Inspection on 18/08/03 for St David`s Nursing Home For Disabled Ex-servicemen and Women

Care Home For Older PeopleSt David`s Nursing Home For Disabled Ex-servicemenCastlebar Hill Ealing London W5 1TEAnnounced Inspection18th & 19th August 2003 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 Address Castlebar Hill, Ealing, London, W5 1TE Email Address Name of registered provider(s)/Company (if applicable) St David`s Nursing Home for the Disabled Ex-Servicemen Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 40 Tel No: 020 8997 5121 Fax No: 020 8997 2447Category(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 9th July 2003 YES YES 15/04/03 If Yes Refer to Part CSt David`s Nursing Home For Disabled Ex-servicemenPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector 1 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspection18th August 2003 10:00 am Mrs Clare Henderson RoeID Code074866Not used Not required Mr Barrie Taylor, Manager DesignateSt David`s Nursing Home For Disabled Ex-servicemenPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementSt David`s Nursing Home For Disabled Ex-servicemenPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), 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 NCSC in respect of St David`s Nursing Home For Disabled Ex-servicemen. 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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-servicemenPage 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 has been undergoing major refurbishment over the past 18 months and these are complete except for some areas such as corridor flooring and roofing repairs and water damage repairs to the newly refurbished dining and seating areas. These refurbishments are still ongoing. The home provides nursing care for 40 ex-service personnel and has been registered to accommodate female as well as male service users since July 2003. The female service users are accommodated in a designated area of the home at the present time. The Manager Designate is Mr Barrie Taylor and the new Registered Individual Designate is Father Abbott Martin Shiperlee. Both persons are going through the process of registration. Until this process has been completed Mr John Poland is still the Registered Individual with the NCSC for the home.St David`s Nursing Home For Disabled Ex-servicemenPage 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.)St David`s Nursing Home For Disabled Ex-servicemenPage 6 This was a positive inspection and the Manager Designate had worked hard to address the requirements from the last inspection. Several of the requirements that were partially outstanding have been addressed since the inspection and evidence to support this has been forwarded to the NCSC. Due to the lack of action taken to address a significant number of the requirements from the previous two inspections, some areas of ongoing concern have been highlighted and need urgent action taken to address them. Choice of Home (Standards 1-6) 4 of the 5 standards assessed were met plus one did not apply to this service. The Manager Designate had worked hard to meet these Standards. The homes Statement of Purpose and Service User Guide documents are comprehensive. The only shortfall was the need to review the pre-admission documentation and this was due to be done. Health and Personal Care (Standards 7-11) 0 of the 3 standards assessed were met. An improvement in the completion of the service user plans was seen but more work was required to ensure that all service user plans are kept up to date and meet the needs of the service user. Minor shortfalls were identified with the medications although generally these were issues to be addressed with the GP and the dispensing pharmacist. The medications room temperature was above the acceptable 25° centigrade for the storage of medications at room temperature. Daily Life and Social Activities (Standards 12-15) 3 of the 4 standards assessed were met. Service users are consulted as to their social and leisure interests. The home has an open visiting policy between 9am and 9pm but is happy for visits to be arranged outside these times if required. At the time of inspection the home did not have an evening cook and concerns were expressed regarding the standard of the evening meal. Information following the inspection stated that 7am to 7pm kitchen cook cover will be provided from 01/10/03. Complaints and Protection (Standards 16-18) 3 of the 3 standards assessed were met. The home has a complaints procedure and details of the NCSC are included. The home follows the Ealing Protection of Vulnerable Adults policies and procedures and the Manager Designate and staff spoken with at the time of inspection said that they would report any POVA concerns. Service users are afforded the right to vote if they wish and the Manager Designate would access advocacy services when needed. Environment (Standards 19-26) 3 of the 8 standards assessed were met. The flat roof over the dining and adjacent seating areas was being repaired at the time of inspection. Unfortunately this had not been done prior to the refurbishments in these rooms and this has resulted in some water damage from the leaking roof to the newly refurbished areas. Locks are still to be installed on most of the bedrooms and the Manager Designate has informed the NCSC that the locks on toilet, bath and shower facilities have been fitted since the inspection. The home was clean and tidy although laundry cleaning records were not available. Review of one boiler and some of the hot water outlets was required to ensure appropriate water temperatures were maintained. The latest LFEPA inspection, which took place on 01/07/03, identified several shortfalls. Correspondence has since been received from the home stating that some areas have been met but action still needs to be taken regarding risk assessment and security of the home. Staffing (Standards 27-30) St David`s Nursing Home For Disabled Ex-servicemen Page 7 1 of the 4 standards assessed were met. There were still significant shortfalls identified in the staff files viewed. These were discussed at the time of inspection and the home must ensure that all required information is held on file. Shortfalls in staff training were also identified and the Manager Designate was very aware of this and was intending to identify each member of staffs training needs and implement a training plan to meet these. The need to ensure that the training provision meets TOPSS requirements was discussed. Management and Administration (Standards 31-38) 3 of the 7 standards assessed were met. Shortfalls in training in mandatory health and safety topics were identified and the company contracted to provide this training had not done so for all topics. A security assessment of the premises had been carried out and the Manager Designate had not received the report at the time of inspection. Once received action is to be taken to meet shortfalls identified. Risk assessments for premises, equipment and safe working practices were still required.St David`s Nursing Home For Disabled Ex-servicemenPage 8 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. No. Regulation Standard Required actions Timescale for action 1 4 Schedule 1 2 3 5(1) 4 5 15 OP8OP8 OP2OP2 5 OP1OP1 A Statement of Purpose is required reflecting the services provided. The Statement of Purpose must be realistic and achievable. A Service Users Guide must be formulated in conjunction with Standard 1.2 The Terms and Conditions for service users must be reviewed in conjunction with Standard 2.2. The pre-admission documentation must be updated in line with Standard 3.3. All assessments must be carried out for each individual service user to include moving & handling, tissue viability, risk of falls, nutrition and continence. These must be reviewed whenever a service users condition changes and as part of any service user plan reviews. The home must ensure that medicines are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society and the requirements of the Misuse of Drugs Act 1971. The home must have a programme for routine maintenance and renewal of the fabric and decoration of all areas of the premises. Suitable locks must be fitted to all bathroom, shower and toilet facilities. Locks must be accessible by staff in an emergency. 01/07/03OP1OP101/07/0301/07/0314(1)OP3OP301/08/0301/07/036 13(2) OP9OP901/07/03723(2)(b) & (i)OP19OP 19 OP21OP 2101/08/038 12(4)(a)01/08/03St David`s Nursing Home For Disabled Ex-servicemenPage 9 9 12(4)(a) OP24OP 24Suitable locks must be provided on the bedroom doors. Service users must be provided with a key unless a risk assessment indicates otherwise.01/08/0310 11 1219 OP29OP Schedule 2 29 18 OP30OP 30 OP36OP 36Staff records must contain the information 01/07/03 required by the Care Homes Regulations 2001. A plan of training must be formulated to meet Standard 30. Individual training and development profiles must be formulated for all staff and the training needs identified catered for in the training programme for the home. All staff must receive mandatory training. This must include food safety training for all staff involved in the handling of food. Risk assessments must be carried out for premises, equipment and safe working practices and action taken to minimise any risks identified. 01/07/031801/07/0313 18 14 13(4)OP38OP 3801/08/03OP38OP 3801/07/03Action is being taken by the National Care Standards Commission 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 years.Met (Yes / No) YESSt David`s Nursing Home For Disabled Ex-servicemenPage 10 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 and recommendations 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. No. Regulation Standard * Requirement Timescale for action 1 14(1) OP3OP3 The pre-admission documentation must be updated in line with Standard 3.3. Service user plans must be complete, up to date and accurately reflect the needs of each individual. All assessments must be up to date and accurately record the condition of and clearly reflect the appropriate intervention required for each service user in relation to each area assessed. These must include nutritional, continence, risk of pressure sores and moving and handling assessments. 19/10/03215(2)OP7OP701/12/03317OP8OP801/12/03413(7)OP8OP8Prior to bedrails being used, a risk assessment must be carried out to identify the need for their use and to show that this is the appropriate safety intervention to minimise the risk of harm to the individual. 01/11/03 This must be reviewed monthly and whenever the service users condition changes. Written consent must always be obtained prior to the use of bedrails. The home must ensure that medicines are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society and the requirements of the Misuse of Drugs Act 1971.513(2)OP9OP901/11/03St David`s Nursing Home For Disabled Ex-servicemenPage 11 613(2)OP9OP9Action must be taken to ensure that the temperatures of the storage facilities for medications are kept within the recommended limits, those being between 2°- 01/11/03 8° centigrade for medications that require refrigerator storage and below 25° centigrade for room storage. A cook must be available to provide good quality meals at each mealtime to include supper. The findings of the LFEPA inspection, which took place on 01/07/03, must all be addressed. 01/11/03718(1)OP15OP1 5 OP19OP1 9 OP19OP1 9 OP21OP2 1823(4)01/11/03923(2)(b) & (i)The home must have a programme for routine maintenance and renewal of the fabric 01/11/03 and decoration of all areas of the premises. Suitable locks must be fitted to all bathroom, shower and toilet facilities. Locks must be accessible by staff in an emergency. Suitable locks must be provided on the bedroom doors. Service users must be provided with a key unless a risk assessment indicates otherwise. 01/11/031012(4)(a)1112(4)(a)OP24OP2 401/12/031213(3)OP25OP2 5Hot water must be stored at a minimum of 60° centigrade and distributed at a minimum of 50° centigrade. Hot water outlets accessible to service users must provide water that does 01/11/03 not exceed 44° centigrade. Where checks identify shortfalls immediate action must be taken to address these. A cleaning schedule and record of cleaning with dates and signatures must be maintained 01/11/03 in the laundry. Staff records must contain the information required by the Care Homes Regulations 2001. A plan of training must be formulated to meet Standard 30. The training needs of each member of staff must be identified and catered for in the training programme for the home. 01/11/031313(3)OP26OP2 61419 OP29OP2 Schedule 2 9 18 OP30OP3 0 OP30OP3 01501/07/03161801/12/03St David`s Nursing Home For Disabled Ex-servicemenPage 12 1716OP33OP3 3 OP35OP3 5All the homes policy and procedure documents must be updated in line with the NMS for Older People and current legislation. Service users monies must be kept individually and not pooled. All staff, including night staff, must receive mandatory training. This must include moving and handling plus health and safety training for all staff. All staff must attend the mandatory training. Staff with a recognised first aid qualification must be available in the home at all times. The results of the security assessment of the premises must be obtained and action taken to address any shortfalls identified therein. This must include all external doors and windows. Risk assessments must be carried out for premises, equipment and safe working practices and action taken to minimise any risks identified.01/11/031820(1)01/11/031918OP38OP3 801/12/032013(4)(c)OP38OP3 801/12/032113(4)OP38OP3 801/11/032213(4)OP38OP3 801/11/03St David`s Nursing Home For Disabled Ex-servicemenPage 13 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) No. Refer to Good Practice Recommendations Standard * The home is strongly recommended to convene a meeting with the GP and the pharmacist so that all discrepancies in recording and the provision of the required prescriptions to cover the 28 day MDS supply is discussed and agreed upon. Thereafter the dispensing pharmacist should carry out regular audit inspection of the homes medication systems and provide a written report of each inspection to the home. The home should take action to ensure that they meet the standard to provide a minimum ratio of 50 of care staff at NVQ level 2 or equivalent by 2005. The home should formulate survey documentation for relatives, visitors and other visiting personnel and, having collated the results from such surveys, review the provision of the service accordingly. All unexplained finds, such as skin tears, should be entered in the accident book as good practice.1OP9OP92OP28OP2 8 OP33OP3 3 OP38OP3 834* 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-servicemenPage 14 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 NO NO NO YES NO YES NO YES YES YES YES NO YES NO YES 10 3 X NO YES YES YES 20 8 18/08/03 10.05 17St David`s Nursing Home For Disabled Ex-servicemenPage 15 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons 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-servicemenPage 16 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 (£) 365 To (£) 600Any charges for extras If yes, please state what the extras are:YESCHIROPODY, NEWSPAPERS, DENTAL OPTICAL CARE, PEG FEED ITEMS NOT ON PRESCRIPTION. 3 Key findings/Evidence Standard met? At the time of inspection the Statement of Purpose and Service Users Guide documentation was available in draft form. The Manager Designate has reviewed this documentation in conjunction with the NMS for Older People and Regulation 4, Schedule 1 of the Care Homes Regulations 2001 and copies of the final documents have been forwarded to the NCSC. These are comprehensive and give a clear picture of the facilities and care offered by the home. The inclusion in the Service Users Guide of service users views which highlight areas that require reviewing, show an open, forward thinking approach by the home.St David`s Nursing Home For Disabled Ex-servicemenPage 17 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? At the time of inspection the current terms and conditions document needed reviewing to meet this Standard. This has been done and a copy forwarded to the Inspector. The document is comprehensive and provides all the required information to meet the standard. 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. 2 Key findings/Evidence Standard met? At the time of admission the documentation being used for pre-admission assessments did not include all areas listed under this Standard. The homes admissions policy has been updated to state that all areas will be covered in the assessment and the Manager Designate is formulating a suitable document to meet this standard. 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 able to meet the needs of the service users. Some service users do have cognitive impairment and this is identified and action taken to meet these needs. Moving and handling equipment was seen in use. The home does accommodate service users who speak Polish and staff who also speak this language are employed at the home. Cultural diets would be provided as needed. The Manager Designate said that he would like to recruit a physiotherapist to help meet the mobility needs of the service users, and is looking towards this for the end of the year. His aim is to have a wider multi-disciplinary team to meet the needs of the service users. 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. 3 Key findings/Evidence Standard met? Potential service users are encouraged to visit the home and have a meal. A qualified nurse will go and assess the service user in their own home or whatever environment they are in, for example, hospital. The home do not take emergency admissions and this is clearly stated in the Admissions Policy. 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 Page 18 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. 2 Key findings/Evidence Standard met? The Inspector viewed four service user plans. Some of the care plans and documentation had been part completed. Two viewed had been well completed and the registered nurse spoken with at the time of viewing the service user plans said that staff were very aware of the need to update and maintain all the service user plans to a satisfactory standard. It was clear that work had been done in this area and that with continued input the service user plans could be brought up to the required Standard.St David`s Nursing Home For Disabled Ex-servicemenPage 19 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. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)25 02 Key findings/Evidence Standard met? The personal and oral hygiene for each service user is maintained. A waterlow pressure sore assessment was seen in each of the service user plans viewed. A wound was not identified on one such assessment. Wound care documentation seen did identify the wound care required but some of it required reviewing, updating and completing. For one service user identified on their pre-admission assessment as needing a very high risk pressure relieving mattress, this was seen in place on the bed. Other pressure relieving equipment was also seen in use in the home. Continence assessments were not seen in service users plans. Care plans for continence care needs had been formulated. Assessments for moving and handling had been carried out but did not fully reflect the moving and handling needs of the service users. Service users psychological care needs are monitored and the home has access to a psychiatrist and community psychiatric nurse via the GP. If the home are no longer able to meet the service users needs, then the placement is reviewed in order to ensure that the service user is accommodated in a home that can fully meet their needs. Risk assessments for falls were seen in service user plans. For one service user a risk assessment and consent were not seen for use of bedrails and the service user was not happy with their use. The Manager Designate said that this would be promptly reviewed. Nutritional assessments were seen in service users plans and needed clarifying as two documents were in use. This has since been done. Food and drink preference documents had also been completed. The home has one main GP and also has input from another GP at the same practice. Weekly and as required GP visits are carried out. The Registered Manager said that they do have access to other healthcare professionals and that the Tissue Viability Nurse Specialist visits the home. The Manager Designate said that service users with diabetes all attend the diabetic clinic and instructions received regarding their care are carried out. The dietician visits the home to review and advise on the care of service users with PEG feeds and those with swallowing difficulties. The home has visiting optical and hearing services. The free nursing care payments are identified on service users invoices.St David`s Nursing Home For Disabled Ex-servicemenPage 20 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 service users medication records. Generally these were up to date but shortfalls were identified. The home uses the Monitored Dosage System. One medication found in the medicine trolley had not been entered on the MAR chart and needed reviewing. Items prescribed for several service users had been dispensed with several labels on the boxes or bottles. This is acceptable for non-prescription medications. The dispensing pharmacist requests weekly prescriptions. Prescriptions must tally with the 28 day monitored dosage system. For medications that had not actually been dispensed for one month, a `number dispensed entry had been made by the dispensing pharmacist. The explanation given for this to the home by the pharmacist was that otherwise the medication would automatically be removed from the chart. The addition in the relevant section of the MAR chart of a statement such as `not supplied this month is required to accurately identify the situation. Some medications were labelled `as directed by prescriber. All entries on the MAR charts must accurately reflect the supply, receipt, administration and disposal of medications. For one controlled drug two entries had been made in the CD register as one was the generic name and one a brand name. This was discussed and corrected at the time of inspection. The medication room was very warm at the time of inspection and a room temperature of 29° centigrade was noted. The drugs fridge temperatures recorded were within accepted range. Clear instructions in the use of oxygen have been given in writing by the GP. A report from the dispensing pharmacists most recent visit had not been received. Inspections by the dispensing pharmacist to include a written report were discussed at the time of inspection. Registered Nurses administer the medications. Up to date policies and procedures for medications were available. The registered nurse said that staff do look for any side effects from medication and report this to the GP for action. Medications are kept in the home for seven days following the death of a service user. 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. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. 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. 0 Key findings/Evidence Standard met? The home now has policies and procedures for handling death any dying. This Standard was otherwise not assessed and will be visited at the next inspection.St David`s Nursing Home For Disabled Ex-servicemenPage 21 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? There is an interests and leisure list completed by the activities co-ordinator with all new service users and she is also getting involved with the care plans for this area of need. The activities co-ordinator did not have previous experience in this field and has attended the National Activities Programme Award training after which she said that she felt more equipped to provide suitable activities. She is planning to put an activities programme in place to address service users wishes. A general programme was already in place. One service user said that they would like to go on more outings and that these need to be fully planned and a pre-visit check carried out for suitability for service users. The activities coordinator said that she usually does this. The home is looking to purchase a minibus to replace the current one which is now old. 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 3 Key findings/Evidence Standard met? The Manager Designate said that the home has an open visiting policy and asks visitors to come between 9am and 9pm unless a specific arrangement has been made. Visiting can take place in service users rooms or in the communal areas. If a service user did not wish to see a specific person this would be recorded and appropriate action taken in the event of a visit. Information for relatives and visitors is now available in the Service Users Guide. The home does have involvement from the Royal British Legion, local schools and also Territorial Army Marches do take place in the grounds for the enjoyment of the service users.St David`s Nursing Home For Disabled Ex-servicemenPage 22 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? Service users do have access to their personal allowances and assistance is available where needed. The home can provide information for contacting the Citizens Advice Bureau or the Patient Advocacy Liaison Service at Ealing Hospital. Agreement regarding the bringing in of personal belongings is made prior to admission and some rooms viewed had been very personalised. The home has an Access to Records policy and service users are facilitated access to their records. 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. 2 Key findings/Evidence Standard met? The menus seen offer a choice to service users and the Inspector viewed one lunchtime meal. The food was well presented and service users expressed their satisfaction. Snacks and drinks are offered between meals. The evening snack provision was to be added to the menu. The Manager Designate said that the chef does provide specialist diets as required. Service user choices of meals are recorded and additional choices are provided as per individual requirements. The lunchtime meal was unhurried and staff were available to assist service users. The home were advertising for an evening cook and the existing arrangement of meals being prepared by the day chef and left to be heated for the evening was not satisfactory and was commented on by service users. The Manager Designate said that this would be addressed in the near future and the home have confirmed that a cook will be available on the premises between the hours of 7am and 7pm from 01/10/03.St David`s Nursing Home For Disabled Ex-servicemenPage 23 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 NCSC Percentage of complaints responded to within 28 days 1 1 0 0 0 0 100 3 Key findings/Evidence Standard met? The home has a complaints procedure which includes contact details for the NCSC. The Manager Designate said that he would ensure that it was clear that the NCSC could be contacted at any stage, should the complainant wish to do so. The NCSC had received one concern and the Inspector had carried out a visit at that time and discussed the issues with the complainant who agreed that the particular issues were for discussion with the home management and a formal complaint was not lodged with the NCSC. 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 Manager Designate said that there was no involvement from advocacy services at present but that he would contact the Citizens Advice Bureau for information if required. Service users who wish to vote in elections can be taken to the polling station or a postal vote arranged.St David`s Nursing Home For Disabled Ex-servicemenPage 24 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 POVA Multi Disciplinary policy and procedures. The Manager Designate was able to explain to the Inspector the action to be taken in the case of an allegation of abuse being made. Staff spoken with were clear about reporting any suspected or witnessed abuse to the management. The home does have a Whistle Blowing policy and procedure and one member of staff said that if they reported witnessed abuse and no action was taken by the home they would contact the NCSC for advice. The home has a policy for physical and verbal aggression. There is a policy for monies and valuables and £1000 per service user insurance cover for losses.St David`s Nursing Home For Disabled Ex-servicemenPage 25 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? The home has identified problems with the roof over the dining/sitting areas. Unfortunately this was not dealt with prior to the refurbishment of these rooms and as a result the new décor has been affected and will need some attention following the roof repairs seen in progress at the time of inspection. The furniture and fittings in the refurbished areas are new and the Manager Designate said that as existing rooms are redecorated they would be refurbished. At the time of inspection the `sun lounge area was not in use due to the refurbishment and some furniture was being stored therein. Adequate communal space was still available. A planned preventative maintenance programme for 2003/2004 was available to cover all items requiring maintenance, such as fire equipment and alarm, hoists etc. A routine maintenance programme for checks and drills was seen, and building and fabric review programme. Month dates were included on each programme. The recording of actual works carried out for routine maintenance and renewal of the fabric and decoration of all areas of the premises was discussed at the time of inspection and an `identified and agreed departmental objectives document to include maintenance has since been forwarded to the NCSC. This is to be completed and identify objectives with completion dates for all areas where there are shortfalls in the home. The courtyard area was tidy and some building materials seen were neatly stored at one end. The Manager Designate said that funds had been applied for to extend the paved area in the main garden for better wheelchair access. There were no requirements or recommendations from the Environmental Health Officer inspection carried out on 01/08/03. The LFEPA Fire Safety Officer identified shortfalls following his inspection on 01/07/03 and these were still to be addressed by the home. Information has since been received from the home stating that automatic door closure devices have been fitted on bedroom doors for all service users who wish to keep their doors open. Risk assessment and security measures are still to be addressed. The home does not have CCTV cameras.St David`s Nursing Home For Disabled Ex-servicemenPage 26 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. 4 Key findings/Evidence Standard met? The communal space within the home is spacious. There are five communal areas available plus a small seating area opposite the nurses office. There is a designated smoking area in the large lounge with a laminated floor and an extractor fan above it. The gardens are accessible to service users and the Manager Designate aims to improve on this if funds are made available. The new furniture and fittings are of good quality. The lighting is satisfactory in the communal areas. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? At the time of inspection locks had still not been fitted on some of the toileting, bathing and showering facilities. Correspondence has since been received from the Manager Designate stating that these have now all been fitted. These will be viewed at the next inspection. The toileting facilities near the dining room were out of order due to the roof repairs and will be re-instated as soon as the roofing has been completed. The home has six assisted bathing and showering facilities. Rooms without en suites have toilet facilities nearby. There are 3 separate sluice rooms available in the home. 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? The home has a passenger lift. Grab rails were seen in corridors, toilets and bathrooms. The home has five mobile hoists and two parker baths. The corridors and doorways are wide throughout the home. The home does not have any loop systems at present but the Manager Designate said that this would be provided if required. Toilet, bath and shower facilities are clearly identified. The home has a new call bell system throughout and the Inspector heard these being answered promptly at the time of inspection.St David`s Nursing Home For Disabled Ex-servicemenPage 27 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 2002) - 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 NO YES NO 32 2 4 0 32 0X X 4 03 Key findings/Evidence Standard met? Five of the single rooms are below 12 square metres. The Manager Designate said that wheelchair users would be accommodated in rooms above 12 square metres. Generally the bedrooms are very spacious. The home has written agreements to share between service users in the double rooms. Some service users prefer to have their bed against a wall but these can be easily moved to provide adequate access for moving and handling requirements.St David`s Nursing Home For Disabled Ex-servicemenPage 28 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. 2 Key findings/Evidence Standard met? Service users can have two comfortable chairs in their room if they wish. The furnishings seen were generally of good quality and met this standard. The home has 30 electronic adjustable beds and the other 10, which are manually adjustable, are due for replacement in December 2003. Six of the bedrooms had locks at the time of inspection. The Manager Designate agreed that suitable locks would be provided for the other bedrooms by 01/12/03. Lockable spaces are provided in the furniture in the new rooms and existing rooms are being refurbished as new admissions are made to the home. The recording in the care plan for service users who are unable to retain the key to this facility was discussed. Screening is provided in double rooms. 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. 2 Key findings/Evidence Standard met? There were window restrictors on all windows with external access except those on the first floor that face into the courtyard, which is an enclosed area. The Registered Manager said that none of the service users in these rooms is at risk of climbing out of the window. Service users can see out of their windows. The lighting was satisfactory throughout the home at the time of inspection. Emergency lighting is provided throughout the home and this is checked monthly. Signatures for checking were needed. The home has 5 boilers and the temperature recordings for one were noted to at times have a recorded outgoing temperature of 58° centigrade and no return temperatures. The other four boilers had records that met the water temperature requirements. This was discussed at the time of inspection. Pre-set valves are fitted locally to hot water outlets accessible by service users to provide hot water at no more than 44° centigrade but some hot water tests recorded exceeded this. The Manager Designate said that action would be taken to address this. 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. 2 Key findings/Evidence Standard met? There had been one complaint received by the home regarding laundry. NCSC feedback cards and feedback from some of those spoken with at the time of inspection identified that there were issues with the laundry and the Manager Designate said that he was reviewing the laundry service within the home. Policies and procedures for the control of infection, safety data sheets for the products being used and good laundry practice information were available in the laundry. There were no laundry room cleaning records seen although the room was generally clean and tidy. Information and washing programmes to ensure that foul laundry is washed at the correct temperature were available. The washing machines were fitted in 2000 and should therefore comply with the Water supply regulations 1999.St David`s Nursing Home For Disabled Ex-servicemenPage 29 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 27 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 7 6 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X7 20 73 Key findings/Evidence Standard met? The home has a minimum staffing notice agreed with the previous registering authority and this was being adhered to at the time of inspection. The registered nurses said that additional staff are rostered when needed, for example to escort service users to hospital appointments. The home was clean and tidy at the time of inspection.St David`s Nursing Home For Disabled Ex-servicemenPage 30 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 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 8 40 2 Key findings/Evidence Standard met? The Manager Designate was aware of the requirement for NVQ qualified staff by 01/04/05. The current induction programme being followed for new staff was not based on a TOPSS certified training programme. The Manager Designate said that he was aware that action needed to be taken to address this. 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. 1 Key findings/Evidence Standard met? The Inspector viewed four sets of staff employment records. The home has staff who have been employed since 01/04/02 for whom CRB checks have not been carried out. The need to directly chaperone all staff employed from this date until a clear CRB check is obtained was discussed at the time of inspection. For two staff only one written reference was seen. In one set of records a letter stating that students do not need to apply for a work permit was seen but there was no record of the college being attended. The home has one volunteer and no CRB check had been carried out. The Inspector discussed the need to ensure that all documentation required under Regulation 19 and Schedules 2 and 4 of the Care Homes Regulations 2001 is obtained was discussed at the time of inspection. Urgent action must be taken to address the shortfalls identified. 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. 1 Key findings/Evidence Standard met? The Manager Designate said that he was aware of the need to develop a training programme to include all annual mandatory training and ensure that all staff attend. The Manager Designate said that the company currently contracted to provide staff training had been unable to provide the necessary training in these identified areas. The need to ensure that staff are supernumerary when attending training was discussed. Staff had not been receiving three paid training days per year and this was to be addressed. Individual staff folders are maintained and training to be done is listed and certificates are retained. The Manager Designate was very aware of the major shortfall in this area. Planned training in other topics were listed on the pre-inspection questionnaire. The homes annual budget plan identified £1,500 per month for staff training and this will be of major benefit to the staff.St David`s Nursing Home For Disabled Ex-servicemenPage 31 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 Manager Designate is a first level registered nurse with general and mental health qualifications. He also has a diploma in higher education for health visiting. He has also attained a BA honours in Healthcare Management. The Manager Designate had been in post for three months at the time of inspection and had identified areas in need of work. From speaking with staff it was obvious that the new management structure was clear and easy to follow. The Registered Individual has recently retired from the home and a new person has been appointed. Both the Manager Designate and the Registered Individual are going through the process of registration with the NCSC. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection and will be assessed at the next inspection.St David`s Nursing Home For Disabled Ex-servicemenPage 32 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. 2 Key findings/Evidence Standard met? The Manager Designate has an operating plan which incorporates quality assurance, the operating of the home and the business plan. The Manager Designate has formulated survey documents for service users and said that he would formulate one for relatives, visitors and other visiting personnel. The Manager Designate said that he would also look at inviting representatives to meetings. He has implemented monthly service user meetings. Service user plans were starting to be formulated and reviewed with service users and their representatives and information regarding this was available in each service user plan. The new Registered Individual Designate has carried out a regulation 26 inspection and the importance of these being carried out each month in accordance with the regulation was discussed. Most of the policies and procedures had been reviewed and updated in conjunction with the NMS for Older People and the Manager Designate agreed that this would be completed by 01/11/03. The notification of inspection poster was on display in the home. There had been a significant improvement in the meeting of timescales of the requirements from the last NCSC inspection and the Inspector was very pleased to note this. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The home has an Operating Plan for April 2003 ­ March 2004. This clearly identifies the homes plans for this year. A copy of the Annual Report and Accounts for year ended March 2002 was also available. The annual budget broken down into monthly sections was seen and identified the home was financially viable. The home has employers liability insurance cover of £5 million. The Manager Designate said that records are kept of all transactions entered into by the home.St David`s Nursing Home For Disabled Ex-servicemenPage 33 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 8 X X2 Key findings/Evidence Standard met? The home has endeavoured to open individual accounts for each service user but the bank has informed them that this is not possible. The home has a patients account into which money is paid. It had been agreed that this would only be used for service users who have no representative and for amounts over £100. The need to review this process to ensure that monies for service users are not pooled was discussed at the time of inspection. The home keeps records for all income and expenditure and receipts are kept for all items bought. Two members of the administration and finance staff are appointees for some service users. Pensions and benefits are paid directly into the bank and then the personal allowance is identified for each service user. The Inspector viewed computer income and expenditure records for four service users and these had been well maintained and were up to date. The home has a safe facility. If items were handed in for safekeeping receipts would be given. Receipts are given whenever money deposits or withdrawals are made. 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. 3 Key findings/Evidence Standard met? The home has policies and procedures for staff development and supervision. The Manager Designate said that he had started formal supervision with all heads of departments and was to cascade this down to the other staff. Care staff will receive supervision at least 6 times a year and all other staff receive supervision as part of the ongoing management of the home. There were no long term volunteers at the time of inspection. The Manager Designate said that any volunteers would receive training, supervision and support.St David`s Nursing Home For Disabled Ex-servicemenPage 34 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? The Manager Designate has ascertained that currently the home does not need to be registered under the Data Protection Act 1998 and records of his telephone conversations regarding this were seen. Shortfalls found in the service user plans have been identified and requirements set under Standards 7 & 8. Service users can access their records. The service user plans are kept in the nurses office which can be locked if no staff are present. 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. 1 Key findings/Evidence Standard met? The training records viewed identified that no moving and handling or health and safety training for staff had taken place in the last 11 months. The Manager Designate said that the annual mandatory training provision was to be reviewed to ensure that all topics are covered and all staff to be advised that must attend the required training. Some first aid training is provided in house and the Registered Manager must ensure that staff are appropriately trained in such numbers to meet the current legislation requirements. All kitchen staff have certificates in food safety and hygiene. Infection control training had taken place and more sessions were to be planned. Some maintenance and servicing records were viewed at random by the Inspector and were up to date. The home staff carry out security checks at 5pm every day. The Inspector noted areas where doors did not appear very secure and the Manager Designate said a full security assessment of the premises had been done but no feedback had been received from the company carrying it out. The area was not being used as a means of escape for fire. At the time of inspection the external door next to the laundry was partially blocked with scaffolding, although an able bodied person should be able to exit this way and doors were available out of the laundry room itself. The home has comprehensive health and safety policies and procedures that include risk assessments to be completed for safe working practices, equipment and premises. One service user had sustained two skin tears that had not been entered in the accident book. This was discussed at the time of inspection. Emergency service contact details were available. The health and safety poster was on display and needed the health and safety officer details updating.St David`s Nursing Home For Disabled Ex-servicemenPage 35 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 Locality Manager DateSignature Signature SignaturePART DLAY ASSESSORS SUMMARY(where applicable) A lay assessor was not present at this inspection. Lay Assessor Date Public reports It should be noted that all NCSC inspection reports are public documents. SignatureSt David`s Nursing Home For Disabled Ex-servicemenPage 36 PART EE.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 18th & 19th August 2003 and any factual inaccuracies: Please limit your comments to one side of A4 if possible An Action Plan has been received and is available at the West London Office.St David`s Nursing Home For Disabled Ex-servicemenPage 37 Action taken by the NCSC in response to provider comments: Amendments to the report were necessaryComments 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 accurate Note: 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. E.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-servicemenPage 38 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Mr John Poland 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 date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Mr John Poland 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 date(s) for the following reasons: Martin Shipperlee Singed Chairman of Trustees 17.10.03Print 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-servicemenPage 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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