Inspection on 13/10/04 for St David`s Nursing Home For Disabled Ex-servicemen and Women

Care Home For Older PeopleSt David`s Nursing Home For Disabled Ex-servicemen and WomenCastlebar Hill Ealing London W5 1TEAnnounced Inspection13th October 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment St David`s Nursing Home For Disabled Ex-servicemen and Women Address Castlebar Hill, Ealing, London, W5 1TE Tel No: 020 8997 5121 Fax No: 020 8997 2447Email address Name of registered provider(s)/company (if applicable) St David`s Nursing Home for the Disabled Ex-Servicemen and Women Name of registered manager (if applicable) Mr Barrie Taylor Type of registration Care Home No. of places registered (if applicable) 40Category(ies) of registration, with (number of places) Old age, not falling within any other category (0), Physical disability (0), Physical disability over 65 years of age (0) Registration number G100000199 Date first registered Date of latest registration certificate 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 15th January 2004 YES YES 28/04/04 If Yes refer to Part CSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of specialist (e.g. Interpreter/Signer) (if applicable) 113th October 2004 10:00 am Mrs Clare Henderson RoeID Code074866Name of establishment representative at the time of inspectionNot required Mr Barrie Taylor, Registered Manager Mrs Lucy Bokaie, Deputy Matron Mrs Kathy Rhind-Tutt, Assistant MatronSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of St David`s Nursing Home For Disabled Ex-servicemen and Women. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. St Davids Nursing Home is situated in spacious grounds in a residential area of Ealing. The home is accessible by bus and the nearest underground and mainline station is Ealing Broadway. The home has a central courtyard that provides a pleasant area in which service users and their visitors can sit. The home provides nursing care for 40 ex-service personnel. The accommodation consists of 32 single rooms, two with en suite facilities, and four double rooms. There are spacious communal sitting and dining rooms and a designated smoking area. The Registered Manager is Mr Barrie Taylor and the Responsible Individual is Father Abbott Martin Shiperlee.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was a positive inspection. The home had worked hard and addressed all the requirements from the last inspection. Service users spoken with were satisfied with the home and any concerns are promptly addressed by the staff. The Registered Manager and the staff are approachable and there is an effective management system in place. The home works hard to meet the National Minimum Standards for Older People and Care Homes Regulations 2001, which is reflected in the low number of requirements contained in this report. Of the CSCI comment cards sent to the home prior to the inspection, 11 of the relatives/visitors cards and 6 of the service users cards were returned. There were some very positive comments regarding the care provision at the home. There were some areas where people were not fully satisfied with the care and these comments were discussed with the Registered Manager in a general manner. Choice of Home (Standards 1-6) 4 of the 6 standards were assessed plus one did not apply to this service. There were no issues arising from these Standards. Health and Personal Care (Standards 7-11) All of the 5 standards were assessed. Requirements have been set regarding stock levels and clear dosage recording for medications, plus a recommendation regarding the recording of service users allergies. There were no other issues arising from these Standards. Daily Life and Social Activities (Standards 12-15) 3 of the 4 standards were assessed. There were no issues arising from these Standards. Complaints and Protection (Standards 16-18) All of the 3 standards were assessed. There were no issues arising from these Standards. Environment (Standards 19-26) 5 of the 8 standards were assessed. A requirement has been set in respect of the frequency of fire drills and training for the night staff. There were no other issues arising from these Standards. Staffing (Standards 27-30) All of the 4 standards were assessed. A recommendation is made regarding the ongoing review of staffing levels in conjunction with service user dependency and need. There were no other issues arising from these Standards.Management and Administration (Standards 31-38) 7 of the 8 standards were assessed. A recommendation has been regarding the Registered St David`s Nursing Home For Disabled Ex-servicemen and Women Page 6 Managers Management qualification. A requirement has been set in relation to the pooling of service users monies. A requirement has been set regarding formal supervision for care staff. A requirement has been set in respect of access to records for service users and/or their representatives.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Service users to include 40 service users over the age of 40 yearsMet (Yes / No) YESSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 13(2) OP9 Appropriate stock levels of medications must be kept in the home to ensure that service users receive their prescribed medication doses. The prescribed dosages of insulin must be accurately recorded on the medication administration record chart and on the dispensed medication. Night fire drills and staff training must take place four times a year. This must be implemented. Service users monies must be held in individual named accounts and not pooled. All care staff must receive formal supervision six times a year. A system must be implemented for this. The service user, or where this is not practicable, their representative, must have access to their records in line with the Data Protection Act 1998 and be involved with the formulation of the service user plan and the reviewing of the service user plan at agreed intervals. A system for this must be implemented. 05/11/04213(2)OP905/11/04323(4)OP1901/12/04420OP3515/12/04518OP3601/12/04615OP3701/12/04St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that a record of the service users allergies is made on their individual medication identification sheet as well as by the pharmacist on the medication administration record sheets. The Registered Manager should ensure that the staffing levels are kept under ongoing review in conjunction with the dependency levels and needs of the service users. The Registered Manager should ensure that he has the appropriate qualifications to equivocate to the NVQ in Management level 4, and undertake any additional training necessary to obtain this qualification.1OP92OP273OP31* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO YES YES YES YES YES NO YES YES YES NO YES YES YES YES NO YES NO YES 9 2 X YES YES YES YES 29 9 13/10/04 10.00 12St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 378.46 To (£) 618Any charges for extras If yes, please state what the extras are:YESHAIRDRESSER, CHIROPODY, NEWSPAPERS 3 Key findings/Evidence Standard met? The home has a comprehensive Statement of Purpose, which has been developed in conjunction with Schedule One of the Care Homes Regulations 2001. Making a copy available at the reception desk for visitors to read was discussed and agreed. The Service Users Guide had recently been updated and the Registered Manager was aware to follow regulation 5 of the Care Homes Regulations 2001 in addition to the information under Standard 1.2. Once the new Service Users Guide has been finally checked, it will be made available to all service users, who presently have copies of the previous Service Users Guide.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Each service user has a copy of the statement of terms and conditions, which are comprehensive. Contracts are drawn up with service users who are privately funded. Social Services and the Primary Care Trusts provide contracts for the service users they fund. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The Inspector viewed three pre-admission assessment documents and these were comprehensive and fully completed and gave a good picture of the service users needs. Social Services needs led assessments can also be obtained for service users being referred to the home by Social Services. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home is registered to accommodate service users with general nursing care needs. Some of the service users have a degree of cognitive impairment and the home arranges training in relevant topics to enable staff to manage each service users needs. Staff are employed who can communicate with service users for whom English is not their first language. The staff team is able to meet the needs of the service users accommodated at the home. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not provide intermediate care.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 14 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The Inspector viewed three service user plans. These were comprehensive, up to date and gave a clear picture of each service users needs and the action to be taken to address them. Risk assessments for falls had been carried out and had been updated following any falls experienced by the service user. The service user plans had been reviewed each month and also whenever the service users condition had changed. Care plans had been formulated for any new needs that had been identified. There was some evidence of service user/representative input into the service user plans.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 15 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 39 03 Key findings/Evidence Standard met? The Inspector viewed three service user plans. Care plans for personal and oral hygiene were in place. Waterlow pressure sore risk assessments had been carried out. At the time of inspection there were no service users with wounds. The Inspector viewed some wound care documentation and this clearly showed the treatment and outcome for a wound that had healed. Pressure relieving equipment was seen in use in the home and is provided in conjunction with the pressure sore risk assessment, to ensure the correct level of provision for each service users need. Continence assessments are in place and care plans had been formulated to address identified continence care needs. Nutritional assessments are carried out and monthly weights are done, plus care plans are formulated for any identified nutritional needs. Any identified concerns are reported to the GP and the home also has access to dietician input. The home now has physiotherapy input on a regular basis each week. The home has access to the psychiatrist and community psychiatric nurse if there are any psychological health concerns. Comprehensive moving and handling assessments had been carried out. The home has 2 GPs who arrange a weekly visit and will also attend at other times as needed. The service users have access to healthcare professionals and this is arranged by the home on their behalf. The Registered Manager said that the home does ensure that service users entitlements to NHS services are upheld.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 16 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The Inspector viewed four sets of service users medication records. All receipts, administration and disposal of medications had been signed for. One medication was out of stock for one service user and the registered nurse said that she had contacted the GP surgery on two occasions and was still awaiting a prescription. This was again to be followed up and the need to discuss this situation with the GP for the future to ensure that a stock is maintained of all prescribed medications was discussed. The dispensing pharmacist had printed any service user allergies at the top of the medication administration record (MAR) charts with the exception of one viewed. The registered nurse said that she would get this addressed. For on service user on insulin, the dose had been written as `as directed on the printed instruction on the MAR chart, whilst the printed unit doses on the container were incorrect and had been altered by hand. The need to ensure that the correct dosages to be given are clearly identified on the MAR chart and on the dispensed medication instructions was discussed and the registered nurse said that she would discuss this with the GP and dispensing pharmacist. Minimum and maximum fridge temperatures were being recorded. There was an agreement for homely remedies, plus an agreement for the use of oxygen in an emergency, both signed by the GP in June 2004. Policies and procedures for medications had been updated in line with the Royal Pharmaceutical Society June 2003 Guidelines. Controlled drugs were correctly stored and records were clear. The registered nurse said that advice is obtained from the dispensing pharmacist and audits are carried out. Staff monitor service users for any side effects to new medications and report any concerns. The medications are stored securely in the home. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Staff were seen addressing service users in a courteous manner and, as part of their induction training are taught how to treat service users with dignity and respect. Private phones can be installed for service users and mobile telephones can also be arranged. Service users clothing viewed was appropriately labelled and the laundry staff ensure clothing is clearly identifiable. Service users are seen by healthcare professionals in their own rooms and can choose to receive other visitors in their own rooms or in communal areas. Screening is provided in the double rooms.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 17 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The wishes of service users in respect of the care they wish to receive during their last days is discussed with the service user, family and GP and a record is made. Pain control is administered as prescribed and staff monitor service users pain control and report any concerns. Service users can choose to spend their final days in their own room unless there is a strong medical reason to prevent this, and again, these wishes would be recorded. The home has access to the local Hospice and also the Macmillan nursing service. Any changes in a service users condition is monitored, to include psychological/dementia care needs, and the situation is reviewed to ensure that the service user is appropriately placed and receiving the care they need. If a visitor wishes to stay overnight when a service user is unwell, a bed, chairs and refreshments can be supplied. The Registered Manager said that a `relatives room is to be built to allow a more comfortable overnight stay. The home has policies and procedures in place for the care of the dying and care after death.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The Registered Manager was very aware of the need to ensure that service users needs in relation to social and leisure activity are met. At the time of inspection there was evidence of various activities having been arranged and also of outings from the home. The home has purchased a newer minibus and the service users enjoy outings. Some of the CSCI comment cards received indicated that at times, especially the weekends, there is a lack of activities arranged. The Registered Manager said that he was very aware of this and was looking to employ an activities co-ordinator for weekend provision. The service user plans clearly identify service users interests and hobbies, and these are used to plan various activities that the service users will then enjoy. The home had recently carried out a survey of the food provision in the home and the menus had been adapted accordingly to reflect service users wishes. The Registered Manager said that he was willing to discuss any issues of this nature with service users to enable the home to plan appropriately to meet their needs. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 19 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The homes finance manager assists service users who wish to manage their own finances. Information regarding Age Concern advocacy services had been obtained and was to be put on display for service users and their visitors to access as they wish. Service users are encouraged to bring in their own possessions in line with fire safety requirements and some of the rooms viewed were very personalised. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The chef and Registered Manager had recently conducted a service user in respect of the meal provision at the home. The Inspector spoke with 8 service users and all said that they felt that the new menu choices were good and that they were satisfied with the meals provided. A cooked meal is available for the three main meal times, with other options also being offered. The Inspector sampled the lunch time meal on the first day of inspection and this was well presented and tasty. Special diets for medical reasons are catered for. The chef and Registered Manager said that a requirement for a special diet for cultural or religious reasons would be discussed at the pre-admission assessment to ensure that the dietary needs of a prospective service user could be met. The Inspector witnessed one mealtime and this was a sociable occasion. Staff are available to assist any service users with their meals.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 X 3 Key findings/Evidence Standard met? The home has a clear complaints procedure, a copy of which was on display in the main communal room on the notice board. The complaints procedure contains contact details for the CSCI and states that complaints will be dealt with within 7 working days. The home has a complaints record book and a copy of all documentation in respect of a complaint is kept on file. A copy of the complaints procedure is also available in the Service Users Guide. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The Registered Manager said that the home had contacted Age Concern advocacy services and agreed that contact details would be displayed in the home. All the service users are on the electoral role and postal votes, or for those who wish, visits to the polling station are arranged.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 21 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The home follows the Ealing Multi-Agency Adult Protection documentation and have their own policies and procedures which dovetail with these. The Registered Manager also had additional documentation regarding the POVA list which came into being on 26/07/04. Staff spoken with were clear that they would report any concerns. There were up to date policies and procedures in place for the management of service user aggression and for managing service users finances.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Requirements set under this standard at the last inspection had been met. An area of garden had been upgraded to make it easily accessible to service users and there was a risk assessment for the grounds, plus future works are planned. The covered walkway area, where problems had been identified at the last inspection, had been made good. Night time fire drills had not been implemented and this was discussed with the Registered Manager regarding the conducting of these in a manner which gives staff a realistic scenario, but so as not to cause distress to service users. This standard was examined in depth at the last inspection. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 23 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Work has taken place at the home over several years to bring it up to the current standard. The Registered Manager said that the physiotherapist advises the home on what equipment is required to meet service user needs. The home has five mobile hoists, two parker baths and three assisted showers. Most of the toilet facilities are spacious for wheelchair access. The corridors and doorways are wide throughout the home. The home has a passenger lift and ramps where required. Grab rails were seen in corridors, toilets and bathing facilities. The home does not have a loop system at present but the Registered Manager said that this would be provided if required. Toilet, bath and shower facilities are all clearly identified. The storage facilities had been reviewed and new areas designated for storage, thus alleviating storage issues in the home. The home has a call bell system and bells were responded to promptly. The Registered Manager said that the call bell system was being reviewed and was not fully satisfactory, so a new system was being considered.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This Standard was not assessed at this inspection. NO YES NO 32 2 4 0 Standard met? 0 32 0X X 4 0St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Each service user has a lockable space in their bedroom. Risk assessments for bedroom door and lockable space keys have been carried out and keys provided for those who wish and are able to manage them. This addresses a requirement from the last inspection report. This standard was examined in depth at the last inspection. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The home was warm and well ventilated at the time of inspection. All radiators and piping have low temperature surfaces or are guarded. Rooms are centrally heated and all radiators have individual temperature controls. The lighting was satisfactory at the time of inspection. Emergency lighting is provided throughout the home and is checked in-house each week and serviced every three months. Hot water flow and return temperatures were recorded and were above the minimum temperatures to prevent risks from legionella. The monthly hot water outlet temperature checks were recorded and there was evidence of the mixer valves being adjusted to hot water is provided at 43º centigrade. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The laundry is situated in a part of the building away from service user areas and was clean and tidy at the time of inspection. Up to date infection control policies and procedures, safety data sheets for the products being used and good laundry practice information was on display. Information and washing programmes to ensure that foul laundry is washed at the correct temperature were available. Liquid soap and paper towels were in place in all areas where staff, visitors and service users require to wash their hands. The laundry person takes a pride in his work and this was clear from the standard being maintained. The home has electronic sluice machine facilities in place. The washing machines have a sluice programme for the management of laundry in line with infection control requirements. A risk assessment of the water systems in the home had been carried out and work was ongoing to address the shortfalls identified.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 10 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 20 10 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X9 29 10 Standard met? 3St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 27 At the time when the home started to accommodate female service users, an additional carer had been rostered on each shift to help with the settling in process. The Registered Manager has recently reviewed staffing in line with service user dependency and had reduced the number of carers on day duty by one per shift, thus returning to the day staffing numbers which had been agreed with the previous registering authority. In addition, one of the two registered nurses on each day shift works with a carer in order to be involved in `hands on work and to use this time to assess the ongoing condition of the service users. It was clear from comparing the dependency levels of service users to those recorded in the inspection report for the last announced inspection, that there had been a shift in service user dependency and more were now in the medium/low dependency brackets. Several of the CSCI comment cards received from service users and visitors had highlighted concerns regarding the changes in the staffing. The Inspector spoke with the Registered Manager at length, and also with the registered nurses on duty regarding the staffing provision and all agreed that the staffing in place was appropriate to meet the needs of the service users. The Registered Manager agreed to keep the staffing under review in line with service user dependency, and also to maintain good communication with service users and their representatives regarding this issue. Additional staff are rostered to escort service users to hospital appointments. The home was clean and tidy at the time of inspection. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 9 50 3 Key findings/Evidence Standard met? The home has 16 full time care staff and in addition 13 bank staff, several of whom are student nurses. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The Inspector viewed three sets of staff employment records. These were comprehensive and up to date and appropriate checks had been carried out. For new employees, POVA list checks had been carried out prior to CRB clearance being received, plus the Department of Health POVA guidance was being followed. The processes to be followed if the home need to employ someone swiftly due to exceptional circumstances were discussed. Copies of the General Social Care Council Codes of Practices and the homes statement of terms and conditions are provided for each employee. The Registered Manager said that they would ensure that correct employment procedures were followed should a volunteer be employed.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 28 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home has a TOPSS certified induction and foundation programme in place, which is implemented with all new staff. NVQ in care training is ongoing in the home. The Deputy Matron said that all staff do receive a minimum of three paid days training per year.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 29 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The Registered Manager is a first level registered nurse with general and mental health qualifications. He has over 10 years experience in healthcare and care home management. The Registered Manager has BA honours in Healthcare Management and the need to ascertain how this qualification equivocates with the NVQ level 4 in management was discussed. He is responsible for one home only. The Registered Manager and staff are familiar with the conditions and diseases associated with old age. The Registered Manager said that his job description enabled him to take responsibility for fulfilling his role. There are clear lines of accountability within the home. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Registered Manager has an open management style and staff, service users and visitors spoken said that they could discuss any issues with him. The Registered Manager said that he is very aware of the need to keep service users and their visitors up to date and clear about matters pertaining to the home. The Registered Manager is planning towards the future of the home whilst considering the differing care needs of prospective service users. The home has an equal opportunities policy which is put into practice. The processes of managing the home are open and transparent.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 30 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The home has a business and operational plan, which includes quality assurance systems in place to reflect the aims and outcomes for service users. Surveys of service users and representatives are carried out and the results published. The Registered Manager was aware of some recent worries regarding staffing levels from service users and representatives and said that he would address this issue again. Service user, relatives, GP, pharmacist and staff meetings are held. There was evidence of policies and procedures being updated in line with new legislation and guidelines. The home had worked hard to meet all the requirements from the last inspection. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 13 X X2 Key findings/Evidence Standard met? At the time of inspection the Finance and Personnel Manager was not available and the Inspector could not view the full records of service user finances. Individual small amounts of money are being securely held for service users, with records of income and expenditure being clearly maintained. It was noted that some service users have substantial amounts of money which is held in a `residents account and this was discussed with the Registered Manager. The need to arrange for named accounts for these service users so that their monies are appropriately invested and not pooled was discussed. The Registered Manager has contacted the Inspector since the inspection to state that he is actively pursuing this. The home has a safe facility and receipts are given for any items or monies handed in for safe-keeping. The home acts as an appointee for 7 service users admitted to the home some years ago, the home has tried to find alternative appointees to take over this responsibility, without success. The Registered Manager said that the home was aware not become appointees for any other service users admitted. St David`s Nursing Home For Disabled Ex-servicemen and Women Page 31 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? Staff appraisals have been carried out to identify individual training and development needs and the supervision contract document is comprehensive. The Deputy Matron said that formal supervision had been commenced with some care staff. The need to implement this for all care staff six times a year was understood. All staff are supervised as part of the homes day to day management. The Registered Manager was aware that sufficient staff supernumerary time must be allotted to allow for formal supervision sessions to be carried out. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? Service user records are maintained securely in the home. Some of the service users and representatives spoken with expressed a wish to view the service user records and this was discussed in line with the Data Protection Act 1998. The need to ensure that service users and/or their representatives are involved in the formulation and review of service user plans and have access to their records was discussed with the Registered Manager and the Deputy and Assistant Matrons. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Staff undertake mandatory training to include fire safety and moving & handling. There are three staff who have undertaken the 4 day first aiders course and the majority of the rest of the staff had completed the one day appointed persons course. Training on infection control had taken place. Food hygiene training had been undertaken with one member of staff booked to attend a certificated course in the next 2 weeks. The Inspector viewed some maintenance and servicing records at random and those viewed were up to date. The five year electrical testing had been carried out and there was evidence that the remedial work was in progress. The Registered Manager said that he ensures compliance with relevant legislation and good practices in relation to health and safety areas were witnessed. Window restrictors are in place in service user areas and the security of the home had been assessed and there was evidence of action taken to address any issues identified. The risk assessments carried out for COSHH, bedrooms, gardens, kitchen, dining room and the corridors were very comprehensive and the Deputy and Assistant Matrons said that they are progressing the risk assessments to cover the laundry and communal areas. Accidents are recorded and Regulation 37 notifications made in line with CSCI guidelines. Safety procedures and good practice posters were seen on display in areas of the home.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance Service users to include 40 service users over the age of 40 years CommentsYESLead Inspector Second Inspector Regulation Manager Date Public reportsClare Henderson Roe Angela Hunt 02/12/2004Signature Signature SignatureIt should be noted that all CSCI inspection reports are public documents.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 13th & 14th October 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Father Abbot Martin Shiperlee of St Davids Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above dates and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Father Abbot Martin Shiperlee of St Davids Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above dates for the following reasons: Martin Shipperlee O.S.B Martin Shipperlee O.S.B (Signed) Chairman of Trustees 19/11/2004Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 36 St David`s Nursing Home For Disabled Ex-servicemen and Women / 13th October 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000010956.V184420.R01© This report may only be used in its entirety. 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