Inspection on 31/07/06 for St Faith`s Nursing Home

This inspection was carried out on 31st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Faith`s Nursing Home 20/03/06

St Faith`s Nursing Home 24/10/05

St Faith`s Nursing Home 01/03/05

St Faith`s Nursing Home 23/09/04

St Faith`s Nursing Home 12/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Faith`s Nursing Home Malvern Road Cheltenham Glos GL50 2NR Lead Inspector Mrs Helen James Key Unannounced Inspection 31st July 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Faith`s Nursing Home Address Malvern Road Cheltenham Glos GL50 2NR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01242 240240 01242 224353 Cheltenham Old People’s Housing Society Limited (The Lilian Faithfull Homes) Mrs Patricia Anne McCluskey Care Home 69 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (69) of places St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Service User under 65 Years. Date of last inspection 20th March 2006 Brief Description of the Service: St Faith’s Nursing Home is a large attractive property, which has been extended and refurbished to provide comfortable accommodation for 69 elderly service users who require nursing care. The home is owned and managed by a charitable organisation and is one of the Lilian Faithfull Homes. It is situated in a residential area, close to the centre of Cheltenham and to local amenities. Service users are accommodated in two wings of the Home. Twenty-seven Residents are cared for in the Fairhaven Wing, which compromises three Floors and two mezzanine levels. Northcroft wing accommodates forty-two residents on three floors. All of the service users have the benefit of a number of accessible sitting rooms and dining areas throughout the building. There is also a well-equipped multi sensory room where aromatherapy and reflexology treatments may be given. The Home has a day care facility to care for people with Dementia. The service users have the benefit of a landscaped garden, which is easily accessible. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced inspection took place over eight hours on one day in July 2006 and was completed by three inspectors. Thirty-one Care Standards for Older People including all the twenty-two Key standards were assessed on this occasion. Of these, four exceeded the standard, twenty-six met the standard and one was not applicable. Time during the inspection was spent speaking with the Manager, Chief Executive, staff, residents and visitors, examining documentation, management records and the environment. Those residents/visitors who were able to converse with the inspectors discussed the admission process, care, food, lifestyle, activities and relationships with the staff at the home. The information in relation to care and welfare gained from these discussions and observations was then cross-referenced with resident individual care records and other appropriate documentation. The Pharmacy Inspector examined Medicine stocks and storage arrangements, Medication Administration Record (MAR) charts and other records and procedures relating to medication. The manager and four other members of staff were spoken to regarding medication. Questionnaires were sent out prior to the inspection and analysed prior to the site visit. The nine responses from residents were all very positive about the care, food, activities and staff. The seven responses received from relatives/visitors were again very positive about the management of the home, care, food and attitude of the staff. A couple of respondents commented that they felt more staff were needed, but the inspectors could find no evidence to support that more staff were required. The twelve responses from the staff were very positive about the home, support, training and management they receive whilst at work. What the service does well: Prospective resident or their relatives/representatives can visit the home prior to admission to see the home, its facilities and the staff. They have all their care requirements fully assessed before they are admitted to ensure that the Home is able to meet their needs. The Home has the benefit of an experienced Manager who is greatly involved in the home on a day-to-day basis. There appears to be an open, friendly approach to the running of the home, whereby resident’s needs are paramount and this is reinforced in the training given to staff. This results in St Faiths being run safely and efficiently with residents’ rights being safeguarded and protected. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 6 It was evident through discussion with residents/relatives who were able to talk to the inspector that they felt their views were always taken into account. They found the Manager and staff approachable and friendly. They were complimentary about the care, of the food served and the pleasant friendly manner of the staff employed at the Home. Many stated that “staff were wonderful, friendly, approachable and helpful”, “they give assistance when its needed”, “ they treat people with respect and dignity”, “you can choose to participate in activities or not”. “Staff spend time with you” and “you can decide your own daily routine and when you do things.” Those spoken with enjoyed living at the home. Where residents were unable to give a view care and interactions were observed and it was noted that care was given appropriately; carers were undertaking tasks diligently, respectfully and compassionately. During tasks they were talking and engaging with the individuals during all interactions. They were all carrying out the day’s duties in a calm unhurried manner retaining the resident’s dignity, privacy and respect. Care plans are well documented and are developed for each resident following admission and in the main contain all the required information for each resident. Lifestyle and hobbies are well recorded and social activities cater for individual interests. The activities are varied (group as well as individual) and are well attended by residents who enjoy the activity programme. Management records relating to health and safety issues and regular checks were in place. There was evidence that if any action had been necessary that it had been completed. All incidents and accidents that require reporting under regulation 37 are completed and sent to the commission. Quality Assurance systems are implemented well within the home. What has improved since the last inspection? Staffing continues to remain stable and staff spoken with enjoy working at the home. Residents/relatives confirm that staff are diligent in looking after the residents and meeting their needs. The stability and hard work of the staff team adds to the quality of the care received by residents. The communication appears good within the staff teams and with the management of the home. Staff appear to work well together. Several of the staff are advancing their knowledge and skills through undertaking in-house training and the National Vocational Qualification (NVQ) and the Manager actively encourages this. Recruitment records are now comprehensive and meet the required standard. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3,4, 5 & 6 Quality in this outcome area is judged to be excellent. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are well informed about the home prior to admission. Arrangements are in place to ensure that each prospective resident is fully assessed prior to admission. This is reassessed on admission, to ensure that all their specific care needs can be met by the Home. Residents or their relatives have the opportunity to visit the home. Intermediate care is not provided. EVIDENCE: The home has a Statement of Purpose and a Service User’s Guide, a copy of which was seen. A yearly review is carried out to ensure that residents and their families receive accurate information about the home and services provided. Residents/relatives spoken with confirmed that there was an assessment by the Manager of the home prior to admission and that they were reassessed St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 10 once they arrived at the home. They confirmed they are involved in the process with their relatives / representatives and the member of staff talking to them about their care. Documentary evidence of the assessment process was available to demonstrate this but none had been signed by residents or their representative. Ways of capturing agreement to the care plan need to be explored. There is a formal review of the placement and contract at three months with family/resident/ staff and all those involved with the individual by the Homes Manager. Residents confirmed that they or their relatives visited the home prior to the admission and found the home to be very suitable. Residents had contracts (a sample were seen) but it was the relatives/representative or Social Services who dealt with this and not the resident; they did not want the worry of this. The contract contained all the required details and had been examined by solicitors to ensure it was compliant with Office of Fair Trading Standards. The organisation is to have the contract reviewed again to ensure it meets legislative requirements. There are also Day care contracts in place. Relatives/representatives of people recently admitted were spoken with and all confirmed that they are very happy with the home and they had no concerns. They felt they were kept well informed and feel that there is appropriate stimulation in the home. These relatives visit regularly each week so have a good picture of the home. The home has admitted six new residents since the last inspection. All were spoken with where the inspector was able. There was confirmation that they were given choice in what they do whilst independence is maintained. All the comments made by residents, relatives/representatives in conversation and via questionnaires were very positive about the home, staff, care and the food. Records of six newly admitted residents were seen and all had assessments completed with care plans and risk assessments. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area regarding medication is adequate. This judgement has been made using available evidence including a visit to this service by a pharmacist inspector. All of the service user’s health, personal and social care needs are set out in an individual plan of care. Health care needs are fully met. Service users are protected by the home’s policies and procedures for dealing with medicines. Medicines are managed and given to residents in a safe way. Service users feel they are treated with respect and their right to privacy is respected. There are some good arrangements in place for the handling and recording of medicines but areas are identified where some actions and more attention to detail are needed to fully comply with this standard and make sure that the arrangements are effective in protecting the health and wellbeing of service users in relation to the use of medicines. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care plans are well documented and are developed for each resident following admission. On examination of care records it was evident that residents have a pre-admission assessment and another assessment on admission that informs the detailed individual plan of care which is developed in consultation with residents/representatives where possible. There is no documentary evidence that residents/their representatives sign to demonstrate they have been involved and agree/disagree with the assessment or the monthly review that in turn would evidence their involvement. The Manager is to explore ways of evidencing the involvement in this process. The care plans seen indicated specific care needs and enabled care staff to know how to assist the resident. Risk assessments, monthly weight and personal background information is recorded for each resident. A photograph of the resident is kept with the care file to aid identification. Daily recording was observed to be appropriate and informative. The care plans are reviewed at least once a month or more frequently if residents care needs change. The inspector read care records for six new residents who were spoken with during the inspection. The records confirmed the assistance and care that the residents required. It also confirmed other information that had been shared with the inspector during the discussions. There is the requirement for some minor amendments to care plans: • To ensure that the required information is recorded when it is asked for. • Where mobility is limited and a person is bed bound the care routine whilst they are in bed must be recorded. All care documentation is kept securely in the home and is readily accessible to all the staff responsible for providing care. There is good support from the Mental Health Nurse employed at the home, external psychiatric services, GP’s and other healthcare professionals. All visits are recorded appropriately with details of the visit and the advice/treatment given. All equipment needed for residents’ health care is supplied appropriately. Care observed given was appropriate; carers were undertaking tasks diligently, respectfully and compassionately. During tasks they were talking and engaging with the individuals during all interactions. They were all carrying out the day’s duties in a calm unhurried manner retaining the resident’s dignity and respect. Pharmacist report: The home has a comprehensive medicine policy and procedures in place. The section on disposal of medicines needs reviewing to reflect the current legal position. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 13 Registered nurses deal with all the medicines and staff spoken to during the inspection were knowledgeable. Sample signature lists are in place to confirm who has signed a record. Some of the lunchtime medicines were seen as given to residents in a safe way. Medicines are supplied from a local pharmacy using a monitored dose system (MDS). Printed Medication Administration Record (MAR) charts are also provided and form the basis on the recording system. Suitable secure storage is provided for medicines in the various units throughout the home. Some of the medicine trolleys were very full. Provision of extra space for back up stock may allow some of the racks of tablets to be kept out of the trolley when they are not needed so making more space. There is a locked medicine fridge that was clean and temperatures recorded each day to check this was in the safe range for the medicines. On Fairhaven (upstairs) the large cupboard for medicines for external use and the ground floor cupboard need sorting out. For example medicines for internal and external use must be segregated to prevent cross contamination and some out of date items were found. The temperature in the ground floor cupboard had been in the range 24 – 31°C. The maximum safe storage temperature for medicines is 25°C so if this limit is consistently exceeded action is needed. Dates of opening liquids medicines were generally (but not always) written on the container. Four bottles of a liquid painkiller were beyond the stated 90-day opened shelf life. Not all had been used recently but one bottle had. Eye drop containers had the dates of opening on the labels but this generally was not the case for tablets or capsules and creams or ointments. This is best practice so that medicines can be used within the ‘in use’ period advised by the pharmacy or manufacturer. It also provides a method to check that medicines are given to residents correctly by sample counts of doses remaining and comparing with the records of medicines given. Such audits were not possible at this inspection. A check of medicines remaining in some of the blister packs showed agreement with records with two exceptions noted. Medicines for external use (emollients for example) are often stored unsecured in the en suite bathrooms (along with cosmetics). This must be checked as being safe for the resident living in that room or for any other resident who may wander into room and use these inappropriately. There are locked cupboards in each en-suite. There are records for the receipt of medicines but there were examples where interim supplies sent between the regular monthly orders were not recorded. Records of medicine received for a new resident admitted to the home were also not made. The home needs to determine legal arrangements for the disposal of unwanted medicines. Return to the pharmacy is not an option now (unless the pharmacy holds a licence) following changes last year. CSCI have also published advice about this at www.csci.org.uk. Storage arrangements provided for controlled medicines do not comply with The Misuse of Drugs (Safe Custody) Regulations 1973. A check of recorded stock balances in the record book with the actual stock was correct. On St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 14 Fairhaven there was one controlled medicine although the record book was on Northcroft. This may be confusing to staff. The recording arrangements for a particular sleeping tablet were complicated and some records had been missed in one or other of the records. It would be best if all records were combined into the one standard controlled medicine record book. The arrangements for transporting these medicines from the central cupboard to residents in other parts of the home must be risk-assessed to check that it is safe for residents and staff. Some medication administration record charts were looked at and the following points noted: • The allergy box should be completed even if this is ‘none known’ to indicate this important issue has been considered. • There were occasional gaps in administration records so in these instances it is not known if the dose has been missed or the recording forgotten. Two instances were checked with the blister packs – sometimes the tablet had gone from pack and others it was still there. • Records of administration are not always made for products applied externally. • Photos to help identify the correct person to give the medicine to are often missing in care plans. • Medicine charts are left on top of the medicine trolley in a public area. These should be kept secure out of a public area, as they are part of personal health records. • A check signature by a second nurse is strongly recommended for any handwritten entries on medicine charts. • Latin abbreviations are occasionally used. These can be confusing especially as nurses on adaptation training may be involved. • There were two examples noted where printed doses on the medicine chart are different to how the medicine is actually given. The prescription must accurately reflect how to use the medicine. • It was difficult to confirm insulin doses between the medicine chart, the insulin administration chart and the care plan. This needs confirming with the Diabetes Nurse. • When residents have anticoagulants the standard yellow record books are not used and doses are not confirmed in writing. The medicine charts are generally marked with dose and test date. There are records in the doctor’s sheet in the care plan but sometimes this may be in the daily record. Some doses are hard to follow through, as there are entries such as – ‘continue same dose’. Recording with these critical medicines needs improving to make sure residents receive the correct treatment. • A care plan looked at for pain control has no mention of how to use a strong liquid painkiller. This should be included so that there is consistency in care provided by all staff. This applies to any medicine prescribed ‘as required’. Some medicines are given in food and the home has developed care plans for this. One such plan looked at was not signed by those involved and was not up to date as it stated ‘now accepting without crushing’ but this was not the case at lunchtime. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 15 For another service user there was no statement from relevant parties that this is in the resident’s ‘best interests’. ‘Crushed’ is printed on the medicine chart indicating that this direction is on the doctor’s prescription. One nurse says he does tell the resident that the medicine is in jam. For another resident ‘crushed’ is printed on the medicine chart. The care plan was reviewed in April 2006 and signed by a close family member. PEG tube feeds are used and support from the hospital with these is indicated in records. Care plans also need to include details of how to give medicines by the tube. The directions on the prescription should include ‘via PEG’ to indicate that the doctor has authorised this. The pharmacist should be asked to confirm that it is safe to mix all the medicines together when giving. Generally advice is not to mix medicines. The correct lancing devices (‘Softclix Pro’) to obtain blood glucose samples were seen. There were also some ‘Softclix’ in stock - these are not safe to use in a care home setting. The oxygen cylinder in the first aid cupboard had an expiry date in September 2000. This must be returned to the pharmacy. The most up to date medicine reference (BNF) seen on the units is March 2005. The Manager keeps the latest BNF outside her office where it is accessible to all staff for reference. Staff dealing with medicines have access to up to date authoritative information about the medicines they are giving. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is judged to be excellent. This judgement has been made using available evidence including a visit to this service. Residents experience a stimulating and varied life at the home with visitors and community links encouraged. There is a full activity programme available to suit all abilities within the home. Residents continue to have the option for a varied lifestyle. Residents continue to be able to exercise choice and control over their lives within the individual ability to do so and maintain contact with family and friends. The meals at the home are wholesome and nutritious with choice at each meal. EVIDENCE: Residents and staff confirmed that service users’ have the opportunity to exercise choice in relation to daily routines. There is access to advocacy services if required. The Activity Coordinator produces the programme of activities and this is displayed in the home. The Activity Coordinator sees every resident on admission and completes a profile of past life, hobbies and interests and the St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 17 resource staff record the activities that are undertaken with residents and these records are kept with the care file. The activity resource care staff work with the day centre and the care home. Four staff are available to see residents in the care home in groups or individually or residents may go to the Day centre and join in activities. The Activity Coordinator meets the Resource staff daily as she is their coordinator and with the home Manager almost daily. Residents/representatives spoken to were very happy with the level of activities provided. These included; trips out, readings, singing sessions, music and movement, craft, board games, outings, hand and foot massage and sensory stimulation etc. Church services are provided by taking residents to the local church every Wednesday or monthly communion at the home or individually weekly from lay preachers or clergy. Visitors were welcomed into the home at any reasonable time and residents spoken to were able to confirm this. One visitor told the inspector, “that they were always welcomed by the staff and always provided with a warm drink”. Meals can also be provided if required by visitors. Residents are supported by the home if they do not wish to see their visitors. Individual likes and dislikes and special needs in relation to food are ascertained on admission, recorded on individual care records and shared with the catering staff. The inspector was told that the Catering Manager has regular meetings with the Manager and audit the catering provision monthly. All residents/representatives spoken to stated they enjoyed the food and the quality and quantity was good. Staff were aware of the specialist dietary requirements of residents and ensured their needs were catered for at each meal. A choice of food is available at all meals and the menus provided evidenced this. Snacks and drinks were available as required and there were well-stocked kitchenettes on each floor with plenty of fresh fruit throughout the home. Once a month the home runs a restaurant for the evening for residents and their families. They can book a table for four, they have menus, wine and waitress service and this is thoroughly enjoyed by all. This also helps with networking relatives/carers so that they have a support network within the home from people who are dealing with the same issues as them. Staff were observed assisting residents with eating and this was done well with them sitting talking to the resident and feeding them slowly and appropriately. Pureed diets were excellently presented with the pureed food served in mould formation that identified to the person eating the food the meat, vegetable or potato that they represented. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The Commission have received one anonymous complaint since the last inspection. The Manager has appropriately dealt with this and a full report has been sent to the Commission. There have been no further complaints. The home has a complaints procedure that all spoken with were aware of. One relative spoken with stated that ‘I have no concerns about the care or the home and I always feel confident to discuss concerns with the sister on the floor, the Manager and staff’. A second relative was also positive about the home, the care and the staff and said they had no complaints but would tell the staff if they did. This was also evidenced from the questionnaires received although a couple did say they didn’t know the procedure. The home has its own policy on abuse and adults at risk file they have also received the ‘Alerters’ Guide’. The Manager is attending enhanced adults at risk training in September. All staff receive training on abuse awareness/adult protection on induction and this is updated regularly. Staff spoken with confirmed they had received this and in discussion they knew what they would do if they saw abusive practice or saw anything that bothered them. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 & 26 Quality in this outcome area is judged to be excellent. This judgement has been made using available evidence including a visit to this service. The standard of décor within this home is good and no maintenance issues were identified. Residents live in a safe well-maintained environment. The standard of cleanliness was good and there were no issues of infection control identified residents live in a clean and hygienic home. EVIDENCE: Most of the rooms in the home were visited. All areas seen were clean and in good decorative order. The home is well maintained and benefits from the attention of the maintenance team. There is a maintenance book for the recording of all maintenance issues to be addressed these are signed as they are completed to ensure an audit trail. Gardens to the side of the home are accessible, attractive and well maintained. There were no unpleasant odours detected in the home. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 20 The Manager reported that she does a monthly audit of the home to check whether any work needs to be completed and to look for any health and safety issues. During the inspection it was noted that hoists were being stored on the landing areas between floors. The Manager reported that there is a storage issue but they have found no solution to date. The Manager will review this in the light of the Health and Safety implications St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers to meet the residents needs and care observed was appropriate. There appears to be a good leadership of the care practice in each area and from the Manager. This ensures consistency of care practice in the home. Morale remains high with a low staff turnover so there is consistency for the residents. The procedures for the recruitment of staff are good and protect the people living in the home. There is a full staff-training programme from the internal training department that covers all mandatory training for all staff and care issues. EVIDENCE: Staff spoken with felt that staffing was sufficient to meet the needs of residents and that they had time to do their job. There are good support staff who deal with domestic chores and catering and this frees them up to deal with care issues only. They receive good support from the sister on the area they work and receive regular team supervision via team meetings. A handover is given at each shift change. The care staff write the daily records and feedback any changes in condition to the Senior Sister on duty. They all St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 22 have access to the records and know all about the residents and how to meet their needs. Staff said that it was a good supportive team on each floor and it was a happy place to work. They feel there is enough time to give care to the residents and they are given choice. Residents spoken with confirmed that the staff were very caring and met their needs. A sample of staff recruitment files were inspected and found to contain evidence that all pre-employment checks had been appropriately undertaken, prior to employment to comply with regulation 19. There were interview records and induction training records on all files seen. The inspector sampled new staff Criminal Record Bureau (CRB) disclosures and now requires the home to destroy them to comply with their obligations under data protection. Where the Disclosure reports criminal offences it is required that a written risk assessment is recorded and kept on the individual personnel file. The home has implemented the induction standards for staff training and evidence was seen of this on new staff files. All new staff receive induction training and mandatory training and all other staff receive regular updates. Training records were seen and evidenced this. The training plan for the year was given to the inspector. Several staff are undertaking National Vocational Training (NVQ). St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 38. Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The Management of the home is good and the Manager provides leadership, guidance and direction to staff on a ‘day to day’ basis. The systems for service user consultation and Quality assurance are well developed in the home. There are processes in place to safeguard the financial interests of residents. The health, safety and welfare of the people using the service are protected and safeguarded. EVIDENCE: St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 24 The staff reported that the Manager is approachable and has an open door policy so is accessible at all times. They feel they have good support from her and enjoy their yearly appraisals with her. Staff reported that they attend a lot of training and any training needed is arranged. Mandatory training and updating is implemented well in the home through the in-house training department. And includes fire, health and safety, moving and handling, food hygiene and first aid training etc ands the training records for staff were seen. A comprehensive Quality Assurance system is in place and the home has accreditation for Investors in People and ISO 9001. The Manager has a comprehensive array of documented auditing tools in place too examine quality of systems and effectiveness of care procedures/practice in the home and these were seen during the inspection; the Health and Safety audit needs to be formalised though. Accidents/incidents are appropriately recorded in the accident book and notified to the Commission for Social Care Inspection (CSCI) via Regulation 37 notices. All financial dealings are completed through the invoicing system. All the required Health and Safety checks were in place in the home and documentary evidence was available pertaining to this. The Manager completes yearly appraisals for all staff. Staff complete a selfassessment questionnaire prior to their appraisal and then this is discussed during the session both parties sign this record. Staff pay incentives have been introduced and these are linked to statutory training completion, performance and attendance at work and this is reported to work well in motivating staff. The sisters on each floor undertake supervision of staff via team meetings evidence of meetings was seen from minutes. The Manager would like to develop supervision to individual sessions but this will take a while to develop. Regulation 26 reports were discussed with the Chief Executive during the inspection so that the quality of information received by the Commission on this report is more detailed and meets the criteria in the regulations. This has already been implemented. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14(1c) & 15(2c&d) Requirement The Manager is to explore ways of evidencing the involvement of residents/representatives in the development of their care plan/reviews, agreement or disagreement. There is the requirement for some minor amendments to care plans: • to ensure that the required information is recorded when it is asked for. • where mobility is limited and a person is bed bound the care routine whilst they are in bed must be recorded. Make safe and effective arrangements for recording, handling, safekeeping, safe administration and disposal of medicines received to address and audit the issues identified in the report. In particular to– • Upgrade storage for controlled drugs to comply with The Misuse of Drugs (Safe Custody) Regulations DS0000016584.V304441.R01.S.doc Timescale for action 30/11/06 2. OP7 15 30/11/06 3. OP9 13,17 30/11/06 St Faith`s Nursing Home Version 5.2 Page 27 • • • • 1973. Review the arrangements for disposal of unwanted medicines to comply with Special Waste regulations 1996. Risk assess the safety of external medicines kept unsecured in bedrooms; Regularly audit that all records of medicines are complete and accurate and that medicine records are kept securely; Make effective use of care plans for matters relating to medicines RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4 Refer to Standard OP9 OP9 OP19 OP36 Good Practice Recommendations Write the date when first opened to use on all containers of medicines. Use the controlled drug record book to record the receipt and administration of temazepam products. Review the storage of hoists on the landings with regard to the implications for Health and Safety implications The home should continue to work towards developing the supervision system further for care staff. St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Faith`s Nursing Home DS0000016584.V304441.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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