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Inspection on 24/10/06 for St Johns Court Nursing Home

Also see our care home review for St Johns Court Nursing Home for more information

This inspection was carried out on 24th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

This imposing building is decorated and maintained to a high standard. The atmosphere is welcoming and the staff friendly and helpful. One resident described the care as `wonderful` and the staff as `kind and helpful`. There is a menu choice and if that does not suit, the residents say alternatives are available when requested. Activities and stimulation is available in the home and in the community for those who wish to participate. Personal choice is respected.

What has improved since the last inspection?

Following the last inspection the home was asked to improve in thirteen areas and eight recommendations were made. These related to personal care, health and staffing. During this inspection it was confirmed that twelve areas had been improved and all of the recommendations had been implemented. Improvements had been made in the planning of care, management of medication, provision of food, recruitment and consultation with residents

What the care home could do better:

Staff need to receive more frequent and regular supervision with the manager or another designated senior so that their skills and development can be guided and supported. This is outstanding from the previous inspection. Residents, or with their consent, their representatives should be involved in planning their care. Wishes regarding end of life care should be sought in order that personal wishes can be carried out sensitively and effectively. Minor improvements to medication management are needed, as are cross infection measures. Staffing level at busy times need to be reviewed to ensure residents always receive the help they need when they need it. Fire safety must be improved by discontinuing the use of door wedges and installing devises that can hold open residents` bedroom doors but close them automatically when the fire alarm sounds.

CARE HOMES FOR OLDER PEOPLE St Johns Court Nursing Home St Johns Street Bromsgrove Worcestershire B61 8QT Lead Inspector Yvonne South Unannounced Inspection 24th October 2006 09:00 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 Johns Court Nursing Home DS0000004139.V310204.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 Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Johns Court Nursing Home Address St Johns Street Bromsgrove Worcestershire B61 8QT 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) 01527 575070 01527 576246 www.srtrust.co.uk Somerset Redstone Trust Mrs Karen Jayne Bevis Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability over 65 years of age of places (44) St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home may also accommodate a maximum of 4 people with a terminal illness (TI). The home may also accommodate a maximum of 3 people over 65 years with a dementia illness (DE/E). The home may also accommodate a maximum of 3 people under 65 years with a physical disability (PD). The home may also accommodate one person over 65 years with a mental disorder (MD/E). Only service users with low dependency care needs are accommodated on the second floor of the home. Date of last inspection Brief Description of the Service: St Johns Court is a care home providing both nursing and residential care for up to forty-four older people of either sex. Currently people receiving residential care are living on units on both the second and ground floor, whilst people receiving nursing care are living in units on first and ground floor. The home is located in the centre of Bromsgrove, close to shops, pubs and other community amenities. It was extensively refurbished in 2002. There is a passenger lift providing access to all floors of the home. Handrails are fitted where necessary. The home has thirty-six single and four shared bedrooms. All the bedrooms have en-suite facilities. The single rooms all measure in excess of ten square metres and the shared rooms in excess of sixteen square metres. Communal facilities include lounges, a conservatory, dining rooms, toilets, and bathrooms with special aids. Somerset Redstone Trust, a charitable organisation, owns the home and the registered manager is Mrs Karen Jayne Bevis. The email address for the home is karen.bevis@somersetredstonetrust.co.uk When the pre-inspection questionnaire was submitted on 18/10/06 the manager quoted the scale of charges to be £1920 to £2520 per month. Additional charges are made for hairdressing, toiletries, newspapers and chiropody. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social care Inspection since 09.02 .06 and the information obtained during fieldwork on 24.10.06. The fieldwork took place over ten hours during which the inspector spoke to five residents, three relatives, four staff, and the manager and the deputy. A partial tour of the premises was also undertaken. Prior to the fieldwork the home was asked by the Commission for Social Care Inspection to distribute questionnaires to the residents, relatives and health care professionals. To date seventeen responses have been received. The focus of this inspection was on the key National Minimum Standards and the requirements and recommendation that arose out of the previous inspection. What the service does well: What has improved since the last inspection? Following the last inspection the home was asked to improve in thirteen areas and eight recommendations were made. These related to personal care, health and staffing. During this inspection it was confirmed that twelve areas had been improved and all of the recommendations had been implemented. Improvements had been made in the planning of care, management of medication, provision of food, recruitment and consultation with residents St Johns Court Nursing Home DS0000004139.V310204.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 Johns Court Nursing Home DS0000004139.V310204.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 Johns Court Nursing Home DS0000004139.V310204.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): 3 (Standard 6 not applicable as this service is not provided by this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families are provided with the information and opportunities they need to help them make a choice regarding their future accommodation and care. Needs are assessed prior to admission to ensure the home is able to provide the care each individual needs. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 9 EVIDENCE: An assessment was made of the care records of four residents. These demonstrated that someone from the home had undertaken an assessment of needs before a place was offered. Minor suggestions for improvement were made regarding the detail and topics covered. A good admission checklist was available but this was not always completed. A resident and relatives confirmed that needs had been assessed; they had been invited to visit the home and have a trial stay. Information was provided about the home and their questions had been answered. They were happy with their choice. Documents were seen that confirmed contract and statements concerning the Terms and Conditions of Residence had been provided. All but one of the residents who returned a questionnaire said that they had a contract. One questionnaire respondent said; ‘Perhaps residents should be made aware of the expected annual percentage increase in payments in the initial contract and have a chat when payments increase. Contracts and details should change immediately in the literature given to clients’. St Johns Court Nursing Home DS0000004139.V310204.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): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are able to obtain the information they need from the care plans in order to be able to provide the correct care. However they need to be better informed in some areas so that there is no risk of care needs being overlooked. There is a risk that residents’ wishes and preferences are not taken into account in their care, as they are not involved in the planning. Residents receive their prescribed medication safely and their rights to privacy and dignity are upheld. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 11 EVIDENCE: Four care plans were assessed. These contained information that informed and guided the staff on how the individual’s care needs should be addressed. Relevant assessments had been undertaken regarding skin care, nutrition, moving and handling and other identified risks. Some topics would have benefited from more detail. This was most relevant to the pre printed care plans that lacked the individuality of those that were free written. In one file there was an excellent plan for moving and handling but the one in another file was out of date. The care plans were reviewed/evaluated each month or more often when necessary. However it was recommended that when changes were necessary this be indicated on the care plan as well as in the review sheet, either in full or as a signpost to the review sheet. A judgement call needed to be made to decide when the care plan needed to be re written. The records indicated that residents were receiving visits from health care professionals including the GPs, district nurses and specialists. The records had been well maintained and demonstrated that advice had been appropriately sought in relation to health concerns. A key worker system was in use. Staff were aware of their duties and a task sheet was available in each bedroom, together with a notice displaying the name of the occupant’s key worker. Residents and relatives confirmed verbally and in the questionnaire responses that health care was provided and they were pleased with the service. Relatives said that communication between them and the home was good. One relative said that they were ’totally satisfied and delighted with the care’. A resident said in the questionnaire response; ‘I get my pills regularly and am transported to medical appointments’. The doctors, who completed and returned the questionnaires confirmed that they were consulted with appropriately, received the correct support from the home and their instructions were carried out correctly. The Commission for Social Care Inspection had been appropriately informed of ill health and accidents. This, in conjunction with the individual records and statements from residents and relatives, demonstrated that staff were taking appropriate action. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 12 Generally the standard of recording was good. However a few documents needed to be signed and dated and there was no information available regarding residents’ end of life wishes and religious needs in the records that were assessed. It is acknowledged that this is a sensitive subject but if the information is not available the needs and preferences of the individual cannot be met and more distress may result. There was very little evidence that residents or, with their consent, their representatives, had been involved in discussion and agreeing care plans. They should be dated and signed by those involved. If people do not wish or are unable to sign the documents this should be recorded. Medication management was assessed. The storage was well arranged and secure. The key safety was acceptable. The amount of stock held was acceptable but containers of eye drops and some ‘short life’ tablets had not been dated when opened. All drops, topical products and some oral medication need to be dated when opened to enable stock control, monitoring and quality to be maintained. A file was maintained containing records on which care staff could indicate when topical medicines had been applied. This was a relatively new system and it was apparent that the staff were still becoming accustomed to it. Some records were incomplete, and some staff had entered ‘ticks’ not initials. In addition the pharmacist had accepted prescription instructions to ‘apply as directed’. This is not an informative direction for the patient or the staff and should not be accepted. Other records were well maintained. It was recommended that when staff referred to prescribed creams and ointments in the care records they should always name the product. Staff had received appropriate training and the home was supported by the supplying pharmacist. It was observed that staff treated the residents and visitors with respect. Residents were able to receive their visitors in private or use a quiet lounge if they preferred. Appropriate locks were fitted to toilet, bathroom, ensuite and bedroom doors. The manager said that only one resident currently held their bedroom door key. All residents had a key to the lockable storage in their room. If residents refuse their key or a risk assessment reveals that it would not be appropriate for them to hold them, this should be recorded in the residents’ records. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 13 Staff and relatives confirmed that mail was delivered unopened and assistance was given if needed. Private phone calls could be made and received using mobile phones or a pay phone. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of in-house and community activities are available in which the residents can choose to participate. They find the variety suits them. Opportunities and support is given to those who wish to attend the church of their choice. Visitors are always welcome and residents are able to choose how they arrange their day. Residents are able to choose from variety of nutritious menus and enjoy their food. EVIDENCE: The pre-inspection questionnaire stated that in-house activities included barbeques, a Valentines party, flower demonstrations, reminiscence sessions, an Easter party, strawberry and cream afternoons, games and music. Community activities had included concerts, a trip to the Falconry centre, a trip to Stourport on Severn, a trip to Jinney Ring and a Fathers’ Day concert. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 15 Four residents made comments in the questionnaires that were returned. Two people considered that there were ‘usually’ suitable activities arranged and two people considered that there ‘always’ was. In addition one resident said ’Quite a lot of activities are arranged. Some can take part. No worries.’ One relative commented that it could be difficult for the visually impaired. However a visually impaired resident said that he was very happy with his life. He received visitors and participating in church events and chatted with staff. He had been offered the talking book service but had declined. An activities organiser is employed for twenty-five hours a week. Following the last inspection it was recommended that the allocation of the activity co-ordinator’s hours should be reviewed to ensure all hours employed were spent on providing leisure opportunities. The manager confirmed that this had been addressed. Of the four records assessed, two residents were Baptists, one had no interest in any religion, and the forth was not recorded. The pre inspection questionnaire indicated that people were able to take part in Communion if they wished and other religious services, and some people went out to church. The records held good information regarding interests and involvement in social activities. Residents’ opinion of the food provided was high. One comment from a resident was; ‘There is always a choice of menu. If nothing suits then the staff will bring something else’. Another person commented; ‘Sometimes food can be a bit dry but if asked for something different or make a comment it is acted on’. The inspector was shown menus that offered an appetising choice and was told that staff talk to residents daily to discover what they would like. It was recommended that a more robust recording system be developed. This would aid monitoring purposes and provide a good record of the food that was provided. Residents had opportunities to be involved in menu planning during meetings and individual activities with staff. The manager confirmed that since the last inspection insulated jugs had been provided to maintain temperatures and as a means of safely and effectively transporting hot soup and drinks around the home. Pureed foods were no longer mixed together and were presented as attractively as possible. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 16 Records indicated that special diets, food supplements and dietary referrals were included in the care provision. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are able to raise their concerns with confidence. Staff are appropriately recruited and trained to ensure the protection of vulnerable people who live in the home. EVIDENCE: The manager said that all residents received a copy of the complaints procedure in the Service Users Guide and relatives had access to a copy in the Statement of Purpose. It was observed that further copies were available in the entrance to the home. Residents’ questionnaire responses indicated that they knew who to speak to if they were worried. Relatives’ questionnaires indicated that they were aware of the complaints procedure and the doctors’ responses indicated that they had never received complaints about the home. A resident commented in the questionnaire response that ‘I can ask questions or make comments. They do listen and do their best to solve situations’. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 18 Another resident said; ‘I talk to a member of staff and it (complaint) is dealt with by them or someone else’. The pre-inspection questionnaire indicated that the home had received one complaint in the past twelve months. This had been substantiated. The complaint record in the home indicated that it had concerned the temperature in a resident’s bedroom. This had been partially addressed and work was in hand to improve matters further. A complaint had been received by the Commission for Social care Inspection concerning the preparation of a special diet, personal care and monitoring. The issues had been investigated by the manager and appropriate responses had been made. Staff demonstrated that they knew what to do should a complaint be made to them and they said that they had received training in the awareness of abuse. Their records confirmed this. Their records also indicated that appropriate checks had been made before they had been offered their jobs. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to live in a clean, comfortable, well-maintained home that meets their needs. Measures are in place to protect residents from infection and reduce the risks where possible. EVIDENCE: A partial tour of the home was conducted during which the inspector met residents and relatives. It was observed from a sample of bedrooms that they were comfortable, well decorated and maintained. They had been personalised with photographs and pictures and ornaments belonging to the occupant. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 20 A good variety of specialised furniture and equipment was in use and a member of staff confirmed that if a need was identified prior to admission the equipment was in place when the person moved in. The home was clean, well decorated and maintained. A shaft lift facilitated movement between floors and handrails were fitted where necessary. Communal rooms were appropriately furnished and arranged for use. A relative commented in the questionnaire response that the lack of offensive smells had a great influence in their choice of home. A resident commented that ‘My room and the rest of the house is cleaned regularly’. Three relatives told the inspector how pleased they were with the environment. The laundry was well equipped and personal protective equipment was readily available. However care needed to be taken to keep the area behind the machines clean. One communal bathroom, that was little used, had become a storage facility. It was also observed that a bar of soap, worn bath mat and drying duvet were also in the room. This is not good for infection control Staff confirmed that they received training in the control of infection and their records and certificates supported this. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is staffed by well recruited and trained people who are able to provide the care the residents need. The staff team is under pressure at times to meet the needs of the residents this could have a detrimental effect on the service. EVIDENCE: The pre inspection questionnaire indicated that there were seven registered nurse, thirty-one care staff and eleven ancillary staff employed in the home. Nine of the care staff held National Vocational Qualifications (NVQ) to level 2 or above. This amounted to 36 , which is below the 50 required by the National Minimum Standards. However the manager said that a further six people were currently doing NVQ courses. When successfully completed this would raise percentage to the 50 . In the residents’ questionnaire responses only one person said that staff were ‘always’ available when needed. The other respondents said that they ‘usually’ were. A resident commented that ‘Sometimes there aren’t a lot of staff on duty and I may have to wait but most of the time it is fine’. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 22 A relative commented that there were not always sufficient staff on duty. A member of staff described the morning shift on one floor as ‘a nightmare’. Another member of staff said that sickness at weekends could be a problem. Staff were loyal and would help cover if they could. The pre inspection questionnaire indicated that over an eight week period agency staff had been used; registered nurse had covered fifteen hours and care assistants had covered thirty-four and a half hours. The manager said that two new care assistants had just be appointed and the recruitment of another registered nurse was in progress. The staff rota had been re organised to provide two trained nurses on duty five days of the week when there was the greatest need however this still left the weekends unchanged. This needs to be addressed. It is apparent that the needs of the residents are considerable and staff team is under pressure. Despite the pressure there was no evidence that the residents were not being appropriately cared for. In the questionnaire responses residents said; ‘ The care we get here is wonderful. All the staff are so kind and helpful’. ’When I need help I ask the staff and they help me to feel more comfortable if I need to move.’ The staff that were interviewed were confident and knowledgeable about the needs of the residents. They had all worked in the home for a considerable number of years. The records indicated that the recruitment process had been acceptable and the necessary checks had been carried out. A risk assessment was in place to assess the suitability of an applicant to work with vulnerable people if their check undertaken by the Criminal Records Bureau highlighted issues of concern. Staff and training records indicated that staff received the training they needed to undertake their duties and develop their careers. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 23 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, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed for the benefit of the residents and their financial interests are safe guarded. Health and safety is addressed for the wellbeing of all in the home St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home manager is experienced and well qualified. She is a registered nurse and has achieved the Registered Manager’s Award. The deputy had also successfully achieved the ‘Award’. Staff considered the manager to be ‘Always available to discuss anything’. ‘Always ready to help discuss problems’. ‘Very good’. ‘Lovely’. ‘Very nice’. ‘All staff are treated the same’. ‘All staff can come to them’. A relative said in the questionnaire response; ‘I have always found the staff and management to be approachable, ready to listen and provide a solution to any problem’. Annual questionnaires were distributed by the home to residents and there was evidence that issues raised in them had been addressed. Residents’ meetings were held and minuted. It had been found that 1:1 sessions and small group discussions were more effective than striving for a large attendance. A quality assurance system was in place and the annual audit was due to commence in November. Residents personal monies held in safekeeping were secure and the records were seen to be well maintained. Staff said that they had had annual appraisals and received 1:1 (supervision sessions). However these were not taking place six times a year as is required. Discussion took place with the manager as to how this could be achieved effectively and profitably include other tasks such a care plan reviews and fire safety training. The pre inspection questionnaire and maintenance file indicated that equipment and services were being appropriately serviced and maintained. Good risk assessments were available for the home and a good COSHH file was available to guide staff on the safe use of chemicals. A detailed health and safety policy and procedure was seen. A Fire Risk Assessment drawn up in July 2005 was seen. This also contained disclaimer forms completed by residents or their relatives regarding the risks involved in wedging open their bedroom doors. It was observed that a number of doors were held open through the home and there was a risk assessment in place. However the measures to reduce the risks were not being complied with. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 25 It is acknowledged that some residents, who like to stay in their bedrooms, avoid the feeling of isolation by having their door held open. However this can be achieved with greater safety if appropriate equipment is used that allows the door to close automatically should the fire alarm be activated. Door wedges are not acceptable. Fire safety training was undertaken and staff demonstrated that they knew the procedure they should follow should the alarm sound. The manager said that each shift a member of staff accepted responsibility for ensuring a hearing impaired member of staff was alerted should the fire alarm be activated. It was recommended that a risk assessment should be drawn up and this arrangement be formalised. St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 26 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 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement Residents’ or with their consent, their representatives should be involved in the planning of their care and the drawing up of their care plans. The resident’s wishes regarding religious needs, terminal care and arrangements after death must be discussed and recorded in order that they can be carried out. 3 OP9 13 Medication must be managed in accordance with the policy and procedure of the home. Measures to control the risks of cross infection must be complied with. Staffing numbers and skill mix must be appropriate to assessed needs of the residents, the size, layout and purpose of the home, at all times. 31/10/06 Timescale for action 31/12/06 2 OP11 12 01/01/07 4 OP26 13 31/10/06 5 OP27 18 31/10/06 St Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 28 6 OP27 18 There must be a minimum of 50 of care staff trained to NVQ level 2 or above. The manager must ensure that staff receive formal supervision at least six times a year. This requirement is outstanding from the previous inspection. The deadline of 01/03/06 had expired. 01/04/07 7. OP36 18(2) 30/11/06 8 OP38 23 Fire doors may only be held open 01/04/07 by equipment that will automatically respond to the sound of the fire alarm. A program to fit these where required by residents must be drawn up and implemented. In the interim the risk assessment relating to door wedges must be complied with. 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 Johns Court Nursing Home DS0000004139.V310204.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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