Inspection on 10/04/06 for St George`s Court Care Centre

This inspection was carried out on 10th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St George`s Court Care Centre 01/09/08

St George`s Court Care Centre 14/02/07

St George`s Court Care Centre 25/10/05

St George`s Court Care Centre 27/01/05

St George`s Court Care Centre 22/06/04

St George`s Court Care Centre 06/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St George`s Court Care Centre Russell Street Cambridge Cambridgeshire CB2 1HT Lead Inspector Nicky Hone Key Unannounced Inspection 10th April 2006 10:45 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 George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 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 George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St George`s Court Care Centre Address Russell Street Cambridge Cambridgeshire CB2 1HT 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) 01223 712135 01223 712138 St George`s Court Healthcare Ltd Care Home 76 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (56) of places St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who require nursing care is 29 Date of last inspection 25th October 2005 Brief Description of the Service: Purpose-built in the late 1970s, St George’s Court (previously called 15 Coronation Street) has recently undergone major building works and refurbishment. This included the building of a large extension with links to the existing building, where replacement of carpets, curtains and some furnishings, as well as kitchenettes, has been carried out. The home is built on three storeys with two passenger lifts accessing the upper floors. Each floor is self-contained with lounge, dining, kitchenette, bathroom and toilet facilities. There are seventy-six single bedrooms, fifty-nine of which have ensuite facilities. There is a main kitchen and laundry on the ground floor, and a courtyard garden. The top floor is mainly for people who need nursing care. The middle floor has two self-contained areas, one of which is for people with dementia care needs. Some of the rooms on the ground floor are used for respite care and some for intermediate care. St George’s Court is situated in a residential area close to the centre of the city of Cambridge. There are local shops, churches, pubs, restaurants, banks and a post office within a few minutes walk; the city centre is a short bus ride away; and the main-line station with direct links to London and the North is in walking distance. The registered manager left in January 2006. A new manager, Mrs Jackie Wicks, has been appointed: she has yet to apply to the Commission for Social Care Inspection to be registered. Another home owned by Excelcare has closed and the residents and some of the staff have moved to St George’s Court. The majority of places at St George’s Court are ‘block-booked’ by Cambridgeshire Social Services. From information provided by the home’s administrator on 27/04/06, the fees are £361 for frail elderly; £445 for EMI; and £530 for nursing. Fees for the privately funded places are £410, £495 and £580. Copies of the CSCI’s inspection reports are available in the entrance foyer of the home. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days. On the first day two inspectors toured the building, looked at records, talked to residents, relatives, the GP and staff and spent time with the acting manager and her line manager. On the second day one inspector checked further records, spoke to two staff and had a discussion with the acting manager, her line manager and the responsible individual. On the first day of the inspection there were 67 residents at the home, plus 2 people in hospital. On the second day there were 65 residents at the home and 3 in hospital. Although some of the outcome areas in this report have resulted in a judgement of poor, the inspectors were impressed by the attitude and enthusiasm of the new manager, and her determination to move the home forward. It was encouraging that the new manager had identified the major issues causing problems in the home, had written both short and long term action plans and had already started to address the concerns. What the service does well: What has improved since the last inspection? What they could do better: St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 6 Three of the requirements from the last inspection had not been met, and this inspection has resulted in a further thirteen requirements being made. The inspectors were seriously concerned about the lack of information in care plans and lack of evidence that residents’ personal and healthcare needs are being met. There is a lack of opportunities for residents to exercise choice and control over their lives, particularly about activities and food, and residents do not all know how to make a complaint. Concerns were raised by staff and residents that there are not always enough staff on duty, and that many of the staff are agency workers. There was an issue about communication, partly due to the number of staff working at the home whose first language is not English. The acting manager had identified that staff had not received adequate training and records to evidence staff training were not available. Several fire doors were found to not close properly and one was wedged open. Doors to rooms such as the lift machinery room and boiler room were not locked. Chemicals were not stored securely. 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 George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 7 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 George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for new residents and assessments are carried out to make sure the home can meet the person’s needs. EVIDENCE: The home has a statement of purpose and service user guide which have been updated. These include most of the information which people thinking of moving into the home would need. Copies are on display in the home’s entrance foyer. When a new resident is put forward for a place at the home, the assessment carried out by the person’s care manager is sent to the home. One of the senior staff then visits the person and carries out the home’s assessment to ensure the home can meet the person’s needs. An example of this assessment was seen. The acting manager said the format for the assessment is changing so that the information is more useful to the home. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 9 At the time of the inspection the manager was in discussion with the Primary Care Trust about the use of the ten places which were allocated for intermediate care. These places were not fully in use as an intermediate care service so this standard was not assessed. The places were mainly being used for short term care, and for people leaving hospital and waiting for places in other homes. The acting manager is aware that standard 6 of the National Minimum Standards for Older People must be complied with when the intermediate care service starts. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 10 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, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some of the care plans seen did not give adequate or accurate information for staff to be sure the resident’s needs, including healthcare needs, are met. EVIDENCE: On the first day of the inspection several care plans were looked at and those completed for residents on the nursing floor all gave cause for serious concern. One person’s plan had been written in July 2004. The review records showed that the plan for each individual need (12 plans in total) had been reviewed every month since then. Every review stated “no change in care plan”. The plan for pressure sore management stated that the person’s skin was intact. This had been reviewed every month from 22/07/04 to 25/02/06, with “no change in care plan” recorded. However, photographs and other documents on the file showed that this resident had developed a small sore in September 2005. Another plan indicated that the resident is diabetic. There was confusion over how this is controlled, and no care plan detailing what staff should be doing St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 11 with regards to medication or diet. There was no evidence that the diabetes was being monitored: the nurse on duty said that the surgery tests the person’s blood every six months (there was no record of this on file) and at present “there’s nothing to worry about”. A third person had returned to the home from hospital thirteen days before the inspection. Care plans for washing and dressing had been written. There was no care plan relating to food and drink, and yet this person was very poorly and needed special drinks and diet. By the second day of the inspection there was evidence that the dietician had visited and drawn up a care plan for nutrition. However, food and fluid charts had not been completed correctly and indicated, for example, that the person had not been offered a drink between 15.15 on one day and 00.20 the next day, and had had nothing between 01.15 and 12 midday on the day of the inspection. Food charts recorded “soft diet” for lunch but with no indication of what the food was or how much had been eaten. Care plans for residents on the ground floor had recently been re-written and were much better. A shorter version of a care plan is completed for people who are only at the home for a short stay. These gave a good, brief summary of the person’s needs, were easy to understand and would enable the staff to offer the correct support. On the first day of the inspection the two care plans looked at on the middle floor were better than on the nursing floor, but not good. There were no risk assessments on one file, and no nutritional screening for a resident said to vomit following meals. On the second day, care plans for the middle floor had been re-written and were much improved. In late 2005, the GP had raised some concerns with the PCT about some aspects of the care being offered at the home. A series of meetings took place and the company worked hard to resolve the issues. The inspectors met the GP on the first day of the inspection: she was pleased to report that the issues had been resolved and she was now very pleased with the care being offered. As well as visiting individual residents when they are ill, the GP has started to visit the home regularly each week to discuss residents’ care, review medication and so on. The CSCI pharmacist carried out an inspection of all aspects of medicine administration on 07/02/06. The inspection resulted in four requirements and two recommendations being made. Compliance with these requirements was not checked at the inspection in April 2006. The acting manager has put daily checks of the medicine practices in place to ensure all staff know that they must follow the procedures correctly. She said that staff have received training in administration of medicines, but there was no evidence of this in the St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 12 home. Since the pharmacy inspector’s visit, all medicines for each floor are now stored securely on the relevant floor. There was evidence to suggest that residents’ privacy and dignity is upheld by staff practices. Staff were seen to knock and wait before entering bedrooms, and it was good to note that a sign is put on the door to show when care is being delivered. Some of the residents spoken to said the staff treat them well. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 poor. This judgement has been made using available evidence including a visit to this service. Residents are not given sufficient opportunities to make choices so that they can take control of the way they lead their lives. EVIDENCE: One resident was very pleased to have been given the task of making cups of tea and coffee for the managers and staff. She has been given her own trolley which she pushes round the ground floor making sure staff have enough to drink. Her efforts have been rewarded by a photograph and thank you note from the staff in a frame in the entrance foyer. She is very proud of her achievement and happy to have something useful to do. Several residents said there is not much to do during the day and they are bored. One person said the day before the inspection there had been a singsong for ¾ of an hour. This resident said there have been no outings yet, but these have been promised for the future. One member of staff said that there are notices about outings, for example a trip on the river costing £19 per person, but not much equipment in the home for day-to-day activities, such as games and painting books. One person has bought his own and sits in his St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 14 room drawing and using colouring pencils. The hairdresser is at the home every week. On the top floor it was very disappointing to note that the television was on on one side of the lounge and a radio was playing on the other side. Several people were sitting in chairs in front of the television but none seemed to be watching the children’s programme that was showing. There was no-one near the radio. Two staff were sitting at the dining table at the back of the room not interacting with residents at all. A relative spoken to said that only half the staff on duty had done any work. Relatives are welcomed at the home at any time and are able to take residents out. There was no evidence on the care plans that relatives are encouraged to be involved in decisions about care. One resident said that there is a notice on the board saying that on one day a week residents can order a cooked breakfast. She had ordered one several times, and on one occasion her son had ordered one for her but no cooked breakfast had yet arrived. A member of staff confirmed that he had also left a note in the kitchen ordering this resident a breakfast, but it had been ignored. Staff said that when the meal arrives in the hot trolley they do not know who has ordered which meal. On the first day of the inspection there was a choice of sausages and mash, or chicken curry and rice for lunch. There was no indication as to whether any of the residents had chosen which they would like to eat. The inspectors asked a staff member how she would decide who should have which meal, and were concerned when she said she thought the gentlemen would eat the sausages and the ladies would like the chicken curry. One resident spoken to said the food is poor. This person does not eat meat and said the choices offered are very limited. Other than the basic menu there is no record kept of what food is provided for individual residents. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, however not all residents have been given information on how to complain. The home follows the correct protocol to make sure residents are protected. EVIDENCE: Any complaints made to the home are logged on computer and sent to head office. The manager also keeps a file in which all actions relating to the complaint are stored. The acting manager dealt satisfactorily with a complaint about access to the home and at weekends, by drawing up a new protocol for staff which was sent, with a letter of apology, to the person who made the complaint. One resident who moved from Etheldred House said she had not been given any information about who to complain to if she was not satisfied. The home has copies of Cambridgeshire County Councils protocol for protection of vulnerable adults and recent concerns have been dealt with appropriately. There was insufficient evidence regarding staff training to judge whether staff have received adequate training in the protection of vulnerable adults. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 16 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a home that is generally well maintained, comfortably furnished, well decorated and clean. Some maintenance issues need to be addressed to make sure residents are safe. EVIDENCE: Part of the home is newly built, and the existing home has undergone complete refurbishment. On the first day of the inspection there were a number of maintenance issues which caused concern. For example, a door from the corridor into the courtyard had a gap between tiles, causing a trip hazard, and the slope had no railings; manhole covers in the corridor were not completely flush to the floor; and several fire doors did not close. The operations manager explained that the builders had still to sort out a long “snagging” list. Only three bedrooms were seen: two were very homely and showed evidence of a number of personal belongings including furniture, pictures, and St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 17 ornaments. The third had fewer homely touches but nevertheless was well furnished, clean and clearly met the resident’s needs. There were no unpleasant smells in any areas visited by the inspectors. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff on duty is not always sufficient to meet the needs of the residents. EVIDENCE: The acting manager was concerned that the home has had to use a large number of agency staff. A high percentage of the agency staff and the home’s own staff come from overseas so English is not their first language. This has led to some communication issues which the acting manager is aware of and is planning to address. A lot of effort has recently been put into recruiting local staff, with some success. Some staff moved to St George’s Court with the residents from Etheldred House. Staff on duty said that the large number of agency staff, some of whom are brought up from London to do a 12-hour shift and then taken back, has created problems in offering a consistent care service. Staff also said that communication is difficult with staff who do not have a good knowledge of English. Retaining night staff has been a particular problem. The acting manager had identified that ‘communication’ and ‘team building’ are two areas that need to be addressed urgently. This had begun by staff working mainly on the same floor for all their shifts, so that teams of staff would know their smaller number of residents better, and work more as a team. The manager had sent a newsletter to all staff. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 19 The acting manager has already held staff meetings, and team leader meetings to ensure staff know their areas of responsibility. She has produced a duty folder (also called the “what to do if….” folder) for each floor which contains all the information staff need to deal with any situation. Two residents said that the home is often short of staff so they have to wait for assistance. The unit for eleven frail elderly people often only has one member of staff to assist people to get up, washed and dressed, assist those who need it with their breakfast, and administer medication. On the first day of the inspection a domestic assistant was struggling to keep the laundry under control. She was working in the laundry on a temporary basis, as the laundry staff had left. The laundry room was piled high with dirty washing, which was also waiting in skips in the corridor outside the door. By the second day of the inspection a laundry assistant had been appointed who was managing the laundry well. By the second day of the inspection the acting manager had made good headway in organising staff training records, and had identified that a number of staff had not been given training (or refresher training when due) in several topics, including mandatory topics such as moving and handling, basic food hygiene, and fire safety. She said she intends that all staff will have completed all this training, including Protection of Vulnerable Adults (POVA) by the end of June 2006. Evidence must be available to demonstrate what training staff have received. For example, there was no evidence in the home to show that staff who administer medicines have been trained by a specialist. Excelcare employ a trainer who works with the staff from all the homes in the area. Dates for many of the courses had been booked. The acting manager said that several staff are interested in starting a National Vocational Qualification in care level 2 or 3, and two will do a level 4. A check of four staff files showed that recruitment procedures are generally thorough: all documents required were on file, except evidence that gaps in employment had been explored. Some overseas staff are recruited centrally through an agency: the home must be sure that their references have been verified by the agency. No staff start to work unsupervised at the home until a Criminal Records Bureau disclosure has been received. New staff undertake an induction programme which includes training days before they start work, sometimes organised at other Excelcare homes. The induction programme seen had some gaps, such as no training in POVA, which should be addressed. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 20 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, 33, 35, 37, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Health and safety is not given sufficient priority to ensure that residents are kept safe. Residents views are sought regularly so that they have the opportunity to be involved in the running of the home. EVIDENCE: The registered manager left the home in January 2006. A new manager Jackie Wicks has been appointed. Mrs Wicks is a registered nurse and has many years experience of working in the community as well as in hospital settings. On the first day of the inspection the acting manager had only been at the home a few weeks. She had identified the same areas of concern as those identified by the inspectors and had already made some changes to address St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 21 the issues. It felt positive that she had written action plans for herself, both long-term and what she wants to achieve each week. On the morning of the first day of the inspection the acting manager had met with senior staff and allocated each of them responsibility for one of the three floors in the building. Each floor manager is expected to take full responsibility for their floor. Team leaders had been promoted from within the staff team to assist the floor managers. By the second day of the inspection the acting manager was able to report that this appeared to be working well, especially on two of the floors. A complaint made in March about the difficulties of getting into the home, and about being able to speak to senior staff, led the acting manager to decide that there should be a manager on duty each weekend. This is split between the four managers and was reported to be working well. Staff spoken to felt confident that, from her actions so far, Mrs Wicks would be a competent manager. The home only assists one resident with finances. The administrator said that records are kept of all transactions: these were not checked as they were locked in the tin in the safe and the resident holds the key. The acting manager held a meeting in March with relatives and residents which was very well attended. A newsletter has also been sent to all relatives. The acting manager hopes to hold the meetings every three months, with the newsletter going out in between meetings. The company sends out questionnaires to residents and relatives. The results are brought together and published anonymously in a bound folder which is kept in the entrance foyer. This contains pie charts of the responses so it is simple to see how many of the responses are positive. Other than copies of the menu, a record of food provided is not kept, so there is no way of assessing whether the diet for each individual is adequate. There were a number of health and safety issues noted at the first inspection which gave cause for concern. Several fire doors including the door to the laundry and the door to the kitchen did not close properly. One bedroom door was wedged open with a plastic wedge. The door to the smoking room did not have an automatic closer, so was allowing the smell of smoke into the corridor near the main kitchen. Doors to the lift machine room and the boiler room were not locked. A door to a cupboard containing a quantity of chemicals was open. The issues about fire doors and storage of chemicals have been the subject of requirements made following previous inspections. Records of tests of the fire alarm and emergency lighting systems were checked and were satisfactory. St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 22 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 2 1 St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Each service user must have a written plan of care (Service User Plan) as detailed in Regulation 15. The registered person must promote and make proper provision for the health and welfare of service users. Care plans must contain sufficient information to show that service users’ health and welfare needs are met. Service users must be given opportunities for taking part in valued and fulfilling activities. Service users must be given opportunities to make choices in all aspects of their lives. The registered person must ensure that a suitable, wholesome and nutritious diet is provided for all service users. The registered person must DS0000015238.V288170.R01.S.doc Timescale for action 30/04/06 2 OP8 12(1)(a) 30/04/06 3 OP12 16(2)(m) & (n) 12(2) 31/05/06 4 OP14 31/05/06 5 OP15 16(2)(i) 31/05/06 6 OP16 22(5) 31/05/06 Version 5.1 Page 24 St George`s Court Care Centre supply a written copy of the complaints procedure to all service users. 7 OP19 23(2)(b) The registered person must ensure that the premises are kept in a good state of repair externally and internally. 30/06/06 8 OP27 9 OP28 The registered person must ensure at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This requirement is carried forward from the inspections on 02/08/05 and 25/10/05. The timescales were not met. 18(1)(c) & Records of staff training and 19(1)(b) qualifications must be available for inspection. 18(1)(c) The registered person must ensure that staff receive training appropriate to the work they are to perform. This must include training in the protection of vulnerable adults. An application by the person proposing to be registered as the Manager of the home must be submitted to the CSCI. A record of food provided must be maintained This requirement is carried forward from the inspection 25/10/05. The timescale was not met. Chemicals must be stored securely. Immediate requirement notices were left at the home DS0000015238.V288170.R01.S.doc 18(1)(a) 30/04/06 30/06/06 10 OP30 30/06/06 11 OP31 8(1) 31/05/06 12 OP37 17(2)&sch (4)(13) 12/05/06 13 OP38 13(4)(a) 10/04/06 St George`s Court Care Centre Version 5.1 Page 25 14 OP38 23(4)(c) 15 16 OP38 OP38 23(4)(c) 13(4)(a) following the inspections on 02/08/05 and 25/10/05 regarding this. The timescale of 25/10/05 was met but there is a further breach of this regulation. Fire doors must not be held in the open position except by a means approved by the fire authority. Fire doors must close correctly. 10/04/06 30/04/06 The registered person must 10/04/06 ensure that all parts of the home to which service users have access are free from hazards to their safety. Doors to areas such as the lift machinery room and the boiler room must be kept locked. 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. Refer to Standard OP15 OP9 OP9 Good Practice Recommendations Residents should be offered a choice of meals This recommendation is carried forward A copy of the signed prescription should be retained in order to validate the prescriber’s instructions. Not assessed at this inspection Detailed operational procedures should be developed pertinent to the practices in the home. Not assessed at this inspection St George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 George`s Court Care Centre DS0000015238.V288170.R01.S.doc Version 5.1 Page 27 - 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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