Inspection on 08/05/08 for St Johns Court Nursing Home

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Johns Court Nursing Home 24/10/06

St Johns Court Nursing Home 09/02/06

St Johns Court Nursing Home 08/06/05

St Johns Court Nursing Home 09/11/04

St Johns Court Nursing Home 02/06/04

St Johns Court Nursing Home 22/12/03

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Maple Lodge

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Ravenhurst

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Inspirations

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE St Johns Court Nursing Home St Johns Street Bromsgrove Worcestershire B61 8QT Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 8th May 2008 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.V363389.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.V363389.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 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.V363389.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 terminall 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. 24th October 2006 Date of last inspection Brief Description of the Service: St Johns Court is a care home providing both nursing and personal care for up to forty-four older people of either sex. Currently people receiving personal care only are living on units on both the second and ground floors, whilst people receiving nursing care are living in units on the first and ground floors. 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 Information regarding the current level of fees was not included within the Service Users Guide. The reader may therefore wish to contact the service directly for up to date information. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We, the Commission, carried out this key inspection without any prior notice. A key inspection is one in which we look at all the aspects of the service that are most important to people using it. This inspection takes into account information we have received since the last inspection as well as the visits to the home. Sometime before the inspection an Annual Quality Assurance Assessment (AQAA) was completed and returned to us. The AQAA is a self-assessment and a dataset that each registered provider is required to complete each year. The AQAA tells us about how providers of the service are meeting outcomes for people who use the service. The AQAA is also an opportunity for people to share with us what they are doing well. We sent out a number of questionnaires to people using the service and some members of staff. Prior to visiting the service we received some of these back. We have included some of the comments obtained within this report. During the inspection, discussions were held with the registered manager, the deputy manager, a number of staff members and some people using the service. We had a look around the home and observed what was happening. In addition, we viewed the care documents regarding some people using the service such as care plans, risk assessments and daily records. We also viewed medication records and staff records. What the service does well: Information about the home is freely available for people to refer to. This information could help people decide whether they wish to reside at St Johns Court. People’s care needs are assessed prior to a new admission taking place. People have a care plan and risk assessments are done. These should ensure that staff have the necessary information to provide the care needed. People receive and enjoy good quality food. A written complaint procedure is available for people to make people aware of their right to make comments about the service provided. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 6 The home is well maintained and attractive therefore making sure that people have a comfortable place to live. What has improved since the last inspection? 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.V363389.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.V363389.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): Standards 1, 3 and 5. Standard 6 is not applicable. Quality in this outcome area is good People can be confident that the home can support their care needs as an assessment is carried out prior to admission. The assessment involves the individual or people close to them. People are able to visit the home and are able to see detailed information about the home to help them decide if the home is suitable for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home was freely available in the reception area. The home has a Service User’s Guide which is specific to the individual home. The guide details what prospective residents can expect from the service. Information within the guide includes details about the accommodation, staff qualifications, how to make a complaint, a typical menu and activities. The section on ‘user survey and views of the home’ gives no details of any St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 9 comments or experiences of people using the service and should to be expanded. A colour leaflet giving basic information about the home was also available. We viewed the pre admission assessment of somebody recently admitted into the home. The assessment was undertaken by the registered manager while the potential resident was in hospital. Although the assessment was not signed by either the manager or the individual concerned, it did contain sufficient information to demonstrate that needs could be met. Prospective users of the service and or their representatives are able to visit the home prior to admission. People therefore have the opportunity to experience what the home is like as well as see the facilities available prior to making a decision about moving in for a trial period. St Johns Court does not provide intermediate care. St Johns Court Nursing Home DS0000004139.V363389.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): Standards 7, 8, 9, 10 and 11. Quality in this outcome area is adequate People’s care needs are written down but staff are not always following the instructions about how these needs should be met. The safe management of medication needs to be concisely maintained to ensure that people are not at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the records of some people who use the service. These records showed that each person has an individual care plan. Care plans were reviewed on a monthly basis however this has changed to completing a progress sheet. The suitability of having one document, as opposed to recording upon each separate care plan, needs to be evaluated to ensure that the information is readily available to carers. The care plans cover aspects of daily living and set out how much help and support is needed. Carers told us that reviews of care plans involve people using the service. We saw evidence St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 11 of this consultation happening. We also saw evidence that end of life wishes are discussed and included within the care plan The registered manager told us of her desire to develop person centred care plans and that people from the Trust have visited other places to get ideas about how to develop this. The manager said that she feels strongly about implementing this approach in the future. The recording on one person’s daily notes gave us cause for some concern. A carer had recorded that a person using the service was in a ‘vile mood’ and had drawn a picture of a sad face alongside this. This was later followed by a smiling face. The terminology used and the drawing of such symbols demonstrated a lack of respect. We had some concerns regarding the outcomes for people using the service. We saw evidence that needs, as detailed within the care plan, were not always acted upon. It was of concern that somebody assessed as having difficulty swallowing was not receiving the diet stipulated within the care plan and an assessment to determine a change had not taken place by a suitably trained professional. Staff seemed to be unclear whether a thickener was needed within drinks. We brought our concerns to the attention of the registered manager. Once we had highlighted this concern action was taken to seek the necessary advice. Written evidence suggested that one person in bed was not receiving sufficient levels of fluid intake. This matter was also brought to the attention of the registered manager. Pressure reliving equipment as identified in the care plan was seen to be in use in one person’s bedroom. One relative commented on a survey ‘ The care is very good and I feel much better knowing that they are looking after my ***.’ During our visit a visitor said that the home is good and that ‘staff are brilliant.’ As part of our first visit to the home we assessed the management, storage and administration of medication. The majority of the Medication Administration Record (MAR) sheets were filled in appropriately to demonstrate that people had received they medicines. We were however concerned to find that one person had not received their medication as prescribed due to the member of staff forgetting to do it. Missing prescribed medication could potentially place people’s health and well-being at risk. We saw evidence that staff had, on occasions, over-signed the original entry on MAR sheets. This practice could indicate that the sheets were signed prior to the member of staff administering the dosage. We found medication remaining within the blister pack, with the seal intact. However the tablets had been signed as given prior to a member of staff over-signing this as St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 12 ‘refused’. Signing for medication outside procedures could potentially place people at risk. We found a number of gaps on the MAR sheets where nobody had either signed for medication given or entered a code for why it was omitted and removed from the blister pack. We were informed that staff would sign the next time they were on duty. This practice is potentially unsafe and therefore could place people at risk. Due to our concerns, we made an immediate requirement stating that medication administration records must be completed accurately and fully, following the safe administration of all prescribed medication. We received a prompt written response to our concerns giving us details of the strategies put in to place to address the shortfalls and to prevent future occurrences. We saw one tube of prescribed cream and a drink thickener in a bedroom where the persons name was crossed out, indicating that staff were using somebody else’s items. It was of concern that we later viewed some reports carried out by the Director of Operations on behalf of the Trust. Reports dated earlier in 2008 demonstrated that concerns were identified in the management of medication within the home. A report from April 2008 stated that medication audits were to be carried out until a higher standard was maintained. When we returned to the home to finish this inspection we were told about the actions taken as a result of the above concerns. We viewed some MAR sheets and found them to be completed correctly. On auditing medication we found the balances recorded to be correct. We saw staff administering medication appropriately. The home has a dedicated fridge for the storage of medication. Staff complete records regarding the temperature of the fridge. The records showed that at times it is close to the maximum level and needs to be closely monitored. Care staff spoke with pride about the level of care provided in the home and their desire to provide a quality service. People using the service were suitably dressed taking into account gender and the weather conditions. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good The home supports people to follow their personal interests and activities. People receive and enjoy good quality meals and are generally able to access food and drink when they wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St John’s Court employs a dedicated activities coordinator who works 25 hours per week. The member of staff concerned had a good knowledge of people’s needs in relation to social activities and understood that for some people a social chat can be as beneficial as a more traditional activity or task. The records were not totally up to date, however there was evidence that events take place on a regular basis. We saw a number of visitors come and go during our time in the home. We are not aware of any restrictions to people visiting. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 14 The home is located close to a church with which the home maintains links. Information was displayed regarding a forthcoming in-house church service. We have previously reported that people using the service have a high opinion of the food offered. Menus were in the dining room. As one for each of a four week cycle was available it was not automatically possible to establish what was on offer unless you knew which week was current. When we visited, the menu consisted of fish pie and peas or chicken curry and rice followed by semolina or fruit cheesecake. The menu stated that, for tea, people were to be offered tomato soup, sandwiches, cheese puffs and side salad. Other days tea menu included sandwiches plus baked potato, sausage roll and chicken pasta bake. Sweets included crème caramel, fruit and Manchester tart. We were told that fresh vegetables are used. We were present during one meal time which was carried out in an unhurried pace. The lunch time meal we saw was well presented and appeared appetising. Liquidised items are served separately to enhance the appearance and potential taste. We noticed that drinks were available and close at hand to people sat in their own bedrooms. We did have some concern about the fluids offered to one person who was in bed. A care plan was in place detailing the amount of fluid to be encouraged on a daily basis. Although carers stated that they had offered drinks the written records did not provide evidence of this having taken place. The registered manager was informed of our concerns and brought it to the attention of staff on duty. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good Information is available for people regarding complaints assuring them that their concerns will be looked into. Staff are aware of what they need to do to help keep people safe and protected against abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A visitor stated that if he had any concerns regarding the care provided he would speak to the nursing staff. One person using the service stated that he would ‘tell Karen (the registered manager) of any problems.’ The homes complaints procedure is included within the Service User’s Guide as well as being displayed within the home. Since our last key inspection we have received one complaint in relation to practices at St Johns. The registered provider was asked to investigate and to let us know the outcome. Copies of the correspondence were held on file in the home. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 16 We saw evidence in a care plan that a representative of one person using the service had raised some concerns. This information was not entered within the complaints log. As part of this inspection we asked the manager and some members of staff a number of questions to explore their knowledge around safeguarding people. The manager was aware of other agencies who may need to be informed in the event of an actual or potential allegation of abuse. The manager was confident that she would be able to seek guidance and support from both her manager and the organisation if needed. We were told that staff had undertaken a study day on the Protection of Vulnerable Adults. Training for staff who have not received training or need a refresher is scheduled for October 2008. We asked staff members about training. One person told us that she attended training of safeguarding a couple of years ago. Another carer told us she had not received training in safeguarding other than what was included within her NVQ (National Vocational Qualification). Staff told us that they would report any concerns or allegations to the nurse on duty or the registered manager. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good People live in a clean, pleasant and well maintained home. Work to prevent fire doors having to be wedged open will ensure fire safety is improved in order keep people safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this inspection we viewed communal areas of the home and a sample number of bedrooms. We were told that a senior manager has done a lot to ensure that the environment where people reside is well maintained and pleasant. At the time of this inspection, decorators were within the home. All areas seen during the St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 18 visit were clean and well maintained. We did not detect any unpleasant odours within the home. Corridors are wide and bright. Fire doors at the ends of corridors have plain glass within them in order to enhance appearance. We saw documentary evidence showing that they were safe in relation to acting as a fire break. Due to the clear glass we recommended that more noticeable motifs are stuck to the glass to prevent people accidentally walking into the glass. The top floor of the home has 3 bedrooms, a small lounge and a kitchenette. The remaining bedrooms are on the first and ground floor. All the bedrooms have en-suite facilities. The home has recently had a new lift installed. We saw evidence that people are able to bring their own possessions and belongings into the home to make the room both more personal and comfortable. Many bedrooms have special beds that are able to be raised and lowered. Once a final order has arrived all bedrooms will have these special beds. Wardrobes are secured to the wall to prevent accidental toppling. Some bedrooms have secondary glazing. A large lounge on the first floor was pleasant. Sitting provision on the ground floor was welcoming. A small lounge is available if people which to use it. Since our previous inspection, magnetic holding devices have been fitted throughout the home in order to afford people using the service ease of access. These devices are designed to ensure that doors close in the event of the fire alarm sounding. The home has experienced difficulties and many of the devices were not working. As a result many bedroom doors were held open by wooden wedges. The manager is aware that this matter needs to be resolved and was working towards this during our visit. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good There are sufficient staff on duty to ensure that people using the service have an appropriate level of support. Staff recruitment procedures are in place and are sufficiently robust to ensure that appropriate people are appointed. Evidence that training has occurred would demonstrate that staff received the necessary input to be able to carry out their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We viewed some staff rotas. These showed that the rota is appropriately covered. We saw no evidence of staff having to work excessive hours. The registered manager confirmed that the use of agency staff is minimal. During the morning shift the rota showed that a trained nurse, a health care assistant and 7 care assistants are on duty. Staff on duty confirmed that these are the normal staffing levels in the morning. In addition to the care and nursing staff, were ancillary and catering staff plus the activities organiser. Staffing levels in the afternoon are reduced by 1 person. The night shift consists of 1 nurse and 3 carers. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 20 One person commented that staff are ‘very good’ but that they have a lot to do. People commented on the surveys we sent out that the majority of staff are very caring and approachable and listen to what people say. One visitor seen during our visit said that staff are ‘cheerful’. Staff told us that they attend a lot of in house training. We were able to see training records for the current year, however records for the previous year were archived and were not available. We were able to establish the number of people who had undertaken training in moving and handling since January but we were not able to establish when staff who had not received training this year last had any. We were told that nursing staff attend clinical training provided by the local Primary Care Trust. At the time of our visit, 24 carers out of a team of 34 were reported to of completed either a level 2 or 3 NVQ (National Vocational Qualification). This number of staff with an NVQ is in excess of the National Minimum Standard and is commendable. We viewed the files of some recently appointed members of staff. We found that systems are in place to ensure that staff are suitable for the work they are applying for. Written references are obtained and CRB (Criminal Records Bureau) checks are undertaken. The manager needs to ensure that information on the application form matches information received on references. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate The home is managed in a way that usually meets the needs of people who use the service. Some important things get missed because the quality of the service is not monitored closely enough. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is experience and suitably qualified to carry out her role. As well as holding a nursing qualification the manager has also achieved the Registered Manager’s Award (RMA) which is a level 4 NVQ (National Vocational Qualification). Staff told us that the manager is very approachable. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 22 The manager told us of her desires to develop person centred approaches within the home. The home has an extensive quality assurance manual at its disposal. There was however evidence to suggest that it is not used to its best potential. For example we found that concerns regarding the recording of medication administration have existed for some time, the section upon medication was last used during November 2005. A representative of the Trust visits the home on a regular basis. Written reports are prepared following these visits which were available for inspection. The reports demonstrated that the representative has recently brought to the attention of the home management team a number of concerns which needed to be addressed. During our visit we established that some of these concerns have received the necessary action while others have not. In order to obtain comments about the service provided questionnaires have in the past been sent out, by the management, to people using the service and or their representatives. There was no evidence to demonstrate any formal collation of the comments or a subsequent action plan to address any issues highlighted. The registered manager intends to carry out a further survey in the near future. A survey has also taken place involving members of staff but there was no evidence of action taken to address shortfalls identified. There was evidence that staff receive supervision. Although the matrix had gaps upon it care staff commented that they do receive regular supervision from trained nurses. The content of supervision sessions should to be in line with the associated National Minimum Standard. As highlighted earlier within this report it was evident that the organisation has invested in providing devices that enable fire doors to be held open as they should automatically close when the fire alarm sounds. Contractors continue to work to address problems that have arisen that were preventing them from working correctly. Systems are in place to visually check equipment such as window restraints on a periodic basis. The frequency of checks regarding such important pieces of equipment should be reviewed to ensure they are sufficient. Evidence was available to demonstrate that equipment is serviced appropriately by visiting contractors. The registered manager has devised a good and comprehensive system for auditing falls. Having suitable risk assessments and noting treads can help to reduce the risk of falls and therefore the risk of people injuring themselves. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Care plans must specify how identified needs in respect of health and welfare are to be met. This is to ensure that people’s needs are met consistently and that people are not placed at risk of any harm. Timescale for action 30/09/08 2 OP9 13(2) Medication administration 08/05/08 records must be completed both accurately and fully. This is to ensure that people using the service receive medication safely and as prescribed. 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 OP1 Good Practice Recommendations The service user’s guide should include comments from people using the service. St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 25 2 OP7 Review the effectiveness of the progress log to ensure that changing care needs are identified and easily assessable to carers. Ensure that the fridge used for the storage of medicines remains fit for purpose. Records relating to concerns and complaints should be maintained using a system that makes them easily identifiable. Further motifs should be fixed to the plain glass doors to act as a visual aid. Evidence of training undertaken should be easily assessable. A review of the supervision process and areas covered within supervision should take place. A review of the effective use of the quality systems available should take place. 3 4 OP9 OP16 5 6 7 8 OP19 OP30 OP36 OP38 St Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Johns Court Nursing Home DS0000004139.V363389.R01.S.doc Version 5.2 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. 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