Inspection on 21/12/05 for St Josephs

This inspection was carried out on 21st December 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 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 11/04/06

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 21st December 2005 09:45 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.V273892.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.V273892.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.V273892.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. 11th October 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.V273892.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over one day in December 2005. The day before this inspection the inspecting pharmacist made an unannounced visit to the home to assess the medication system. It was the second of the statutory visits to the home for 2005/2006. To get a full overview of all the standards assessed during this inspection year this report should be read in conjunction with the report written following the inspection on October 11th 2005. This inspection was undertaken earlier than scheduled as a complaint had been lodged with the CSCI in relation to several issues, some of which had been raised at the previous inspection. The issues of the complaint were, poor hygiene in the home, night staffing levels, staff breaks and the quality of the food. The complaint was investigated as part of this inspection and the details of the findings are included in the report. During the course of the inspection a tour of the premises was made, one care plan, staff recruitment and training records were sampled as well as other care and health and safety records. The inspector spoke with, the manager, the proprietor, six of the twelve residents, two visitors and briefly to two staff members. What the service does well: What has improved since the last inspection? St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 6 New systems had been put in place for care planning and assessing risks for the residents however at the time of the inspection only one file had been updated. This file was sampled and found to be well ordered and easy to follow. Manual handling and personal risk assessments had been put in place detailing how any risks were to be minimised. The privacy and dignity of the residents were being better maintained than at the previous inspection. The records of food being served to the residents had improved and demonstrated a varied diet with choices available. Since the last inspection a variety of drinks were being offered to the residents at lunchtime. There had been discussions with the residents as they had been having breakfast in bed and this was being served very early. In light of the discussions breakfast was now served later in the dining room unless any resident specifically chose otherwise. The ongoing use of powdered milk in the home had been stopped since the last inspection and the order of fresh milk increased accordingly. There were more documented activities available for the residents to participate in if they wished. The recommendation made following the last inspection that a larger television and either a video or DVD player be purchased had been met and more of the residents could now see the television and had an alternative to watching television programmes. The recruitment procedures in the home had been improved. A new application form was being used enabling more information to be gained about prospective employees. References and POVA first checks were being obtained for staff prior to employment and all the CRB forms for the existing staff group had been sent off. There had been some improvements in the general hygiene in the home, for example, new commodes had been purchased and a washing machine with a sluice cycle had been installed. Further improvements were still required. It was also pleasing to note that the wooden wedges that were evident at the last inspection and being used to wedge open fire doors had been removed improving the safety of the residents. What they could do better: Numerous improvements were needed at this home and for these to be progressed the manager needed to be based there, with the exception of emergency situations. To ensure the residents were not put at risk two waking staff needed to be on duty each night. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 7 To ensure staff were equipped with the necessary skills and knowledge to fulfil their roles the induction procedure at the home needed to be cross referenced to the specifications laid down by Skills for Care. All residents needed to have their care plans and risk assessments updated within the new systems to ensure they detailed how all their needs were to be met by staff and how all the identified risks were to be minimised. Medicine management remained poor in some instances dangerous. The registered manager of the home must improve all aspects of medicine management to ensure the safety of the service users. The outcome of the inspection resulted in an enforcement notice being issued to the registered individual. To ensure that any possible injuries following an accident were followed up and monitored there needed to be details in the daily records so that staff on duty following the accident would be aware of what had happened. Food records needed to be further developed to include evidence that any medical diets were being catered for. The registered manager needed to develop some 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. Several issues needed to be addressed to ensure the home was safe for the residents particularly in relation to cleanliness and infection control. 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.V273892.R01.S.doc Version 5.0 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.V273892.R01.S.doc Version 5.0 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): These standards were not assessed during this visit. Any requirements made at the previous inspection have been brought forward to this report. EVIDENCE: St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The systems in place for care planning and assessing risks had improved. All residents needed to have their care plans and risk assessments updated within the new systems to ensure they detailed how all their needs were to be met by staff and how all the identified risks were to be minimised. More consideration was being given to the privacy and dignity of the residents. At the time of the inspection the medication records did not reflect accurately what had been administered to the service users in all instances. EVIDENCE: New systems had been put in place for care planning and assessing risks for the residents however at the time of the inspection only one file had been updated. This file was sampled and found to be well ordered and easy to follow. The care plan included some detail of the personal care needs of the resident concerned, for example, details of incontinence and that she was to be encouraged to clean her own teeth and glasses but this would vary according to her mood. There was also a little information about diet and social activities. The care plan did not include information about the person’s preferred daily routines, any likes, dislikes or preferences in relation to such things as, bathing or showering, food or religious or cultural needs. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 11 There was little information about the resident’s abilities to self care and nothing detailed about mobility or communication. The care plan needed to be further developed to ensure it covered all areas and detailed how all needs in relation to health and welfare were to be met by the staff. The file included a falls risk assessment and a manual handling risk assessment that detailed how the resident was to be assisted in the event of a fall if uninjured. There was a well detailed personal risk assessment that included the actions to be taken by staff in the event of any challenging behaviour. However when reading the individual’s daily records it was evident that the person needed to have risk assessments n place for such things as wandering at night and going up and down the stairs. There was a nutritional assessment that evidenced the resident was at some risk however the manager had consulted with the appropriate medical professional and detailed the outcome. The weight chart for the same resident stated she must be weighed weekly but this was not being done and she had not been weighed for over a month. There was no mention of this on her care plan in the dietary needs or any other section. Risk assessments needed to be cross referenced to the care plans wherever necessary. There was no evidence that a tissue viability assessment had been undertaken. Daily records evidenced that generally personal care needs were being met and that health care needs were being followed up and there was evidence of visits from G.Ps. opticians and chiropodists. It was noted when checking the accident records in the home that a resident had sustained a fall and was complaining of pain in her arm. This had been appropriately recoded on the accident records but there was no mention of it on the daily records at all. To ensure that any possible injuries were followed up and monitored there needed to be details in the daily records so that staff on duty following the accident would be aware of what had happened. 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 many 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 dispensed medicines into the home. It was not possible to confirm the actual prescribed dose regimen in a number of instances. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 12 One service user had had a medication review by the doctor and a lower dose or medication had been prescribed and dispensed. The higher strength had been discontinued but was still available for administration in the trolley in addition to the lower strength. It could not be demonstrated if he had been administered both strengths or not. This is extremely dangerous, as the service user could have received three times the prescribed dose. Other tablets prescribed by the hospital were available but not recorded on the MAR chart. It could not be demonstrated whether these had been administered or not. Medicines had been recorded on the previous MAR chart and there was no explanation why they were not recorded on the new MAR chart. One medicine had not been ordered on time which resulted in the service user not having the prescribed dose or medicine for two days. Evidence of the home secondary dispensing into a pharmacy dispensed box was found. This is considered poor practice and may lead to errors. Medicine for one service user who no longer was a resident in the home was found in the cabinet. Two loose sachets of one medicine were found underneath the trolley. These had not been stored in the locked trolley and were unlabelled. Storage for Controlled Drugs remained inadequate but a cabinet was on order at the time of the inspection. One Controlled Drug had been consistently administered incorrectly over a period of 5 days and the service user did not receive the prescribed dose. Records in the CD register were inconsistent and did not reflect the actual transaction despite being witnessed by a second member of staff. A medicine trolley and a new medicine refrigerator had been purchased since the last inspection. The medicine cabinet had not been reserved for medicines only. Two cigars were found in the cabinet. Key security for the Controlled Drug box was poor. The systems for medicines in the home were so poor that an enforcement notice was issued to the registered individual. The privacy and dignity of the residents were being better maintained. Residents were seen to be appropriately dressed, there were no named toiletries seen in the wrong bedrooms and instructions for care staff on how to care for residents were not on display in the bedrooms. To further enhance the privacy of the residents the telephone for their use needed to be relocated as it was in the entrance hall and did not afford any privacy. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 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. Visitors appeared to be made welcome. Residents spoken with were satisfied with the catering arrangements at the home. EVIDENCE: Residents spoken with were quite content and there did not appear to be any rigid rules or routines in the home. Residents were observed to wander freely around the home, spend time with visitors, sit chatting to each other and watching television. There were some documented activities which included, carol singers visiting, nails being manicured, viewing of films, word association games, crosswords, bingo and a Christmas party. There did not appear to be any restrictions on visitors to the home within reasonable hours. The visitors seen were made welcome by staff and relation ships were good. Two visitors were spoken with, for one it was her first visit to the home and she said her first impressions were good and that her relative was happier than at a previous home. The other relative was satisfied with the care given by the home. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 14 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. Residents had been encouraged to personalise their rooms to their choosing and personal effects were evident in all the bedrooms. One of the issues raised in the complaint that was investigated during this inspection was in relation to the food both in respect to food stocks and standards of food. All the residents spoken with were satisfied with the catering arrangements at the home. The records of food being served to the residents demonstrated a varied diet with choices available. Since the last inspection a variety of drinks were being offered to the residents at lunchtime. Also there had been discussions with the residents as they had been having breakfast in bed and this was being served very early. In light of the discussions breakfast was now served later in the dining room unless any resident specifically chose otherwise. The ongoing use of powdered milk in the home had been stopped since the last inspection and the order of fresh milk increased accordingly. Food stocks in the home at the time of the inspection were at an acceptable level. Due to the above evidence this aspect of the complaint was not upheld. Although staff were keeping records of the foods served to the residents these needed to be further developed to include details of any medical diets being catered for. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home had a complaints procedure but this needed to be further developed to ensure complainants were aware that they could lodge a complaint with the CSCI at any point. There were policies and procedures on site in relation to adult protection. Staff needed to undertake training in adult protection issues to ensure they were equipped with the skills and knowledge to identify and report appropriately any concerns. EVIDENCE: There was a complaints procedure on site however this needed to be amended to ensure that complainants were aware they could lodge a complaint with the CSCI at any point. A copy of the complaints procedure needed to be on display in the home and a copy issued to all residents or their representatives. One complaint had been lodged with the CSCI in relation to the home. The issues of the complaint were, poor hygiene in the home which was upheld, night staffing levels which was partially upheld, staff breaks, which was inconclusive, and the quality of the food which was not upheld. The evidence to support these decisions is documented under the relevant sections of this report. There were appropriate procedures on site in relation to adult protection and whistle blowing. There needed to be a concise procedure developed for staff to follow in the event or suspicion of any adult protection issues that was accessible to them at all times. Staff needed to undertake training in adult protection issues to ensure they were equipped with the necessary skills and knowledge to identify and report appropriately any issues that may arise. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 16 There was also a policy on restraint on site and a policy and procedure for managing aggression. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 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 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: 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 requirements made by the fire officer were not fully assessed during this inspection however the issue in relation to only one night care assistant was being addressed by the new proprietors. It was pleasing to note that the wooden wedges that were evident at the last inspection and being used to wedge open fire doors had been removed. There was adequate communal space at the home comprising of a large lounge and a dining room. Both were adequately furnished and decorated. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 18 It was noted that the seats of the dining room chairs and in between the wooden slats on the backs of the chairs were quite dirty and that the lounge carpet did not appear to have been vacuumed. The recommendation made following the last inspection that a larger television and either a video or DVD player be purchased had been met and more of the residents could now see the television and had an alternative to watching 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 inspector were informed this was not used. This room had been cleared of all the clutter that was in there at the time of the last inspection giving residents safe access to the toilet. There was one large bathroom on the ground floor that had a bath hoist, which also housed the tumble drier. At the time of the inspection this bathroom was less cluttered than at the last inspection but there were still several baskets of laundry in there and apart from not being a pleasant environment to have a bath continued to raise some concerns in relation to infection control. All toilets and bathrooms had had new toilet roll holders and paper towel dispensers fitted since the last inspection and all had a supply of liquid soap. 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 staff were continuing to use these without footrests which was dangerous practice and was raised at the last inspection. There had been no changes to the bedrooms since the last inspection which 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.V273892.R01.S.doc Version 5.0 Page 19 Although there had been some improvement in the home in relation to cleanliness and hygiene, for example, all toilets had bins, toilet paper, liquid soap and disposable towels and all the rusting commodes had been replaced, this was still not at an acceptable level: • The underside and back of the bath hoist seat needed to be thoroughly cleaned. • The commode chairs and pots all needed to be cleaned. • 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, the fridge, freezer, food store 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. • There was a bottle of cleaning fluid accessible to the residents in the laundry. Several of these issues were raised at the last inspection and this was also one of the issues raised in the complaint, which was upheld. This was discussed with the proprietor and the manager and the inspector was informed that a contract cleaning company was being explored, the documentation for this was seen. They would be asked to undertake a hygiene clean throughout the home to get it to an acceptable level and then staff at the home would ensure it was maintained. A new washing machine had been installed in the home which had a sluice cycle. As there were numerous commodes in use in the home to ensure these could be effectively cleaned a requirement has been made for the home to have a mechanical commode pot washer fitted. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 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 There was a fairly stable staff group that was good for the continuity of care of the residents. To ensure the residents were not at risk two waking staff needed to be on duty each night. To ensure staff were equipped with the necessary skills and knowledge to fulfil their roles the induction procedure at the home needed to be cross referenced to the specifications laid down by Skills for Care. The recruitment procedures 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 sometimes exceeded on the morning shift but there were not always two staff on night duty. This was discussed with the manager and proprietor and they were aware they had to comply with this. The situation had improved since the last inspection. The rotas seen evidenced that there were two staff on duty at least three nights a week and further staff were being recruited. There was also a domestic assistant and two cooks employed at the home. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 21 The inspector was informed that twenty five percent of the staff were qualified to NVQ level 2 and others were undertaking the training. There was evidence that staff had received training this year in health and safety, basic food hygiene and infection control. The manager needed to ensure that staff received updated training in manual handling and first aid. There was an induction procedure on site however this needed to be cross referenced to the specifications laid down by skills for care to ensure all the necessary areas were covered within the specified time scales. It was also strongly recommended that the manager developed a training matrix for all staff so that training undertaken could be easily tracked. The recruitment procedures in the home had been improved. A new application form was being used enabling more information to e gained about prospective employees. References and POVA first checks were being obtained for staff prior to employment and all the CRB forms for the existing staff group had been sent off. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 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, 33, 38 Some improvements had been made in the home towards meeting the National Minimum Standards and ensuring the safety of the residents and the staff. For the improvements in the home to be ongoing the manager needed to be based there on an ongoing basis. EVIDENCE: The registered manager of the home was undertaking her Registered Manager’s Award qualification and had several years experience of working with older adults. She demonstrated a good knowledge of the residents in her care. It was of concern to the inspector to learn that since the last inspection the manager had spent very little time at the home and had been working at another home owned by the same proprietors. Numerous improvements were needed at this home and for these to be progressed the manager needed to be based there, with the exception of emergency situations. This was discussed with the proprietor at the time of the inspection. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 23 The registered manager needed to develop some 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. There were still several issues in relation to health and safety that needed to be addressed in the home including infection control and updated training for staff. Some of the staff had received updated fire training however all staff needed to undertake this. The weekly checks on the fire alarm and monthly checks on the emergency lighting had improved since the last inspection. The water system had been checked for the prevention of legionella. As the electrical wiring certificate could not be found the proprietor was making arrangements to have the wiring inspected again. The reporting of accidents and incidents to the CSCI was appropriate. St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 1 2 X 2 2 1 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X X X 2 St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 26 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. (Not assessed for compliance at this visit.) 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 scale of 01/12/05 partially met.) Care plans must be cross referenced to any risk assessments undertaken to ensure both documents agree. (Previous time scale of 01/12/05 partially met.) There must be evidence that the residents or their representatives have been consulted about the care plans. (Previous time scale of 01/12/05 not met.) Care plans must be updated as the needs of the residents change. (Previous time scale of 01/12/05 not assessed for compliance at this visit.) Timescale for action 01/02/06 2. OP7 15(1)(2) (a,b,c) 01/02/06 St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 27 3. OP7 13(4)(c) 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. (Previous time scale of 01/12/05 partially met.) All residents must have tissue viability assessments and actions must be taken to minimise any identified risks. (Previous time scale of 14/11/05 not met.) Any accidents sustained by the residents must be clearly documented in the daily records so that residents are monitored for any injuries. 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. This was a requirement from the last inspection. 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. This was a requirement from the last inspection. 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. This was a requirement from the last inspection. All medicines must be administered as prescribed in all DS0000064278.V273892.R01.S.doc 01/02/06 4. OP8 12(1)(a) 14/01/06 5. OP8 12(1)(a) 01/01/06 6. OP9 13(2) Sch3(3)(i) 20/01/06 7. OP9 13(2) Sch3(3)(i) 20/01/06 8. OP9 13(2) Sch3(3)(i) 20/01/06 9. OP9 13(2) 21/12/05 Page 28 St Josephs Version 5.0 10. OP9 13(2) 11. OP9 13(2) 12. OP9 13(2) 13. OP9 13(2) Sch3(3i) 17(1a) 13(2) 14. OP9 15. OP9 13(2) 16. OP9 13(2) 17. OP9 13(2) 17(1)(a) 18. OP10 12(4)(a) instances. This was a requirement from the last inspection. Medicines must be ordered from the doctor in time to ensure that the service users do not go without prescribed medication. All medicines must be administered from a pharmacy dispensed and labelled box. All secondary dispensing by the staff into previously dispensed boxes must cease immediately. Written protocols for all “when required” doses must be written and endorsed by a clinician to ensure correct use. The Controlled Drug register must reflect actual administration in all instances. Witnesses must sign to confirm actual administration. The purchase of a Controlled Drug cabinet that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 is required. This was a requirement from the last inspection. The medicine cabinet and trolley must be reserved for medicines only. Key security must improve to limit access to the Controlled Drug storage within the home All medicines must be returned to the pharmacy if they are no longer required, out of date or the service user has left the home. This was a requirement from the last inspection. All staff must complete accredited training in the safe handling of medicines. This was a requirement from the last inspection. The phone for the use of the residents must be relocated to ensure they are afforded some DS0000064278.V273892.R01.S.doc 21/12/05 21/12/05 20/01/06 21/12/05 20/01/06 21/12/05 21/12/05 20/03/06 01/02/05 St Josephs Version 5.0 Page 29 privacy. (Previous time scale given had not lapsed.) 19. OP12 16(2)(m) (n) The residents must be consulted about their preferred activities and action taken to ensure their leisure needs are met. (Previous time scale of 01/12/05 not assessed for compliance at this visit.) 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. (Previous time scale of 01/12/05 had been partially met.) 01/02/06 20. OP15 17(2) Sch 4(13) 01/02/06 21. 22. OP18 OP18 18(1)(a) 13(6) 23. OP19 23(4)(a) All staff must undertake training 01/04/06 in the prevention of abuse. There must be on site a concise 01/02/06 adult protection procedure for staff to follow in the event or suspicion of abuse that is accessible to them at all times. Any requirements made by the 01/01/01 fire officer must be met within the given time scales. (Previous time scale given had not lapsed.) An alternative location for the tumble drier must be found. (Previous time scale had not lapsed.) Wheelchairs must not be used without footrests unless specifically detailed in a care plan. (Previous time scale of 12/10/05 not met.) An audit of the aids and adaptations available in the home must be undertaken and additional equipment fitted as necessary. (Previous time scale had not lapsed.) DS0000064278.V273892.R01.S.doc 24. OP21 13(3) 01/02/06 25. OP22 13(4)(c) 22/12/05 26. OP22 23(2)(n) 01/03/05 St Josephs Version 5.0 Page 30 27. OP24 16(2)(c) (p) The furnishings and fittings in the bedrooms must be audited against the National Minimum Standards and shortfalls rectified. (Previous time scale had not lapsed.) The hot water temperatures that were identified as being in excess of 43 degrees must be rectified. (Previous time scale of 18/10/05 not met.) All areas of the home must be kept reasonably clean. (Previous time scale of 01/11/05 not met.) The odour control issues in the bedrooms must be addressed. (Previous time scale of 01/11/05 not met.) Any substances that could be harmful to the residents must be locked away. (Previous time scale of 11/10/05 not met.) All commode chairs and pots must be thoroughly cleaned. 01/04/06 28. OP25 13(4)(c) 01/01/06 29. OP26 23(2)(d) 14/01/06 30. OP26 16(2)(k) 14/01/06 31. OP26 13(3) 22/12/05 32. OP26 13(3) Foods stored in the fridge must be dated on opening. (Previous time scale of 12/10/05 not met.) The underside and back of the bath hoist seat must be thoroughly cleaned. (Previous time scale of 13/10/05 not met.) All areas of the kitchen must be thoroughly cleaned. (Previous time scale of 14/10/05 not met.) 22/12/05 33. OP26 13(3) 23/12/05 34. OP26 13(3) 35. OP26 13(3) Fridge and freezer temperatures must be recorded on a daily basis. (Previous time scale of 13/10/05 not met.) A commode pot washer/disinfector must be DS0000064278.V273892.R01.S.doc 14/01/06 20/08/06 Page 31 St Josephs Version 5.0 installed in the home. (Time scale given had not lapsed.) 36. 37. 38 OP27 OP28 OP30 18(1)(a) 18(1)(a) 18(1)(a) There must be two waking night staff on duty every night. There must be a minimum of fifty percent of staff qualified to NVQ level 2 or the equivalent. The induction procedure for the home must comply with the specifications laid by Skills for Care. All staff must have updated manual handling and first aid training. The registered manager of the home must be based at the home unless an emergency situation arises. The manager must be qualified to NVQ level 4 in care and management or the equivalent. (Previous time scale given had not lapsed.) 01/02/06 01/04/06 01/04/06 39. OP31 9(1) 14/01/06 40. OP31 9(1)(b)(i) 31/01/06 41. OP33 24(1)(a) (b) 42. OP38 23(2)(c) The home must have a system in 01/06/06 place for monitoring the quality of the service offered based on seeking the views of the residents. There must be evidence on site 01/02/06 that the hard wiring in the home has been checked. (Previous time scale given had not lapsed but has been extended.) All staff must receive updated fire training. (Previous time scale of 11/11/05 partially met.) 14/12/06 43. OP38 23(4)(d) St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 32 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 OP29 Good Practice Recommendations It is strongly recommended that records of interviews undertaken and any discussion about gaps in employment with prospective employees are kept. It is strongly recommended that a training matrix is set up for all staff so that training that has been undertaken can be easily tracked. 2. OP30 St Josephs DS0000064278.V273892.R01.S.doc Version 5.0 Page 33 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.V273892.R01.S.doc Version 5.0 Page 34 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!