Inspection on 23/10/08 for St Christopher`s Residential Home

This inspection was carried out on 23rd October 2008.

CSCI found this care home to be providing an Excellent service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Christopher`s Residential ... 26/10/06

St Christopher`s Residential ... 03/02/06

St Christopher`s Residential ... 21/07/05

St Christopher`s Residential ... 07/12/04

St Christopher`s Residential ... 26/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: St Christopher`s Residential Home 47/49 Rutland Gardens Hove East Sussex BN3 5PD     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jennie Williams     Date: 2 3 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: St Christopher`s Residential Home 47/49 Rutland Gardens Hove East Sussex BN3 5PD 01273327210 01293526991 terriehounsome@tiscali.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Theresa Hounsome Type of registration: Number of places registered: Mr Sandhu,Mrs Theresa Hounsome care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Service users must be older people aged sixty-five (65) years or over on admission The maximum number of service users to be accommodated is nineteen (19) Date of last inspection Brief description of the care home St Christophers Residential Home is a care home providing personal care for up to nineteen (19) older people. The home is situated in a quiet residential area in Hove, within walking distance to the seafront. There are nearby local amenities and access to public transport. There is restricted paid parking available in adjacent streets. Residents’ accommodation is provided over three floors in a large property that has been converted from two houses. Stair lifts are provided to ensure that residents can access all areas of the home. The home is not suitable for wheelchair users. All residents residing above ground floor must be mobile. There are thirteen single rooms with five being provided with en suite facilities. There are two rooms for shared Care Homes for Older People Page 4 of 30 Over 65 19 0 Brief description of the care home occupancy, of which one has en suite facilities. These rooms are used for single occupancy unless people have chosen to share. There are a number of communal toilet and bathing facilities located throughout the home to meet the needs of residents. The home is furnished to a high standard. Communal areas include a large lounge, dining area, quiet room, conservatory and a paved rear patio area. Current fees charged are between £400 to £650 per week. There are additional fees for hairdressing, chiropody and newspapers/magazines etc. A full list of what is not included in the fees can be found in the Statement of Purpose/Service Users Guide. This information was provided to the CSCI on the 18 November 2008. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. It was confirmed to the Inspector that people who use this service are called residents. For the purpose of this report, people who use the service will be referred to as residents. There are two registered providers of the service of which one of them is also the Registered Manager. For the purpose of this report, this person will be referred to as the Registered Manager. This unannounced key site visit took place over 6.8 hours on the 23rd October 2008. Evidence obtained at this site visit, previous information regarding this service and information that the CSCI have received since the last inspection forms this key inspection report. The last key inspection was undertaken on the 26th October 2006. Care Homes for Older People Page 6 of 30 Seven residents, of both genders and over the age of sixty-five years, were spoken with throughout the site visit. One residents care plan was inspected and specific areas of care were viewed in a further eight care plans. A visitor was spoken with. Both registered providers and three staff were spoken with throughout the visit. Two newly recruited staff files were viewed and training records for staff observed. The environment was briefly observed and some individual rooms were looked at, with individuals permission. Systems for the administration of medication were inspected and the quality assurance and quality monitoring system in place discussed. An Annual Quality Assurance Assessment (AQAA) was sent to the home prior to the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. An Annual Service Review was undertaken on 16 January 2008 and information provided in this has also been incorporated into this inspection report. There were fifteen residents residing at the home on the day of the inspection. What the care home does well: What has improved since the last inspection? What they could do better: The CSCI is confident that the home has sufficiently robust internal mechanisms to identify its own areas for improvement, as such only two requirements have been made as a result of this inspection. Good practice recommendations have been made in Care Homes for Older People Page 8 of 30 relation to medication and recruitment. Advice needs to be sought and confirmation obtained that the controlled drugs cupboard complies and is installed correctly to ensure compliance with current legislation. Thorough and robust risk assessments need to be undertaken on unguarded radiators and hot water pipes and action taken if identified as being needed. This will ensure the home is free from hazards and minimise risk to further safeguard staff and service users. Any minor shortfalls noted, of which no requirement or recommendation has been made, have been highlighted throughout the report of which was acted upon immediately or the registered providers confirmed they will address. The AQAA received from the home evidences that the home is working to improve the quality of the service provided at St Christophers Residential Home. It provides CSCI with information on what their plans for improvement are within the next twelve months. Staff and residents, when asked, could not identify any significant changes they would want to make in the running of the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs and expectations can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. Evidence: The home has a Statement of Purpose and Service Users Guide that provides prospective residents with information on the services and facilities provided at the home to make an informed decision if the service can meet their needs and expectations. The Registered Manager undertakes an assessment for all prospective residents to ensure that their needs can be met with the services and facilities provided at the home. Additional information is obtained from social services and other health Care Homes for Older People Page 11 of 30 Evidence: professionals wherever possible. There was a suitable pre admission in place for a resident who had recently been admitted. Residents spoken with confirmed that they or a representative visited the home prior to moving in. There is no dedicated accommodation to provide intermediate care, however respite is available if there is a place available. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are being met with the information provided in the care plans on the assessed needs of residents and are generally safeguarded by the medication procedures in place. Residents privacy and dignity are respected. Evidence: The Inspector viewed one care plan and specific areas of care within a further eight care plans. There was guidance in place for staff on how to meet the individual needs. Some minor shortfalls were noted of which the Registered Manager addressed immediately. Three staff spoken with confirmed that they find the care plans informative and easy to understand. Whilst the majority of residents asked confirmed that staff discuss their care with them, two residents identified that they wouldnt want to read their care plans and leave this for the staff to deal with. One resident identified that they do not want to be involved in their care planning. One resident confirmed that they had been involved in their reviews. Staff confirmed that they review care plans with the Care Homes for Older People Page 13 of 30 Evidence: residents. Care plans are reviewed every 3 months or earlier if the needs of an individual changes. The Registered Manager undertakes a client assessment if someones needs changes. The Registered Manager confirmed that she monitors care plans every 6 weeks. It was confirmed that reviewing care plans every 3 months and using a communication book works well within the service. In order to fully comply with Standard 7, care plans should be reviewed on a monthly basis. There is a key worker system in place. The four residents asked did not know who their key worker was, however staff confirmed that all residents were written to advising them of who their key worker was and what the role entailed. Residents felt that all their needs were being met at the home. A visitor confirmed that staff discuss the care of their relative with them. There was evidence that residents have access to health professionals when the need arises. All residents have access to their own GPs and referrals are made to the relevant professional bodies when required. Daily notes are not recorded, however staff use a communication book to advise the next staff on duty about individuals. Notes are written within an individuals file if there is any changes to an individuals well being. It is recommended that the home write daily notes on individuals. Daily records are a good source of evidence to show that care is being provided, as detailed in the care plan. Daily records when well written, help ensure a consistent approach and good quality of care for residents. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. Using one communication book for all residents, the home must ensure that confidentiality is promoted should someone request to view the records the home has written about the resident. It was confirmed that there are policies and procedures in place for all aspects of dealing with medication and records are maintained of medicines received into and leaving the home. Medication Administration Records (MAR) charts were generally well maintained. There was one incident where medication had been signed for, however not administered. No requirement or recommendation has been made in relation to this, as the Registered Manager will address this with the individual involved. It was confirmed that the supplying pharmacist undertakes an audit of the medicines every three months. Only staff who have received training administer medicines. Residents are provided with an opportunity to self medicate. Two residents were selfadministering. The home must ensure detailed risk assessments are undertaken for Care Homes for Older People Page 14 of 30 Evidence: residents who self medicate to ensure that they are capable and it is safe for themselves and others to do this. The Registered Manager contacted their supplying pharmacist whilst the Inspector was still on site to request support and advice regarding risk assessments. The home will also seek advice to ensure the controlled drugs cabinet complies and is attached to the wall in line with current legislation. The Registered Manager was advised that temazepam should be stored as a controlled drugs, she will seek advice from this from their supplying pharmacist. Written confirmation was received by the home two weeks following the inspection to identify that risk assessments have been implemented and a policy and procedure implemented in relation to self-medicating. The home must ensure that information is provided to identify what level of self-administration the individual undertakes and what the home undertakes. ie: do they order and arrange their own prescription or does the home do this. It is recommended that all hand written prescriptions are double signed by two staff who are trained in medication to further safeguard colleagues and residents from errors occurring. All residents spoken with confirmed that they felt their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents and were heard to be calling them by their preferred term. Staff were noted to knock on residents doors prior to entering. A resident also confirmed that staff always knock on their room door before entering. A comment from a resident was staff are very polite and we can ask for anything. It was observed that there are lists of residents names and room numbers located throughout the home to assist staff in the event of an emergency occurring. The Registered Manager confirmed that residents were asked and were happy with this personal information being displayed. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Evidence: Residents spoken with confirmed that routines and their lifestyle within the home are their own choice. Residents were observed to move freely within and outside of the home environment at the site visit. A resident confirmed that there are no restrictions imposed at all within the home. One resident commented we can go out and about. One resident advised the Inspector that they still maintain links with clubs within the community and they can do as I like. Staff facilitate activities within the home. The majority of residents confirmed that they felt there was enough activities provided at the home should they choose to be involved. For those that felt there could be more offered, when asked, could not identify what else the home could offer them to make their living at the home more enjoyable. A comment received was cant offer anything more to make time more enjoyable. One resident identified that they would like a musical evening and this information was passed onto the Registered Manager. Care Homes for Older People Page 16 of 30 Evidence: Whilst outings are arranged, staff commented that the residents sometimes are reluctant to make use of these opportunities. Staff identified that they are aware of the need to increase the enthusiasm amongst residents when outings are arranged. Weather permitting and when enough residents are interested, trips are arranged monthly. Visitors are welcomed and encouraged to visit the home. There are no restrictions imposed for visitors. A visitor spoken with confirmed that they were welcomed at the home and that there were no restrictions imposed. It was observed that all residents are offered a glass of sherry prior to lunch. Residents were complimentary about the food provided at the home. Comments ranged from not bad, not excellent, very nice, and if dont like main meal, offered alternative. The Registered Manager confirmed that the menu is devised on a weekly basis, with residents generally being involved in this process. Meals are prepared freshly each day. An alternative is offered if residents do not like the main meal being provided. A resident stated that they had no involvement in the menus. The Registered Manager confirmed that the menu continues to be well balanced and nutritious. The AQAA identifies they have introduced more varied menus such as stir frys and authentic spicy foods for those who enjoy this cuisine. The Registered Manager confirmed that they have received four scores on the door from when Environmental Health undertook their assessment. It was confirmed that any shortfalls identified have been addressed. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Safeguarding Adult procedures and the training of staff ensure residents are safeguarded. Evidence: There is a complaints procedure available at the home and four of the residents spoken with confirmed that they know who to speak to and feel comfortable to make a complaint and feels that appropriate action would be taken to address their concerns. One resident stated they would not feel comfortable, however if it were a serious matter they would speak up. A visitor spoken with also confirmed that they would feel comfortable raising any concerns with the service. There is a book located at the home where anyone can write in if they wish to raise any issues anonymously. The Registered Manager confirmed and the AQAA identified that there has been no complaints made since the last inspection. Staff spoken with confirmed that they are provided with Safeguarding Adults training (Protection of Vulnerable Adults) and this includes whistle blowing. The three staff confirmed that they would feel comfortable to whistle blow within the service. The Registered Manager will look into accessing the Safeguarding Adults training provided by the local authority specifically designed for managers. Care Homes for Older People Page 18 of 30 Evidence: The Registered Manager informed the Inspector at the site visit, that they have raised a Safeguarding Adults alert with the local social services Safeguarding Adults team. This incident is currently being dealt with through the local Multidisciplinary procedures. This alert is not related to any practices within the home. Records are maintained for any complaints and Safeguarding Adults alerts/investigations made to the service. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a clean, well maintained and homely environment and are provided with comfortable communal facilities. Evidence: Rooms are located over three floors with stair lifts been installed to assist residents to access all floors. There are two mezzanine landings. The home is two buildings that have been joined together for its current use. One side of the home has a stair lift that goes to the top floor. The Registered Manager confirmed that everybody who resides above the ground floor must be able to mobilise. This information must be included in the Statement of Purpose/Service Users Guide. The location of the room available is taken into account when assessing any news prospective resident. There are 13 single rooms of which 5 are provided with en suite facilities. Two rooms are for double occupancy, however are used for single occupancy unless people have chosen to share. One of the double rooms has en suite facilities. There are suitable numbers of communal toilets located throughout the home and three communal bathrooms throughout the home where assisted bathing facilities are provided. Residents have access to a paved patio area at the rear of the home, where table and chairs are provided for there use. Care Homes for Older People Page 20 of 30 Evidence: The ASR, AQAA and information received at this site visit identifies that work has been done and is continuing to be done to improve the environmental standards within the home. Residents and staff spoken with were happy with the environment within the home. Rooms were seen to be personalised to reflect the individuals choice and preference. There is a call bell system at the home and all residents bedrooms are provided with a call point to ensure that residents can call for assistance when required. The home was clean and communal areas free from offensive odours on the day of the inspection. An offensive odour was limited to one area, of which the home is aware of and is addressing. Alcohol gel is provided at the entrance of the home for visitors to use when entering and leaving the service. This practice assists in promoting infection control. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are being met with the number and skill mix of staff on duty and are generally safeguarded by the recruitment procedures in place. Evidence: Residents spoken with were very complimentary about the staff working at the home. Residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. Staff spoken with stated that they enjoyed working at the home. Some comments received about the staff were; excellent, marvellous, friendly and very polite. The AQAA identifies that one part time care staff member has left in the last 12 months and no agency or temporary staff have been required to cover any shifts in the last 3 months. The Registered Manager informed the Inspector that since completing the AQAA, an additional full time care staff member has left employment. This low turnover of staff assists in ensuring continuity of care is provided. An additional two new staff have been recruited. It was confirmed that there are two care staff members working during day time hours, plus management and one staff member works a waking night. The Registered Manager confirmed that they have lone working risk assessments in place to ensure all people are protected. Care Homes for Older People Page 22 of 30 Evidence: Two new staff files were viewed. Evidence at the home identified that a staff member had commenced work without a Protection of Vulnerable Adults (POVA) First check. Both Registered Providers confirmed that no staff member commences employment without a POVA First check having been received. It was confirmed that a POVA First check clearance had verbally been informed to the home from their umbrella agency. This was prior to the worker commencing at the home. The home must ensure that clear written evidence is provided and available for viewing at the service. One reference was provided verbally to the service. It was confirmed that the home will ensure the written reference will be returned. It was discussed with a Registered Provider that clearer dates of employment should be provided. The AQAA received confirms that all people that have worked at the home in the past 12 months had satisfactory pre-employment checks undertaken. A staff member confirmed that they felt their recruitment was done fairly. Staff spoken with stated that they are kept up-to-date with mandatory training and are provided with opportunities to undertake additional training relevant to their roles. A list of training opportunities was noted to be on display for staff. The Registered Manager confirmed that once a month general quizzes are provided to staff on various subjects to ensure staff have a good understanding eg. medication quizzes. New staff undertake an in house induction. It was discussed with the Registered Manager that she ensures this complies with the Common Induction Standards as set by Skills for Care. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff and residents benefit from a well managed home and the quality assurance system in place ensures the home is run in the best interest of residents. Evidence: Staff were complimentary about the management at the home and find the Registered Providers and Registered Manager very approachable and supportive. It was observed throughout the inspection that both had a good professional rapport with residents. The manager is registered with the CSCI and has the necessary skills, experience and competencies to manage the service. The AQAA identifies that the management are actively involved on a day to day based, ensuring continuity of service and supervision. There is quality assurance and quality monitoring system within the home. Resident questionnaires are undertaken twice a year with alternative themes. It was discussed with the Registered Manager that a general survey be implemented, covering all relevant themes about living in a home to evidence that they are maintaining the same Care Homes for Older People Page 24 of 30 Evidence: level of satisfaction for residents. Feedback is actively sought from relatives/representatives and visiting health professionals on an annual basis. Results are analysed and action taken if any areas for improvement have been identified. Results are not currently shared with those with an interest within the service. Discussions took place with the Registered Manager on ways they can ensure that results are shared with residents, staff and other stakeholders. The home has trialled residents meetings, however found that these were not working. Staff meetings are held where staff are provided with an opportunity to raise any issues. Staff surveys are not implemented as staff and the Registered Manager confirmed that there is openness and transparency within the service and would feel comfortable raising any issues/concerns. The AQAA identifies areas that the service are aware of what they could do better and provides us with information on areas that they have improved within the last 12 months and their plans for improvement in the next 12 months. Discussions were had with the Registered Manager on ways to ensure the information in the AQAA is improved the next time we ask for it. All key standards need to be addressed and clearer evidence provided to demonstrate the high level of service the home is committed to providing. The home had sent the CSCI copies of two letters they had received from a family of a previous resident wishing to make a donation to the home and to say thank you for the wonderful care St Christophers had provided to their relative. It identified the manager and staff had been truly supportive and had kept them informed of the relatives well being, despite living overseas. The home does not hold any personal allowances for residents. Residents manage their own finances or make their own arrangements should they require assistance. The AQAA identifies that there are relevant policies and procedures in place and these have recently been reviewed to ensure that they are reflective of current guidelines. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. A new fire protection system has been installed. There were unguarded radiators, that are not guaranteed low surface temperature, and unguarded hot water pipes noted throughout the environment. Furniture had been placed in front of some radiators. Management was advised that should these remain unguarded, thorough and robust risk assessments must be in place to evidence that residents are not placed at risk. The providers demonstrated a willingness to ensure compliance and a provider rang someone whilst the Inspector was still on site to arrange quotes for radiator guards. There was material on site that a provider showed Care Homes for Older People Page 25 of 30 Evidence: the Inspector that can be used to cover hot water pipes and assured that this would be addressed immediately. It was confirmed that all relevant health and safety checks are undertaken on a regular basis. The home reports relevant accidents/incidents to the CSCI as required by regulation. The AQAA identifies that equipment, as applicable, has been services or tested as recommended by the manufacturer or other regulatory body. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 That advice be sought and written confirmation obtained that the controlled drugs cabinet complies and is installed correctly. This is to ensure compliance with current legislation. 30/01/2009 2 38 13 That a comprehensive risk assessment is undertaken regarding unguarded radiators and hot water pipes and action taken if identified as being required. This will ensure the home is free from hazards and minimise risk to further safeguard staff and service users. 19/12/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 To ensure daily notes are recorded as evidence to show that care is being provided, as detailed in the care plan. Page 28 of 30 Care Homes for Older People 2 3 9 9 To have written documentation to clarify the exact level of self-administration. That hand written prescriptions are double signed by staff who have undertaken medication training to further safeguard service users and colleagues. That the home ensures that written evidence is maintained within the home and available for inspection to evidence that robust recruitment procedures are followed. 4 29 Care Homes for Older People Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - 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!