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Inspection on 31/07/07 for St Helen`s Nursing Home

Also see our care home review for St Helen`s Nursing Home for more information

This inspection was carried out on 31st July 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People`s needs are fully assessed prior to admission and this means that staff are aware of these needs and feel able to meet them. This is reassuring for the residents and their families. Food provided is good and well liked by residents. The care staff are a dedicated and committed team that are much appreciated by residents and relatives. They commented, `Great care is given`, and `staff try very hard and generally succeed`.St Helen`s Nursing HomeDS0000063755.V335910.R01.S.docVersion 5.2The manager is well liked and approachable. People said of him, `the manager is clearly supportive and goes out of his way to spend time with...` and `the home manager is on the ball and very caring`. Relatives feel confident with the home and the staff. They feel they are kept well informed of their loved ones condition. One person said, ``When I have been unable to visit I have telephoned and been able to speak to ........, staff have always updated me on these occasions as to how ......is. Needless to say this is reassuring`.

What has improved since the last inspection?

Since the last inspection the fire doors are no longer held open with door wedges. Those identified where the door closers were broken and the intumescent strips were loose have been repaired. New beds have been purchased along with pressure relieving mattresses. Bed rails for use on these beds have also been purchased and a system set up to ensure they are used safely. All hot water outlets are regulated and the water is delivered at a suitable temperature to reduce the risk of scalding to people at the home. Staff are not deployed in the home until all pre employment checks have been received and are satisfactory. This means that only safe staff care for people.

What the care home could do better:

To ensure that all residents assessed needs are planned for, those identified at the pre admission assessment must be transferred into a care plan. The care plans should be individual and person centred to make sure that people`s individual needs are addressed. To ensure that the current staffing levels are appropriate a full review must be carried out in consultation with residents, their relatives and the staff. This is in particular relation to night staffing and provision of appropriate activities. This will ensure that there are sufficient staff available to meet the needs of people. Where changes to peoples care needs indicate that the accommodation provided should be changed this should only be done following full consultation with the resident, their relatives and any relevant professionals. This will ensure those residents` wishes and feelings are taken into consideration. To make sure that people remain safe the requirements around health and safety that include correct fitting of fire doors and the fitting of windowSt Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 restrictors must be met. The temperature in the conservatory must be kept at a suitable temperature at all times to ensure people`s comfort and safety.

CARE HOMES FOR OLDER PEOPLE St Helen`s Nursing Home 41 Avenue Victoria Scarborough North Yorkshire YO11 2QS Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 09:30 31st July 2007 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 Helen`s Nursing Home DS0000063755.V335910.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 Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Helen`s Nursing Home Address 41 Avenue Victoria Scarborough North Yorkshire YO11 2QS 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) 01723 372763 01723 501502 Hamilton Care Limited Mr George Roy Tomlinson Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (26) St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2006 Brief Description of the Service: St Helens is a care home providing nursing care for up to 26 people from the age of 65 years of age who have dementia and/or mental disorder. The home is located close to the town centre of Scarborough, its amenities and facilities. There is a small garden area to the front of the house and parking for visitors is limited on the road at the side of the house. A local bus route serves the home. The accommodation provided is in both single and double bedrooms on three floors and there is a passenger lift giving access to the upper floors. Information about the services that the home offers is made available to residents and their relatives prior to admission in the form of an information booklet. A service user guide is available in each bedroom. The fees charged at 31st July 2007 range from £442 to £525 per week. Extra charges are made for the chiropodist, hairdresser and personal toiletries. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • • • Reviewing information that has been received about the home since the last inspection. Information gained from a random inspection that was carried out on 9/3/07 in response to a complaint. Information provided by the deputy manager on a pre inspection questionnaire; Comment cards returned from 13 relatives, 5 residents (completed with assistance), 4 staff, 1 health care professional and 1 care manager. A visit to the home carried out by one inspector. Evidence gained from the use of an observational tool developed to help inspectors gain an insight into services that people with a dementia receive. A site visit was carried out and lasted for five hours. Two relatives and six staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit a sustained period of time was spent observing wellbeing, engagement and interaction of residents in a communal area. This helped the inspector to gain an insight of what life is like at St Helen’s Nursing Home for the people that live there. The manager, his deputy and staff on duty assisted the inspector during the day. The manager was given feedback from the inspection at the end of the day. What the service does well: People’s needs are fully assessed prior to admission and this means that staff are aware of these needs and feel able to meet them. This is reassuring for the residents and their families. Food provided is good and well liked by residents. The care staff are a dedicated and committed team that are much appreciated by residents and relatives. They commented, ‘Great care is given’, and ‘staff try very hard and generally succeed’. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 6 The manager is well liked and approachable. People said of him, ‘the manager is clearly supportive and goes out of his way to spend time with…’ and ‘the home manager is on the ball and very caring’. Relatives feel confident with the home and the staff. They feel they are kept well informed of their loved ones condition. One person said, ‘‘When I have been unable to visit I have telephoned and been able to speak to …….., staff have always updated me on these occasions as to how ……is. Needless to say this is reassuring’. What has improved since the last inspection? What they could do better: To ensure that all residents assessed needs are planned for, those identified at the pre admission assessment must be transferred into a care plan. The care plans should be individual and person centred to make sure that people’s individual needs are addressed. To ensure that the current staffing levels are appropriate a full review must be carried out in consultation with residents, their relatives and the staff. This is in particular relation to night staffing and provision of appropriate activities. This will ensure that there are sufficient staff available to meet the needs of people. Where changes to peoples care needs indicate that the accommodation provided should be changed this should only be done following full consultation with the resident, their relatives and any relevant professionals. This will ensure those residents’ wishes and feelings are taken into consideration. To make sure that people remain safe the requirements around health and safety that include correct fitting of fire doors and the fitting of window St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 7 restrictors must be met. The temperature in the conservatory must be kept at a suitable temperature at all times to ensure people’s comfort and safety. 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. The summary of this inspection report can be made available in other formats on request. St Helen`s Nursing Home DS0000063755.V335910.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 Helen`s Nursing Home DS0000063755.V335910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 6 is not applicable. People who use the service experience good quality outcomes in this area. People can be assured their needs will be assessed prior to admission to ensure that the services provided will be able to meet these needs. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Three care records looked at each contained a needs assessment that had been completed before the person had moved to the home. The assessments looked at physical, emotional and social needs to make sure that the home could meet their needs before the person decided to live at St Helens. Information about the home and the services provided are sent out to people making enquires about living at the home. Surveys returned from relatives indicate that people feel they receive sufficient information about the service before their relatives move in. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 10 A visitor spoken with on the day said that they had met the manager before their relative had moved in and they had also received an information pack about the home. This process makes sure that the staff at the home are fully aware of peoples needs and feel confident that they can care and support the person effectively. This in turn reassures people using the service that their needs will be met. Intermediate Care is not provided at St Helens. St Helen`s Nursing Home DS0000063755.V335910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use the service experience adequate quality outcomes in this area. Residents would benefit from a more person centred approach to meeting their holistic needs. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Residents look well cared for and appeared calm and content on the day of the site visit. Staff were observed speaking with residents respectfully and giving them time to respond. The care plans are very generalised and those looked at were not specific to individuals and did not always fully address the mental health needs and social care needs identified at the pre admission assessment. Work has started on developing ‘life histories’ for each person and ensuring that the care plans address people’s mental health needs as well as social needs. This will help to make staff aware of people’s life experiences and family contacts so they can then have meaningful conversations with people. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 12 The care plans looked at show that healthcare needs have been addressed and planned for. Staff are aware of residents preferences in relation to bedtime and food preferences and said that these were met. The plans also show that advice has been sought from other healthcare professionals when needed including the tissue viability nurse. A relative commented on the survey, ‘Great care is given’ another said, ‘staff try very hard and generally succeed’. A community psychiatric nurse felt that the staff ‘endeavours to meet peoples personal lifestyles within their facilities’. The frailty of people living at the home mean that staff are fully occupied meeting the resident’s physical care needs and do not always have the time to address the social and mental healthcare needs. A staff member commented, ‘There is precious little time left to spend with people on an individual basis’. A relative had commented, ‘we do not feel his needs are addressed as he gets no conversational or mental stimulation at all’. However another relative had commented, ‘This home seems to have calmed……down and they are now secure, content and happy’. One person had been moved from a single room to a shared room on the ground floor. The manager stated that this had been for safety reasons as the person was at risk from falling and agreement had been given by the care manager (this was confirmed). A risk assessment to this effect had been completed several weeks following the move. However the family state that the resident would never have chosen to share a room and that they were not consulted about this. The family had been very distressed about this as they felt the resident would prefer to spend time in their own private room. They said that their relative was ‘increasingly depressed and angry at the situation’. Systems are in place to ensure that medications are stored, handled and administered correctly. This means that residents receive prescribed medication safely. St Helen`s Nursing Home DS0000063755.V335910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use the service experience adequate quality outcomes in this area. People enjoy the meals at the home and are encouraged to maintain contact with relatives. However, staff are not able to support people to fully meet their social and recreational expectations. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff spoken with feel that they do not have sufficient time to help people fulfil their social and recreational expectations. No activities were observed during the visit. Staff appeared rushed. A staff member said ‘we would like to do more with the residents but we do not have sufficient time’. Another staff member said, ‘they never hardly get out and if they do it’s the same people’ and ‘it would be good to get to know people better but it is not happening’. Visiting clergy of different denominations enable people to continue to worship as they choose. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 14 The meals provided at the home are nutritionally balanced and are presented well so that they appeal to people. Staff were seen assisting people that needed help in a sensitive and considerate way. Mealtimes were unhurried and help was given on an individual basis. All the residents were given the opportunity to wash their hands and faces following lunch. Visitors are welcome at the home at anytime. A relative spoken with confirmed that they are able to visit at anytime. A cordless telephone system has been installed so that calls may be taken in private if people wish. One relative said, ‘When I have been unable to visit I have telephoned and been able to speak to …….., staff have always updated me on these occasions as to how [my relative] is. Needless to say this is reassuring’. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience good quality outcomes in this area. People are protected and any concerns listened to. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has a clear complaints procedure that is displayed at the home and contained in the home’s information pack. Relatives indicated on comment cards returned that they were aware of the procedure as they had received an information pack. A relative spoken with on the day of the site visit was able to confirm that they knew what to do if they were unhappy about anything. They were aware they could speak to an inspector if they were unhappy about any aspect of their relatives care. The Commission had received one complaint since the last inspection. This related to residents not receiving encouragement with meals, not always receiving hot food; inappropriate care practices and poor manual handling techniques. The complaint resulted in a random inspection and was found to be partially substantiated in relation to the food storage. A requirement was made about reviewing procedures around mealtimes and the storage of hot food. The adult protection policy is made available to all staff. Staff spoken with were very clear about reporting any suspicion or allegation of abuse. The manager had referred a case to the Adult Protection Team and this had St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 16 resulted in the dismissal of a member of staff. There had been some delay in reporting this, as the manager had not received the complaint in writing. However he is now aware that this is not required and reporting should not be delayed for whatever reason. St Helen`s Nursing Home DS0000063755.V335910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience adequate quality outcomes in this area. People live in a clean and comfortable environment, however some elements need addressing to ensure the home remains safe. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The décor and atmosphere within the home is warm and welcoming. There is an ongoing programme of renewal and redecoration in place. Plans are underway to replace carpets in the communal area to make these areas more pleasant for people. Most of the beds in the home have been replaced and special mattresses purchased to prevent pressure damage. New bedrails have been bought that are compatible with the new beds, so ensuring that they will be used safely. There is now a system in place for staff to check the continued St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 18 safe use of bedrails. New lifting equipment has been purchased to assist the staff to move and handle people correctly and safely and they were observed doing this. All hot water outlets are now regulated and the temperature is at an acceptable level. A legionnaires certificate has been obtained to confirm the water supply is safe. Time was spent sat in the conservatory area to observe activities in the home. This area was extremely warm and reached a maximum of 27.2ºC even with the doors and windows open. This was a very uncomfortable temperature on a very warm day and there were no additional drinks available or offered. The manager eventually turned on two fans and the room cooled down to 25ºC. Call bells in the communal areas are situated on the walls. This means that only people able to stand and walk can summon assistance and people who are immobile cannot and have to depend on shouting or on other people to press the button. A relative commented, ‘the length of the call bell lead is very short when people are in bed or sat in the chair. If they are unable to stand it is hard to reach’ Some fire doors in the home were not closing tightly into the door rebates without firm pressure and so in some instances they were not closed correctly. This means that they would be ineffective in the event of a fire. In some bedrooms on all floors window restrictors had not been replaced following redecoration and could be opened sufficiently to allow somebody to fall through. An urgent action letter has been sent to the home to address these issues as a matter of urgency. The manager has since confirmed that these issues have been attended to. St Helen`s Nursing Home DS0000063755.V335910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience adequate quality outcomes in this area. People are cared for by a dedicated and committed staff team, however people would benefit from access to additional staff. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The rotas show that there are five to six staff on during the mornings and four to five on during the evening. On occasions agency staff have been utilised to maintain these numbers. The care staff were observed during their interactions with the residents. They were seen to treat people respectfully and spoke to people in an appropriate way. Time was given for people to respond and staff were very patient. Staff were seen to be very busy attending the physical care needs of the residents and had little time to sit or spend time with individuals. The providers had given written information to the Commission for Social Care Inspection on 07/02/06 that night staff levels were now at three waking staff as had been agreed verbally. At the last inspection this was not the case. A requirement had been made to restore the night staff levels to previously agreed levels but this has not happened. The care needs of the current service St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 20 user group indicate that three night staff are needed to ensure the continued safety of service users. Staff spoken with agreed that two night staff are insufficient and that this had been discussed on an individual basis and at meetings. One staff member reported, ‘It is difficult with only two staff on duty’. Another said, ‘It’s fine if everybody is asleep but if two or more people require attention or are wandering then this is difficult.’ All staff receive an induction to the home and currently 80 of care staff hold an NVQ qualification at level 2 or above. The remaining staff are starting training within a month. Staff said they receive sufficient training to enable them to carry out their roles efficiently. Staff do not yet receive formal supervision on a regular basis but are currently preparing for their annual appraisals. St Helen`s Nursing Home DS0000063755.V335910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37. People who use the service experience adequate quality outcomes in this area. To ensure the home continues to be managed well the manager needs to be proactive in the area of health and safety. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager is undertaking his Registered Managers Award. He has many years experience as a general nurse and one that specializes in caring for this service user group (Registered Mental Nurse). He is assisted in his role by a supportive management team. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 22 Quality assurance is carried out within the service. However this needs to be further developed to ensure that the views of all who have an interest can be taken into account when planning the future of the service. The manager also needs to ensure that communication with people is maintained at all times. Meetings with staff groups are held regularly and minutes are maintained. The manager deals with some personal allowances for service users. Accurate records are kept of all transactions made. Comments received from surveys included, ‘the manager is clearly supportive and goes out of his way to spend time with…’ and ‘the home manager is on the ball and very caring’. Residents were observed freely approaching him during the day. Staff have not received any formal supervision. One commented, ‘I have had one supervision meeting from somebody who left a while ago.’ One staff commented on the survey form that they feel the manager listens to them but does not always act on issues. Another commented in discussions, ‘We have spoke about staffing levels but nothing changes.’ To ensure the continued safety and care of residents the issues identified around health and safety and night staffing levels need to be addressed. St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 1 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 1 St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 24 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 OP10 Regulation 12(3) Requirement Where changes are proposed to any service offered to a resident then these should be carried out only when sufficient consultation has taken place with the resident or their representatives and mutual agreement has been reached. This refers to moving people to different bedrooms and requiring them to share a room. Residents and/or their relatives must be consulted about the resident’s social interests and preferences and these should be recorded. Arrangements must be made so that people have access to sufficient and varied activities in order that they meet with their expectations and they lead a varied lifestyle that is acceptable to them. The conservatory must be kept at an acceptable temperature at all times to ensure peoples comfort and safety. The call bell system must be DS0000063755.V335910.R01.S.doc Timescale for action 10/08/07 2. OP12 OP13 16(2(m)) 05/09/07 3. OP19 13(4(c)) 10/08/07 4. OP19 16(2(c)) 05/09/07 Version 5.2 Page 25 St Helen`s Nursing Home reviewed to ensure that it is appropriate to meet the needs of people at the home. 5. OP27 18(1(a)) The night staffing levels must be restored to previously agreed levels to ensure the continued safety of service users. Previous timescale of 22/9/06 not met. A review of the staffing provided must be carried out in consultation with residents (or their representatives) and staff at the home 6. OP19 OP38 13(4(c)) A risk assessment must be completed to assess the risk to the service users involved where window restrictors are not in place on their bedroom windows. Control measures must be put in place to ensure that the risk to service users is reduced significantly. Arrangements must be made to have window restrictors fitted to these windows. (This timescale was agreed at the inspection). 31/07/07 11/09/07 7. OP19 OP38 13(4(a)) 03/08/07 8. OP19 OP38 09/08/07 23(4(c)(i)) All fire doors within the home must be reviewed to identify those that need work carrying out on them in order that they fit correctly and provide sufficient protection from any fire risk. You must then arrange for this work to be carried out. This must be completed within one week from the date of this letter. 26 Copies of the regulation 26 visit 14/08/07 reports must be forwarded to the CSCI on a monthly basis. DS0000063755.V335910.R01.S.doc Version 5.2 Page 26 9. OP33 St Helen`s Nursing Home 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 Care plans should continue to be developed. They must clearly direct staff as to how people’s needs are to be met and also be ‘person centred’. It is recommended that the manager continue to work towards completion of the Registered Managers award. It is recommended that the quality assurance system that is in place is developed further to ensure all stakeholders’ views are taken into account and acted upon. 2. 2. OP31 OP33 St Helen`s Nursing Home DS0000063755.V335910.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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