Inspection on 12/10/06 for St Joseph`s Rest Home

This inspection was carried out on 12th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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 Joseph`s Rest Home 29/10/08

St Joseph`s Rest Home 07/11/05

St Joseph`s Rest Home 23/05/05

St Joseph`s Rest Home 06/09/04

St Joseph`s Rest Home 10/05/04

St Joseph`s Rest Home 18/11/02

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Joseph`s Rest Home 3 - 7 Bristol Road Brighton East Sussex BN2 1AP Lead Inspector Jennie Williams Unannounced Inspection 12th October 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Joseph`s Rest Home DS0000014242.V309501.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 Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Joseph`s Rest Home Address 3 - 7 Bristol Road Brighton East Sussex BN2 1AP 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) 01273 626151 01273 570948 zen84109@zen.co.uk Trustees Of The Sisters Of Mercy Sister Noeleen Ryan Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is seventeen (17) Service users will be aged sixty-five (65) years or over on admission Date of last inspection 7th November 2005 Brief Description of the Service: St Joseph’s Rest Home is a care home providing care for up to seventeen (17) residents over the age of sixty-five (65). Nursing care is not provided at this establishment, however district nurses will visit those residents requiring nursing input. St Joseph’s is a detached purpose-built property situated in a residential area in Kemp Town, Brighton. There are local amenities within walking distance of the home and nearby access to public transport. There is car parking at the home for approximately five cars and there is restricted parking in the adjacent streets. The home is owned by the Trustees Of The Sisters of Mercy, however admission to the home is for residents of any denomination. There is a chapel on site at the entrance of the home that is wheelchair accessible. Rooms are located over three floors and the kitchen and laundry are located in the basement of the home. Each floor has a small kitchenette where residents/visitors can make their own refreshments, if they wish. There is a passenger shaft lift available to assist residents to access all areas of the home. There is also a stair lift available on the rear stairway for use in emergencies. There are fifteen (15) rooms for single occupancy and one double room, currently being used for single occupancy. All rooms are provided with en suite facilities. There is one wheel in shower and three baths for residents to use, of which two are assisted. There are eight communal toilets located throughout the home for residents. There is a good-sized dining room and lounge room, which includes a small library. There is also a good-sized conservatory lounge area. There is an area on the second floor designed like a hairdresser salon. There are grab rails and level access available throughout the home to promote residents independence when mobilising. There is a well-maintained garden area that is accessible to residents. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 5 Weekly fees range between £298 and £420. There are additional fees; hairdressing (£6), Chiropody (£12), newspapers and personal toiletries. This information was provided to the CSCI on the 30 August 2006. Prospective residents/representatives are provided with a Statement of Purpose and Service User Guide that offer information on the services and facilities provided at the home. Residents/relatives know about the service through social service referrals, word of mouth, from living in the area, having previously been a visitor to the home or through the church. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at St Josephs’ Rest Home will be referred to as ‘residents’. This unannounced key inspection took place over approximately eight and a quarter hours on the 12 October 2006. The Inspector returned to the home for an hour and a half the following day to assess additional standards and provide feedback to the Registered Manager. Ten residents, of both genders and over the age of 65 years, were spoken with during the inspection. All residents were offered to speak privately with the Inspector. Eight resident surveys were sent to the home prior to inspection, of which two were returned. The Inspector assisted one resident in completing their survey. One care plan was looked at in detail and specific areas of care needs were looked at in three other care plans. The Registered Manager and seven staff; deputy manager, four carers, one carer/cleaner and the Personal Assistant (administrator) were spoken with. Three staff files were inspected. A visiting district nurse was spoken to during the inspection. Out of five GP comment cards sent out prior to inspection, none were returned. Ten relative/visitors comment cards were sent to the home of which two were returned. A pre-inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Fire records, accident records and medication procedures were inspected. The quality assurance system was discussed and complaint records were inspected. Previous requirements and recommendations at the home were assessed to ensure compliance. The staff rota and menus were viewed. The Inspector ate lunch with the residents. Apart from fire records, no other health and safety records were viewed as this information has been provided in the preinspection questionnaire. There were 16 residents residing at the home on the day of the inspection. What the service does well: St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 7 Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents felt that their privacy and dignity are respected. The home has a good rapport with visiting health professionals, ensuring that residents’ health needs are being met. Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home. Residents feel comfortable and know how to make a complaint and feel that they will be listened to. Residents are happy with their individual rooms and are able to personalise them. Residents’ benefit from a low turnover of staff, ensuring continuity of care is provided. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Residents and staff benefit from supportive and approachable management within the home. What has improved since the last inspection? What they could do better: The home has a detailed Statement of Purpose and Service User Guide, however information should be provided to inform the reader that a copy of the most recent CSCI inspection report is available. This will ensure that prospective residents are provided with additional information to assist in making an informed decision if the home can meet their needs. Daily care notes written provide limited information on the health status of an individual. Care notes needs to be expanded and a requirement has been made in respect of this. Some risk assessments are in place but additional ones need to be implemented, to ensure any activity that poses a risk is identified and eliminated so far as is practicably reasonable. The home needs to ensure that they have written confirmation from their head office that an enhanced CRB has been undertaken, that includes a POVA check. It should include information that the checks are satisfactory for the individual to commence employment, ensuring that residents are safeguarded. A more structured quality assurance and quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives and ensure the home is run in the best interest of residents. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 8 Good practice recommendations have been made for medication procedures that will better safeguard staff and residents. It has been recommended that hand-drying towels be removed from communal bathrooms to assist in promoting infection control. It is also recommended that the health questionnaire for prospective employees obtain further information regarding the mental health status of an individual, to evidence that staff are mentally fit for the purposes of the work which they are to perform at the care home. 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 Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 9 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 Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre-admission assessment process ensures that only residents whose needs can be met are admitted. EVIDENCE: The Statement of Purpose and Service User Guide were found to be located at the entrance of the home and within individuals’ rooms. These documents contain information for prospective residents/representatives on the facilities and services provided at the home. This document should contain a copy of the most recent inspection report or at least provide information to the reader that a copy of the most recent inspection report is available. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 11 The home has a good pre admission assessment process that ensures only residents whose needs can be met are admitted. Relatives/representatives are involved in this process wherever possible. Information is obtained from other health professionals and copies of current care plans are taken, wherever applicable. The deputy manager confirmed that there was no one residing at the home from any minor ethnic community or social/cultural groups with any specific needs or preferences. The home does well to ensure that religious needs are met at the home. There is a chapel on site that all residents may use if they wish. Some residents go out to church, whilst others may have their own minister come to visit at the home. All prospective residents are encouraged to visit the home prior to moving in. The first six weeks is a trial period. Of the residents that were asked, all confirmed that they or a relative had visited the home prior to moving in. There is no dedicated accommodation to provide intermediate care. Respite care is available if there is a spare room. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. Residents are safeguarded by the medication procedures in place. EVIDENCE: The Inspector viewed care plans with the deputy manager. All residents have care plans implemented, however one was noted not to have been updated to reflect actual current practice. This had been addressed by the time the Inspector returned the following day. Care plans provide clear guidance for staff on the assessed needs of the individuals. There was evidence that care plans are reviewed on a monthly basis. There was evidence that the initial care plan was drawn up with the involvement of the individual, however no evidence that these were being reviewed with the individuals on a monthly basis. Of the residents that were asked, all confirmed St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 13 that staff discuss their care with them and they are involved in the monthly reviewing process. There is a key worker system in place that provides continuity for residents and staff. Of the residents that were asked, all were able to identify who their key worker was. A relative/visitor comment card received demonstrated that they are kept informed of important matters affecting their relative/friend. A comment received was ‘A wonderful, caring home. The care and consideration could not be better.’ The home has good risk assessments in place, however it was discussed with the deputy manager that risk assessments be implemented for door locks There are very detailed risk assessments in place for falls. Although no resident chooses to have a key to their room, all room doors can be locked from the inside. The Registered Manager confirmed that there are procedures in place should staff need to access locked rooms. One nutritional risk assessment viewed recommended that dietetic advice be sought. The deputy manager confirmed that this had been done, however there was no evidence to show that there had been any follow up. Care notes written on individuals do not provide sufficient information to monitor their health. Writing ‘no problems’ or ‘she is fine’ does not provide suitable information. A district nurse spoken with was very complimentary about the care provided at the home. She confirmed that the home will always seek advice if there are any concerns regarding an individual. She confirmed that when visiting the home, all staff are knowledgeable of the residents needs. Some residents were observed to be wearing glasses and of those asked, all confirmed that they receive an annual eye test or whenever they request. Some residents spoken with confirmed that a chiropodist visits the home and dental appointments are arranged when needed. The Registered Manager confirmed that there are policies and procedures in place for all aspects dealing with medication. The content of these were not read. The home needs to develop and implement a policy and procedure for when residents may go on social leave for a period of time. Records are maintained of all incoming and outgoing medication. Since the last inspection a new medication room has been built where all medications are kept. The Registered Manager confirmed that their supplying pharmacist undertakes audits of their medication twice a year. Medication Administration Record (MAR) charts inspected demonstrated that medication is being signed for at the time of administration. All MAR charts have photos of the residents on them to assist in the identification of individuals. All staff administering medication have received medication training. Five staff have undertaken a three month long distance course on medication. Sample signatures are maintained of all staff who administer St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 14 medication. It is recommended as good practice that all hand written prescriptions are double signed by two staff who are medication trained and any hand written amendments are signed. Residents are supported and provided with an opportunity to self medicate if they wish. Risk assessments are undertaken for those choosing to selfmedicate. One resident self-medicating had no risk assessment in place. The home was pro active and had addressed this issue prior to the Inspector returning the next day. Staff were observed to have a good professional rapport with residents and were heard to be calling them by their preferred term. Staff were observed to knock on room doors prior to entering. All residents spoken with felt that their privacy and dignity are respected. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 15 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. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: There is no activities person employed at the home. Staff will provide activities for the residents. The Inspector observed some residents enjoying a game of bingo in the conservatory. All residents spoken to confirmed that they felt there were enough activities provided at the home, if they choose to be involved. Staff spoken with also confirmed that they felt that there were sufficient activities provided. Some of the activities provided are bingo, painting, quizzes and reading. All residents spoken with confirmed that their lifestyle is their own choice within the home. A comment made was ‘it’s the next best thing to being home’. Residents choose when to go to bed and get up, what clothes they want to wear and their own daily routine. Residents were observed to move freely around the home. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 16 Visitors are welcomed at the home and visitor comment cards demonstrate that they are always welcomed at the home. Of the residents that were asked, all confirmed that they are able to receive visitors in private. Residents are encouraged to maintain links with their family and friends. There is a visitor’s book at the entrance of the home that all people must sign upon entering and leaving the home. Residents were satisfied with the food provided at the home and comments ranged from ‘alright’ to ‘suits me’. Residents confirmed that there is usually a choice in meals, however on the week of the inspection there was no choice in meals. The regular cook was on annual leave and an agency cook was working. All residents were aware of the reason why there was no choice for the week and were happy with the arrangements. The Inspector ate a tasty lunch with the residents. Lunchtime was observed to be a social time and was unhurried. Staff are available to offer discreet assistance if needed. St Joseph`s Rest Home DS0000014242.V309501.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. Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Protection of Vulnerable Adults procedures ensure residents are safeguarded. EVIDENCE: The home has a suitable complaints procedure that all involved with the home has access to. No complaints have been made directly to the CSCI. There has been three complaints made directly to the home since the last inspection. One was logged as a complaint, but it was a misunderstanding of communication and terminology used. One complaint was withdrawn and the resident requested a different key worker. One complaint is about the food provided at the home. This complaint was unresolved. Records are maintained of complaints and what action is taken. Records demonstrate that the home investigates these in an unbiased manner. Residents surveys received demonstrated that residents know who to speak to if they are not happy about something and know how to make a complaint. Of the residents that were asked, all confirmed that they know who to speak to if they had any concerns and feel comfortable making complaints. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 18 A copy of the Protection of Vulnerable Adults (POVA) flow chart was forwarded to the Inspector following the inspection. This provides information and contact numbers for staff to follow in the event of an allegation being made. There has been one POVA investigation since the last inspection. The home followed the correct procedures following initial contact with the Inspector, who advised the home to contact social services. CSCI was not involved in this investigation and it was dealt with through social services procedures. Staff spoken with confirmed that they are familiar with POVA procedures and have undertaken training. The Registered Manager has undertaken training with the local authority on POVA procedures. This course was designed for Registered Manager and Providers of services. Additional training for POVA was also being arranged for November 2006. St Joseph`s Rest Home DS0000014242.V309501.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: St Josephs Rest Home is a purpose built care home. Rooms are located over three floors and there is a passenger shaft lift available to assist residents to access all areas of the home. There is also a stair lift available on the rear stairway for use in emergencies. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 20 Residents confirmed that they were happy with their rooms, which were observed to be personalised to reflect the personality and character of the individual. Residents spoken with confirmed that they were able to bring personal items with them when moving into the home. There were dressings, sterile gloves and personal items that were not labelled and prescribed cream for an individual being kept in communal bathrooms. The Registered Manager will address this. Hot water taps are regulated. Hot water sampled by the Inspector evidenced that water was being dispensed around the recommended 43°C. Windows were noted to be restricted. It was noted that there were hand towels in communal areas. This practice does not promote good infection control and suitable measures should be implemented. The home was clean and free from offensive odours on the day of the inspection. Residents’ surveys demonstrate that the home is always fresh and clean. St Joseph`s Rest Home DS0000014242.V309501.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. Residents’ needs are being met with the number and skill mix of staff on duty and are safeguarded if robust recruitment procedures are followed. EVIDENCE: Residents were very complimentary about the staff working at the home. Staff spoken with confirmed that they enjoy working at the home. All residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. There are usually three staff working in the morning, plus management, two during the afternoon and one waking night carer, with a senior doing sleep in duties in case of an emergency. There is a nightly checklist that staff must sign to show that regular checks of all residents are undertaken during the night. Head office of the organisation undertake the Criminal Record Bureau (CRB) checks on all staff. The Registered Manager confirmed that staff do not commence employment without a POVA First and CRB check being cleared. The home needs to ensure that they have written confirmation from their head office that an enhanced CRB has been undertaken and that a POVA First has been undertaken. It should include information that the checks are satisfactory for the individual to commence employment. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 22 It was discussed with the Registered Manager that the health questionnaire be expanded to include information about the mental health status of an individual. At present it only asks about a nervous disorder. Whilst looking through staff files, discussions took place with the Registered Manager regarding recruitment checks not being in place for one staff member. An explanation was provided and the Registered Manager will take action to address this shortfall. This shortfall has not been reflected as a requirement, as there is no detrimental impact on the residents and safety measures have been implemented. There are 13 care staff employed at the home, of which nine have obtained National Vocation Qualification (NVQ) level 2 or above. The deputy manager has NVQ level 4 in care and another carer has completed their NVQ level 3. This is above the recommended 50 ratio of NVQ level 2 trained staff. Staff spoken with confirmed that they are kept up to date with all mandatory training and stated that there was good training opportunities. Comments from staff were ‘there are definitely enough training opportunities’, ‘brilliant training provided’, ‘the manager encourages everyone to reach their full potential’. There was a training chart in the office that identified training sessions that are arranged. Staff confirmed that some recent training undertaken were: manual handling, dementia, infection control, fire training, medication training and food hygiene etc. Staff commented favourably on a recent Mercy Care course that provided them with an insight and awareness of the role of the Sisters of Mercy, assisting them in understanding the ethos of the home. The home has an induction programme in place and has information available on the new Common Induction Standards that have been newly implemented. Residents benefit from a low turnover of staff, ensuring continuity of care is provided. St Joseph`s Rest Home DS0000014242.V309501.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 & 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 generally run in the best interest of residents, however a more structured quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: Staff spoken with were very complimentary about the Registered Manager at the home and find her approachable and supportive, both personally and professionally. They were also complimentary about the deputy manager in post. Staff confirmed that there are clear lines of accountability within the St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 24 home. The Registered Manager confirmed that she has completed the Registered Manager Award course. The deputy manager has also completed her NVQ level 4 in care. Some comments received about the homes’ management were: ‘couldn’t wish for better people to work with’, ‘brilliant’, ‘it is family like’, and ‘fantastic’. It was discussed with the Registered Manager that a structured quality assurance and quality monitoring system be developed and implemented. Staff and resident meetings are held on a monthly basis, which provides opportunities for people to view any concerns or ideas. There is a suggestion box located at the home that provides an opportunity for people to express concerns or ideas anonymously. The Registered Manager confirmed that questionnaires are provided to residents about once a year. These were due to be undertaken again. The Registered Manager confirmed that there was no set timescale, but done about once a year. Staff surveys are done nearly every two years and no written feedback is sought from any visiting health professionals. There are surveys left near the visitors’ book for people to complete if they wish. The Registered Manager was advised that an analysis is also undertaken of the surveys and results be made available for people involved with the home. The home is an appointee for two residents and holds personal allowance for some other residents. The Registered Manager confirmed that most residents are able to manage their own finances or have family members assisting them. There are clear records maintained of residents monies and receipts are obtained for any financial transactions. The monies checked evidenced that there are clear records of financial transactions being maintained. The Registered Manager and staff spoken with all confirmed that all staff are kept up to date with mandatory training. The pre-inspection questionnaire demonstrates that fire alarms are tested weekly. The most recent fire drill was in August 2006. A fire risk assessment was undertaken in May 2006 and the Registered Manager confirmed that any areas identified as shortfalls are being addressed. The Registered Manager undertakes at least monthly checks on the environment, however as she is at the home on a daily basis, these are not recorded. It was recommended that as part of the homes quality assurance that a quick checklist is devised for the Registered Manager to complete when undertaking the monthly environment checks. No other health and safety records were inspected on this occasion as this information has been provided in the pre-inspection questionnaire. Any shortfalls noted in health and safety during the inspection has been highlighted in the relevant sections of the report. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 25 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 4 X 2 X 3 X X 3 St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 26 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. 2. 3. Standard OP7 OP29 OP33 Regulation Schedule 3 (k) 19 Schedule 2 24 Requirement Timescale for action 30/11/06 That daily records about service users are expanded. That written evidence be 30/11/06 provided that all staff have cleared a POVA and CRB check. That a more structured quality 15/12/06 assurance and quality monitoring system be implemented and results be made available. 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 OP9 Good Practice Recommendations That a policy and procedure be developed for when medication is taken home with the individual to ensure all medication provided and administered can be accounted for. That handwritten prescriptions on MAR charts be checked and double signed by two staff who have undertaken medication training. That any hand written amendments on MAR charts are signed. DS0000014242.V309501.R01.S.doc Version 5.2 Page 27 2. 3. OP9 OP9 St Joseph`s Rest Home 6. OP29 That information regarding the mental health status of a prospective employee be expanded. St Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Joseph`s Rest Home DS0000014242.V309501.R01.S.doc Version 5.2 Page 29 - 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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