Inspection on 11/10/05 for St Josephs

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Josephs 25/07/07

St Josephs 11/04/06

St Josephs 21/12/05

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 11 October 2005 09:50 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.V256995.R01.S.doc Version 5.0 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.V256995.R01.S.doc Version 5.0 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.V256995.R01.S.doc Version 5.0 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 ancilliary 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. March 3 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.V256995.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out by two inspectors over one day and was the first of the statutory inspections for 2005/2006. The home had changed hands three weeks prior to the inspection and this should be taken into account when reading this report. During this visit a tour of the home was carried out, three resident files and the recruitment documentation for three staff were sampled as well as other care and health and safety records. The inspectors spoke with the manager, proprietor, cook, one visitor, seven of the eleven residents and briefly to two care staff. What the service does well: What has improved since the last inspection? What they could do better: Several issues in relation to the health and safety of the residents and staff were raised at this inspection that needed to be addressed as a matter of urgency including, infection control, general cleanliness and fire prevention. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 6 There needed to be some consultation with the residents about their preferred leisure time activities and actions taken to offer some stimulating pastimes for the residents. The manager needed to ensure that staff were mindful of the privacy and dignity of the residents at all times. Medicine management remained poor in the home and this needed to improve to ensure the safety of the residents. Care plans in the home were very basic and did not include sufficient detail of the residents’ individual needs or how these were to be met by staff. There was no evidence that the residents or their representatives had been consulted about the care plans. There needed to be manual handling and personal risk assessments for all residents so that any risks were minimised and staff knew what actions they had to take. The manager needed to ensure that staff followed any risk assessments that were in place as there was evidence that this was not always happening. Records of food being served to the residents needed to be kept to evidence that that they were receiving a balanced diet, that choices were being offered and that any special diets were being catered for. The recruitment procedures needed to be further developed to ensure they were robust and offered protection to the residents. An application needed to be made to the CSCI to vary the condition of registration in relation to night staffing levels and include evidence as to how the residents’ needs would be met during the night. 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.V256995.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The needs of prospective residents referred to the home via social care and health were being appropriately assessed and the staff were able to determine if they could meet the individuals’ needs. The assessment procedure for self funding residents needed to be further developed to ensure staff had all the required information to determine if the home could meet the needs of the individual. EVIDENCE: Three resident files were sampled and the one for the most recent admission to the home evidenced that a social worker had undertaken the assessment prior to admission and a copy of this was available. For residents who were self funding the assessment tool being used at the home was very basic and did not cover all the required areas. The information collected on this document did not provide enough details to enable the staff at the home to determine if the prospective resident’s need could be met by them. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 9 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 Care plans and risk assessments needed to be further developed and updated to ensure they included sufficient detail to enable the residents’ needs to be met and ensure all identified risks were minimised. At the time of the inspection the medication records did not reflect accurately what had been administered to the service users in all instances. The privacy and dignity of the residents were not being adequately considered. EVIDENCE: Three care plans were sampled during the inspection. The care plans were very basic and did not reflect the current needs of the residents. One of the care plans stated the individual was not incontinent when reading the daily records for the individual this was not the case. It was evident when speaking to the individual concerned that communication was a major problem and although mentioned on the care plan the extent of the difficulty was not clear. Another care plan stated the individual walked unaided and was very steady whereas the falls risk assessment, which was dated the same day, indicated there was a medium risk of falling. Another resident’s risk assessments indicated there was a high risk in relation nutrition and falls but there was nothing indicated on the care plan as to how this was to be managed. Care plans were being reviewed St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 10 monthly but not updated appropriately. There was no evidence to suggest that the residents or their representatives had been consulted about the care plans. There was no evidence on any of the files sampled of manual handling risk assessments. These needed to be undertaken for all residents and include the actions to be taken by staff in the event of a fall if no injury was sustained. This was of particular importance as there was no hoist available in the home. No tissue viability assessments had been undertaken for the residents and some were quite frail and appeared to be seated for long periods of time which adds to the risk of pressure sores. Residents did have nutritional screenings but where a risk had been identified the actions to minimise this were not being carried out, for example, one resident should have been weighed weekly and food intake monitored, there were no food records and the last recorded weight was six weeks previously. One of the residents had diabetes controlled by medication and diet however the cook was not aware of this therefore it was unlikely his dietary needs were being met. Other residents’ weights were being monitored, albeit a little ad hoc at times. Where there had been a significant weight loss for one of the residents there was documented evidence that this had been followed up with the appropriate health care professionals. Daily records evidenced that generally health care needs were identified by staff and followed up and there was evidence of visits from the G.P., chiropodist, district nurse and liaison with health care specialists for dementia. There was no evidence on any of the files of any personal risk assessments. It was evident from one of the resident’s daily records that there were some challenging behaviours. There was no risk assessment for this or any strategies in place for managing the presenting behaviours. All residents needed to have personal risk assessments for any identified risks with guidelines for staff to follow to minimise the risks. If there were no risks identified this needed to be documented. The inspecting pharmacist visited the home. Her findings are detailed below: Audits undertaken to demonstrate that the medicines had been administered as prescribed indicated that they had not been in all instances. Some medicines had been signed as administered but they had not been. Gaps were found on some Medicine Administration Record (MAR) chart and it could not be demonstrated whether the medicines had been administered and not recorded or not administered and the reason for non-administration not recorded. Medicines were unaccounted for. Carry over balances from previous MAR charts had not been routinely recorded so audits could not be undertaken in these instances. Inadequate checks had been taken to check the received medicines into the home. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 11 One service user had two different formulations of the same medicine and it could not be demonstrated if he had been administered both formulations at once and thus received double the prescribed dose. “As directed” doses had not been confirmed with the doctor and assumptions had been made as to the correct dose. Out of date creams were found in the office and medicines for service users that were no longer resident in the home. The Controlled Drug register was incorrectly completed after each transaction and the storage of Controlled Drugs and general medicines inadequate. The medicine refrigerator was broken at the time of the inspection and inappropriately sited. The system installed in the home for administration of medicines was poor. The privacy and dignity of the residents were being maintained to a degree, for example, staff were seen to knock on bedroom doors before entering and there was appropriate screening in double bedrooms. However further improvements needed to be made, for example, the telephone for the use of the residents was located in the entrance hall and did not afford any privacy, one of the residents was dressed in clothing that had obviously shrunk in the wash, was too short and had not been ironed, one resident had very dirty glasses, toiletries named for one resident were seen in another resident’s bedroom and one bedroom had a notice on the mirror instructing care staff how to care for the person. The manager needed to ensure that staff were mindful of the privacy and dignity of the residents at all times. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 12 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, 15 There were no rigid rules or routines in the home and visitors were made welcome. There needed to be some consultation with the residents about their preferred leisure activities and action taken to ensure social needs were being met. Residents were generally satisfied with the catering arrangements at the home. EVIDENCE: Residents spoken with stated there were no rigid rules or routines in the home and that they could spend their time as they chose. Residents were observed to wander freely around the home, spend time with visitors, sit chatting and take part in a singsong session. The residents spoken with stated they got bored and there was little going on in the home in the way of activities. The visitor spoken with also stated there appeared to be a lack of activities in the home. There was an activity programme on the door of the lounge but there was no documented evidence to suggest this was undertaken. There needed to be some consultation with the residents about their preferred leisure time activities and actions taken to offer some stimulating pastimes. There did not appear to be any restrictions on visitors to the home within reasonable hours. The visitors seen appeared to be made very welcome by staff. One of the residents confirmed that his wife was able to visit him. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 13 The residents spoken with were generally happy with the meals served at the home and comments included: ‘the food is well cooked’, ‘food quite good’, and ‘food good’. There was only one menu available in the kitchen as the new proprietors were in the process of compiling new ones. The menu seen was varied and nutritious and although there were no stated choices the residents confirmed if they did not like what was on the menu an alternative was offered. One of the residents was celebrating a birthday on the day of the inspection and a birthday buffet tea was on the menu for that day. The dining room was a pleasant room, well furnished and decorated and overlooked the garden. It was noted that the residents’ drinks had all been poured out and left on the tables prior to lunchtime and all had been given the same. There needed to be a choice of drinks available and residents should be consulted about their preferences on a daily basis. At the time of the inspection residents were having breakfast in their rooms however the manager felt this was being served too early as it started at 7a.m. This was to be discussed with the residents and staff with a view to improving the time and the variety of food that was being offered. At the time of the inspection food stocks in the home were quite low however the proprietor was shopping regularly for the home and was in the process of setting up some regular orders with suppliers. It became apparent after discussion with the cook and the manager that the supply of fresh milk to the home was not enough for the numbers of people being catered for. Powdered milk was being used on a regular basis to supplement this. This was not acceptable practice and powdered milk should only be used as a stand by. The inspectors were informed that records of food served to residents were not being kept. This was discussed with the manager and she was made aware that records needed to be kept that evidenced residents were receiving a balanced diet, of any choices served and of any special diets being catered for. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 14 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): These standards were not assessed at this inspection. Requirements from the previous report have not been brought forward to this report as they were made to the previous manager. The standards will be assessed at the next inspection. EVIDENCE: St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 15 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 home was generally well maintained. Several issues needed to be addressed to ensure the home was safe for the residents particularly in relation to cleanliness and infection control. EVIDENCE: The location and layout of the home were suitable for its stated purpose and it was generally well maintained. There were some outstanding issues from the visit made by the fire officer that the new proprietor was aware of and these needed to be addressed within the given time scales. At the time of the inspection some of the fire doors were wedged open and numerous wooden wedges were seen in the residents’ bedrooms indicating that they were also at times wedged open. Wedging fire doors open is dangerous practice and the manager needed to ensure this stopped and alternative solutions explored if residents wanted their doors left open. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 16 There was adequate communal space at the home comprising of a large lounge and a dining room. Both were adequately furnished and decorated. It is strongly recommended that a larger television is purchased for the lounge as the present one is very small and would be difficult for residents to see. It would also be beneficial for the residents to have a video or DVD player to enable them to watch alternatives to television programmes. There were adequate numbers of toilets throughout the home however very few had any hand or grab rails to help the residents when sitting down or standing up. An audit of the aids and adaptations in the toilets needed to be carried out and additional equipment fitted as necessary. 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 were several items being stored in this bathroom, for example, old chairs and old bath hoist making it very cluttered. All the items needed to be removed as there was also a toilet located in this room, which was likely to be used by the residents, and the clutter could make it hazardous for them. There was one large bathroom on the ground floor that had a bath hoist. This room also housed the tumble drier and at the time of the inspection there was an array of laundry both dry and wet spread throughout the room in baskets and on hangers. This would have made it impossible for residents to have a bath until it was cleared and it would have been very hazardous for any resident wanting to use the toilet. This situation also raised some concerns in relation to infection control. There were some aids and adaptations throughout the home to assist those residents with mobility difficulties including shaft lift and a portable ramp for going into the garden. There were no handrails in any of the corridors and although there were wheelchairs available these were being used without footrests which was dangerous practice. Bedrooms varied in size and the majority of the required furnishings and fittings were evident. 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 facility and residents were able to have keys to their bedroom doors if they wished. Bedrooms were personalised to the occupant’s choosing. There was central heating throughout the home and the radiators had been guarded. All hot water outlets had thermostatic mixer valves fitted however some of the water temperatures to the wash hand basins were in excess of 43 degrees and needed to be addressed. All bedrooms were naturally ventilated and window restrictors had been fitted where appropriate. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 17 Numerous issues were raised throughout the inspection in relation to general cleanliness and infection control including: • In the majority of the toilets and bathrooms and the laundry there were no disposable towels or any liquid soap and there was only liquid soap in the kitchen. It was difficult to see how any of the staff or residents could effectively wash their hands. • There were no bins in toilets or bathrooms. • There were several items of toiletries and opened creams found in a drawer in the ground floor bathroom. Other personal toiletries had also been left in bathrooms instead of being returned to the appropriate bedrooms. • The underside of the bath hoist seat needed to be thoroughly cleaned. • Only one of the residents’ toilets had a supply of toilet paper. • The majority of the commode chairs were badly rusted and the commode pots very badly stained. • There were bedrooms with an odour control problem. • Some of the bedroom carpets were heavily stained. • Some of the flooring in the bathrooms and toilets was not to an acceptable level of cleanliness. • The flooring in the kitchen and some of the shelving needed to be thoroughly cleaned. • Fridge and freezer temperatures were not being recorded to ensure the equipment was working efficiently. • There were opened foods being stored in the fridge that had not been dated when opened. • It was also noted that a bottle of nail varnish remover had been left on top of the fish tank in the lounge which was very accessible to the residents. The washing machine at the home did not have a sluice cycle and there was evidence of a considerable amount of incontinence. One of the conditions of registration is that a washing machine with a sluice cycle is installed in the home. There were also numerous commodes being used in the home and the effective cleaning of the commode pots appeared to be an issue therefore the home should at their earliest opportunity install a mechanical commode pot washer/disinfector. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 18 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, 29 There was a fairly stable staff group at the home which was good for the continuity of care of the residents. The manager needed to apply to the CSCI to vary the condition of registration in relation to night staff and include evidence that the residents’ needs could be met with staffing numbers reduced. The recruitment procedures needed to be further developed to ensure they were robust and offered protection to the residents. EVIDENCE: Some of the staff employed at the home had worked there for a considerable amount of time which was very good for the continuity of care of the residents. All the residents spoken with were very positive in their comments about the staff team and friendly relationships were evident. The condition of registration in relation to staffing stated that 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. This was being complied with during the day and exceeded on the morning shift but there was only one member of staff on night duty. This was discussed with the manager and proprietor and they were made aware that an application must be made to the CSCI to vary this condition and include evidence as to how the residents’ needs would be met during the night. There was also a domestic assistant and a cook employed at the home. A maintenance operative was also employed and was based at this home two days a week. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 19 The recruitment files for the three newest staff were sampled. The application form being used by the former proprietor/manager was not adequate as it did not include enough space for former employment and the health section was inadequate. This was discussed with the proprietor and manager who were in the process of developing a new form. None of the files sampled had CRB disclosures or evidence of any POVA checks. Although not appointed by the present manager these needed to be pursued urgently. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 20 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, 35, 38 The home had recently changed hands and the manager had recently been registered with the CSCI. Several improvements were needed in the home to ensure the safety of the residents and to ensure the home met with the National Minimum Standards. EVIDENCE: The manager of the home had been employed at the home for approximately one year as the deputy manager and had recently been registered with the CSCI as the care manager. Prior to this she had several years experience of caring for older people. She was undertaking her Registered Manager’s Award and anticipated this would be complete by the end of January 2006. She appeared to be aware of the majority of the shortfalls in the home and saw this inspection as the starting point to addressing them. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 21 Numerous issues were raised that needed to be addressed to ensure the home meets the National Minimum Standards and these were discussed in depth with both the manager and the proprietor. The home was managing the finances for several of the residents for their everyday needs. The records for these were sampled and found to be appropriate, money received was receipted and documented, all expenditure was signed for by two staff and there were receipts available. All the balances checked were correct. Several issues in relation to the health and safety of the residents and staff were raised at this inspection including infection control and fire prevention. It was also noted that the fire alarm was not being checked on a weekly basis and the emergency lighting was not always checked monthly as is required. The fire training for staff was also out of date. There was evidence on site that a fire drill had been carried out. There was evidence on site that the majority of the equipment in the home had been serviced including, gas equipment, bath hoist, portable electrical appliances and the lift. The electrical wiring certificate was not available on site and there was no evidence that the water system had been checked for the prevention of legionella. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 3 1 2 X 2 2 1 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 1 St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Previous requirements were given to former owner. 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 OP3 Regulation 14(1) Requirement The assessment procedure for self-funding residents must cover all the areas detailed in Standard 3 of the National Minimum Standards. 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. Care plans must be cross referenced to any risk assessments undertaken to ensure both documents agree. There must be evidence that the residents or their representatives have been consulted about the care plans. Care plans must be updated as the needs of the residents change. 3 OP7 13(5) All residents must have manual handling risk assessments that detail the actions to be taken by DS0000064278.V256995.R01.S.doc Timescale for action 01/12/05 2 OP7 15(1)(2) (a)(b)(c) 01/12/05 14/11/05 St Josephs Version 5.0 Page 24 4 OP7 13(4)(c) 5 OP8 12(1)(a) 6 7 OP8 OP9 12(1)(a) 13(2) S 3(3)(i) 8 OP9 13(2) S 3(3)(i) 9 OP9 13(2) S 3(3)(i) 10 11 12 OP9 OP9 OP9 13(2) 13(2) 13(2) S 3(3,i) 17(1,a) 13 OP9 13(2) the staff in the event of a fall if the resident is not injured. All residents must have personal risk assessments. Where any challenging behaviours are identified there must be strategies in place for managing these. If no risks are identified this must be documented. All residents must have tissue viability assessments and actions must be taken to minimise any identified risks. The manager must ensure that any medical diets are catered for. All prescriptions must be checked prior to dispensing and a system installed to check all the dispensed medicines and Medicine Administration Record (MAR) charts received into the home. The quantities of all medicines received or balances carried over must be recorded to enable audits to take place to confirm staff competence in medicines management. Staff drug audits must take place on a regular basis to confirm staff competence and appropriate action must be taken if errors in administration and recording are found. All medicines must be administered as prescribed in all instances. All “as directed” doses must be confirmed with the doctor in all instances. The Controlled Drug register must be signed by the member of staff administering the medicines and signed by a second staff member who witnessed the transaction. The purchase of a trolley to DS0000064278.V256995.R01.S.doc 01/12/05 14/11/05 14/11/05 25/10/05 25/10/05 25/10/05 18/10/05 18/10/05 18/10/05 25/10/05 Page 25 St Josephs Version 5.0 14 OP9 13(2) 15 OP9 13(2) 16 17 18 OP9 OP9 OP10 13(2) 13(2) 17(1)(a) 12(4)(a) 19 OP10 12(4)(a) 20 OP12 16(2)(m) (n) 16(4) 17(2) Sch 4(13) 21 22 OP15 OP15 23 OP15 16(2)(i) 24 25 OP19 OP19 23(4)(a) 13(4)(c) safely store the medicines and to administer the medicines from must be purchased. The purchase of a Controlled Drug cabinet that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 is required. The purchase of a new dedicated refrigerator is required and this must be installed in the medication room and not the kitchen. All medicines must be returned to the pharmacy if they are no longer required or out of date All staff must complete accredited training in the safe handling of medicines. The manager must ensure that staff are mindful of the privacy and dignity of the residents at all times. The phone for the use of the residents must be relocated to ensure they are afforded some privacy. The residents must be consulted about their preferred activities and action taken to ensure their leisure needs are met. Residents must be offered a choice of drinks at lunchtime. Records of food served to the residents must be kept in sufficient detail to evidence that the diet is nutritious, choices are offered and any special diets are being catered for. The amount of fresh milk delivered to the home must be increased to prevent the routine use of powdered milk. Any requirements made by the fire officer must be met within the given time scales. Fire doors must not be wedged DS0000064278.V256995.R01.S.doc 25/10/05 25/10/05 18/10/05 12/02/06 14/11/05 01/02/05 01/12/05 01/12/05 01/12/05 13/10/05 01/01/01 11/10/05 Page 26 St Josephs Version 5.0 26 OP21 13(4)(c) open. The first floor bathroom must be cleared of all unused items. The manager must ensure that the toilet in the ground floor bathroom is accessible to the residents. An alternative location for the tumble drier must be found. Wheelchairs must not be used without footrests until specifically detailed in a care plan. An audit of the aids and adaptations available in the home must be undertaken and additional equipment fitted as necessary. The furnishings and fittings in the bedrooms must be audited against the National Minimum Standards and shortfalls rectified. The hot water temperatures throughout the home must be checked to ensure they are not in excess of 43 degrees and rectified where necessary. All areas of the home must be kept reasonably clean. The odour control issues in the bedrooms must be addressed. All toilets must have a supply of toilet paper. Any substances that could be harmful to the residents must be locked away. All personal toiletries must be removed from bathrooms after use and returned to the appropriate bedrooms. Foods stored in the fridge must be dated on opening. There must be liquid soap and disposable towels available in all DS0000064278.V256995.R01.S.doc 14/11/05 27 28 29 OP21 OP22 OP22 13(3) 13(4)(c) 23(2)(n) 01/02/06 12/10/05 01/03/05 30 OP24 16(2)(c) (p) 01/04/06 31 OP25 13(4)(c) 18/10/05 32 33 34 OP26 OP26 OP26 23(2)(d) 16(2)(k) 13(3) 01/11/05 01/11/05 11/10/05 35 OP26 13(3) 12/10/05 36 OP26 13(3) 13/10/05 St Josephs Version 5.0 Page 27 toilets, bathrooms, laundry and kitchen. The underside of the bath hoist seat must be thoroughly cleaned. There must be waste bins in all toilets and bathrooms. Fridge and freezer temperatures must be recorded on a daily basis. The floor areas and the shelving in the kitchen must be thoroughly cleaned. Commodes that are rusting and have badly stained pans must be replaced in order of priority. A washing machine with a sluice facility must be installed in the home. A commode pot washer/disinfector must be installed in the home. The manager must apply for variation to the condition of registration in relation to staffing numbers on nights. Prior to the employment of staff a minimum of a POVA first check must be carried out. CRB forms must be completed and sent off for any staff working in the home who have not had this check undertaken. The manager must be qualified to NVQ level 4 in care and management or the equivalent. There must be evidence on site that the water system has been checked for the prevention of legionella. There must be evidence on site that the hard wiring in the home has been checked. The fire alarm must be tested on DS0000064278.V256995.R01.S.doc 37 38 39 40 41 OP26 OP26 OP26 OP26 OP27 13(3) 13(3) 13(3) 13(3) 18(1)(a) 14/10/05 11/11/05 20/02/06 20/08/06 01/11/05 42 43 OP29 OP29 19 Sch 2 19 Sch 2 12/10/05 25/10/05 44 45 OP31 OP38 9(1)(b)(i) 13(3) 31/01/06 01/12/05 46 47 OP38 OP38 23(2)(c) 23(4)(c) 01/01/06 12/10/05 Page 28 St Josephs Version 5.0 (v) a weekly basis. The emergency lighting must be checked on a monthly basis. All staff must receive updated fire training. 48 OP38 23(4)(d) 11/11/05 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 OP20 Good Practice Recommendations It is strongly recommended that a larger television and either a video recorder or DVD player are purchased for the lounge. St Josephs DS0000064278.V256995.R01.S.doc Version 5.0 Page 29 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. 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