CARE HOMES FOR OLDER PEOPLE
St Clair House Care Home 32 Basset Road Camborne Cornwall TR14 8SL Lead Inspector
Lynda Kirtland Unannounced Inspection 9:30am 1st and 15th April 2008 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 Clair House Care Home DS0000041642.V361775.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 Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Clair House Care Home Address 32 Basset Road Camborne Cornwall TR14 8SL 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) 01209 713273 01209 610699 stclaircare@yahoo.co.uk stclaircare@yahoo.co.uk St Clair Care Limited Mr David William Maund Mr David William Maund Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st May 2007 Brief Description of the Service: St Clair provides care and support for up to eighteen elderly people. The registered provider is St Clair Care Limited. Mr David Maund, the owner of the home, is also the registered manager. The home is a two storey Georgian building, which has been extended at the rear. The home is situated close to the town of Camborne where a range of amenities and facilities are available. The home generally has satisfactory access for people who experience disabilities with bedrooms situated on both floors and a passenger lift is also provided. The ground floor provides two homely communal sitting rooms at the front and rear, and an attractive dinning room. The building is maintained to a good standard. There are very attractive and well-maintained gardens are at the rear of the home. A copy of the full inspection report is available from the manager, and it is suggested a copy is requested from them or CSCI if required. The range of fees at the time of the inspection is £470 to £595 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
It is to be noted that all sections of the report, with the exception of the complaints/ adult protection section are rated as achieving good outcomes for the people who use the service. However as there has been a safeguarding issue in the home this has meant that the overall rating of the home has achieved an adequate rating. A key inspection took place on 1 April 2008 and a further visit to the home on the 15 April allowed the opportunity to meet with the registered providers who were absent on the first day. The visits lasted for approximately 10 hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that people who use the service needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved interviews with people who use the service, observation of their daily life and care provided. There was an inspection of the home’s premises and of written documents concerning the care and protection of the residents and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the registered providers. The principle method used was case tracking. This involves examining the care notes and documents for a select number of people who use the service and following this through with interviews with them and staff working with them. This provides a useful, in-depth insight as to how their needs are being met in the home. At this inspection, three people who use the service were case tracked. In talking with some of the people who use the service they said that they were ‘happy’, ‘care is excellent’ and ‘its good here’. They cold not think of any improvements on the care and services that St Claire’s House currently provides. The Commission received the Annual Quality Assurance Assessment, which is a questionnaire that the registered provider completed. The AQAA describes the services and facilities that St Claire’s provide and identifies what areas they do well in and where they want to make further improvements. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 6 What the service does well:
A Statement Of Purpose and Service Users guide informs prospective and current residents of the facilities and services that St Claire’s House provide. Each resident admitted to the care home is provided with a contract or terms and conditions of residency. New residents to the home confirmed that they met with a member of the management team prior to admission so that they were aware of what care they would receive at St Claire’s House. People who use the service commented this was done in a ‘sensitive’ and ‘informative’ manner and did not feel this area could be improved upon. From inspection of case records it was evident that staff undertake their own assessment plus gains the views and opinions of any specialist workers involved with the individual. From this an individual plan of care that summarises the person’s needs is implemented. The care plan forms the basis of the care and support provided. The plans are regularly reviewed to make sure the person’s needs are met at all times. People who use the service were positive about the care and support provided by the staff and said the staff was flexible and responsive to their needs. Some comments include ‘I get spoilt here’ and ‘nothing is too much trouble…staff are so helpful’. People who use the service also stated they were always treated with dignity and respect. Good arrangements are in place to meet individual’s health needs and medical services are promptly accessed when required. Staff have been suitably trained in the administration of medication. People who use the service are able to decide the pattern of every day living and therefore the providers have a flexible approach to the care and support provided. Flexible visiting arrangements are in place and residents decide where they meet with their visitors. People who use the service are positive about the varied and nutritional menu that reflects their preferences and choices. Some saying the food is ‘good’ and we get ‘plenty of it’. The kitchen is suitably equipped and good standards of cleanliness are maintained. The environment is homely, clean and comfortable and people who use the service said they were satisfied with the accommodation provided. The communal space is on the ground floor and bedrooms are located on all floors of the house. The recruitment, selection and vetting arrangements are robust to ensure that good arrangements are in place that safeguard residents. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 7 The care home is well managed by an experienced management team who plays an active role in the day-to-day operations. Suitable arrangements are in place to review the quality of the services and facilities each year. What has improved since the last inspection? What they could do better:
In recent discussions with the registered person a safeguarding issue was highlighted. The registered persons reported the matter with the Commissions direction to the Department of Adult Social Care immediately. The registered persons are now more aware that any concerns must be notified to the Commission sooner under the adult protection remit and/or under regulation 37 notifications. By doing this it will ensure better protection of people who use the service and staff. The registered persons are able to acknowledge this and have learnt that in future concerns/incidents must be notified to the commission without delay. In speaking with the staff team there is a mixed knowledge of adult protection and what to do if they have concerns, particularly around the whistle blowing process. Therefore training in this area for all staff is essential and one that the registered person was attempting to organise during the inspection. In addition the management team need to attend the Multi Agency Safeguarding training
St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 8 and ensure that the up to date Cornwall Multi Agency policy and procedure is in the home and that all staff are aware of its contents. In discussion with the staff team and some people who use the service they commented that they now feel more confident to raise issues sooner then previously. Recommendations have been identified to review the medication policy, to ensure medication is stored at the correct temperature and that formal recorded supervision of staff should occur a minimum of 6 times a year. The inspector would like to thanks residents, staff and the management team for their kind assistance and cooperation during this inspection process. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 9 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 Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective service users are assessed so that they can be assured that the home can provide adequate care. EVIDENCE: Managers from the home visit prospective residents and complete a needs assessment. This documentation shows that prospective residents physical, emotional, social and diverse needs are taken into account. All the residents’ records case tracked contained needs assessments completed by the home’s managers. These assessment records recorded their assessed needs in detail and included their views and preferences and who was present at the assessment. People who use the service feel that the home involved them in their care arrangements. The registered person said that each person that is admitted to the care home is provided with a contract or a statement regarding the terms and conditions of residency. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written care plans direct and inform staff about peoples health and personal care needs so that these can be consistently met. The healthcare needs of people are monitored and addressed so that their needs are met. People who use the service stated they are treated respectfully at all times so that they retain their dignity and enjoy a good quality of life in the home. EVIDENCE: Each person who uses the service has a care plan that covers the individuals physical, emotional, and diverse care needs. The care plans guide and inform staff in specifying what caring interventions are needed, this then allows consistent care to be provided. Care plans are regularly reviewed to make sure they are up to date and appropriately reflect the individual’s needs, preferences and choices. Some people who use the service stated they participate in the reviewing of their care plans. People who use the service were satisfied with the care and support they receive and many were positive about the manner in which the staff undertakes their duties and responsibilities St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 12 Risk assessments in respect of mobility are completed when an issue of mobility has arisen and identify what equipment if any, is needed to assist in the moving of an individual. From discussion with people who use the service and their relatives plus looking at recent surveys completed by them, it is clear that positive relationships are established with staff and that individuals who use the service feel that they are treated with dignity and respect at all times. Some comments from individuals who use the service describe staff as “very kind”, “marvellous” and “I get spoilt here”. The daily records for people who use the service summarised if care had been provided that day and reflect for example when visitors or participation in activities occurred. Care needs to be taken regarding how information on occasions is recorded. People who use the service are registered with local GP practices. They felt that their health care needs were monitored and attention obtained promptly when needed. Surveys from medical practitioners were positive in how the home consulted them appropriately, and how they then followed through medical treatment with the individual. The homes medication policy and procedure needs to be updated to accurately reflect current practices. Medicines are stored in a secure facility and after recommending to the registered persons to monitor the temperature of the room (to ensure medicines are stored under 25 degree centigrade as the area is hot) the registered persons have agreed to liaise with the pharmacist regarding if they are stored correctly. A medication round was observed and staff were competent in the administering medication and it’s recording. Staff responsible for administering medication has been suitably trained and clear records are maintained. After discussion with staff regarding the auditing of PRN medication, which on the first visit medication in the home did not tally with records kept, staff took immediate action to rectify this. There is now a clearer audit trail of PRN medication so that medication kept in the home tallies with MAR records. The Pharmacist safely disposes of any medicines that are no longer required. People who use the service and their relatives made positive comments on the skills and caring qualities of staff. People who use the service felt well cared for and reported that staff delivered care sensitively, respected their privacy and dignity and listened to their concerns. People who use the service said that staff were “lovely” and “kind”. Examples of staff providing skilled and sensitive care were observed during the inspection. People who use the service and relatives found it difficult to identify any area where the home could improve. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are supported in a lifestyle, which accords as far as possible with their own expectations and preferences. A range of activities takes place that meets peoples’ social, religious and recreational interests. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: People who use the service felt that they had control over their daily lives and were supported to make choices about their routines and activities. They felt that there was ‘enough to do’. Individual care plans detail their social and activity interests. The home provides a range of planned activities. This includes outings, music, bingo and, painting. People who use the service were observed during the inspection to, read the paper, have visitors and generally socialising. People who use the service and their relatives said that they found the visiting arrangements open and flexible. They felt that visitors were made welcome and could choose where they meet their guests. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 14 People who use the service confirmed they have a lockable facility for small items of value and can bring in possessions and furniture at admission by agreement with the provider. People who use the service were aware that they could lock their rooms if wished, but have chosen not too. People who use the service were complimentary about the quality and quantity of food provided, comments such as ‘excellent’, ‘good’, ‘very tasty’ and ‘big portions’ were given. Some were aware of the meal to be provided for that day, and menus are being developed. Each person’s preferences and choices of food are recorded. People who use the service are encouraged at the residents meeting to provide ideas for the menus. Breakfast can be taken in the dining area or in the resident’s room and people were very happy with the choices available. A mealtime was observed to be a relaxed and unrushed occasion with staff providing sensitive support in a pleasant manner. Staff knew residents’ likes and dislikes. Hot and cold drinks are served between meals. Kitchen staff are aware of individual dietary requirements and cater for this. Kitchen staff have relevant qualifications in food hygiene but it is recommended that one of the catering staff undertake the intermediate food hygiene course. Kitchen staff are available daily and therefore undertake the preparation of the main meal and tea in the home. Kitchen staff demonstrated an awareness of a person’s likes/ dislikes of food and any special dietary requirements. The environmental health inspection occurred last July and was satisfactory. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The registered person has suitable procedures regarding complaints and adult protection. The registered person must notify the Commission of any events that affect People who use the service safety. Staff must attend safeguarding training to develop their knowledge in this area. EVIDENCE: The registered person has suitable procedures regarding complaints. The people who use the service said they felt able to approach the registered persons if they had any concerns. The Commission for Social Care Inspection has not received any complaints regarding this service. In recent discussions with the registered person a safeguarding issue was highlighted. Due to confidentiality details of how this incident was managed cannot be disclosed. The matter with the Commissions direction was reported to the Department of Adult Social Care immediately and an investigation was undertaken. Whilst the Commission appreciates that the registered persons have not needed previously to report under this remit and therefore lacked the knowledge to do so, the concern the Commission has is that St Claries House should have reported the incident sooner under both the adult protection remit and under regulation 37 notifications which did not occur. If this had occurred then the delay in the process would not have occurred and would have led to people who use the service and staff being better protected. The registered
St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 16 persons are able to acknowledge this and have learnt that in future concerns must be notified to the commission without delay. In speaking with the staff team there is a mixed knowledge of adult protection and what to do if they have concerns, particularly around the whistle blowing process. Therefore training in this area for all staff is essential and one that the registered person was attempting to organise during the inspection. In addition the management team need to attend the Multi Agency Safeguarding training and ensure that the up to date Cornwall Multi Agency policy and procedure is in the home and that all staff are aware of its contents. The registered persons have stated in their AQAA that under the section what we could do better in relation to complaints and protection as: ‘provide more focused training with staff…. to add clarity to understanding these matters and their associated procedures’. They plan to address this by ‘ gain greater clarity at management level on up to date procedures and industry sector requirements. Drive in large quantity quality training’. Due to the time delay in informing the Commission of this issue and the need for training to increase staffs knowledge in this area this section has to be rated as adequate. What is positive is that the registered persons fully cooperated with the investigation, are taking appropriate actions to address concerns raised and that the staff team and some people who use the service now feel more confident to raise issues then previously. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is accessible, well maintained and safe. A homely, clean and comfortable environment is provided that is maintained to the required standard. EVIDENCE: From a tour of the home it was observed that St Claire’s House appears to be well maintained, clean, pleasantly decorated and homely. There is a very pleasant garden, which people who use the service can use. There are two pleasant lounges and a dining room. The rear lounge overlooks an extremely pleasant garden. There are large patio doors, which enable people who use the service to look outside even if they cannot walk in the garden and there are tables and chairs outside for people to use. Bedrooms are individualised and comfortable. A shaft lift is provided to assist people to go upstairs. Decorations are to a high standard. Bathroom and shower facilities are to a suitable standard. Suitable kitchen and laundry
St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 18 facilities are provided. Domestic staff are employed, and felt that they had sufficient support and training to assist them in their work. They demonstrated knowledge in the areas of infection control and COSHH. The home was clean and hygienic at the time of inspection. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The managers are aiming to increase staffing levels at particular times of the day to meet people’s needs safely. Staff are qualified and competent to work with the residents. They are recruited on the basis of fair, safe and effective recruitment and selection policies and practices. They have good access to ongoing training to maintain their knowledge and skills. EVIDENCE: From surveys completed plus discussion with people who use the service, their relatives and staff it was noted that all raised the need for an increase in staffing levels around teatime as care staff need to undertake the final preparations of tea plus undertake caring duties. The management team have responded to this and want to recruit an additional member of staff at this time to assist at this busy time of day. The staff team and people who use the service were also aware of this recent decision made by the management team and stated they felt supported and listened too when this issue was raised. In the mornings the kitchen and domestic staff assist with caring duties, as again this is a busy period of time when people are getting up. People who use the service and staff felt this arrangement was satisfactory. People who use the service, their relatives and staff commented that they felt overall there was sufficient numbers of staff on duty each day and night. Currently there are three care staff on duty in the morning, two in the afternoon/evening and two waking nights plus management and
St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 20 housekeeping/maintenance support. People who use the service confirmed that staff attends to them promptly, when they call for assistance. People who use the service were very positive about the staff and it is clear that positive and trusting relationships have been established. People who use the service said they felt in control of the care and support provided which they viewed as sensitive, positive, reliable and flexible. The majority of care staff have achieved a minimum of NVQ at level 2 and some are in the process of completing it. When completed the staff will have exceeded the NVQ level 2 minimum qualifications. Some staff are working towards achieving qualifications at NVQ level 3 in care, and two staff members have NVQ at level 4 so that residents can be confident of the competency of the people looking after them. Recently recruited staff spoke positively about their appointment seeing it as a fair process. They felt their induction programme was appropriate to their work. The registered person is currently reviewing the induction programme in line with the Skills for Care guidance. Staff records showed that for all staff a satisfactory POVA and CRB had been gained along with references. Staff at the home said they were well supported and were clear about their roles and responsibilities. It is clear the staff group are committed to helping people maintain their independence as far as possible. Staff confirmed that there has been recent training and the registered person was booking future courses for staff to attend in the area of health and safety, food hygiene, first aid, Makaton, intermediate food hygiene and manual handling. There is a staff-training plan for the home, which sets out training staff have had and are expected to undertake, so that they maintain their knowledge and skills. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,33, 35, 36,37 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an experienced and qualified management team who have a sound understanding of their responsibilities. The home is well run and managed for the benefit of the residents. Quality assurance processes demonstrate that service users their representatives, and staff are consulted about the service that the home provides. Records are maintained and handled in accordance with good practice, for the welfare and safety of the residents. EVIDENCE: The registered persons have managed St Claire’s House for 5 years and ensure that training in elder persons care is kept updated. They are competent managers in the daily running of the home and are viewed positively by staff and people who use the service. The deputy manager is completing her
St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 22 application for registered manager to be submitted for consideration by the Commission. The registered persons have established a range of measures to annually review and monitor the quality of the service and facilities and sent these findings to the Commission. From the issues raised i.e. more staffing at teatime, the management team are responding to this positively. The surveys demonstrated that People who use the service, their relatives, external professionals and staff felt positively about the care that St Claire’s provide. In addition resident and staff meetings are held which is another avenue to express ideas on how to improve the service further. The registered person invoices the individual or their representative monthly on any financial costs that they have incurred i.e. hairdressing, newspapers etc. This means that the registered person does not have direct access to the individual’s money. A range of measures has been put in place to promote safe working practices and the equipment and services to the care home are regularly maintained and serviced. The risk assessment and risk management arrangements for individual people is satisfactory and the deputy manager is aiming to update her training in this area so that she can undertake this role more fully. The registered persons and deputy manager were informed about the need to notify the Commission under Regulation 37 of incidents that occur in the home as this has not been happening in certain incidents. The registered persons agreed to act on this immediately. The providers have established a policy and procedure for fire detection and prevention. This has been reviewed by the fire authority who were satisfied with the documentation, which also evidence that equipment is regularly serviced and monitored. The staff at the home are appropriately trained and a regular programme of refresher training is in place. The deputy manager acknowledged that formal supervision has not been occurring a minimum of 6 times a year, or recorded and agrees with the recommendation this needs to be in place. The deputy manager stated that annual appraisals are now due and that she is organising this. Records reviewed at this inspection indicate that they are appropriately maintained and held, to ensure the welfare and safety of people who use the service. There are suitable storage facilities and records are kept in ways that protect their confidentiality. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 2 3 2 St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 24 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 OP18 Regulation 12(5)(a)( b) 13(6)(b) 17(1)(a) Schedule 3(j) 37 Timescale for action All staff working at the home 16/05/08 must attend relevant adult protection training to increase their knowledge and skills in this area to ensure that People who use the service are protected from abuse. All incidents under Regulation 37 16/05/08 must be notified to the commission without delay as per the Care Standards Act. Requirement 2 OP38 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 Refer to Standard OP9 Good Practice Recommendations The medication policy should be reviewed and amended to ensure that it covers all aspects of medicine care ire the use of oxygen, training etc. In addition the update Safe handling of medicines should be gained and kept in the home for reference for staff. St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 25 2 OP9 3 OP36 The registered person should liaise with the pharmacy regarding the correct storage temperature for medication in the home and take appropriate action to ensure it is stored correctly. Formal recorded supervision of staff should occur a minimum of 6 times a year St Clair House Care Home DS0000041642.V361775.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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