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Inspection on 18/05/07 for St John`s Nursing Home Limited

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

This inspection was carried out on 18th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Comments received from surveys included: `Manager tells us to be kind and gentle to our residents.` `St John`s Nursing Home is well run, efficient and professional. They are doing everything as well as I would hope.` [The resident] has been in the home for four years now, and there was nothing to offer the residents, but there has been a big improvement since Jane has been there helping everyone also organising lots of entertainment.` `All staff that we meet are very friendly and helpful and seem to be looking after [the resident] well.` `the carers are always available to take care of the clients. The nursing staff always give any necessary information about doctor`s visits and medication. They will always ask your opinion first. The home has an excellent activities organiser that keeps the clients well occupied and stimulated.` The home provides a calm, peaceful homely environment, which is generally well maintained. Appetising home cooked food, is served. Residents Birthdays are celebrated. Residents spoken with made positive comments about the home, their room, the staff, the care and the food that they receive.

What has improved since the last inspection?

Some improvement has been made with staff files, but further work is needed. See main body of report.

What the care home could do better:

Assessments must be factual and provide the basis for care plans. Records of wound care must be improved to ensure up to date information is available on progress. A separate care plan must be in place for each wound, to prevent confusion. Regular photographs must be taken which show the wound and improvements with the date included. One resident said `tea could be better`, this was seen to be discussed at a residents meeting, with action taken by staff to address this. Staff must protect people`s privacy and dignity when showing visitors around. Shared rooms must have appropriate screening, one survey stated: `A dividing curtain round the bed which we were told was going to be done for privacy.` A few communal areas are in need of redecoration and some radiator covers need repairing or replacing. Staff files must include a CRB check. References should be addressed to the home, rather than `to whom it may concern`. Application forms must be completed prior to commencing employment. Health and safety checks of the electrical supply and portable electrical appliances need to be up to date and available for inspection. Fire exit signs must be lit at all times, ensuring residents, staffs and visitors health and safety is protected. Other information regarding improvements required are detailed in the main body of the report and in the requirement section.

CARE HOMES FOR OLDER PEOPLE St John`s Nursing Home Limited St John`s Nursing Home 129 Haling Park Road South Croydon Surrey CR2 6NN Lead Inspector Janet Pitt Key Unannounced Inspection 18th May 2007 10:35 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 John`s Nursing Home Limited DS0000019041.V338084.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 John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St John`s Nursing Home Limited Address St John`s Nursing Home 129 Haling Park Road South Croydon Surrey CR2 6NN 020 8688 3053 020 8649 9611 primecare@hotmail.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) St John’s Nursing Home Limited Care Home 45 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (22) of places St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: St Johns is a 45-bed nursing home set in South Croydon. It lies within easy reach of the centre of Croydon, and a selection of public transport links. It is registered to cater for elderly clients who require general nursing care, (22 beds) and also clients with dementia who require nursing care (23 beds). The stated aim of the home is to provide a safe and comfortable environment with a happy atmosphere. At the time of this inspection St John’s had an acting manager, who is not yet registered. The home provides information about its services in a Service User Guide, which is made available to current and potential Service Users. Additional information can be found in the home’s Statement of Purpose. The current weekly fees range from £525 - £675. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced inspection. Two site visits were made which lasted a total of fourteen and a half hours. Fifteen surveys were sent to relatives and eight were returned. Fifteen residents’ surveys were sent and nine returned. Ten staff surveys were left at the home and two completed surveys were returned. Information from the surveys is included in this report. Residents, visitors and members of staff were spoken with. Mealtimes were observed. Staff files, care documentation and health and safety records were examined. What the service does well: What has improved since the last inspection? Some improvement has been made with staff files, but further work is needed. See main body of report. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Admission to the home is process driven with little consideration of the individuals needs. Practice needs to be consistently applied. Assessments need to be developed to make sure all needs are identified. EVIDENCE: Survey respondents stated that they usually had sufficient information when choosing St John’s. However, a few of respondents were not satisfied with the process. One person reported that they ‘were told this was the only one available’. Another person said that: ‘although was shown a room that [the resident] was to have, but when [they] arrived was put on a different floor and different room which we were not happy about.’ One person said that they had ‘checked out a couple of homes in the area’ prior to choosing St John’s. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 9 It is important that prospective residents are not mislead about the room that they will occupy. Assessments of prospective residents are made prior to and on admission. Details on the admission assessment were noted to be basic. Information from pre admission sources has not been included in the home’s assessment. Assessments undertaken on admission were basic. Information available from pre-admission assessments was not consistently used in the home’s assessment. This meant that social and personal wishes were not always recorded. Different levels of information were available in the files seen. Assessments must be factual and available to staff, to ensure peoples needs can be fully met. Specific information such as type of glasses needed and mobility were not detailed. Elimination needs were recorded as no problems. There were some good examples of specific details in assessments e.g. times for going to bed and getting up. Detail of type of glasses needed, what type of assistance is required should be included to enable needs to be identified and care planned to meet these needs. There was limited detail on hobbies and interests. On one assessment a resident’s hobby was noted as ‘cards’, this was followed by a statement that they had a pack of cards. There was no information on the type of games the person enjoyed playing. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff treat people who use the service in a way, which does not respect their privacy and dignity. Staff fail to treat people who live in the home as individuals and their choices, decisions and wishes are not respected. Health care is reactive rather than proactive, ongoing monitoring of health care is poor. EVIDENCE: Case files must contain the required information. Care plans identified that they had been developed from assessments. However, they must be more detailed to evidence people’s needs and how they are to be met. Staff demonstrated that they knew the residents and how to meet their needs, however this was not confirmed in care plans and daily recording. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 11 Some care plans seen were written in a residents focussed way, personal hygiene, i.e. ‘ask [the resident] when [they] would like to be attended with personal hygiene. There was no evidence to indicate that it was the individual’s choosing to have a bath and hair wash once a week. The activities person was heard talking to potential hairdressers, that individual’s hair was washed on bath days. This does not promote choice. Risk assessments need to be individualised to make sure that people are able to carry out activities safely. It was not clear what involvement residents and their representatives have in developing care plans. Daily records contained bland statements such as ‘cheerful and co-operative’ and ‘toileted’. This does not indicate how needs were met and whether interventions were appropriate. Wound care plans in place, however these need to have a separate plan for each wound, photos to include the date and photo of each wound in accordance with good practice guidelines. One plan had details of a ‘small red area on middle back. Scratched whilst dressing.’ There was no other information of whether this had healed. Also it was not clear how a person with a weakness was able to scratch their back. Waterlow Pressure scores did not consistently reflect the individuals’ condition. For example someone who had a progressive disease, an indicator for one section had decreased, even though the disease was progressive and the person said their condition was worse. Residents must be treated with respect. One resident wished to use the toilet, but was told: ‘[you] have to wait’ ‘Just been’. It is irrelevant whether a person has just been to use the toilet. Requests for assistance must be carried out in a timely manner. Staff must not judge what a resident is thinking or feeling. Eight peoples medication records were examined. An urgent requirement was made for an auditable trail of medications within the home. The provider wrote to confirm that this had been actioned. Medications were generally kept securely, but it was difficult to track individual’s usage. There were discrepancies in amount of medication that should have been in the home; either too many or too few tablets were available. Variable doses of medications were not always detailed; therefore it was difficult to track how many had been given. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 12 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home are able to take part in a variety of activities. The food is of satisfactory quality and well presented. Staff do not interact positively with residents and do not respect their rights as individuals. EVIDENCE: A person is employed to organise activities five days a week. There are regular quizzes on a Tuesday and Bingo on a Friday, an entertainer is invited to the home once a month and an annual Strawberry Tea is held. Mealtimes are generally a sociable occasion. Lunch was observed to be relaxing and at the pace of the people eating. A good standard of food is provided and residents made positive comments about the meal and food they get. Staff made sure that they were seated to assist residents with their meals, but this was not consistent. Some staff moved between residents. Food was hot and well presented. Pureed diets were also well presented. However, staff mixed this together, instead of taking a bit of each type of food. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 13 Some areas of the mealtime could be improved, to make it a better experience for people. Tables being prepared prior to residents sitting down and condiments being available. Use of ‘bibs’ should be discouraged. Residents’ dignity would be maintained by the use of cloth napkins. Staff need to make sure that they inform residents of actions they are about to take. One resident was moved with no interaction from staff. Choice of beverages must be evident. Residents were only offered orange squash to drink with their meal. Residents were not consistently asked whether they had finished their meal, prior to plates being removed. Staff need to make sure that they do not have discussions over the heads of residents, as this is perceived as rude. The manager made sure residents were offered second helpings, but one member of staff answered for a resident, before the resident had time to consider the question. Attention to the way residents are regarded by staff members is needed; use of derogatory language does not respect residents. Examples of this: ‘He drink morning, I feed.’ And ‘Wipe your mouth.’ Comments about the food included ‘lunch was very good’, ‘tea is not sufficient’, ‘lunch is usually this good’, ‘the food is good’ Evening meals were discussed with residents at their meeting and attention is being paid to improve choice and food offered. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are aware of how to raise concerns. The complaints policy is accessible and generally followed. Staff must be trained appropriately to make sure that residents’ needs are met. EVIDENCE: Complaints received are logged and actioned. A book containing complaints was in the entrance hall on the first site visit. Two complaints were recorded for 2006. On the second visit this record was on the first floor bookshelf. The record of complaints, including actions taken and outcomes should be stored securely. Survey respondents indicated that they were aware of how to make a complaint if they needed to. One relative and three residents confirmed that they had no complaints or concerns and would speak to staff should there be an issue. The manager also provided a number of ‘thank you’ cards from relatives, which identified that they had been satisfied with the services provided. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 15 Staff training records showed that thirty members of staff completed training in the protection of vulnerable adults in June 2006. However, the content and who provided the training was not on the signing sheet. There has been no protection of vulnerable adult investigations since the previous inspection. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no ongoing maintenance programme in place. Some of the décor requires upgrading. Attention must be paid to making sure the home is clean and hygienic. Better use of the communal space would enhance the residents’ lives. EVIDENCE: The home provides suitable communal space, but this was not widely used. Residents rarely used a lounge at the front of the home. There is a large lounge/dining area on the ground floor, which residents tend to use. A lounge/dining room is also available on the second floor. More attention to detail is required with the cleaning programme to ensure that all areas of the home are maintained at a clean and hygienic standard. The St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 17 cleaning programme must include deep cleaning programme for the kitchen, bathrooms and shower rooms and general dusting. The redecoration schedule must be continued to ensure the home is maintained at a good standard for people. It is expected that the planned programme of redecoration is submitted to the CSCI. Bedrooms seen had generally been personalised to the individuals taste. One bedroom had condensation in the double-glazing unit and another had no window restrictor. One resident said that they like looking at the garden. The garden was seen to be well-kept and colourful for residents to look at and access during good weather. Residents had requested that the path in the garden was altered to make it more accessible. This has been actioned. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not support the development of a competent staff team. Training is not targeted at individuals and mandatory training is not current. Recruitment processes need to ensure the safety of residents. There are shortfalls in the recording and processes used. EVIDENCE: Staff files were examined. Generally these contained the information required in the schedules and regulations. However, there must be evidence that all staff have a job description and a copy of their signed contract. A review of the application form would make sure that appropriate information is obtained and compliance is achieve with employment law. Gaps in employment and a request for cautions to be declared will make sure that residents are protected from harm. One file had detail of a disciplinary procedure, the employee did not sign this and there was no information to show it had been monitored. Files did not always contain application forms or contracts. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 19 To comply with good employment practice it is recommended that there is evidence of person specifications for use in short listing and offering position. Also records of interviews. Training records indicated that training had been provided on Protection of Vulnerable adults, Fire Safety, Dementia Care and Moving and Handling. However not all staff have received mandatory training. This must be achieved to make sure that residents are cared for by skilled and competent staff. The training signature sheet did not include details of who carried out the training or what the training included. Comments regarding staff from surveys included: [the resident] cannot speak, but the staff seem to know her needs,’ and ‘ ‘look after [the resident] very well, also visitors.’ St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home, however there are no clear lines of accountability within the company. Residents’ health and safety is not protected. Routine checks are generally carried out, but infection control is poor. EVIDENCE: The manager must register with the CSCI Residents and their relatives have been surveyed for their views. This must be continued to make sure views on the running of the home are heard. Residents meetings are held regularly. The inspectors were invited to attend one. Involvement of residents was apparent and there was good interaction with residents and time allowed for then to express their views. To enhance these St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 21 meetings it is recommended that more residents are encouraged to attend, or small meetings are held on each floor to enable those who may be shy to voice their views on the running of the home. Health and safety records were generally in good order and up to date with the exception of the portable electrical appliances, which needs checking every year. The check of the electrical supply must be available for inspection. The fire brigade visited during the second site visit for a familiarisation of the home session. Fire policies were also examined. A Gas safety check was completed in June 2006, this noted that one boiler was not working. The manager reported that a new boiler had been fitted after this date. Lifts had all had an annual examination in 2005 and been serviced in 2006 Records indicated that hoists had been serviced in July 2006 and were due in January 2007, however hoists seen had been tested in November 2006 with one exception. Bars of soap were seen in some bathrooms. Toiletry items must be available for each individual, as communal use may lead to infection control issues. The inspectors were concerned that nursing staff were not carrying out blood glucose monitoring in a safe manner. The pen that is used for putting lancets in was broken. Staff reported that the lancets were ‘stabbed’ into the residents’ fingers. An immediate requirement was left with regard to obtaining single use disposable lancets. Staff are also required to undergo refresher training in diabetes care, in particular making sure blood glucose levels are measured in accordance with good practice. CSCI has concerns regarding the roles of the management team within the home. The current manager needs to be able to run the home in the best interests of those that live there. Information was requested at one site visit and a member of the Provider’s company was reluctant to provide this information. The registered person was informed verbally of this obstruction. It is imperative that the Provider and the Manager are aware of their role and responsibilities and the necessity to comply with the law. St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X X 1 St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4&5 Requirement The registered person must ensure that prospective residents are given choice and have all necessary information to assist them in making a decision on where to live. The registered person must ensure that information from pre admission assessments are included in the home’s assessment. The registered person must ensure that the homes assessments involve the resident or their representative. The registered person must ensure that assessments are completed fully, including risk assessments. The registered person must ensure that language used within assessments is not derogatory. The registered person must ensure that care plans contain detail of how care is to be provided. The registered person must ensure that the resident or their representative is involved in the DS0000019041.V338084.R01.S.doc Timescale for action 30/09/07 2 OP3 14 30/09/07 3 OP3 14 (1) (c) 30/09/07 4 OP3 14 (2) 30/09/07 5 6 OP3 OP7 12 (4) (a) 15 (1) 30/09/07 30/09/07 7 OP7 15 (1) & (2) (c) 30/09/07 St John`s Nursing Home Limited Version 5.2 Page 24 8 OP7 15 (2) (b) 9 OP7 17 (1) (a0 and Sch 3 10 OP8 17 (1) (a) & Sch 3 (k) 17 (2) & Sch 4 (12) (b) & (c) 11 OP8 12 OP9 13 (2) care planning process and this is evidenced. The registered person must ensure that care plans include appropriate interventions and reviews of these interventions. The registered person must ensure that daily records reflect care given. Entries must be dated, timed and signed. There must be evidence of whether care given is effective and whether needs have been met appropriately. The registered person must ensure that wounds are accurately documented and evidence is available to indicate effectiveness of treatment. The registered person must ensure that skin integrity is monitored and recorded accurately. Any episodes of bruising or scratching must be evidenced fully and action and outcomes detailed. The registered person must ensure that all medication received at the home is correctly accounted for, and that all medication administration records are accurately completed at all times. Previous timescale of 30/11/06 not met. The registered person must ensure that privacy and dignity of residents is maintained. Staff must not talk over residents’ heads. The registered person must ensure that residents’ meals are a social occasion and promote choice. The registered person must ensure that communal areas in the home promote interaction between residents. DS0000019041.V338084.R01.S.doc 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 13 OP10 12 (4) (a) 30/09/07 14 OP15 12 (1) (a) 30/09/07 15 OP19 12 (1) (a) 30/09/07 St John`s Nursing Home Limited Version 5.2 Page 25 16 17 OP26 OP29 16 (2) (j) 19 18 19 OP29 OP30 18 (2) (a) 18 (1) (a) 20 OP31 10 (1) 21 22 OP38 OP38 13 (4) (c) 17 (1) (a) & Sch 3 (3) (j) 23 (2) (b) 23 OP38 24 OP38 13 (3) The registered person must ensure that the premises are kept clean and hygienic. The registered person must ensure that a comprehensive recruitment process is followed. All information required must be in staff files. The registered person must ensure that disciplinary actions are properly recorded. The registered person must ensure that staff receive mandatory training at prescribed intervals. The registered person must ensure that there are clear lines of accountability and management within the home. The registered person must ensure that risks to residents are minimised. The registered person must ensure that accident records detail outcomes and actions taken. The registered person must ensure that all areas of the home are maintained or checked to make sure that residents are not placed at risk. The registered person must ensure there are effective infection control procedures within the home. 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 26 St John`s Nursing Home Limited DS0000019041.V338084.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI St John`s Nursing Home Limited DS0000019041.V338084.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!