Inspection on 30/04/04 for St Joseph`s

Care Home For Older PeopleSt Joseph`sAlbert Road Bognor Regis West Sussex PO21 1NJUnannounced Inspection30th April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of Establishment St Joseph`s Address Albert Road, Bognor Regis, West Sussex, PO21 1NJ Email Address Name of Registered Provider(s)/company (if applicable) Grace & Compassion Benedictines Name of Registered Manager (if applicable) Sister Mary Breslin Type of Registration Care Home No. of places Registered (if applicable) 22 Tel No: 01243 864051 Fax No:Category(ies) of Registration, with (number of places) Old age, not falling within any other category (22) Registration Number H110000700 Date first Registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of Registration apply? Date of last inspectionDate of latest Registration Certificate 29th October 2002 YES NO 20/01/04 If Yes refer to Part CSt Joseph`sPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 330th April 2004 10:00 am Mrs G DavisID Code076990Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMary BreslinSt Joseph`sPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementSt Joseph`sPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of St Joseph`s. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.St Joseph`sPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. St Josephs is a privately owned Care Home registered to provide accommodation for up to 22 service users in the of category OP (Old Age) The establishment is a large detached house, which has been further extended to provide accommodation on three floors all of which are served by a vertical lift. There is an area for car parking to the front and a private and well-tended garden to the rear. Situated in a quiet residential road in Bognor Regis it is approximately half a mile from the town centre and within easy walking distance from the seafront. The registered provider is the Grace and Benedictines (Organisation) and the Registered Manager is Sister Mary Breslin.St Joseph`sPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)St Joseph`sPage 6 This unannounced inspection took place over one day in April 2004. It found that all of the National Minimum Standards inspected had been met in full. On this occasion not all of the standards were inspected and this report should be read in conjunction with the previous report to gain a full picture of the service provided by the establishment. Where there have been no changes in the standard this will be reflected in the report. The overall quality of care provided was good and all the residents spoken to expressed satisfaction with the care they received and in particular were very complimentary regarding the staff team and registered manager. The establishment was found to be comfortably furnished, warm and in good decorative order. There was high standard of cleanliness throughout the home. The home has achieved the Investors in People Award and International Standard for Quality Policy and Procedures (ISO 9001:2000). The Registered Manager achieved the Care Choices Care Training Excellence Awards Trained Manager of the Year Award 2003. Choice of Home (Standards 1-6) 5 of the 6 standards were assessed and were met. A Statement of Purpose and Service User Guide was available. Service users and their relatives are encouraged to visit the home prior to admission and a thorough assessment of need is carried out to ensure that the home will be able to meet the service users needs on admission. Health and Personal Care (Standards 7-11) 4 of the 5 standards were assessed and were met. Detailed care plans identified arrangements that were in place to meet the health and personal care needs of each service user. Regular review of the care plans had been undertaken. In addition a visual diary had been compiled for each service user. Daily Life and Social Activities (Standards 12-15) 3 of the 4 standards were assessed and were met. Details of each persons interests and leisure pursuits were recorded on the care plans. Daily activities are provided. Music and movement was provided on a regular basis. Visits by the hairdresser and clergy provided opportunities for the service users to maintain their independence. Service users were offered a wide choice of well-balanced and wholesome meals. Complaints and Protection (Standards 16-18) 3 of the 3 standards assessed were met. The home has a complaints procedure in place and all the service users spoken to confirmed that they knew how to access it and able to complain if necessary. Environment (Standards 19-26) 8 of the 8 standards assessed were met. The location and the layout of the home are suitable for the service user group. A programme of work to ensure continuing high standards is being completed.St Joseph`sPage 7 Staff (Standards 27-30) 3 of the 4 standards were assessed and were met. The home is adequately staffed with employees who are experienced and competent to care for older service users. Formal supervision of care staff takes place, as well as a yearly appraisal. The staff group has a commitment to training and in-house training courses have been undertaken as well as National Vocational Qualifications. Management and Administration. (Standards 31-38) 5 of the 8 standards were assessed and were met. All records, policies and procedures required were available and appropriate. All areas concerning the health and safety of service users and staff members were appropriately maintained and monitored.St Joseph`sPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). St Joseph`sMet (Yes / No) Page 9 St Joseph`sPage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.St Joseph`sPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NA NO YES YES YES YES YES NO NO NO YES NO YES 14 X X NA NA YES YES 16 3 30/04/04 10.00 4.5St Joseph`sPage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.St Joseph`sPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/EvidenceYES CHIROPODY, HAIRDRESSING, NEWSPAPERS/MAGAZINES, TOILETRIES 4 Standard met?The Service Users Guide and Statement of Purpose has recently been reviewed and copies given to the service users and the National Care Standards Commission. The documents have been combined into one single document, which is very easy to access. Copies have been provided on CD Rom and Tape. A service user proofread a version in Braille, which will also be available for those who are visually impaired. An up to date Schedule of Rooms has been provided following alterations to the accommodation.St Joseph`sPage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The statement of terms is contained in the Statement of Purpose / Service User Guide and each service user has a copy.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Prior to admission a full assessment of need is recorded on a form, which has been designed specifically for the purpose. The form is comprehensive and includes details of the individuals personal and financial details, psychological status, likes/dislikes and allergies, medication and general health details. This will include any information obtained through assessment made by other professionals i.e. the Occupational Therapist. Identification of action to be carried out following admission is also included. The inspector was able to evidence that the most recent admission had undergone a thorough pre-admission assessment with full consultation with the service user taking place.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Following an assessment of needs, an analysis is undertaken to ensure that the care home can meet them, a letter regarding the outcome is sent to the prospective service user with an explanation if the outcome is negative. The Service User Guide is specific with regard to the service that the establishment can provide and includes those things that they cannot provide.St Joseph`sPage 15 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The admission policy is found in the Service Users Guide/Statement of Purpose. Whenever possible a prospective service user will be visited at their home or hospital to be assessed and they and their relatives if appropriate will be invited to make as many visits to the home as required. A trial stay of an indefinite period is invited to ensure that the service user makes an informed decision to stay.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 0 Key findings/Evidence Standard met? Not applicableSt Joseph`sPage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 4 Key findings/Evidence Standard met? Detailed information from the pre-admission assessment of need is used as a basis to inform the care plan and with the service user further areas of need are considered and identified, including a Waterlow pressure sore skin assessment and a nutritional assessment. Risk assessments regarding all areas of potential harm to the service user are undertaken. The inspector was able to evidence that the plan had been drawn up in collaboration with the service users and noted that the plan encompassed the service users specific wishes regarding the arrangements to be carried out with regard to their dying and death. In addition a visual diary is compiled for each service user. This contains photographic material from their past and a record of all aspects of the activities undertaken as part of their life at the home. The diaries are used in a variety of ways and are a useful tool when carrying out reminiscence or orientation therapies with the service users.St Joseph`sPage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence X X Standard met? 3All service users are registered with a General Practioner of their choice and all other health related needs i.e. dentist, optician etc. are available as required. If the service user is unable to make their own arrangements then a member of staff will provide support and transport as required. Often a visit to the surgery is used as an opportunity to enjoy lunch out. Domiciliary visits are arranged if preferred. The care plans reflect the assessed health care needs and include nutritional assessment. Specialist equipment is provided if required and this includes that which will prevent pressure sores. Keep fit sessions are held twice monthly and service users are encouraged to attend. A close liaison is maintained with the community support systems i.e. community nurses and the local hospice.St Joseph`sPage 18 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 4 Key findings/Evidence Standard Met? A medication policy is in use. All staff members who administer medication have had accredited training. A local pharmacist monitors the policy and procedures including the recording, administration and storage of medication. There is a controlled drugs register with double signatures used to witness. All records were found to be well maintained and up to date. Evidence was available on the personal care plan that the service users had been consulted regarding their preference or not to self medicate. An up to date photograph of the service user was on the medication record. A key to their bedroom door lock or a secure lockable box is available to ensure a secure environment if the service user chooses to self medicate.St Joseph`sPage 19 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 4 Key findings/Evidence Standard met? Values are explicit in the Statement of Purpose/Service User Guide in regard to privacy and dignity. The personal care plans contain detailed guidance for staff members regarding the care needs and procedures to be carried out for each individual. A dedicated treatment room is available to carry out any treatment required i.e. eye drops. From the information available through the care plan it was apparent that service users had been consulted about their preferred mode of address and lifestyle choices. Most service users have their own telephone lines, for those that do not there is a call box or mobile phone available. There is an emphasis on training in the home and all aspects of the aims and objectives and philosophy reflect the core values of privacy and dignity. Service users confirmed that they were accorded respect by the care staff.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 9 Key findings/Evidence Standard met? Not assessed on this occasionSt Joseph`sPage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 4 Key findings/Evidence Standard met? Evidence is found in the Service User Guide/Statement of Purpose and care plans that the routines of the establishment are flexible and crafted to suit the individual. Plenty of visual stimulation is available, in particular photos of recent outings and occasions. Outings for individuals or groups take place on an almost daily basis. The enhanced staffing numbers enjoyed makes this possible. Activities and entertainment is provided on a daily basis and includes song and dance sessions, discussions, garden club and videos. Visits to the theatre and other places of interest take place on a regular basis, going out to a pub for lunch is particularly popular. Four new activities, a Discussion Group, Art and Music Therapy and Poetry Appreciation have been introduced and are popular. In the afternoon several people met to enjoy a video and an entertainment had been organised for later in the afternoon.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 9 Key findings/Evidence Standard met? Not assessed on this occasionSt Joseph`sPage 21 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? All service users manage their own finances-advocates are arranged for those who wish it. A policy regarding access to records is available. Each service users bedroom has been personalised according to their preferences.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? The care plans reflect the service users preferences regarding likes and dislikes and dietary needs. A large menu is put on display in the hall to inform those who are unable to read the menu board. The inspector did not sample the meal on this occasion. Individual serving dishes are provided on each table so that service users can help themselves to the food. A well-balanced meal was provided with a choice of two main dishes, cooked to perfection, and with enough food provided to allow each person to have a second helping if they wished. A vegetarian alternative was available. The dining room was comfortably and attractively furnished and promoted a congenial atmosphere. The tables were elegantly set in a red and white theme to compliment recent celebrations for St Georges Day and each service user was provided with their own linen napkin. Wine is served with the meal to celebrate special days and occasions. Those that preferred took their meals in their room. Some service users have their own kettles and a small kitchen. Milk, coffee, tea bags etc have been provided to allow those people who are more independent the opportunity to make themselves snacks and drinks at any time. Other service users can ask for additional drinks and snacks, as they require. The service users unanimously considered the food excellent.St Joseph`sPage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The establishment has only received verbal complaints `grumbles, which the inspector found had been recorded. They involved small domestic issues, all of which were appropriately resolved. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? All service users are encouraged to pursue their legal and civil rights. All have been entered onto the electoral roll and are assisted to vote if required. Information regarding Advocacy services is noted in the Statement of Purpose/Service User Guide.St Joseph`sPage 23 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES X 3All written policies in regard of the registered provider ensuring the service user is safe from any form of abuse are in place and staff members awareness has been raised via in house training. Appropriate recruitment policies further protect by ensuring that the staff members with appropriate skills and attributes are selected. The service users manage their own finances.St Joseph`sPage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is large and rambling and has been fitted with appropriate aids and equipment to assist with independence. There is a dedicated person who is responsible for the maintenance of the building and an ongoing programme of redecoration and refurbishment is followed. Regular visits in accordance with Regulation 26 (Care Standards Act 2000) monitors that all health and safety checks are undertaken and that the general fabric of the building is satisfactory. The home is surrounded on three sides by buildings that belong to the Order and provides accommodation for the care staff members as well as sheltered housing. There was evidence that the home complies with all health and safety legislation. The location of the establishment provides an opportunity for the service users to go for a seafront walk and is near to bus services, which afford the more mobile service user an opportunity to visit other towns in the vicinity.St Joseph`sPage 25 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 4 Key findings/Evidence Standard met? There are eight separate lounge areas within the home, which provide a variety of options for the service users. A large dining room caters for all of the service users however there are two additional dining rooms available elsewhere on the campus, which provide the service users with a private place to entertain their friends. Both have been fitted with the call bell system. A private chapel also provides somewhere for the service user to use for quiet reflection even if they do not wish to attend the religious services held there. There are private areas in the garden for those who prefer their own company as well as larger areas for a group to utilise, all areas have been provided with comfortable garden furniture. A toilet has been provided for service users to use when in the garden. A call bell has recently been fitted externally. A wheelchair store has been provided with a battery charger. A loop system has been fitted to the sitting, dining rooms and chapel. The call bell system has been completely renewed with additional bells introduced in some areas.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 4 Key findings/Evidence Standard met? All but one bedroom has their own ensuite facilities and those with ensuite baths have been fitted with either a bath hoist to promote maximum independence. The bedroom without ensuite facilities has a suitable bathroom nearby. There are sufficient toilets provided near to the communal facilities. Thermostatic mixer valves have been fitted to all water outlets and this system has recently been replaced.St Joseph`sPage 26 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The Registered Manager had commissioned a recent survey of the premises and facilities by a qualified Occupational Therapist, which confirmed that the home had provided appropriate disability equipment and environmental adaptations. A copy of the report is on the National Care Standards Commission records.St Joseph`sPage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence YES NO NO 16 16 4 3 Standard met? 4 16 XX X 3 1All rooms apart from one double (used as a single) are en-suite and provide accommodation that exceeds the standard. One of the single rooms has a suite of rooms, which include a small sitting room and kitchen; two others have a small kitchenette.St Joseph`sPage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? All the service users have provided their own furniture and each room is individual to the occupant. Many service users have electric postural beds, reclining chairs. All have lockable storage space. All rooms comply with the National Minimum Standards in fixtures and fittings. All service users have the opportunity to have a key to their bedroom and a key to the front door, four service users have their own front doors and the key to the garden door, thus they are free to come and go as they please within the boundaries of health and safety precautions.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Water temperatures are maintained by thermostatic mixer valves at all outlets used by the service users. Risk assessments have been undertaken regarding the radiators and covers have been provided. Room audits are undertaken on a monthly basis. Legionella assessment has been undertaken. Aids to mobility are discreet.St Joseph`sPage 29 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Appropriate policies regarding infection control are in use and all care staff members have undertaken training in this subject. The establishment was found to be clean and there were no offensive odours throughout. Satisfactory arrangements regarding laundry are in place and a new washing machine is in place. A new floor has been put down in the kitchen.St Joseph`sPage 30 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 4St Joseph`sPage 31 The home has a very high number of care staff members working each day. These are comprised of a number of ordained nuns and postulants and on average there will be up to seven members of care staff on duty at any given time apart from night-time. Others work in the kitchen or on domestic duties. There is a good mix of skills and ages. All staff members receive regular in house health and safety training and other service related topics. Thirteen members of staff have achieved National Vocational Qualification level II, two are enrolled on an National Vocational Qualification level III training course.Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Not assessed on this occasion X X Standard met? 9Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? There are appropriate recruitment procedures in place and the inspector was able to examine the file of a recently employed staff member. Staff members are given a job description, and security checks are undertaken. All the information required by schedule 5 of the Care Standards Act 2000 was included on the file. Details of the training undertaken and a training profile were included.St Joseph`sPage 32 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? An induction and foundation training programme has been introduced to meet the National Training Organisation workforce training targets. All staff members are encouraged to undertake National Vocational Qualification training. Specific service related in house training is ongoing and a copy of the training dates and subject matter was provided to the inspector. Group and individual supervision is provided. A yearly self-appraisal/appraisal is carried out to evaluate the learning of the previous year and to set targets for the coming year.St Joseph`sPage 33 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 4 Key findings/Evidence Standard met? The Registered Manager has a Registered General Nurse Qualification and has twenty-five years of experience of working in a care home. Twenty of those years have been as a Manager. She has recently completed the National Vocational Qualification in Care Management levels IV and V. and was awarded the Care Choices Care Training Excellence Awards, Trained Manager of the Year Award 2003. The manager maintains an ongoing interest in training and intends to add to her management skills and qualifications.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager appears to be very open and transparent in her approach to management and all care staff spoken to confirm that they considered that she delegated appropriately and that they all felt included and knowledgeable.St Joseph`sPage 34 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 9 Key findings/Evidence Standard met? Not assessed on this occasion.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 9 Key findings/Evidence Standard met? Not assessed on this occasion.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 3 11 X XAll service users control their own finances with the help of a chosen representative if necessary. Individuals money is held separately for each service user and receipts are given. The records were noted to be appropriately managed and up to date. Each service user is supplied with a key to their door or a lockable box to keep private or valuable possessions safe or they can keep them in the homes safe.St Joseph`sPage 35 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The induction training reinforces the aims, objectives, policies and procedures of the home. Regular bi-monthly supervision has been carried out and a training plan is devised through supervision.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 9 Key findings/Evidence Standard met? Not assessed on this occasion.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 4 Key findings/Evidence Standard met? There was a health and safety policy concerning safe work practice. A monthly room audit is undertaken to identify any problems/issues regarding the room or maintenance. Risk assessments have been carried out regarding all areas of possible harm to service users and staff members. All health and safety regulations have been complied with. Staff members have regular refresher training sessions in manual handling, first aid, fire safety and safe food handling. Dangerous substances are used and stored appropriately. Reasonable precaution to protect service users from accidental injury has been carried out i.e. window restrictors, thermostatic mixer valves on water outlets and radiator protection where needed. A new nurse call system with individual remote call pendants added has been introduced to ensure that all those who are immobile have access to staff at all times.St Joseph`sPage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateMrs G DavisSignature Signature Signature25th May 2004St Joseph`sPage 37 Public reports It should be noted that all CSCI inspection reports are public documents.St Joseph`sPage 38 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 30th April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleSt Joseph`sPage 39 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by N/A, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here St Joseph`sPage 40 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of St Josephs confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date signed Or D.3.2 I of St Josephs am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Care Manager 13th June 2004 Mary BreslinPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.St Joseph`sPage 41 - 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. 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