Inspection on 18/09/06 for St Giles Residential Home

This inspection was carried out on 18th September 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 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 Giles Residential Home 10/02/06

St Giles Residential Home 03/08/05

St Giles Residential Home 08/09/04

St Giles Residential Home 18/06/04

St Giles Residential Home 25/02/04

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

CARE HOMES FOR OLDER PEOPLE St Giles Residential Home St Giles Mews Vicarage Road Stony Stratford Milton Keynes Buckinghamshire MK11 1HT Lead Inspector Joan Browne Unannounced Inspection 18th September 2006 09:30 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 DS0000032628.V304288.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. DS0000032628.V304288.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Giles Residential Home Address St Giles Mews Vicarage Road Stony Stratford Milton Keynes Buckinghamshire MK11 1HT 01908 566077 01908 261371 anne.walker@milton-keynes.gov.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) Milton Keynes Council Mrs Anne Walker Care Home 35 Category(ies) of Dementia (35) registration, with number of places DS0000032628.V304288.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 Brief Description of the Service: St Giles is a purpose built residential care home for elderly people suffering from dementia, it is owned by Milton Keynes Council. The home is located in Stony Stratford, close to shops, pubs, the post office and other amenities. Public transport is easily accessible. It consists of a two-storey building with three separate lounge areas, each with its own dining area. There are thirty-five bedrooms, which are fitted with wash hand basins. The first floor can be accessed via a passenger lift. A laundry is provided on site. The gardens are well maintained. The weekly fees are £430.00. Additional charges are made for hairdressing, toiletries, clothing, footwear and confectionery. DS0000032628.V304288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took place on 18 September 2006. Prior to the fieldwork visit previous information about the home was reviewed and the outcome of the previous inspection noted. Comment cards were received from ten residents, (It was noted that they were completed by relatives on behalf of residents) three relatives and one placement officer. Overall they were happy with the care provision. Residents and those family members who were visiting on the day of the fieldwork were interviewed. A tour of the premises was undertaken and care records and documentation were examined. The care of three residents was ‘case tracked’ from their original contact with the home to the care that they are now receiving. Care practices and the home’s approach to quality and diversity issues were observed. What the service does well: The home continues to care for a resident who has had to remain in bed for over three years, there was no pressure damage. Residents looked very well cared for with the appropriate attire and attention to detail. The home has good relationships with the general practitioner and the district nursing services. The home provides appropriate activities to meet the social and psychological needs of the residents. The home has a quality monitoring group that meets monthly, which is made up of staff members and other stakeholders. Good interaction between the residents and the staff team was noted. More than 50 of the staff team have achieved the national vocational qualification (NVQ) in direct care in level 2 and above. The staff team is able to access an ‘on track’ five-day induction training, which supports them to meet the at times challenging and diverse needs of residents. DS0000032628.V304288.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans must be reviewed monthly and contain essential and detailed information to ensure that residents’ needs would be fully met. Two staff members should check handwritten entries on medication administration record sheets to minimise the potential risk of recording errors. The home should review how information is recorded in the concerns record book to ensure that confidentiality and data protection are not breached. A cleaning schedule must be introduced in the laundry room to ensure that walls and ceiling lights are kept clean. Arrangements must be made to ensure that copies of references, a recent photograph and a declaration of health statement are held in the home in staff’s files. All staff must undertake updated training in food handling and hygiene, adult protection and infection control to ensure that they acquire the appropriate skills and knowledge to care for residents. A risk assessment must be developed for barrier creams and soaps to minimise any potential risk of harm to residents. Staff should check and record hot water temperatures when assisting residents with baths and showers to reduce any potential risk of scalding. Please contact the provider for advice of actions taken in response to this DS0000032628.V304288.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000032628.V304288.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 DS0000032628.V304288.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a system in place to ensure that prospective residents’ needs are assessed prior to being admitted to the home. EVIDENCE: The practice in the home is that all admissions are referred through care management arrangements. The home receives a summary of individuals’ care management health and social services assessment and a copy of the care plan produced for care management purposes. The home’s staff use the information in these two documents to assist in developing their own care plan. The home provides specialist care for people with dementia therefore, it would not be possible for a prospective resident to make an informed choice about whether or not the home was suitable to meet their needs. Family members are involved in the assessment process and decide whether admission is appropriate. Prospective residents are admitted to the home on a four- week trial period. After the trial period a review is held on whether the placement DS0000032628.V304288.R01.S.doc Version 5.2 Page 10 should be made permanent. One relative spoken to was complimentary on the admission process and felt that staff were ‘supportive, understanding and welcoming’. Staff spoken to had some knowledge of residents’ assessed needs and the home’s admission procedure. DS0000032628.V304288.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 good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that residents’ health and personal care needs would be met. However, some inconsistencies in the detailing of information in care plans could compromise on residents’ care. EVIDENCE: Three care plans were examined in detail. There is a comprehensive care plan format in place. However, inconsistencies in recording of information were noted in the care plans seen. Essential information relating to individuals’ preferred name, religion, known allergies, next of kin details, and their wishes in the event of death was not always completed. Care plans did not outline how all aspects of residents’ health, personal and social care needs would be met. It is acknowledged that staff spoken to were able to describe the level of assistance they were providing to residents but their good practice was not recorded in care plans seen. Individuals’ personal profiles, nutritional screening, physical and mental health assessments and pressure sore assessments were fully completed. It was noted that the care plans seen were not reviewed monthly. DS0000032628.V304288.R01.S.doc Version 5.2 Page 12 Entries in the daily log reported on residents’ physical care, eating and drinking. Some entries referred to residents’ mood and one judgemental entry that was not appropriate was noted. Comments within the surveys from relatives stated that the standard of care provided was good. The following comments were noted: “The care provided at St Giles couldn’t be improved upon. The staff are first class and all seem to do more than should be expected of them. At St Giles the residents wellbeing is paramount.” “Absolutely no problems with the care my mother receives. I would be quite happy to reside there myself if needed.” All residents are registered with a general practitioner (GP) who visits the home weekly or as and when required. The district nurse visits the home daily to administer insulin injections and to provide wound care treatment. It was noted that the district nurse was providing treatment to a particular resident in the lounge. This could be perceived as a breach in the individual’s privacy. It is acknowledged that at times it could be difficult to provide treatment in individuals’ rooms. In such situations the care plan should reflect how the treatment is provided and this should be agreed in a multi-disciplinary forum. Residents at risk of developing pressure sores are provided with the appropriate pressure relieving mattresses and cushions. Residents have access to the continence adviser and two staff members work closely with the adviser to ensure that residents’ needs are assessed and the appropriate continence aids and equipment are provided when required. All residents have access to a chiropodist who visits the home regularly. Dental and optical treatment can be accessed as and when needed. The medication administration record (MAR) sheets on two units were checked. No gaps were noted but handwritten entries recorded on MAR sheets were not checked and countersigned by two staff members to make sure that they were correct. When a course of antibiotic treatment has been completed as a good practice it is recommended that the staff member recording the entry should record a short note for example, course completed, and date and sign the entry. Staff spoken to confirmed that their competencies are assessed on a regular basis and that they undertake regular updated training in the administration and safe handling of medication. The manager confirmed that the home’s pharmacist carries out quarterly audit of the home’s medication. The storage cupboards seen were tidy and generally well maintained. Residents’ attire was clean and tidy with attention to detail. Staff appeared to have an overall understanding of the needs of people with dementia and were observed interacting with residents and providing personal care in a sensitive and discreet manner. Staff were able to describe how they were meeting the diverse needs of individual residents. Five visitors were spoken to in the home DS0000032628.V304288.R01.S.doc Version 5.2 Page 13 on the day of the site visit. One said “mum’s appearance is always clean and tidy, which is good because she could not look after herself anymore.” DS0000032628.V304288.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that residents’ leisure, social and dietary needs were being met. EVIDENCE: Since the last inspection a full time activity organiser post had been created. A programme of activities is advertised in the home weekly and includes activities such as hairdressing, exercise, manicures, dominoes, board games, cake making and video showing. Twice a month entertainers visit the home to perform. The activity organiser provides one to one activity for those residents who are not able to participate in group activities. A PAT dog visits the home weekly. Residents are also taken out in wheelchairs for short trips. Because of the residents’ mental frailty it was difficult to ascertain if the lifestyle experienced in the home matched their expectations. Relatives are requested to complete personal profiles, which have assisted staff in ensuring that residents’ social cultural religious and social needs are met. During the site visit residents were observed participating in a sing-a-long, which they appeared to have enjoyed. It was noted that two residents were being supported by their friends and the staff team to practice their chosen religion. DS0000032628.V304288.R01.S.doc Version 5.2 Page 15 Visitors spoken to during the site visit said that they are made to feel welcome when they visit. One visitor said, “staff always offer me a cup of tea or coffee or encourage me to make one for myself.” There were no residents in the home who were able to look after their own finances. Staff spoken to during the site visit described assisting residents to make choices such as choosing what clothes they wished to wear, or respecting their wishes if they wanted to spend time on their own or to eat alone. If requested to, the home would provide information to relatives and residents on how to contact external agents such as an advocate. The home provides three meals a day with drinks and snacks available during the day and night. Specialist diets such as, diabetic or soft diets are provided. Staff were observed prompting and encouraging residents to eat and drink in a sensitive and discreet manner. Lunch consisted of sausages, mashed potatoes and baked beans with angel delight for desert. A small portion of lunch was sampled during the visit and it was tasty. Dining areas looked welcoming and attractive. DS0000032628.V304288.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has policies and procedures and processes in place to protect residents from any potential risk of harm or abuse. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Information submitted on the pre-inspection questionnaire indicated that the home had received one complaint since the last inspection. The manager confirmed that the complaint was satisfactorily resolved. At the last inspection a recommendation was made for the home to keep a record of all concerns brought to the attention of staff. It is pleasing to report that the recommendation had been acted on. The manager was advised to review the system in place on how complaints and concerns are recorded to ensure that confidentiality and data protection are not breached. The Commission has not received information concerning any suspicion or allegation of abuse or neglect made to the service since the last inspection. Staff spoken to were aware of what action should be taken if they suspected or witnessed a resident being abused. Information submitted on the preinspection questionnaire in section D6 indicated that staff had undertaken training in the protection of vulnerable adult. However, all staff would need to undertake regular training to update their knowledge and skills. DS0000032628.V304288.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Maintenance work has been carried out in some areas of the home, which has significantly improved its appearance. However, further maintenance and housekeeping work would need to be addressed to ensure that the environment is well maintained for those living there. EVIDENCE: The home is situated close to a shopping area and is accessible by public transport. It is situated on two floors and was generally clean and tidy on the day of the inspection with no odours. There has been a programme of routine maintenance and renewal of the fabric and decoration of the premises to enhance the appearance of the building. Units looked homely and welcoming with fresh flowers. However, in some areas of the building such as corridors and some bedrooms maintenance work remains outstanding. The manager stated that plans are in hand to have the outstanding work carried out. The following comment was noted from a relative: “I feel St Giles is really trying and succeeding in providing a happy caring homely environment for my DS0000032628.V304288.R01.S.doc Version 5.2 Page 18 mother. The makeover has made such a difference to the general look and atmosphere of the home and the staff do a great job in an often difficult situation.” The home was inspected by the local fire service in February 2006 and has complied with the requirements made. All requirements made by the environmental health officer who visited the home in October 2005 have been complied with. The laundry room is situated away from the kitchen. The floor and walls of the laundry are impermeable. It was noted that the walls were dusty and covered in cobwebs. There was a build up of dust behind the washing machines and driers. The ceiling lights contained dead insects. It is required that a cleaning schedule is introduced in the laundry room to ensure that the room is adequately maintained. Staff were observed providing personal care to residents and not changing their gloves. This practice is unacceptable and could pose a risk of cross infection and should cease. It was noted that the clinical waste bin was left unlocked. Staff are reminded of their duty to ensure that the bin is kept locked to prevent rodents and vermin gaining access and to reduce the spread of infection. Two panomatic sluice disinfectors were recently installed in the sluice rooms to ensure that urinals and commode pots are appropriately cleaned. DS0000032628.V304288.R01.S.doc Version 5.2 Page 19 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 the service. Although a high percentage of staff have acquired NVQ there need to be a more robust procedure in place to ensure that mandatory training for all staff is regularly updated. Records relating to staff recruitment need to be kept in the home in line with current good practice guidelines. EVIDENCE: Comments in surveys indicated that some relatives felt that overall residents were receiving all the support they needed from staff. The following comments were noted: “All I can say is that my family and myself are happy with what goes on in the home at St Giles residential home at Stony Stratford when we go and visit.” “We have always found the staff at St Giles to be helpful kind and compassionate.” “We are very happy with the standard of care. The staff are exceptional and communicate with relatives.” The home submitted a copy of the staff rota with the pre-inspection questionnaire. This was discussed with the manager during the site visit and she confirmed that she is supernumerary to the rota. There are six carers and a team leader allocated on an early shift. The afternoon shift is cover by five carers and a team leader. The activity organiser works full time and is available until 17.30 pm. The number of staff covering the night shift has been increased from three to four. An administrator who works full time supports the home and there is a chef and other kitchen and domestic staff employed to maintain standards and cleanliness in the home. The staff group DS0000032628.V304288.R01.S.doc Version 5.2 Page 20 is multi-cultural. Staffing levels are determined by residents’ needs and there are occasions when the home has to depend on agency carers. The home employs twenty-three permanent staff and eight relief staff. Information submitted on the pre-inspection questionnaire indicated that twenty-one permanent staff, which is a percentage of 67 , have achieved an NVQ in direct care at level 2 or above. The file for the most recently appointed staff member was examined. It is the practice in the home that original records are held centrally. A copy of the individual’s criminal record bureau (CRB) clearance was seen along with a copy of the application form. Copies of references, a declaration of health statement and a recent photograph for the individual were not available. The practice of not keeping copies of references for individuals in the home was discussed with the manager. It is required that the home reviews its recruitment practice to comply with the regulation. Information seen in the individual’s file indicated that induction training had been undertaken. Information submitted with the pre- inspection questionnaire indicated that the home’s staff are able to access training in-house facilitated by the Council or the local college that meets the ‘skills for care’ criteria. Topics included core skills such as food hygiene, moving and handling, first aid, medication administration, NVQ, infection control, fire awareness and adult protection. Additional specialist training can also be obtained. There is also a five -day induction training for staff which is called ‘On Track’ that covers the following topics: person centred care, developing knowledge and practice, diversity and communication, health, safety and security in the work place, emergency aid and protection of vulnerable adults. Staff spoken to during the site visit said that they found the ‘On Track’ training invaluable. It helped them to understand their role, and what was expected from them. It also heightened their awareness of the actions they needed to take to promote equality and diversity. The staff training matrix list seen highlighted that some staff have not undertaken training in food handling, adult protection and infection control. This was discussed with the manager during the inspection. It is required that all staff including bank staff must undertake updated training to ensure that they acquire the appropriate skills and knowledge to care for residents. DS0000032628.V304288.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that the home is run in the best interests of residents. However, some improvement relating to health and safety practice in the home is needed to ensure that residents’ safety and welfare are not compromised. EVIDENCE: The home has an experienced manager, who holds the national vocational qualification (NVQ) 5 in operations management. She is also a first level registered mental health nurse and has been managing the home for six years. She also has line management responsibilities for two day care establishments. The manager and her senior staff team have a lot of experience and knowledge in caring for residents with mental frailty. Staff spoken to said that the manager was approachable, equitable and operated an open door policy. The manager has delegated some of the care responsibilities to her two group leaders. They are responsible for supervising staff and for DS0000032628.V304288.R01.S.doc Version 5.2 Page 22 organising monthly unit meetings. She endeavours to hold general staff meetings with the staff team at least twice yearly. She was confident that there were clear lines of accountability within the home and externally. To ensure that the home is run in the best interests of residents the home has a quality monitoring group, which is called ‘Heart of St. Giles’. The group consists of relatives, staff members and is chaired by the activity organiser. Stakeholders such as the district nurse and a care manager regularly attend the meetings. The purpose of the group is to look at areas in the home that need to be improved on. This could be a range of issues such as, maintenance, maintaining the garden, laundry, activities and food menus. The views of family and friends and stakeholders are also sought on how the home is achieving its goal in providing a quality service to residents. A copy of the minutes of the most recent meeting held was made available for inspection purposes. It was noted that some of the home’s policies and procedures submitted under section B1 on the pre-inspection questionnaire, which reflect the Regulations and Standards had not been reviewed within the last five years. These would need to be reviewed in line with best practice guidelines. None of the residents at the home are able to manage their own finances. The home has systems in pace to address this. There are currently six residents whose finances are managed by the Council’s finance director. Their funds are held centrally and day-to-day expenses such as hairdresser fees, toiletries and personal clothing are paid for out of the home’s petty cash float that is reimbursed via an imprest account. Records of all transactions are maintained electronically and are monitored by the Council’s financial system called SAP. The home also holds small amounts of cash for residents whose relatives look after their finances, which are topped up when required. Written records are kept of expenditures made. The home was expecting an eminent visit from the Council’s auditor. Information recorded on the pre-inspection questionnaire under section A5 indicated that the fire equipment in the home was serviced on 2 February 2006. Staff spoken to confirmed that fire drills are carried out monthly and this was reflected in the fire records. This is deemed as good practice. Information recorded in the fire records indicated that the home’s emergency lighting is checked monthly. The fire panel is checked weekly and during the site visit a check was carried out. The central heating and gas appliance were serviced on 12 December 2005. The home’s hot water system had been checked for the prevention of legionella and found to be satisfactory. The electrical hardwiring certificate for the building was up to date. The home’s lift was serviced in June 2006. The home’s bath hoists and mobile hoists were serviced in April 2006 and the emergency call bell system is serviced annually. During a tour of the building it was noted that several tablets of soap, creams and liquid wash solutions were visible in bathrooms, toilets, and the shower DS0000032628.V304288.R01.S.doc Version 5.2 Page 23 area. This is not a good practice as it could pose a hazard to residents. It is required that a risk assessment be put in place to minimise the risk of any potential hazard. Staff are reminded of their duty to return all toiletries, creams and lotions to residents’ bedrooms after use. Facilities for the storage of pads in toilets and bathrooms were available. However, pads were on view in some areas. Staff would need to use the storage facilities to ensure that residents’ dignity is not compromised. It was noted that some bedroom doors were wedged open with chairs and other obstacles. This was discussed with the manager during the inspection. It is acknowledged that common sense decisions are taken. However, there would need to be an appropriate risk assessment in place to support any decision that is taken. It was noted that hot water temperatures are not checked and recorded when staff assist residents with baths. As a good practice it is recommended that hot water temperatures are checked and recorded when staff are assisting residents with baths and showers as restrictor valves could fail. It is acknowledged that hot water temperatures in areas of the building are checked and recorded regularly. DS0000032628.V304288.R01.S.doc Version 5.2 Page 24 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000032628.V304288.R01.S.doc Version 5.2 Page 25 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 2 3 Standard OP7 OP19 OP29 Regulation 15 23(2)(d) 19 Schedule 2 Requirement The registered manager must ensure that care plans are reviewed monthly. The registered manager must introduce a cleaning schedule in the laundry room. The registered manager must ensure that copies of references, a recent photograph and a declaration of health statement are held in the home in staff’s files. The registered manager must ensure that all staff undertake updated training in food handling and hygiene, adult protection and infection control. The registered manager must ensure that a risk assessment is in place for creams and soaps to minimise any potential risk of harm to residents. Timescale for action 30/10/06 30/10/06 30/10/06 4 OP30 18(c)(i) 30/11/06 5 OP38 13(4) 30/11/06 DS0000032628.V304288.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP7 Good Practice Recommendations It is recommended that the registered manager should ensure that care plans contain essential and detailed information to allow a new member of staff or an agency carer to care appropriately for residents. It is recommended that the registered manager should ensure that any treatment provided to residents in a communal area that could be perceived as a breach of privacy should be documented in the care plan and agreed in a multi-disciplinary forum. It is recommended that the registered manager should ensure that two staff members check handwritten entries on the medication administration record sheets to minimise the potential risk of errors in recording. It is recommended that the registered manager should review how information is recorded in the concerns book to ensure that confidentiality and data protection are not breached. It is recommended that the registered manager should ensure that staff change their gloves for each resident when providing personal to prevent the spread of cross infection. It is recommended that the registered manager should ensure that staff record hot water temperatures when assisting residents with baths and showers. 2 OP8 3 OP9 4 OP16 5 OP26 6 OP38 DS0000032628.V304288.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford, OX4 2SU 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 DS0000032628.V304288.R01.S.doc Version 5.2 Page 28 - 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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