0000064065.V280506.R01.S.doc Version 5.1 Page 15 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, 24, 25, 26 The home offered residents clean, comfortable, spacious and well maintained accommodation. Some issues needed to be addressed to ensure there were adequate, accessible bathing facilities available for the residents. EVIDENCE: There had been no changes to the layout of the home since the last inspection which was generally suitable for its stated purpose and it was well maintained. Some conditions of registration had been imposed on the owner/manager to ensure the home met with the National Minimum Standards. The manager had been liaising with the fire officer in relation to the requirements at his last visit and the vast majority of these had been met. The fire officer was to visit the home again to ensure compliance. At the last inspection several fire doors were found to be wedged open and it was pleasing to note this practice had stopped. The issue raised at the last inspection in relation to the carpet tiles that were lifting had been addressed and a potential tripping hazard had been addressed. DS0000064065.V280506.R01.S.doc Version 5.1 Page 16 There was adequate communal space in the home comprising of a large lounge, dining room and a large conservatory. All were adequately decorated and furnishings and lighting were domestic in character. The dining room had been redecorated and had had new chairs since the last inspection and was also to have new lighting. As at the last inspection there were some bedrooms that had en-suite facilities and there were a number of bathrooms throughout the home. There was however, only one assisted bathing facility, this was the medic bath on the second floor. On the first floor there was a shower but this was not accessible to the residents and only the toilet in this room was used. The two bathrooms on the ground floor were very small and not adapted and again only the toilets were used. The home needed to have at least one assisted bathing facility on each floor and one of the conditions of registration was in relation to this. The manager was in the process of obtaining guidance from architects in relation to this. The aids and adaptations in the home included, shaft lift, grab rails and ramped entrance. There was an emergency call system throughout the home however the manager needed to ensure it was accessible from all bathing and toilet facilities. The bedrooms seen were of good size. The registration of the home allows for four rooms to be used as doubles, however only one bedroom was equipped to be used as a double at the time of the inspection. The manager needed to ensure that if any other bedrooms were to be used for double occupancy that they were in excess of 16 square metres so that each occupant had adequate space for furniture and belongings. This was also a condition of registration. The bedrooms were well furnished and nicely personalised. Not all the rooms had all the furnishings required by the National Minimum Standards and although rooms had a lockable facility the residents could not lock their bedroom doors. Again these issues were included as conditions of registration. The home was centrally heated and all radiators had been guarded. All rooms were naturally ventilated and window restrictors had been fitted where necessary. The manager was making arrangements for the water system to be checked for the prevention of legionella. The home was clean and hygienic. The requirement made following the last inspection in relation to cleaning the underside of the seat in the medic bath had been met. The laundry was appropriately located and a new washing machine had been installed and a new tumble drier was on order as the existing one had broken down. The issues raised at the last inspection in relation to the kitchen, for example, COSHH items left out and dirty paper covering the shelving had generally been met. The exception was that there were still some opened food items in the fridge that had not been dated on opening. At the previous inspection some of the food storage was at the rear of DS0000064065.V280506.R01.S.doc Version 5.1 Page 17 the laundry which was not appropriate. This had been addressed and all food was now stored in the kitchen area. DS0000064065.V280506.R01.S.doc Version 5.1 Page 18 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 There was a stable staff group at the home which was good for the continuity of care of the residents. The manager needed to apply to the CSCI to vary the condition of registration in relation to staffing and include evidence that the residents’ needs could be met with staffing numbers reduced. Recruitment procedures needed to be improved to ensure they safe guarded the residents. All new employees needed to undertake structured induction training to ensure they were equipped with the necessary skills and knowledge to fulfil their roles. EVIDENCE: There had been little staff turnover at the home since the new owner/manager had taken over and many of the staff had worked at the home for a considerable amount of time. This was very good for the continuity of care of the residents and friendly relationships were evident between the staff and residents. The condition of registration in relation to staffing stated that there must be three care staff on duty each morning, two care staff during afternoons and evenings and two care staff on night duty, one waking and one sleeping in. As at the last inspection this was not being adhered to during the morning shift, as there were only two care assistants on duty. This was discussed with the manager and she was made aware that she must apply to the CSCI in writing to vary this condition and include evidence as to how the residents’ needs would be met with reduced staffing numbers. The home also employed a domestic assistant five days a week and a cook seven days a week. DS0000064065.V280506.R01.S.doc Version 5.1 Page 19 The recruitment and training files for two staff employed by the present owner/manager were sampled. The recruitment files were incomplete. One of the staff had not completed an application form, there was no CRB or POVA first check, no evidence that the employee was eligible to work in this country and no medical declaration. The second file did not have any evidence of a CRB or POVA first check being undertaken and no proof of I.D. Both files included two references. These issues were discussed with the manager and she was aware of the requirements and had identified an umbrella body to undertake the required CRB checks. Well over 50 of percent of the care staff employed at the home were qualified to NVQ level 2 or above. There was evidence that the majority of staff had undertaken a range of training and further training was planned including, fire, manual handling, skin care, first aid and dementia. The manager had also arranged for the two new staff to undertake an induction day off site in February. One of the new employees had evidence on her file that she had undertaken a TOPSS induction course at her previous employment but there was no record of any induction at St. Catherine’s. The other file did not evidence that any training had been undertaken. The manager needed to ensure that all new employees undertook induction training in line with the specifications laid down by Skills for Care. It was strongly recommended that all staff had individual training records and that a training matrix was set up for the staff team to enable easy tracking of the training they had completed. DS0000064065.V280506.R01.S.doc Version 5.1 Page 20 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 The owner/manager ensured the smooth running of the home in a competent manner and several improvements had been made in a relatively short space of time. Further improvements were needed to ensure residents at the home were fully safeguarded. EVIDENCE: The owner/manager of the home had taken over approximately six months prior to this inspection and several improvements had been made in quite a short space of time. The manager had many years experience of caring for elderly people and the running of a care home. She had a relevant management qualification but had chosen to also undertake the Registered Manager’s Award and will then undertake the required care modules to give her all the required qualifications. It appeared that relationships between the manager, residents and staff were very good. DS0000064065.V280506.R01.S.doc Version 5.1 Page 21 There had been some consultation with the residents about leisure activities and the meals being offered and the manager showed commitment to furthering this. The home needed to have a quality assurance system in place based on seeking the views of the residents in order to be able to continually improve the service offered at the home. The manager stated she did not manage any money on behalf of the residents and that generally the residents had no issues of concern in this area. One resident’s access to money had caused some concern and ways of overcoming this were discussed. Some of the residents continued to hold small amounts of their own money for every day items. The health and safety of the staff and residents was generally well managed and the manager was committed to ensuring that staff had updated training in safe working practices. The fire logbook was checked and all the required checks were up to date. As requested at the last inspection there was evidence on site that the gas equipment had been serviced. As previously mentioned the manager needed to ensure that the water system was checked for the prevention of legionella. Since the last inspection thorough premises risk assessments had been undertaken and highlighted any areas that needed to be addressed. The notification to the CSCI of any events detailed under Regulation 37 had improved however it was noted that some incidents and accidents had not been notified, for example, accidents where residents had sustained injuries. Accident recording was generally comprehensive however it was noted that one resident had sustained two falls and only one of these had been recorded in the accident book. DS0000064065.V280506.R01.S.doc Version 5.1 Page 22 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 1 2 X 2 2 2 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 DS0000064065.V280506.R01.S.doc Version 5.1 Page 23 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 OP3 Regulation 14(1) Requirement The manager must ensure that prior to admission to the home a comprehensive assessment of the individuals needs is undertaken and records maintained. Previous time scale of 01/12/05 not met. All residents must have manual handling risk assessments that include details of the actions to be taken by staff in the event of a fall. Previous time scale of 01/12/05 not met. All residents must have personal risk assessments in place. All residents must have tissue viability and nutritional screenings. The complaints procedure must be amended to ensure complainants are aware they can refer a complaint to the CSCI at any point. Staff must undertake appropriate training in the prevention of abuse. Assisted bathing/showering DS0000064065.V280506.R01.S.doc Timescale for action 01/03/06 2. OP7 13(5) 01/04/06 3. 4. 5. OP7 OP8 OP16 13(4)(c) 12(1)(a) 22(7)(b) 01/04/06 01/04/06 14/03/06 6. 7. OP18 OP21 13(6) 23(2)(j) 01/05/06 12/02/07 Page 24 Version 5.1 (n) 8. OP22 23(2)(n) 9. OP24 16(2)(c) 10. OP24 12(4)(a) 11. OP25 13(3) 12. OP26 13(3) 13. OP27 18(1)(a) 14. OP29 19(1)(a) (b) Sch2 15. OP30 18(1)(a) 16. OP31 9(2)(b)(i) facilities must be povided on the ground and first floors. Previous time scale had not expired. The emergency call system must be extended to all bathing, toilet and showering facilities. Previous time scale given had not expired. All bedrooms must be equipped with all the furnishings as detailed in the National Minimum Standards. Previous time scale given had not expired. Suited bedroom door locks must be fitted. Previous time scale given had not expired. There must be evidence on site that the water system is regularly checked for the prevention of legionella. Previous time scale of 01/12/06 not met. All opened foods stored in the fridge must be dated on opening. Previous timescale of 30/09/05 not met. The manager must apply for a variation to the condition of registration in relation to staffing numbers. Previous time scale of 01/11/05 not met. The manager must ensure that all the documentaion detailed in schedule 2 of the Care Homes Regulations is obtained for all staff prior to their commencing their employment. All new employees must undertake induction induction training that complies with the specifications laid down by Skills for Care. The registered manager must be qualified to NVQ level 4 in care DS0000064065.V280506.R01.S.doc 12/02/06 12/08/06 12/08/06 01/03/06 01/03/06 01/03/06 01/03/06 01/04/06 01/06/06 Page 25 Version 5.1 17. OP33 24 18. OP38 37 19. OP38 12(1)(a) and management or the equivalent. The home must have a quality assurance system in place that is based on seeking the views of the residents with a view to continually improving the service on offer. The CSCI must be notified of all events in the home detailed under Regulation 37 of the care homes regulations in a timely manner. Previous time scale of 01/11/05 not met. Any accidents sustained by the residents must be recorded in the accident book. 01/06/06 01/03/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP1 OP10 OP9 OP18 OP30 Good Practice Recommendations It is recommended that all residents are issued with a copy of the updated service user guide. It is recommended that the telephone for the use of the residents is relocated to an area where they cannot be overheard. Undertake staff drug audits before and after a medicine round to confirm staff competence in medicine management. It is strongly recommended that the manager obtains a copy of the multi agency guidelines for adult protection. It is recommended that all staff have individual training records and that a training matrix is set up for the staff team. DS0000064065.V280506.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 DS0000064065.V280506.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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