CARE HOMES FOR OLDER PEOPLE
St Georges Nursing Home 2 - 4 Marine Drive Fairhaven Lytham St Annes Lancashire FY8 1AU Lead Inspector
Vivienne Morris Unannounced Inspection 09:30 13 February 2007
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13/02/07 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 Georges Nursing Home DS0000006086.V303890.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 Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Georges Nursing Home Address 2 - 4 Marine Drive Fairhaven Lytham St Annes Lancashire FY8 1AU 01253 730502 01253 730502 stgeorges@centuryhealthcare.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Century Healthcare Limited Mrs Marie Noblett Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (2) of places St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4 November 2005 Brief Description of the Service: St.Georges Nursing Home offers personal care and nursing care for up to 29 older people, including two places for people with a physical disability. The home is situated within five minutes walk of Fairhaven Lake complex and is within easy reach of local shops, post-office, and churches. There are regular bus services near by and Ansdell Railway Station is 10 minutes walk away. Accommodation is provided in a detached property, which has been modernised to suit the needs of the people living at the home, whilst still encapsulating the many original features of the Victorian period in which it was built. The fees at the time of the site visit ranged from £360.50 to £505.00. Additional charges were incurred for hairdressing, chiropody, toiletries, cigarettes, magazines and newspapers. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced site visit, which formed part of the key inspection process, was conducted over one day in February 2007. During the course of the site visit to this service, discussions took place with those living at the home, as well as relatives and staff. Relevant records and documents were examined and a tour of the premises took place, when a random selection of private accommodation was viewed and all communal areas were seen. Comment cards were received from fifteen people involved with the service and their feedback is reflected throughout this report. The information provided by the home on the pre-inspection questionnaire has also been taken into consideration when writing this report. The inspector ‘tracked’ the care of three people during the site visit, not to the exclusion of other residents. The total key inspection process focused on the outcomes for people living at the home. The Commission for Social Care Inspection had not received any complaints about this service since the last inspection. What the service does well:
People were provided with sufficient information about the services and facilities available to enable them to make an informed choice about moving into the home. The information gathered before admission was detailed, providing staff with a clear picture of individual needs, so that the home was able to determine how the staff team could meet the assessed needs of people. The plans of care provided staff with clear guidance about how the assessed needs of people living at the home were to be met and how people were supported to maintain their privacy and dignity. A variety of external professionals had been involved in the care of people living at St Georges Nursing Home to ensure that their health care needs were being appropriately met. A range of risk assessments were in place at the home to ensure that some systems were in place to protect the health and safety of anyone on the premises. The service offered a range of activities, both indoors and within the local community, so that people were entertained. Those less able to participate received 1:1 input from the activities co-ordinator and staff, ensuring that some form of stimulation was provided. However, no one was pressurised to join in activities if they did not wish to do so, showing that people had a choice
St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 6 and were able to have some control over their lives. One person said, “My relative is very happy living at this home” and a resident commented, “The staff are all lovely, they really are decent”. Relatives spoken to were happy about how visitors were received into the home and they informed the inspector that the staff were all very friendly, kind and caring. Sufficient information was provided to people about the use of the local advocacy services to act on their behalf, should they so require and people living at the home were able to have some control over their lives by managing their own finances, should they so wish. Service users were provided with nutritious, well-balanced meals so that their dietary intake was adequate and those requiring support with eating their meals were assisted in a discreet manner, whilst others were encouraged to eat independently. The complaints procedure was freely available within the home and it was also included within the service users guide so that people were given enough information about how did they could make a complaint should they so wish. The policies and procedures in relation to safeguarding adults were in accordance with the Department of Health guidance ‘no secrets’, so that people knew the procedure to take should an allegation of abuse be received by the home. The home was tastefully furnished and pleasantly decorated to a high standard and the premises, both internally and externally were well maintained providing those living at St Georges Nursing Home with a safe, clean, comfortable and homely environment. Effective infection control measures were in place to ensure that the health and safety of people was adequately protected. Staffing levels were calculated in accordance with the assessed needs of people to ensure that adequate care was delivered. Robust recruitment procedures and financial arrangements were in place at the home, which demonstrated that those living at St Georges Nursing Home were adequately protected. The registered manager holds relevant qualifications, has a lot of experience and is appropriately trained to manage the care home. Residents, relatives and staff thought highly of her and they all felt supported by the management of the home. Comments received from relatives included, “St Georges is extremely well run by the matron and her excellent staff” and “ An excellent and sensitive service. I feel lucky to have found this home for my relative”. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 7 The health, safety and welfare of residents was, in general protected by the policies, procedures and practices of the home to ensure that any hazards, which could pose a potential risk, were minimised or eliminated. What has improved since the last inspection? 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 Georges Nursing Home DS0000006086.V303890.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 Georges Nursing Home DS0000006086.V303890.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 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home had been given sufficient information about the service before moving into the home. The preadmission process was thorough enough to ensure that individual needs could be adequately met. EVIDENCE: At the time of the site visit the inspector ‘tracked’ the care of three people living at the home. The care records seen showed that detailed information had been obtained prior to admission and that the needs of people had been thoroughly assessed, to ensure that the staff team could meet the individual needs of everyone moving into the home. The detailed assessments had been retained on residents’ files so that those working at the home were aware of individual assessed needs. One relative spoken to confirmed that the manager of the home had visited the prospective resident before admission and that their individual needs had been discussed, so that they were confident that the home could meet their
St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 10 assessed needs. This relative also said that they had been given a lot of useful information to enable them to decide if the home was suitable for their relative’s needs. Policies and procedures were in place at the home, so that staff were provided with guidance about the admission process and the admission criteria was clearly stated in the service users’ guide so that people wishing to move into the home were aware of the admission process. The assessed needs of those admitted to the home were consistently recorded within the care plan therefore staff were provided with detailed information as to how service users’ needs were to be met. One relative said that he had seen the plan of care for his relative and a staff member had discussed it with him. Staff spoken to knew about the needs of people and how to access the care plans, policies and procedures, which showed that they were able to obtain relevant information if they needed it. St Georges Nursing Home DS0000006086.V303890.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of people living at the home were being consistently met and their privacy and dignity was always respected. EVIDENCE: The care of three people living at the home was ‘tracked’ during the course of the site visit. All three plans of care had been developed from the information gathered prior to admission so that staff were aware of the assessed needs of people living at the home. One care plan was extremely informative, providing staff with clear, detailed guidance as to how the assessed needs of the resident were to be met. The other two care plans were well written documents, showing that the care planned for people was appropriate to their needs. However, there was no documented evidence to suggest that service users or their representatives had not been involved in the care planning process to show that they had been given the opportunity to have some input in the care planned for them. The plans of care had not been consistently reviewed every month to show that the needs of people were being regularly assessed so that their current needs were accurately reflected.
St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 12 The care records showed that a variety of external professionals were involved in the care of people living at the home to ensure that their health care needs were being appropriately met. Specialised equipment was seen to be provided to make the lives of people living at the home as comfortable as possible. All comment cards received from residents, relatives and General Practitioners showed that they were satisfied with the overall care provided to the people living at the home. The management of medications was in general satisfactory. However, hand written transcription on the Medication Administration Records had not been signed, witnessed or countersigned in order to reduce the possibility of any transcription errors. The inspector observed staff speaking to residents in a respectful manner and knocking on bedroom doors before entering to ensure that privacy and dignity was consistently maintained. One relative said, “Staff are very respectful to both residents and relatives” and another stated, “the staff are very friendly and caring”. A written policy was in place and available to staff, which demonstrated that those living at the home were supported to maintain their privacy and dignity at all times. Induction records showed that staff had been instructed to treat service users with respect and care records demonstrated that the wishes of people were respected in relation to maintaining privacy and dignity when giving personal care. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities met residents’ expectations and those living in the home received a healthy, varied diet according to their preferences. EVIDENCE: The home employed a person to be responsible for the organisation and provision of activities and although she only attended St Georges for a few hours each week the people living at the home were satisfied with the level of leisure activities provided. A discussion took place with the activities coordinator, who was very aware of individuals social care needs and people told the inspector what a busy and enjoyable Christmas period the home had provided for residents. The pre-inspection questionnaire showed that a variety of activities were provided, both within the home and in the community so that people were provided with some form of stimulation and entertainment, if they wished to participate and they were encouraged to join in local community life. The activities programme was displayed in the reception area and posters were displayed around the home informing people of various events and activities,
St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 14 which were planned and relatives were also welcome to join in, so that they had the opportunity to be involved in what was going on in the home. Information about the provision of activities was included within the statement of purpose and service uses guide, so that people knew what was going on in the home. Records were kept of what activities people joined in with and if they were enjoyed, which showed that those who were less able to participate were given the same opportunities as others by the provision of 1:1 activities. The statement of Purpose included an explanation of the six principals of care, including rights and choices, showing that those living at the home were able to make decisions and informed choices. The plans of care showed that people’s choices had been taken into consideration and they included information about the leisure interests of residents so that staff were able to provide activities in accordance with people’s preferences. One service user confirmed that religious ministers visited the home regularly to conduct services and the statement of purpose supported this information. The inspector saw that plans of care had been written in relation to individual religious beliefs, showing how people could be supported in meeting their spiritual needs. Church magazines were readily available in the reception area for people to read. A visiting policy was in place at the home and information relating to visiting was also included in the statement of purpose and service user guide to ensure that all interested parties were aware of the visiting arrangements of the home. Relatives were seen to be visiting service users in private and visitors spoken to felt that they were welcome to the home at any time and that a friendly environment was provided for both residents and visitors. The comment cards received supported this information. One visitor said, “ Staff are very friendly and approachable”, and another said, “I am made to feel very welcome when I visit my relative”. The inspector noted that personal possessions adorned individual rooms, where appropriate to create a homely environment and audits of service users’ belongings had been conducted on admission to protect the safety of individual’s personal possessions. People living at the home were able to manage their own finances, if they so wished and if they were capable to do so, showing that they were able to have some control over their lives. One person living at the home was using an advocate to help them in making decisions. Leaflets were freely available in the home informing people of the choice to access advocacy services, should they wish to do so. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 15 The inspector examined the four weekly menus and found that a well-balanced diet was offered to ensure that those living at the home received a nutritious dietary intake. The menu of the day was clearly displayed, so that people were aware of the choices they had been given for lunch. The chef was seen offering people the choices available on the menu and a resident confirmed that there were alternatives to the menu available if required. The pre-inspection questionnaire showed that residents were offered a choice of menu and that special diets were provided as required. The food served appeared appetizing in order to aid nutrition. The inspector noted that specialised utensils were provided to aid in independent eating, but that people were also supported with their meals in a dignified manner as needed. Those living at the home were more than satisfied with the meals provided. One resident said, “The chef is great”, and another commented, “I really enjoy the food, I could eat it all day”. The dining rooms were found to be relaxed areas for people to eat in, with well-presented tables and unhurried atmospheres, so that those dining were comfortable and enjoyed having their meals in pleasant surroundings. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints were well managed and people living at the home were adequately safeguarded. EVIDENCE: A detailed complaints procedure was in place at the home, which was displayed prominently within the home and which was included within the service users guide, showing that people were given enough information about making a complaint should they wish to do so. However, three of the fourteen comment cards received from relatives indicated that they did not know how to make a complaint, should they wish to do so. Residents spoken to at the time of the site visit said that they would know what to do if they were not happy about something. A system was in place at the home so that any complaints received could be recorded and any recurring patterns identified and regularly monitored. The pre-inspection questionnaire showed that the home had received one complaint since the last inspection, which was upheld. The Commission for Social Care Inspection had not received any complaints about this service since the last inspection. Policies and procedures were in place at the home in relation to safeguarding adults, which were in accordance with Department of Health guidance, so that people were fully aware of the action to take should an allegation of abuse be reported to the home.
St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 17 Staff spoken to confirmed that they had received training in relation to safeguarding adults and the training matrix seen supported this information. Staff were aware of what they should do if they had any concerns about the welfare of anyone in their care to ensure that appropriate action would be taken. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 18 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided, in general a safe, well-maintained environment for people to live in, which was homely, clean and tidy. EVIDENCE: The inspector toured the premises during the course of the site visit and found the home to be tastefully decorated and well maintained, providing a very homely and pleasant environment for people to live in. A comment received from one relative was, “St Georges Nursing Home is clean, warm and comfortable”. The pre-inspection questionnaire showed that a number of bedrooms had been redecorated since the last inspection and the plan of routine maintenance showed that decoration and refurbishment was continued on a rolling programme, so that comfortable surroundings were provided for those living at the home. Residents spoken to were satisfied with the standard of private accommodation provided. One stated, “My bedroom is very comfortable and is kept clean by staff”.
St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 19 The communal lounges and dining rooms were pleasant and comfortable for people to sit during the day, providing a homely environment for those living at the home. The bathroom on the ground floor was being used as a storage area for commodes and linen trolleys, making the bath inaccessible to residents, should they prefer to use this bathroom. The fire extinguisher in the corridor near room 8 was occluded by the sit on weighing scales, making it difficult for staff to access. The building was fit for purpose and was maintained to a good standard of repair so that people living at the home were provided with a safe environment. Odour control was effective so that the home was pleasant smelling. The laundry department was fit for purpose and was suitable for the needs of the residents’ and the home. Detailed policies were in place at the home to ensure that the control of infection was being adequately met so that the health and safety of people living there was appropriately safeguarded. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff working at the home were trained, skilled and in sufficient numbers to fulfil the aims of the home and to meet changing needs of residents. The recruitment procedures adequately safeguarded those living at the home. EVIDENCE: At the time of the site visit there were 26 people living at St Georges Nursing Home. The number of staff on duty was being calculated in accordance with the assessed needs of people living at the home and records showed that a good skill mix of staff made up the staff team so that residents’ needs were being met. The pre-inspection questionnaire showed that agency staff were rarely used so that continuity of care was maintained. Residents spoken to felt that their needs were being fully met and that the staff were patient and did not rush them when assisting them with activities of daily living. There was a total of thirteen care staff employed by the home, seven of whom had achieved a National Vocational Qualification at level 2 or above, giving a total of 54 of care staff with a National Vocational Qualification showing that sufficient numbers of care staff were adequately trained to do their job. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 21 A formal induction process had been adopted by the home so that staff understood their role and were able to perform the duties expected of them. . A staff-training matrix was in place, which showed that a wide range of training was provided for staff so that people working at the home received adequate training to look after the people in their care. All staff completed mandatory core-training courses to ensure that there was a skilled workforce and that people had the necessary knowledge to meet the needs of the people they were caring for. Staff spoken to felt that a lot of training was provided to meet their needs and the training certificates available on staff files supported this. Three staff files were examined at the time of the site visit. It was found that recruitment procedures were being adequately followed in day-to-day practice and sufficient checks had been undertaken on staff to ensure that those living at the home were adequately protected. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 22 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, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was being well managed by a competent person, having effective systems in place for monitoring the quality of service provided and the health, safety and welfare of people living at the home were, in general adequately protected. EVIDENCE: The manager of St Georges Nursing Home has been in post for many years. She has the required qualifications and experience and is competent to run the home. During the time she has been in post she has worked hard to improve the service and to provide an increased quality of life for residents. She has completed a management qualification showing that she has the management skills to operate the home efficiently and effectively for people living there. There is a strong belief of being open and transparent in all areas of running the home so that people were kept informed of matters involving them. The manager has completed a variety of additional training courses and is resident
St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 23 focused and leads and supports the staff team who have been appropriately recruited, so that those living at the home are adequately protected. Three comment cards were received from General Practitioners who were all satisfied with the care provided to their patients and one stated, “A superb nursing home with an excellent matron and senior staff”. Surveys had recently been conducted so that the views of residents, their relatives and stakeholders had been obtained about how the service was performing. The information gathered was put together and produced to show interested parties the strengths and weaknesses of the service. A variety of meetings had been held and these were recorded as minutes, so that people were kept informed of any relevant matters. However, it is recommended that the meetings for service users and their relatives be held on a more regular basis so that current and up to date information is passed to all concerned. The home had been accredited with two external awards, showing that it is audited on a regular basis by external professional bodies. The registered manager had put in place a variety of regular, detailed checks. This enabled her to identify and address any shortfalls within the systems in place at the home and closely monitor the quality of service provided. Four comment cards received from relatives stated that they do not have access to the inspection reports. However, ten indicated that they did and it was evident at the time of the site visit that the last inspection report was displayed in the reception area. A wide range of risk assessments had been conducted, which were sufficiently detailed, showing that some systems had been put in place in order to reduce the possibility of injury to people living at the home. However, risk assessments had not always been conducted for people at risk of falling or for those requiring the use of bed rails to ensure that residents were consistently protected. Systems were in place at the home to ensure that residents’ finances were adequately protected. The relatives of residents were often responsible for the management of their money. However, personal allowances of a small number of people were retained by the home, where residents were unable or did not wish to manage their own affairs. Clear records were kept of any money or valuables retained at the home on behalf of service users so that the possibility of any mishandling was reduced. The pre-inspection questionnaire showed that all systems and equipment within the home had been appropriately checked so that the health and safety of people living at the home was protected. This was confirmed by examination of a random selection of service certificates. Accidents occurring in the home had been accurately recorded so that the manager was able to audit and monitor the frequency of accidents. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 24 The environment was free from any hazards, which could pose risks to those living at the home. St Georges Nursing Home DS0000006086.V303890.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 X 3 X 3 X X 2 St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? 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 (1) Requirement Timescale for action 30/06/07 2. OP7 15(2)(b) 3. OP19 23(2)(l) Service users or their relative must be given the opportunity to be involved in the care planning process. Where this offer is declined then this must be recorded. (Timescales of 31/08/05 and 31/01/06 not met) Service user care plans must be 30/06/07 kept under review. (Timescale of 31/01/06 not met) The registered person shall 30/06/07 having regard to the number and needs of the service users ensure that suitable provision is made for storage for the purpose of the care home. This includes making sure that all facilities are accessible for residents and that emergency equipment is freely accessible by staff. The registered person must 31/03/07 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, including conducting risk assessments for people at risk of falling and those requiring the use of bed rails.
DS0000006086.V303890.R01.S.doc Version 5.2 4. OP38 13(4) St Georges Nursing Home Page 27 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 OP7 OP9 OP33 Good Practice Recommendations Care plans should be reviewed on a monthly basis or more often if care needs change. Any hand written transcriptions on the Medication Administration Records should be signed, witnessed and countersigned. It is recommended that residents and relatives meetings be held more frequently with minutes retained. St Georges Nursing Home DS0000006086.V303890.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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