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Inspection on 24/05/06 for St Clements Nursing Home

Also see our care home review for St Clements Nursing Home for more information

This inspection was carried out on 24th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All bedrooms have en-suite facilities consisting of toilet and wash hand basin. The choice and standards of meals provided are good; this was confirmed by talking to residents. There is a good supply of pressure relieving equipment and where necessary the input of the tissue viability nurse is encouraged. The home has a comprehensive supply of personal protective equipment to assist in preventing cross infection. There is a dedicated activities organiser who works five days per week. The relative and residents spoken with, provided positive comments about the home and standards of care.

What has improved since the last inspection?

What the care home could do better:

The commenced work for the improvements of care plans needs to be completed. The gaps in staff training must be addressed. Cascading of formal staff supervisory meetings needs to be carried out. The practice of unsafe administration of medications must cease. Staff must carry out and document the changing of resident`s positions as directed within the care plans. All staff must treat residents by appropriate means to ensure that their dignity is maintained. Staff CRB checks must be renewed every three years. The arrangements for social activities need to be reviewed and improved upon. The quality assurance system carried out by the organisation needs to be changed and further developed to reflect the National Minimum Standards before compliance can be achieved.

CARE HOMES FOR OLDER PEOPLE St Clements Nursing Home 8 Stanley Road Nechells Birmingham West Midlands B7 5QS Lead Inspector Kath Strong Unannounced Inspection 24th May 2006 09:00 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 Clements Nursing Home DS0000024892.V295227.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 Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Clements Nursing Home Address 8 Stanley Road Nechells Birmingham West Midlands B7 5QS 0121 327 3136 0121 328 1461 stclements@bmlhealthcare.co.uk 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) Noblefield Limited Care Home 37 Category(ies) of Dementia - over 65 years of age (37), Old age, registration, with number not falling within any other category (37) of places St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home may accommodate a total of 37 service users, categories DE(E) and OP. Accommodation may be provided for up to 37 service users who require nursing care, categories DE(E) and OP. Accommodation may be provided for up to 10 service users who require personal care, categories DE(E) and OP. Minimum staffing levels must be maintained at two nurses plus six carers during the morning shift and two nurses plus five carers during the afternoon shift when there are 36 service users requiring nursing care. In addition to the above minimum staffing levels there is one nurse and three carers overnight plus a second nurse who remains on duty until 10pm when there are 30 service users in the home requiring nursing care. The care managers hours and ancillary staff should be provided in addition to the care staff. 27th January 2006 5. 6. Date of last inspection Brief Description of the Service: St Clements is a purpose built three-storey home situated in a built up residential area in Birmingham. The home provides accommodation to thirtyseven elderly residents in 27 nursing beds and 10 residential beds. There are twenty-five single bedrooms and six double rooms, one of which is located on the lower ground floor and all have en-suite facilities consisting of a toilet and wash hand basin. Access to the home is gained by the lower ground floor and a passenger lift gives access to the ground and first floors. There is limited covered parking on the lower ground floor to the front of the property. There is a small garden with steep elevations that is accessed from the ground floor. Communal facilities consist of a large lounge on the ground and first floor. There is also a dining room situated on the ground floor that is adjacent to the kitchen, which provides all the meals. Residents are able to have meals on either of the upper floors. A laundry facility is situated on the lower ground floor, where washing of resident’s personal clothing is undertaken. There are bathing facilities on each floor; however, some of these are not suitable for the client group. St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first statutory inspection for the current year, which was carried out over a long day. The recently appointed manager provided assistance for the majority of the inspection. The outcome was determined by various methods. Relevant documentation was examined including four residents care plans, one of which was case tracked to ensure that all identified needs were being met. One relative was spoken with as well as six residents. Due to mental illness discussions with some residents was either restricted or not possible. Staff practices were observed, five personnel files examined, four weeks duty rota reviewed and two care staff were interviewed. The food menu was reviewed and serving of lunch and the evening meal were observed. Arrangements for the administration of medications were checked and a tour of the premises carried out. At the conclusion verbal feedback was given to the manager, no Immediate Requirements were made. What the service does well: What has improved since the last inspection? The recently appointed manager has commenced a number of initiatives to improve the standards of the service supplied: • Development of a staffing structure and allocation of trained staff to specific floors • Bedrooms include charts for staff to complete when they provide care to facilitate tracking when issues are identified St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 6 • • • • • The manager organised and held a barbeque for residents the previous week. This was also used as an exercise to educate staff regarding residents needs in leading a full quality life Improvements regarding staff supervision and direction and action taken when poor standards are discovered Establishment of a nurses station on each floor Staff reported that the new manager is approachable and effecting positive changes Commenced improvements in care planning and education of staff in these carrying out. Further improvements have been achieved: • Twenty-three hot water valve restrictors have been replaced • Relatives have been issued with questionnaires, the results to date are generally positive. • The floor of the treatment room has been renewed and broken wall tiles replaced • The system for securing medication trolleys to the wall has been improved • Net curtains have been fitted to ground floor bedrooms to improve residents privacy • The deputy manager has completed specialist training in care of pressure ulcers. What they could do better: The commenced work for the improvements of care plans needs to be completed. The gaps in staff training must be addressed. Cascading of formal staff supervisory meetings needs to be carried out. The practice of unsafe administration of medications must cease. Staff must carry out and document the changing of resident’s positions as directed within the care plans. All staff must treat residents by appropriate means to ensure that their dignity is maintained. Staff CRB checks must be renewed every three years. The arrangements for social activities need to be reviewed and improved upon. The quality assurance system carried out by the organisation needs to be changed and further developed to reflect the National Minimum Standards before compliance can be achieved. St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 The quality outcome in this area is good. The majority of written information serves to assist prospective residents and external professionals in making an informed decision about the home. Comprehensive pre-admission assessments are carried out, which also confirms the homes ability to meet the assessed needs. EVIDENCE: Examination of the statement of purpose indicated that two minor further developments are required. Information about mandatory staff training should include Health and Safety training and care plans should be developed and reviewed with the resident and relatives invited to participate. The home has a policy of supplying each new resident with a pack containing the service user guide, a contract of terms and conditions of residency, a copy of the complaints procedure and other relevant information. The manager or deputy manager carry out pre-admission assessments at a venue that is convenient to the prospective resident. The tool used lends itself to the assessor making details recordings, which include psychiatric history St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 10 and social problems. The recordings made for a recent admission includes details in respect of communications and social interactions. On the day of the inspection the manager assessed a resident who had been admitted to hospital from the home. He had identified specific needs and equipment that would be required and was organising these items during the course of the day prior to the residents return to the home. Prospective residents and relatives are encouraged to view the home and following admission a trial of one month, which can be flexible followed by a review is carried out before a placement is confirmed. St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The quality outcome for this area is poor. Although health care needs appeared to be being assessed and met care plans do not provide adequate information regarding care needs or instructions to staff on how to deliver the care. The unsafe practice observed regarding the administration of medications puts residents at risk. Some care staff fail to ensure that the dignity of residents is preserved. EVIDENCE: Some improvements were noted with the process of care planning and one file included the family tree and background details. Recordings made by staff varied in standard. A number of concerns were reported to the manager: • The mobility assessment for resident MM has not been reviewed since April 2005 • Bed rail assessments were not dated • More details are required regarding the triggers, likely resultant behaviour and how staff should respond when difficult to manage behaviour is displayed • Personal hygiene documentation does not include preferred method i.e. bath or shower or how often St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 12 • • • • • • There was no evidence of formal reviews being carried out with the residents and relatives being invited to participate Those residents who are transferred by a mobile hoist should have the sling size recorded Care plans need to include a section outlining life history, background and preferences. This is especially important for those residents who have mental health problems Risk assessments need to be further developed to include the action to be taken to minimise the risks and as a result there may be a need in some instances to generate a care plan The care plan of GB does not include if the resident is able to understand simple questions or instructions Another file states tears to gaiter areas but does not include how many or size. There appeared to be good multi-agency involvement with external professional such as Social Workers, Hospital Discharge Liaison Nurses, GP’s Tissue Viability Nurse, Dietician and Psychogeriatricians. One resident has been referred to the speech and therapy department. A notice on display on each floor advising that an Optician would be visiting the home over a three day period during the month of June. The food and fluids taken by a resident who has a poor appetite was being recoded. There was an obvious improvement in the care of and documentation of pressure ulcers. The manager advised that the deputy manager has recently completed a specialist course in this aspect of care. This is viewed as being good practice. The turn chart of a resident was checked; it indicated that re-positioning of the resident had been carried regularly throughout the day but inadequate frequency during the three previous days. The manager was advised that this needs to be addressed as a matter of priority. Residents generally made positive comments about the home, “She’s lovely that one”, (carer standing close by) “Everyone is good to me here”, “They are very kind to me”. A relative was spoken with and he reported, “Very happy with standards, satisfied with her bedroom, staff are excellent and offer refreshments”. The manager was observed talking to a resident they appeared to have a good relationship. The inspector observed a resident reporting to a carer that she was having problems with her nails, the carer located nail clippers and attended to the residents needs. In general the arrangements for the administration of medications was satisfactory but two concerns have been raised. Gaps were found on MAR (medication administration record) charts in a number of instances where prescribed creams should have been administered. A significant concern related to the observation of a trained nurse who was placing medications and slips of paper with residents name into medicine pots on top of the medications trolley, this is considered as unsafe practice. There were numerous instances where the prescribed medication was to be administered as directed, this is St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 13 unacceptable as the home is unable to ensure the safety of residents. The manager reported that he has been in contact with the GP in order to resolve the problem. Observations revealed that some staff did not ensure the dignity of residents was being maintained. Whilst some staff were noted to have excellent interpersonal skills, others had ample opportunity but failed to communicate with residents. A carer was noted to be chopping and mashing portions of food together thus limiting the residents ability to enjoy the various flavours of the meal. Following lunch a carer was seen providing personal hygiene but carried out this duty without communicating at all with some of the residents. There was evidence that the home liaises with medical staff, relatives and the respective resident regarding the preferred location for the care of very ill persons i.e. remaining at the home or being transferred to hospital. St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality outcome in this area is adequate. The activities provided require review to reflect resident’s preferences and enhance the quality of their lives. The variation and standards of meals are good but meals are not served appropriately to facilitate the resident’s enjoyment. EVIDENCE: The internal activities programme was on display, it was noted to be lacking in variation. The home needs to document individual’s interests and preferences and subsequently review the programme to reflect this. Those residents who have participated is being recorded. The manager advised that there are plans to assist the activities organiser by utilisation of care staff to increase the amount and variation. External entertainers are invited into the home and the manager received positive feedback from the recently organised barbeque. A hundredth birthday party was being planned. A carer was observed quietly socialising with a resident. Information was provided that one resident goes out independently, uses buses and frequents pubs and shops. Another resident is escorted by a friend in attending church twice a week. The manager reported that currently there are no residents meetings held, as attendance would be limited but he is planning to introduce regular relatives St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 15 meetings. The manager also advised that he ensures that he makes himself available as much as possible to residents and relatives. The menus supplied prior to the inspection indicate that a varied, balanced and wholesome diet is provided. Breakfast includes cooked eggs if requested, lunch is the main meal of the day with the main course offering two choices. The evening meal consists of soup, a light cooked meal, sandwiches and a dessert. The cook advised that supper is available on request but this information is not included on the menu. The serving of lunch and the evening meals were observed. The presentation of food and staff assistance was noted to be appropriate and courteous. During the lunchtime meal some meals were served in resident’s bedrooms, both courses were served simultaneously. Courses must be served individually to prevent over cooling of courses thus ensuring residents ability to enjoy the meal. The evening meal served on the first floor did not ensure that the food was served at an acceptable temperature. Two carers served the meal from an unheated trolley. Residents said, “Food is lovely”, another said, “Soup tastes good”. St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality outcome for this area is adequate. Residents and relatives opinions are listed to and acted upon. The written policy regarding adult protection was incomplete and lack of staff training puts residents at risk of abuse. EVIDENCE: The written complaints procedure was found to be satisfactory, a copy is supplied to each bedroom. The home has received two complaints since the last inspection. The outcome of one found that another agency had made an error, not the home. The other complaint regarding mal odour resulting in a carpet being cleaned and subsequent ongoing monitoring. The written policy regarding adult protection had been developed 1999, there was no evidence supplied to the inspector that it had been reviewed. The policy was found to be grossly inadequate and did not provide sufficient staff guidance. There was evidence that the manager had responded appropriately to a recent incident. When interviewed two staff demonstrated some knowledge but they did not possess knowledge of how situations of alleged abuse should be dealt with. The training matrix indicated significant gaps in staff training within this aspect of care. St Clements Nursing Home DS0000024892.V295227.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The quality outcome for this area is adequate. The accommodation is generally comfortable, safe and hygienic. Bathroom facilities for assisted bathing need to be increased to be acceptable for use by residents. EVIDENCE: There is a large lounge situated on the ground floor and a separate dining room. The last inspection determined that the dining room is too small to accommodate all residents. This has been resolved with some residents being served meals in the lounge/dining room on the first floor. The communal rooms are quite well appointed and residents were noted to be seated in comfortable chairs. There is a small garden, which partially surrounds the premises for residents to frequent during clement weather. All bedrooms include en-suite facilities consisting of toilet and wash hand basin. There are communal toilets and bathrooms strategically situated throughout the home but assisted bathing facilities are limited and are St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 18 therefore inadequate for the current client group. This remains outstanding from March 2004; the organisation is advised to address this issue. The home has a good supply of specialist equipment and a call system is available in all rooms. Those bedrooms visited appeared to include the required amount of furniture and were personalised to the extent preferred by the respective resident. A number of rooms did not have a lockable facility for storage of resident’s financial and personal items and suited door locks have not been fitted. These remain outstanding from previous inspections and continue to restrict safekeeping of personal items and privacy of residents. There was a good supply of natural light and ventilation and lighting was noted to be adequate. Radiators are low surface temperature style. A reputable company has carried out water testing. Regular random checks and recordings of hot water outlets accessible by residents has resulted in 23 valves recently being replaced. The hygiene levels were generally acceptable but one bedroom was found to have a mal odour. The kitchen was tidy, hygienic and all checks; food storage systems and cleaning schedules were being adhered to. The laundry room was found to provide restricted space for an operative to carry out her role. St Clements Nursing Home DS0000024892.V295227.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality outcome in this area is adequate. Sufficient staff are rostered to meet the needs of the current client group. Recruitment practices were robust but ongoing CRB checks are not carried out thus putting residents at risk of harm. Staff training is not comprehensive and fails to provide staff with knowledge and skills to carry out their role. EVIDENCE: The most recent staffing rotas indicated that the home is complying with the conditions of registration. Two trained staff are on duty during all daytime hours with six care each morning and five during evenings. One trained nurse and three care staff cover nighttime shifts. The use of agency staff is restricted as far as possible. The home has a full complement of ancillary staff including a maintenance operative. Staff files examined revealed that recruitment has improved to an acceptable standard. The home is advised that it is good practice undertake regular CRB checks. A copy of the training matrix supplied prior to the inspection indicates that 50 of care staff have successfully obtained NVQ level 2 in care or equivalent. Other courses have been attended by some staff, which will enhance staff skills in meeting the individual needs of residents. The homes induction programme for care staff is not satisfactory; it must include all aspects of the Skills for Care programme. There are significant gaps in mandatory training for: • Food Hygiene St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 20 • • • • Dementia Care Protection from Abuse Moving and Handling, a few gaps found Health and Safety Further training is planned and on display regarding Fire Safety, Moving and Handling and Infection Control. St Clements Nursing Home DS0000024892.V295227.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 The quality outcome for this area is adequate. The manager has a clear development plan and vision for the home. The quality assurance system is not adequate to comply with National Minimum Standards. Health and Safety arrangements are acceptable with the exception of some staff training in Fire Safety, which puts residents and staff at risk. EVIDENCE: The recently appointed manager is a trained nurse with a wealth of experience in the care sector. During the inspection he demonstrated his ability to manage and a proactive approach to improvements needed in the home. Staff who were interviewed provided positive feedback regarding their ability to approach the manager and the improvements made. The manager advised that he carries out the majority of on call duties. The organisation needs to develop a formal and proportionate on call system. Senior managers carry out regular Regulation 26 visits and supply the manager with a written report. A questionnaire supplied to relatives in March St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 22 of this year has to date provided positive feedback. The organisations quality assurance programme is not adequate and does not comply with Standard 33. The system needs to be reviewed and further developed to correspond with Standard 33.1 to 33.10 inclusive. The arrangements for the safekeeping and financial transactions of personal monies held on behalf of residents were found to be satisfactory. The manager advised that all trained staff with the exception of one has been formally supervised and that the system will be cascaded to include all staff who provide personal care. The mandatory checks and servicing of equipment was found to be satisfactory. The annual gas check had been arranged to be carried out the following week. The fire alarm and emergency lighting is tested and documented regularly and fire drills are carried out and staff attendance documented. The training matrix indicated that some staff have not had Fire Safety training, however this has been arranged. St Clements Nursing Home DS0000024892.V295227.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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 2 3 X 2 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 2 St Clements Nursing Home DS0000024892.V295227.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 OP1 Regulation 4 Requirement The registered person must further develop the statement of purpose to include Health and Safety training of all staff and that care plans are developed and formal reviews carried out with the resident and relatives invited to participate. The registered person must ensure; All staff undertake training in respect of caring for people with dementia, commensurate with their position. Timescale for action 30/09/06 2. OP4 18(1)(c)i 15/09/06 3. OP7 All staff must undertake training in challenging behaviour. Timescale of 30/10/03 not met. 15(1)(2) a-d The registered person must ensure that care plans are comprehensive and provide clear staff guidance as outlined within the body of this report. Care plans must include a life history, background and personal preferences regarding activities of daily living. Initial development of care plans 31/08/06 St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 25 4. OP8 12(1)(a) 5. OP9 13(2) 6. OP10 12(4)(a) 7. OP12 16(2)(m,n) 8. OP14 12(2) 9. OP15 12(4)(a) and six monthly formal reviews must be carried out with the resident and relatives invited to participate. The registered person must ensure; Staff undertake regular changes of position for residents who require this and records are maintained accurately. The registered person must ensure; • That prescribed creams are administered and recorded • The practice of secondary dispensing into medicine pots must cease. The registered person must ensure that staff practices are such to maintain the dignity of all residents. The registered person must ensure all residents are consulted about past interests/hobbies, review and expand the activities programme and ensure that records are kept in the home. The registered person must complete the already commenced work in establishing regular relatives meetings. The registered person must ensure that meals served on the first floor are maintained at an acceptable temperature. 20/06/06 20/06/06 20/06/06 31/07/06 31/07/06 20/06/06 10. OP18 13(6)(7)(8) Meals served to residents in their bedrooms must be provided in individual courses to ensure food is served at the appropriate temperature. The registered person must 30/09/06 ensure; All staff undertake training in respect of restraint. All staff must undertake training St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 26 11. OP18 13(6) 12. 13. OP19 OP21 16(2)(k) 23(2)(j) 14. OP24 16(2) 23(2)(n) 15. OP30 18(1) 16. OP30 OP38 18(1) 17. OP31 10(1) in prevention of abuse. The registered person must develop a written policy regarding adult abuse and update the policy in respect of restraint. The registered person must ensure the home is kept odour free at all times. The registered person must install additional assisted bathing to meet the needs of all residents. The registered provider must: • Provide suitable locks to all residents’ bedroom doors • Provide a lockable facility for all residents. This remains outstanding from the last inspection. The registered person must ensure all newly appointed care staff complete updated induction training within 12 weeks to the Common Induction Standards for Skills for Care. This remains outstanding from the last inspection. The registered person must ensure that all staff undertake training in: • Health and Safety • Moving and Handling and relevant refresher courses • Food Hygiene. The registered person must develop a formal and proportionate on call system and ensure that staff are informed. The registered person must implement a quality assurance system ensuring that stakeholder’s views are obtained and an annual development plan is drawn up as per Standard 33.1 to 33.10 inclusive. Timescale of 30/10/04 not met. DS0000024892.V295227.R01.S.doc Version 5.2 31/07/06 30/06/06 31/10/06 30/09/06 15/07/06 30/09/06 31/07/06 18. OP33 24 30/09/06 St Clements Nursing Home Page 27 19. OP36 18(2) The registered person must ensure all staff receive formal supervision at least six times a year and records are retained in the home. Timescale of 30/11/03 not met but work has commenced towards this. The registered person must ensure that staff who undertake supervision have training in the process to provide them with the appropriate skills. The registered person must review and update the written policies and procedures. Timescale of 30/10/04 not met. The registered person must ensure sufficient staff undertake training in first aid to ensure that a ‘First Aider’ is on duty at all times. The registered person must ensure all staff undertake training in respect of infection control and records are retained in the home. The registered person must ensure systems are in place to effectively evaluate staff training to ensure it is suitable and it will lead to an improvement in practice. The registered person must ensure all staff undertake annual training in Fire Safety and attend at least one fire drill per annum. 15/08/06 20. OP36 18(1) 31/07/06 21. OP38 13(4) 30/09/06 22. OP38 13(3) 30/09/06 23. OP38 12(1) 18(1) 31/08/06 24. OP38 18(1) 15/09/06 St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 28 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 OP14 Good Practice Recommendations It is recommended that all residents be informed in writing of their right to access records and provide information regarding advocacy schemes. (Carried forward). It is recommended as being good practice for the home to carry out ongoing CRB checks for those staff that have been employed in excess of three years. 2. OP29 St Clements Nursing Home DS0000024892.V295227.R01.S.doc Version 5.2 Page 29 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. 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