Inspection on 11/04/06 for St Josephs

This inspection was carried out on 11th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Josephs 25/07/07

St Josephs 21/12/05

St Josephs 11/10/05

Similar services:

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

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

CARE HOMES FOR OLDER PEOPLE St Josephs 46 Silverbirch Road Erdington Birmingham West Midlands B24 0AS Lead Inspector Brenda O’Neill Unannounced Inspection 11th April 2006 08:30 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 Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Josephs Address 46 Silverbirch Road Erdington Birmingham West Midlands B24 0AS 0121 373 0043 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) Care First Class (UK) Ltd Miss Victoria Louise Boylin Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is registered to provide care and accommodation to 15 older people. Provide a sluice facility within six months of registration. In addition to the manager and ancillary staff a minimum of two care staff must be on duty during the waking day and two care staff on night duty. That one named person who is diagnosed as having dementia at the time of admission can be accommodated and cared for in this home. 21st December 2005 Date of last inspection Brief Description of the Service: St. Josephs is a large, extended detached property situated in a quiet, residential road between Wylde Green and Erdington and provides residential care for up to 15 older people. The home is conveniently located for public transport, shops and local facilities. There is off road parking to the front of the home for a limited amount of cars. Accommodation for the residents is over the ground and first floors with the second floor being used as office and storage space only. There are nine single and three double bedrooms throughout, one of the double bedrooms has ensuite facilities. There is a shaft lift for ease of access to the first floor. There are adequate numbers of toilets and bathrooms throughout the home however not all are equipped with the necessary aids and adaptations for any frail older people or those with any mobility difficulties. Communal space consists of a large lounge and a dining room that has a view of the well-maintained garden, which has a patio, lawn, mature shrubs and a pond. The kitchen, a small laundry and staff facilities are also located on the ground floor. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection over one day in April 2006. During the inspection a tour of the premises was carried, the inspectors joined the residents for lunch, three resident and three staff files were sampled as well as other care and health and safety records. The inspectors spoke with the manager, proprietors, one staff member and five of the fourteen residents. What the service does well: What has improved since the last inspection? Further improvements had been made in the home since the last inspection in a number of areas and several of the requirements made had been addressed. This had been possible as the manager had been based at the home on an ongoing basis. Consultation with the residents had improved and resident’s meetings were being held on a regular basis to discuss such things as menus and activities. The manager had made progress in taking residents out into the local community, for example, a visit to the local school for some entertainment. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 6 The system in place for care planning and risk assessments for the residents had improved. Care plans generally included the likes, dislikes and preferences of the residents and to what extent they were able to self-care. There was also evidence that wherever possible the residents had been consulted about their care plans. There were several risk assessments in place for the residents however some further improvement was required for some of these. There had been a vast improvement in the management of medication in the home since the last inspection. The system was safe and ensured the residents received their medication appropriately. Only minor requirements were made following this inspection. The safety of the residents at night had improved as staffing levels had been increased to two waking night staff every night. There had been further improvements in the cleanliness of the home particularly in the kitchen. The safety of the residents and the general hygiene in the home had improved further, for example, the excessively hot water temperatures had been addressed, the electrical wiring in the home had been checked, odour control issues had been addressed, fridge and freezer temperatures were being kept and all foods being stored in the fridge were being dated on opening. What they could do better: The manager needed to ensure that all staff were mindful of the privacy and dignity of the residents at all times. Staff needed to speak to the residents in an appropriate manner at all times and make sure they used appropriate terminology when making recordings. The manager needed to ensure that a copy of the social workers assessment was obtained prior to the admission of any residents so that an informed decision can be made as to whether the home can meet the needs of the individual. On admission to the home residents needed to be issued with a statement of their terms and conditions of residence. Further improvements were needed to some of the care plans and risk assessments for the residents to ensure all their individual needs were identified and met and to ensure that all risks were minimised. Practice at meals times needed to be changed to ensure that all residents received appropriate assistance individually whilst also encouraging independent eating. To ensure the safety of the residents and the staff the manager needed to ensure that all staff undertook all regulatory training in safe working practices. To ensure the protection of the residents all the required checks needed to be in place prior to new employees commencing work at the home. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 7 The home needed to have in place a formal system for monitoring the quality of the service offered based on seeking the views of the residents. There were still some issues in relation to hygiene that needed to be addressed to ensure the home was entirely safe for the residents and staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 8 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 Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents taken into the home were not always known by staff and therefore the home was not able to ensure all individual needs would be met. Prospective residents were able to visit the home prior to admission and assess the suitability of the home. Residents were not being issued with a contract of residence or a statement of terms and conditions of residence. EVIDENCE: Three resident files were sampled. All the files included evidence of social workers being involved in the admission process as all had initial care plans drawn up by them. The care plans gave little detail of the individual needs of the residents and only one of the files included a copy of the full assessment undertaken by the social worker. One file included an in depth assessment by the manager of the home and another only a brief assessment which were undertaken on the pre admission visit. The manager needed to ensure that a copy of the social workers assessment was obtained prior to the admission of St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 10 any residents so that an informed decision can be made as to whether the home can meet the needs of the individual. There was no evidence on any of the files sampled that residents were being issued with a statement of terms and conditions of residence at the point of admission. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there were overall improvements care plans needed to include details of how all the individual needs of the residents were to be met. Risk assessments needed to include complete details of how risks were to be minimised to ensure safer outcomes for residents. The medication system was generally well managed and safe. The privacy and dignity of the residents were not being adequately considered. EVIDENCE: Three care plans were sampled. Two for residents who had lived at the home for two months and one for a resident who had only lived at the home for a week. The care planning system at the home had been changed since the last inspection and had improved. The care plans for the individuals who had been at the home for two months were quite comprehensive and included information about their likes, dislikes and preferences and to what extent they were able to care for themselves. For two of the residents the manager had also written a brief over view of their needs and their abilities which were very informative. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 12 It was noted there were some omissions and discrepancies in the care plans, for example, oral care was not included and for one resident the care plan stated ‘walks with two sticks’ and he was using a walking frame on the day of the inspection. It was also evident from the daily notes that one of the residents liked helping in the kitchen but this was not included on the care plan as to how this was to be facilitated. The third care plan was very brief and did not give enough detail of the assistance required by the individual. This may have been because the individual had only been in the home for a very short period of time and it may have been better to leave writing the care plan until staff had had sufficient time to get to know the individual’s needs. The overview for this individual gave details of her having diabetes and suffering confusion but the needs arising from these were not fully detailed in the care plan and could have been misleading for staff. There was evidence that where possible residents had been consulted about their care plans but there was no evidence of any monthly reviews. All the resident’s files sampled included manual handling risk assessments, which included details of the actions to be taken in the event of a fall but where the use of the hoist was indicated the sling size had not been included. All residents had falls risk assessments and where a risk had been identified there was a personal risk assessment in relation to this. Another of the files also included a personal risk assessment in relation to challenging behaviour but this was incomplete and did not detail how staff were to proceed if the strategies included did not address the behaviours. The other file sampled did not include any personal risk assessments. Tissue viability and nutritional screenings had been undertaken for all the residents. It was noted that one of the nutritional screenings records stated staff were to monitor the individual’s food intake and record the information in the food diary. Although this was done it did not detail the actual amounts the person was eating. Where there was a particular problem with any of the residents the manager needed to ensure that individual food records detailed specifically the amounts of food eaten and what actions were being taken to follow this up. For another resident the nutritional assessment stated ‘offer food and drink throughout the day’ as the individual was diabetic this needed to be much more detailed due the requirements of her diet. This must be done so that staff did not offer foods high in sugar that could cause health problems. There was no evidence on the resident’s files that they were being weighed regularly. The manager stated they had been weighed recently but the details had not been recorded on their files. The daily records for the residents were generally well detailed and evidenced that staff were identifying, following up and then monitoring any health care needs. There was evidence of visits to hospitals, visits from G.P.s, community psychiatric nurses and district nurses. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 13 At the time of the last inspection the systems for medicines in the home were so poor that an enforcement notice was issued to the registered individual. The inspecting pharmacist had visited the home to follow up the required action of the home contained in the enforcement notice and all the requirements that had been made had been met. At the time of this inspection the system continued to be generally well managed with only two requirements being made about there being two signatures for all controlled medication administered and that there needed to be a specimen signature sheet for all staff administering medication. The manager needed to ensure that staff were mindful of the privacy and dignity of the residents at all times. There was a staff communication book in use at the home and it included a lot of personal information about the residents that needed to be in their individual daily records. The terminology being used in some of the daily recordings was inappropriate, for example, words being used included ‘snappy’, ‘sarcastic’, ‘in a right paddy’ with no explanation as to what they meant. It was also noted that a member of staff spoke very abruptly to one of the residents at lunchtime which was not acceptable and could have deterred residents from making any future comments. A cordless phone had been made available for the use of the residents since the last inspection so they could make and receive calls in a private area of the home. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were no rigid rules or routines in the home and there were some activities available for residents to take part in if they wished. The arrangements for visiting the home enabled visitors to come at any reasonable hour. The menu at the home was varied and nutritious. Practice at meals times needed to be changed to ensure that all residents received appropriate assistance individually whilst also encouraging independent eating. EVIDENCE: There did not appear to be any rigid rules or routines in the home. Residents were seen to wander freely around the home, sit chatting to each other, watching television or reading the newspaper. The residents spoken with were generally satisfied with the service they were receiving. Documented activities included such things as good old times game, four in a row, pictionary, bingo, trip out to the local school, church visitors and individuals playing drafts, cards and dominoes. Residents meetings were taking place on a monthly basis and the range of activities being offered had been discussed however there was no evidence to suggest that some of the activities asked for by residents had been tried, for example, crosswords, carpet bowls and DVDs. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 15 There did not appear to be any restrictions on visiting within reasonable hours. There was evidence on the daily records of frequent visitors to the home and that residents went out with their relatives. There was also evidence that the manager was trying to take the residents out more into the local community, for example, a trip to the local school and out for a drive with the proprietor. It appeared that residents were encouraged to exercise choice and control over their lives in such things as choosing what they did during the day, what to wear, when to get up and go to bed and what to eat. Care plans included details as to what extent the residents could self care and of their preferred waking and retiring times. Residents had been encouraged to personalise their rooms to their choosing and personal effects were seen in all the bedrooms. The residents spoken with were generally happy with the catering arrangements at the home. Residents were waiting for their breakfast when the inspectors arrived and informed the inspectors that they had cereals and toast. One resident did comment it would be nice to have a bacon sandwich occasionally. There was evidence that the range of food being offered had been discussed with the residents at their meetings and some alterations to the menus had been made, for example, residents stated they did not like mince and wanted egg custard and jam tart on the menu. The inspectors joined the residents for lunch and some of the practices at meal times needed to be reviewed. Two residents were sitting in the lounge and had their lunch on small tables. One of the residents was asleep and his food was going cold, the other residents had no help and kept dropping his food. In the dining room one resident kept getting up and leaving the table and was having difficulty eating her food as it kept sliding off the plate, three residents were asked half way through the meal if they wanted their meat cut up and one member of staff was trying to assist two residents on different tables. As mentioned previously one of the residents was spoken to very abruptly during the course of the meal time, no residents were asked if they wanted any more food and one clearly stated she did not like the pudding but no alternative was offered. All these issues were discussed with the manager and she was advised she needed to look at the whole issue of meal times and ensure it was an enjoyable experience for all residents and that they all received the assistance they required. The menus seen offered a good variety and were nutritious. The records of food being served to the residents had improved since the last inspection however as previously stated these needed to be more detailed for some residents. The food stocks in the home were at an acceptable level. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a complaints procedure on display in the home but this needed to include the time scales within which a response would be made to any complainant. There were policies and procedures on site about adult protection and to ensure the residents were safe guarded training had been booked for staff. EVIDENCE: There was a complaints procedure on display in the home. This needed to be further developed to include the time scales within which a response would be made to any complainant and the telephone number of the CSCI. The home had not had any complaints since the last inspection and none had been lodged with the CSCI. The adult protection procedure for the home had been further developed and gave staff a clear procedure to follow in the event or suspicion of abuse however it also needed to include details of the points of contact for the staff, for example, phone numbers if required. Staff were due to undertake training for adult protection during April. Also on site were policies and procedures on managing aggression. As it was evident from the daily records that some of the residents had some challenging behaviours to ensure these were managed appropriately staff needed to undertake training in this topic also. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home was well maintained and provided a good level of comfort to residents. Some issues in relation to infection control needed to be addressed. EVIDENCE: There had been no changes to the layout of the home since the last inspection which was suitable for its stated purpose. The home was generally well maintained. The inspector discussed with the manager and the responsible individual for the home the requirements that had been made by the fire officer and all these had been met including that the home have two waking night staff on duty every night. It was noted during the tour of the home that there was an exposed light bulb in the linen cupboard, which was a potential fire risk, and the ceiling rose to the light fitting was not secured to the ceiling. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 18 There was adequate communal space at the home comprising of a large lounge and a dining room. Both were adequately furnished and decorated. It was noted that both areas were cleaner than at the last inspection. There were adequate numbers of toilets throughout the home and some had had new hand or grab rails installed however there was still a need to carry out an audit of the aids and adaptations in the toilets to ensure they met with the needs of the residents. There were two bathrooms on the first floor of the home, one with a medic bath, which did allow for staff assistance but residents needed to be able to negotiate quite a big step into this. The other bathroom had a domestic style bath and the inspectors were informed this was not used. There was one large bathroom on the ground floor that had a bath hoist fitted since the last inspection the tumble drier had been removed from this room and housed elsewhere which had improved accessibility and infection control. It was also noted that the call bell in this bathroom was not accessible from the bath should a resident wish to bathe on their own. There were some aids and adaptations throughout the home to assist those residents with mobility difficulties including shaft lift, portable ramp for going into the garden, mobile hoist and wheelchairs. The practice of using wheelchairs without footrests had stopped unless specifically requested by any resident and the inspectors were informed this was also detailed in the care plans. There were no handrails in any of the corridors. As at the last inspection there had been no changes to the bedrooms which varied in size and the majority of the required furnishings and fittings were in place. The majority of the rooms had only one chair and there was not always access to bedside lighting. The bedrooms should be audited for furnishings and fittings against the National Minimum Standards and any shortfalls rectified. All rooms had a lockable piece of furniture and residents were able to have keys to their bedroom doors if they wished. Bedrooms were personalised to the occupant’s choosing. The heating, lighting and ventilation in the home appeared to meet the needs of the residents. All the hot water temperatures tested were at an acceptable level. There had been a noticeable improvement in the cleanliness and hygiene in the home particularly in the kitchen and the home was odour free. To further enhance this the manager needed to ensure that: • All cotton towels were removed from the communal bathrooms. • The underside and back of the bath hoist was thoroughly cleaned. • All extractor fans were cleaned. • The temperatures of the freezer kept upstairs were recorded on a daily basis. • General purpose mops were not stored in the laundry with mops to be used in toilet areas and that any worn mops were replaced. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 19 • The bin for the storage of clinical waste must have a tight fitting lid. The proprietor was pursuing the requirement made at the last inspection for the home to have a mechanical commode pot washer installed. The previous time scale given for this had not lapsed. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were being maintained. To ensure residents were being cared for the home needed to make improvements to the staff induction programme to ensure staff were fully equipped to deliver adequate and appropriate care. To ensure the protection of the residents all the required checks needed to be carried out on employees prior to them commencing their employment. EVIDENCE: There had been some staff turnover at the home since the last inspection. Staffing levels were being maintained at two care staff throughout the day and night and the manager’s hours were generally supernumery. The home also employed a cook and a domestic assistant. This complied with the condition of registration for staffing at the home. The residents spoken with were positive in their comments about the staff team and friendly relationships were evident. Of the twelve care assistants at the home four had completed their NVQ level 2 and another two were expected to complete their training by the end of April 2006 and this would give the home the required fifty percent. General training undertaken over the last year included food hygiene, fire training, health and safety and manual handling however these topics had not been completed by all staff and no staff had undertaken first aid training. The manager needed to ensure that all staff completed all regulatory training. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 21 There was no evidence on the files sampled that new staff were undertaking induction training in line with the specifications laid down by skills for care. The manager stated this had been started for one member of staff. The recruitment files for three staff were sampled. Two of the files included CRB checks and one a POVA first check. However it was noted that the POVA first check had not been obtained until after the employee had commenced her employment. All files had completed application forms but there was no evidence to suggest that the gaps in previous employment had been explored with the employees. Two written references had been obtained for all the employees but one of these was not always from the most recent employer. The manager needed to ensure that all the appropriate documentation was obtained for new employees prior to their commencing their employment and that issues, such as gaps in employment, were explored with them. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. Further improvements had been made to the management of health and safety in the home. The home needed to have in place a formal system for monitoring the quality of the service offered based on seeking the views of the residents. EVIDENCE: The manager of the home had worked there for a considerable amount of time. She had a good knowledge of the residents in her care and the running of a residential care home. She appeared to have a good relationship with the staff and residents. The manager was undertaking her Registered Manager’s Award. At the time of the last inspection there was an issue of the manager being St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 23 placed at another home on an ongoing basis, it was pleasing to note this had been resolved. As mentioned previously the use of the communication book was an issue as personal information about the residents was being recorded in this. Also this book appeared to be being used as a way of the night shift commenting on the care delivered by the day staff and vice versa. From these recordings it could be concluded that either staff relationships were poor or care being delivered was poor and adequate cleaning products were not being provided. The manager needed to explore these issues with the staff team and resolve them. There were some systems in place for monitoring the quality of the service offered at the home, for example, residents meetings and regulation 26 visit reports by the responsible individual. However the registered manager needed to further develop some formal methods for monitoring the quality of the service offered at the home based on seeking the views of the residents with a view to continuous improvement. The home was managing some of the personal allowances for the residents. The records kept were sampled and found to be appropriate although it was strongly recommended that the chiropodist and hairdresser were asked to sign for the monies paid to them. The management of health and safety at the home had further improved but there were still some areas that needed to be addressed, for example, ensuring all staff had up to date training in safe working practices. There was evidence on site of the servicing of equipment and since the last inspection the electrical wiring in the home had been checked. All the in house checks on the fire equipment were up to date and fire drills were taking place regularly. Accident and incident recording were appropriate and the CSCI were being notified accordingly of any accidents but as previously stated, were not being notified of incidents occurring in the home. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 1 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 1 X 2 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 2 St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1)(c) Requirement All residents must be issued with a contract/statement of terms and conditions of residence at the point of admission to the home. The manager must ensure that a copy of the social workers assessment is obtained prior to any residents being admitted to the home. All residents must have care plans that detail how all their current needs in respect of their health and welfare are to be met by staff. (Previous time scales of 01/12/05 and 01/02/06 partially met.) Care plans must be reviewed monthly. All residents must have personal risk assessments. Where any challenging behaviours are identified there must be strategies in place for managing these to a satisfactory conclusion. If no risks are identified this must be documented. (Previous time DS0000064278.V288347.R01.S.doc Timescale for action 01/06/06 2. OP3 14(1) 01/06/06 3. OP7 15(1)(2) (a,b,c) 01/06/06 4. OP7 13(4)(c) 01/06/06 St Josephs Version 5.1 Page 26 5. OP7 13(5) 6. OP8 12(1)(a) scales of 01/12/05 and 01/02/06 partially met.) Where the use of a hoist is indicated in a manual handling risk assessment the size of the sling must be included. Where any risks are identified on a nutritional screening the actions to be taken to minimise the risk must be clearly detailed. Residents’ weights must be monitored on a regular basis. Food intake charts must be put in place for any residents where a risk has been identified. Two staff must sign for the administration of controlled medication at the time it is administered. There must be a specimen signature sheet for all staff that administer medication. The manager must ensure that staff are mindful of the privacy and dignity of the residents at all times. Staff must speak to residents in an appropriate manner at all times. Personal information must not be recorded in communication books. Appropriate terminology must be used in daily recordings. There must be evidence that the outcomes of the resident’s meetings in relation to activities have been acted upon. Practice at meal times must be reviewed and changes made to ensure: DS0000064278.V288347.R01.S.doc 01/06/06 01/06/06 7. OP9 13(2) 14/05/06 8. OP10 12(4)(a) 14/05/06 9. OP12 16(2)(m) (n) 12(1)(a) (b) 01/06/06 10. OP15 01/06/06 St Josephs Version 5.1 Page 27 That residents receive the assistance they require at the appropriate time. That staff ensure the residents have had enough to eat. That an alternative is offered if a resident states they do not like something. That advice is sought from an occupational therapist in relation to appropriate crockery and cutlery where necessary. The complaints procedure must include time scales within which a response to any complainant will be made and the telephone number of the CSCI. The adult protection procedure must include details of the points of contact for staff. Staff must receive training in managing challenging behaviour. The bulb in the linen cupboard must be covered and the light fitting repaired. An audit of the aids and adaptations available in the home must be undertaken and additional equipment fitted as necessary. (Previous time scale of 01/03/05 partially met.) The emergency call system must be accessible from all bathing facilities. The furnishings and fittings in the bedrooms must be audited against the National Minimum Standards and shortfalls rectified. (Previous time scale of 01/04/06 not met.) The underside and back of the bath hoist seat must be thoroughly cleaned. (Previous time scales of 13/10/05 and 23/12/05 not met.) DS0000064278.V288347.R01.S.doc 11. OP16 22 01/06/06 12. 13. 14. 15. OP18 OP18 OP19 OP22 13(6) 13(6) 13(4)(c) 23(2)(n) 01/06/06 01/08/06 08/05/06 01/07/06 16. 17. OP22 OP24 13(4)(c) 16(2)(c) (p) 01/06/06 01/07/06 18. OP26 13(3) 08/05/06 St Josephs Version 5.1 Page 28 All cotton towels must be removed from communal bathrooms. All extractor fans must be regularly cleaned. General purpose mops must not be stored in the laundry with mops to be used in toilet areas and any worn mops must be replaced. The bin for the storage of clinical waste must have a tight fitting lid. The temperatures of the freezer kept upstairs must be recorded on a daily basis. A commode pot washer/disinfector must be installed in the home. (Time scale given had not lapsed.) Fifty percent of staff must be qualified to NVQ level 2 or the equivalent. (Previous time scale of 01/04/06 not met.) The manager must ensure that all the documentation detailed in Schedule 2 of the Care Homes Regulations is obtained for staff prior to their employment. Any gaps in the employment history of prospective employees must be explored with them. Wherever possible a written reference must be obtained from the most recent employer. The re must be evidence on site that new employees are receiving induction training in line with the specifications laid by Skills for Care. (Previous time scale of 01/04/06 not met.) DS0000064278.V288347.R01.S.doc 19. OP26 13(3) 20/08/06 20. OP28 18(1)(a) 30/06/06 21. OP29 19(1) schedule 2. 01/06/06 22. OP30 18(1)(a) 01/06/06 St Josephs Version 5.1 Page 29 23. OP30 18(1)(a) 24. OP31 9(1)(b)(i) 25. 26. OP32 OP33 12(5)(a) 24(1)(a) (b) All staff must undertake all regulatory training. As a minimum this must include: • Fire procedures • Manual handling • Basic food hygiene • First aid • Health and safety • Infection control (Previous time scales of 14/12/06 and 01/04/06 partially met for some training.) The manager must be qualified to NVQ level 4 in care and management or the equivalent. (Previous time scale of 31/01/06 not met.) The manager must explore and resolve the issues identified within the staff team. The home must have a system in place for monitoring the quality of the service offered based on seeking the views of the residents. (Previous time scale given had not expired.) 01/09/06 01/07/06 01/06/06 01/06/06 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 OP35 Good Practice Recommendations It is strongly recommended that the chiropodist and hairdresser are asked to sign for the money paid to them. St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Josephs DS0000064278.V288347.R01.S.doc Version 5.1 Page 31 - 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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