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Inspection on 25/04/06 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 25th April 2006.

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

During the inspection the opportunity was taken to talk briefly with several residents and their relatives. In spite of the shortcomings in a number of areas, they all said that generally they were happy with the service they received. Although there was a high number of new staff, they did appear to work well together and were supportive of each other and the service users.

What has improved since the last inspection?

One very positive action by the provider since the last inspection had been to recruit an activities co-ordinator. This has been a long time in coming, but the new incumbent is proving popular and is keen to establish an activities programme and then encourage as many residents (and their relatives/ visitors) as possible to join in. While a necessary focus had been placed on the requirements that have not been met, it is only fair to also acknowledge that action has been taken to resolve eight of the requirements that were contained within the November inspection report. The recent recruitment of a deputy manager is also beneficial.

What the care home could do better:

Clearly, with a total of seventeen requirements to meet there are a number of areas in which the home can improve. The recruitment of a manager is of paramount importance, as without this key figure the home will continue to struggle on a day-to-day basis, with little or no direction being provided for the staff team, and no established patterns of work, supervision or guidance. This can only have a negative impact on the care provided to the service users (it is acknowledged that the recruitment of a deputy manager will have a positive impact on the running of the home, but there will be a limit to what they can do and they should not be expected to cover both the deputy and the manager`s roles at the same time).

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 Margaret Lynes Key Unannounced Inspection 25th April 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 St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 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 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 Miss Jayanti Bhowanee 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.V289652.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 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. The home 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 the home was without a registered manager. 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 home has an inspection report on display in the lobby (unfortunately it was over a year old and should be replaced by the most recent report). The current weekly fees (as provided at the time of this inspection) range from £525 - £675. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of 8 1/2 hours, and involved examining paperwork, conducting a tour of the premises and meeting with service users, relatives and staff. The November inspection had resulted in five new requirements being made, while there were eleven that remained outstanding from previous inspection visits. Of these 16, eight are still to be met. St Johns received a total of five inspection visits during the course of the last year, a reflection of the concerns of the Commission about the overall quality of care being provided. Additionally two statutory enforcement notices were served due to poor recruitment practice. Initially improvements were noted but the departure of the registered manager early in the New Year has again led to the Commission expressing concerns over the day-to-day functioning of the home. This visit has resulted in nine new requirements, and seven good practice recommendations. Coupled with the eight outstanding requirements that the home has yet again failed to meet, it is clear that there is an urgent need for both a suitable manager to be recruited, and for more a concerted effort from the registered provider to raise the standards in this establishment. Evidence to support the comments below was gathered from a range of sources – the service users themselves, relatives, members of staff and inspection records. What the service does well: What has improved since the last inspection? One very positive action by the provider since the last inspection had been to recruit an activities co-ordinator. This has been a long time in coming, but the new incumbent is proving popular and is keen to establish an activities programme and then encourage as many residents (and their relatives/ visitors) as possible to join in. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 6 While a necessary focus had been placed on the requirements that have not been met, it is only fair to also acknowledge that action has been taken to resolve eight of the requirements that were contained within the November inspection report. The recent recruitment of a deputy manager is also beneficial. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is not applicable) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It was not felt that the home always carried out or obtained a full assessment prior to offering a placement. This means that it is feasible that the home may admit clients whose needs it is unable to fully meet. EVIDENCE: Five service user files were examined, all relating to new or relatively new admissions. Two contained both a placing Authority and an in-house assessment. One had the former and just one page of the in-house proforma completed, while a fourth just contained the first page of the in-house assessment. One file did not contain any assessments at all. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It was not felt that the service user plans were sufficiently detailed so as to enable staff to provide the all-round comprehensive care that would be needed and is expected. Inconsistency in the health care records means that it is possible staff will be unaware of or overlook a specific issue. Errors in the medication administration charts means that service users are placed at unnecessary risk. This was an unmet requirement from the preceding inspection. EVIDENCE: None of the service user plans examined contained reference to social care needs. Indeed, one of the plans was extremely brief, while another was clearly out of date but had not been reviewed. The health care records were slightly better kept, with most of the files examined containing a pressure area assessment, dependency chart, moving St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 10 and handling assessment and a record of weight. These latter records were missing on one file, while several did not contain a nutritional assessment and none of those examined contained a continence assessment. Aside from the moving and handling assessment, there was no other indication that an assessment of risk had been undertaken. A number of errors were found in the medication administration records. These predominantly related to staff not signing the charts, but there were a couple of instances where it appeared that staff had given more than the prescribed dose. This was immediately brought to the attention of the deputy manager. Staff were seen to observe service users privacy, and to a great extent their dignity. Several staff were heard to frequently refer to service users as “dear”, “darling” and “love”. While in themselves these terms are not at all derogatory, staff need to ensure that each service user is happy to be referred to in this way, rather than by their given name. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. For the first time in a number of inspections it was felt that the home was able to offer activities to suit service users social and recreational interests and needs. More effort is being made to enable service users to maintain contact with family and friends, and to exercise choice in their lives. The residents are provided with a choice of main meals – no adverse comments were received with regard to the menu. EVIDENCE: The proprietor had recently employed an activities co-ordinator. The Inspector was able to have a lengthy discussion with them regarding their plans for activities, their intention to involve family and friends a lot more in the home, and their understanding that service users needed to have their social and recreational needs met in the same way that their health and personal care needs are catered for. The new co-ordinator appeared enthusiastic and, with a nursing background, showed an understanding of the importance of trying to maintain service users lifestyles to the extent it is possible. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 12 While not sampled, the midday meal was observed. Service users were offered a choice of hot meals. A number of service users are able to sit around a dining table in the main lounge to have their lunch. The remainder either stay in their armchairs (in the communal areas) with a small pull-over table, or eat in their bedrooms. If service users are able to sit at a table, then every effort should be made for them to do so. Meals can then become a social event, and the monotony of sitting in an armchair all day can be relieved. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has an adequate complaints procedure, however from relatives comments it was not obvious that staff were sufficiently aware of how to receive/deal with a complaint. Staff cannot have adequate knowledge of adult protection/adult abuse issues until there is an acceptable procedure in place. The lack of such a procedure potentially places service users at risk. EVIDENCE: The home’s complaints procedure is displayed in the lobby, while close by there is a comments box with forms that can be completed by any service user or visitor. Although the procedure is clear, one relative commented that they did not feel that the staff were willing to accept criticisms, and that if they did raise issues then the general impression given was that they always had the option to find an alternative placement. While the Inspector did not see evidence of this attitude it would be good practice for the staff team to be enabled to attend training in dealing with complaints. At a number of the preceding inspections it has been required that the home revise both the adult protection and the restraint procedures. The latter has now been done however the former still states that in the event of an allegation of abuse the proprietor will decide what action to take. This is incorrect and the procedure must be amended so that it is clear that staff are expected to follow the multi-agency procedures and any such matter must be St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 14 referred to Croydon social services. They are the lead agency in such matters and they will decide how/if an investigation is to proceed. Under no circumstances should the proprietor commence an investigation without first referring to the lead agency. The procedure also states that on a 6-monthly basis the proprietor will review the adult protection records and inform the Commission of such a review. To date this information has not been forthcoming. While the Commission does not require this information, it would be good practice for the home to follow its stated procedure in this respect (or otherwise amend it). St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has yet to meet all of the outstanding requirements regarding the premises, in general the home was comfortable and maintained to a satisfactory level. There was a faint, but still noticeable odour in some of the communal areas however, which means that the environment is not as pleasant as it could be. EVIDENCE: A tour was made of the communal areas and some of the bedrooms. It was noted that the previously made requirements regarding the need for bedside lights to be within reach of service users (while in bed) had not been met, and neither had the requirement to ensure that the inside of the microwaves were regularly cleaned. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 16 It had also been previously required that the staff team ensure that the home was free of offensive odours. While an improvement was noted, a faint but still detectable odour was present on entry into the home, and in some of the corridors. Further effort is therefore needed in this respect. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The rota provided indicated that staffing numbers were again below the minimum levels previously agreed. This means that the needs of service users cannot always be attended to promptly. Following on from two Statutory Enforcement Notices, the recruitment practice had improved. On this visit, however, there had been some slippage, meaning that service users were not being fully supported and protected by the recruitment practice. On this visit it was not possible to evidence that new staff were receiving a formal induction, or that the staff team in general had attended any recent training. This means that it is possible that the staff team has not had the appropriate training to care for the service users at St Johns. EVIDENCE: The rota provided indicated that while there were always the requisite numbers of trained staff on duty (although yet again, it was not possible to determine if there was always an RMN on duty (as required) as the rota did not indicate qualifications), on almost every morning shift the number of carers was below the minimum expected. Previously agreed staffing levels are 3 qualified staff (one RMN) plus 7 carers in the morning; two qualified (one RMN) plus 6 carers St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 18 on in the afternoon/evening; and two qualified (again one RMN) plus 3 carers at night. It is of concern that this issue has yet to be resolved. The home has recruited a considerable number of staff since the last inspection visit. The files of approximately half of these new staff were examined – 12 in all. A number of discrepancies were noted – several of the application forms had unexplained gaps in the employment history; there was no evidence that explanations had been sought as to why staff had left previous employment where they were working with vulnerable people; there was no evidence to show that references had been verified (particularly in the case of two which were not particularly good); and there was no evidence in several files to confirm that the individual concerned did not need a work permit/visa. It was also noted in some files that the references supplied were up to 6 years old. The proprietor was reminded that where he wished to employ staff in advance of the return of their CRB disclosure, he not only had to obtain a POVA first, but also had to seek the agreement of the Commission in each and every case. He was also reminded that no member of staff could start work without at least the POVA first – from the files it was evident that one had started the day before the POVA first arrived. Similar recruitment practice in the past had already led to two enforcement notices being issued to this home. Unfortunately it was not possible to evidence what training staff had undergone since the last inspection visit, as the records were not available. One of the trained staff explained that they (the trained nurses) were responsible to carrying out the induction training for the carers, but that the latter carried their training records with them. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 19 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 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. As mentioned in the summary the home is, at present, without a registered manager. This means that service users are unable to benefit from having a suitably competent person in day-to-day control of the home, overseeing the delivery of care and ensuring that it is of a satisfactory standard. Although the previous manager had started to introduce quality assurance systems, since she left the systems have not been kept up to date. This means that it is difficult to determine that the home is being run in the best interests of the service users. There were a number of health and safety issues that required attention. This means that the home is not fully promoting the health, safety and welfare of the service users and staff. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 20 EVIDENCE: It is clear that the recruitment of a manager is of paramount importance so that the day-to-day running of the home is being directed and the quality of care is being monitored. In the absence of a manager, even greater emphasis falls upon the monthly (Regulation 26) visit by the proprietor. It is of some concern that the issues that will be outlined below were not picked up and acted upon in a timely manner. Up until October of last year a daily manager’s audit was being carried out, and the views of service users and their relatives were being periodically sought. Since the manager’s departure, none of these systems have been kept up to date. When looking at quality assurance, consideration must be given to ensuring that the cultural, religious and ethnic needs of service users are catered for (at the time of this visit the client group was almost 100 British, with no one from an ethnic minority). A clergyman visited a resident during the course of the inspection and staff are given a proforma to complete for each resident which should indicate their pastoral and spiritual needs. Unfortunately none of those in the files inspected had been fully completed. Following the last inspection it was required that the proprietor install appropriate devices to bedroom doors where the residents wished them to be kept open. It was of concern to find that on this visit a number of them were still being wedged open. This is contrary to fire safety regulations and the practice must cease. It was also noted that not all of the fire extinguishers had been serviced within the last year. The fire records indicated that weekly alarm checks were being carried out but there was no evidence of any recent fire drill or that the new staff had received fire safety training. The training records showed that over the course of the last year only one member of the night staff had attended training – this is poor practice. The last visit by the London Fire Brigade had resulted in a number of recommendations being made. Again, it was not possible to determine if these had been met. It was previously required that the (health and safety) risk assessment for the home be regularly reviewed and updated. While it has been reviewed it would be good practice for staff to actually follow the guidance set out in the assessment. For example, the assessment for infection control stated that there would be quarterly infection reports – these could not be found. While walking around the home a basket containing cleaning substances (that would fall under COSHH regulation) was found in the main lounge. Closer attention needs to be paid to the safety of the service users, many of whom suffer from cognitive impairment. It could not be evidenced that the annual checks of portable electrical appliances had been carried out, or that the water system had been checked for Legionella. On a more positive note, the maintenance of the gas St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 21 installation, electrical installation, lift and hoists was up to date. The home had also had a visit from the Local Authority Environmental Health officer, who had conducted a satisfactory food safety inspection. It was not possible on this inspection to examine the service users’ financial records, as they were not accessible. They will be inspected on the next visit. St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X X X 1 St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement The manager must ensure that medication administration records are accurately completed at all times. The previously set timescale has not been met. The POVA procedure must be amended. The previously set timescale has not been met. Staff must ensure that the inside of the microwave oven is regularly cleaned. The previously set timescale has not been met. Staff must ensure that all overbed light cords/switches are within reach of service users whilst they are in bed. The previously set timescale has not been met. The proprietor must ensure that minimum staffing levels are met at all times. The previously set timescale has not been met. The manager must ensure that the required records are DS0000019041.V289652.R01.S.doc Timescale for action 25/04/06 2. OP18 13 15/05/06 3. OP19 16 25/04/06 4. OP24 23 30/05/06 5. OP27 18 25/04/06 6. OP37 17 25/04/06 St John`s Nursing Home Limited Version 5.1 Page 24 maintained to a satisfactory standard. The previously set timescale has not been met. 7. OP26 16 The manager must ensure that the home is free from offensive odours. The previously set timescale has not been met. Bedroom doors must be wedged open. Appropriate, fire safety approved, devices must be fitted. The previously set timescale has not been met. A full assessment must be conducted/obtained prior to any placement agreement. Service user plans must cover all identified needs - including social care needs. Health care records must be fully completed. These include full, individual service user risk assessments. The registered person must ensure that all recruitment documentation is obtained and verified before work commences. The registered person must ensure that the staff team is suitably qualified and that training can be verified. The registered person must recruit a manager as a matter of urgency. The registered person must ensure that there are satisfactory quality assurance systems in the home. The registered person must ensure that the home meets health and safety standards (as outlined in this report). Staff must ensure that COSHH substances are securely stored at all times. DS0000019041.V289652.R01.S.doc 25/04/06 8. OP38 13 15/05/06 9. 10. 11. OP3 OP7 OP8 14 15 13 25/04/06 25/05/06 25/05/06 12. OP29 19 25/04/06 13. OP30 18 25/04/06 14. 15. OP31 OP33 8 24 25/05/06 25/05/06 16. OP38 13 25/04/06 17. OP38 13 25/04/06 St John`s Nursing Home Limited Version 5.1 Page 25 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 OP3 Good Practice Recommendations It would be good practice to review the pre-admission methodology to seek ways of making it more comprehensive. The manager should ensure that all care plans are regularly reviewed, and that this is recorded. It would be good practice for staff to attend training in dealing with complaints. It would be helpful to service users if handrails could be fitted in all corridors. It would be beneficial to both service users and staff if the home purchased an additional hoist. There remains an ongoing need for more hospital type beds to be purchased. It would be good practice for staff to take into consideration how they can meet any religious/cultural and ethnic needs their service users might have. 2. 3. 4. 5. 6. 7. OP7 OP16 OP22 OP22 OP22 OP33 St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St John`s Nursing Home Limited DS0000019041.V289652.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!