Inspection on 25/07/07 for St Josephs

This inspection was carried out on 25th July 2007.

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

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

Other inspections for this house

St Josephs 11/04/06

St Josephs 21/12/05

St Josephs 11/10/05

Similar services:

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

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

CARE HOMES FOR OLDER PEOPLE St Josephs 46 Silverbirch Road Erdington Birmingham West Midlands B24 0AS Lead Inspector Brenda O’Neill Unannounced Inspection 25th July 2007 09:05 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.V341791.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 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 Jacqueline Dowling Care Home 15 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (15) of places St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care without nursing to service users of both sexes whose primary needs on admission to the home are within the following categories: - Old age not falling within any other category (OP 15) - Service users with dementia who are over 65 years of age (DE(E) 2) The maximum number of service users to be accommodated is 15. 2. Date of last inspection 24th May 2007 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 people living in the home 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 en-suite 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 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. The fees at the home ranged from £320.28 to £338.64 per week. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key unannounced inspection over one day in July 2007. During the course of the inspection a tour of the premises was undertaken, the files for two staff and three of the people living in the home were sampled as well as other care and health and safety documentation. The inspector spoke with the manager, the proprietor, three staff members and five of the people living in the home. Prior to the inspection the manager had completed and returned to the Commission an Annual Quality Assurance Assessment which gave some additional information about the home. Questionnaires were sent out to some of the people living in the home and their relatives. At the time of writing the report only one had been returned from a relative however all the people living in the home had returned theirs. The home had not logged any complaints since the last inspection and none had been raised with the Commission. What the service does well: Thorough assessments were carried out prior to admitting anyone to the home to ensure the staff were able to meet any identified needs. People wanting to go and live in the home could visit and assess the facilities available. The systems in place for care planning and risk assessments were good and ensured the needs of the people living in the home were met and any identified risks were minimised. The was ample evidence to show the health care needs of the people living in the home were met and that the medication system was well managed and safeguarded the people living in the home. Despite being a very busy time of day when the inspector arrived the home was calm and the atmosphere very relaxed. No rigid routines were observed during the course of the inspection. The people living in the home appeared to be 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. The people living in the home were generally satisfied with the meals comments received included: ‘The food is good I eat it all.’ ‘Well prepared food.’ St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 6 ‘There are a lot of things I cannot eat due to allergies and the cook will always make me an alternative.’ It was evident throughout the course of the inspection that the people living in the home had good relationships with the staff and the manager and were at ease in their presence. Staffing levels were appropriate for the needs of the people living in the home and there had been very little staff turnover since the last inspection which was good for the continuity of care of the people living in the home. The health and safety of the people living in the home and the staff were well managed. The home was generally well maintained and comfortable. What has improved since the last inspection? What they could do better: St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 7 The daily records for the people living in the home needed to include details of their general well being and the care being given. This will provide evidence that the needs of the people living in the home are being met. There should be evidence that the outcomes of the meetings held with the people living in the home in relation to activities have been acted upon and that the activities available are suitable for the people living in the home. To evidence that the nutritional needs of the people living in the home were being met food records needed to be an accurate record of the food they had eaten and include details of any specific diets being catered for. Staff needed to ensure that the portions of food being served to the people living in the home were adequate. To ensure the people living in the home were fully safeguarded all staff needed to undertake adult protection training. The registered person needed to ensure that all staff had completed the appropriate training in safe working practices to including manual handling, food hygiene, health and safety and infection control. This will ensure the safety of the people living in the home. The home needed a formal system in place for monitoring the quality of the service offered to the people living in the home to ensure it was continuously improved. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 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.V341791.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment procedures in the home ensured the needs of the people being admitted to the home were known and could be met by staff. People moving into the home were able to visit prior to admission if they wished and were being issued with a contract that detailed the terms and conditions of their stay. EVIDENCE: The files for three people admitted to the home since the last inspection were sampled. All the files included copies of comprehensive assessments undertaken by the manager of the home prior to the admission of the individuals. Areas looked at during the assessment were health, abilities, needs in relation to personal care and memory. The assessment also included a summary of needs which detailed some of the individuals’ likes, dislikes and preferences. There was also evidence that social workers had been involved in the assessment process and copies of their assessments and the initial care St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 10 plans drawn up them were on file. It was also pleasing to note that the manager wrote up quite a detailed profile of the individuals on the day of admission to give staff as much information as possible. This was the first entry on individuals’ daily records. All three files sampled included signed copies of the terms and conditions of residence at the home. Anyone wanting to go and live in the home was able to visit the home prior to admission if they wished. One of the people living in the home said she had chosen not to do this but her relative had been to several homes to have a look and thought St. Josephs would suit them. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place for care planning and risk assessments were good and ensured the needs of the people living in the home were met and any identified risks were minimised. The health care needs of the people living in the home were met. The medication system was well managed and safeguarded the people living in the home. Staff were mindful of the privacy and dignity of the people living in the home. EVIDENCE: The care plan files for three of the people living in the home were sampled. Two were looked at in some depth the other was only scanned. All three of the people had been admitted to the home since the last inspection. The care plans in the home were entitled Individual Service Statements (ISS). All the files sampled included an ISS. These were quite comprehensive and included details of what the individuals were able to do for themselves and their preferences. Areas covered in the ISSs included personal care, St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 12 continence, mobility and social and cultural needs. Where applicable issues identified on the care plans had been cross referenced to risk assessments, for example, pressure care. The files also included an overview of each person’s day which gave staff details about their preferred rising and retiring times, what times and where they liked to eat, where they liked to sit and how they liked to spend their days. All the ISSs were being reviewed on a monthly basis and in the majority of cases any changes were noted. There were some minor changes that had not been updated, for example, after an assessment by the continence advisor the incontinent pad sizes for one individual had changed and this had not been updated on the ISS. It was pleasing to note that the requirement made following the last inspection in relation to ISSs being drawn up in a reasonable amount of time after admission had been met. All the files sampled included manual handling, tissue viability, nutrition and personal risk assessments. The risk assessments detailed how any risks were to be managed and in most instances were being cross referenced to the ISS. One of the risk assessments seen for falls did not cross reference to the ISS where there was information about an illness that may make the individual go giddy when standing. However staff should have been aware of this if they had read all the documentation. Risk assessments included details of any equipment being used for pressure relief or any that was to be used for manual handling. Where the people living in the home had additional risks these were detailed, for example, there was guidance for staff in relation to one person’s anxiety and depression and the signs staff should watch for and report that may indicate any deterioration in their mental health. It was strongly recommended that the manager placed read and sign sheets with the ISSs and risk assessments that indicated staff had read, understood and agreed to follow them. All the files sampled included visiting professionals sheets. It was very clear from these that health care needs of the people living in the home were met. There was evidence of visits from G.P.s, district nurses, medication reviews, visits to outpatient clinics, telephone conversations with doctors as result of hospital visits and visits from the continence advisor, dentist and optician. Where necessary the advice of more specialised health care professionals was sought, for example, community psychiatric nurses. The daily records detailed any concerns with individual peoples’ health that care staff had noted and this was then followed up and monitored. Wherever possible the people living in the home were being weighed and any weight loss was being followed up by the manager. There were some difficulties weighing all the people living in the home as staff had only bathroom scales which were difficult to use for those individuals with any mobility difficulties. It was strongly recommended that consideration be given to purchasing sit on scales to enable all the people living in the home to be weighed. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 13 The daily records in relation to the general well being of and the care given to the people living in the home were quite brief. There was some mention of personal care being given but there was little about the amount of care given or how people were spending their days making it difficult to determine if all their needs were met. Medication continued to be administered via a 28 day monitored dosage system. The system was well managed and the requirements made following the last inspection had been met. Copies of prescriptions were being kept, all medication was being acknowledged as received into the home, any balances of medication held in the home at the end of the 28 cycle were being carried forward and medication was being signed for when given. The system could be easily audited and no discrepancies were found during the random audit undertaken. The home was administering some controlled medication and this was appropriately recorded and administered. The requirements made following the last inspection in relation to medication had been met. No issues were raised by the people living in the home about their privacy or dignity. Staff addressed the people living in the home appropriately. Personal care was offered discreetly. There was a cordless telephone available for the use of individuals so that they could make or receive calls in private. All bedroom doors were lockable with keys available for residents. Double bedrooms had screening available for privacy. The manager stated the issue raised at the last inspection in relation to personal information being recorded in the communication book had been addressed. An issue was raised on one of the questionnaires completed by a relative about there not being a separate room to be used for visitors which meant a lack of privacy. However due to layout of the home and the space available it is difficult to see how this could be overcome. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There did not appear to be any rigid rules or routine in the home. It could not be evidenced that the activities on offer met the needs of the people living in the home. The arrangements for visiting the home enabled visitors to come at any reasonable hour. The people living in the home were generally satisfied with the catering arrangements. EVIDENCE: When the inspector arrived some of the people living in the home were having breakfast, others had finished and were sitting in the lounge. Despite being a very busy time of day the home was calm and the atmosphere very relaxed. No rigid routines were observed during the course of the inspection. The people living in the home were seen to wander freely around the home, meet with visitors, spend time in their bedrooms, watch television and chatting to staff and each other. Some activities were recorded in the diary these included bingo, board games, sing a longs, watching a DVD, communion, nails being done and a visiting entertainer. Some days there was nothing recorded and much of the time it appeared to be the same people taking part in the activity. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 15 As at the last inspection activities and trips out had been discussed at the meetings with the people living in the home but there was no evidence that their suggestions had been followed up. Questionnaires had been sent out by the home about the service and the lack of activities was an ongoing theme through these. The manager needed to ensure that the information that had been gathered about activities was followed through and that activities were available to suit individual people. One of the comments received suggested that this was not the case, ‘would not take part in activities because of our disabilities.’ It was also noted that one person was being cared for in bed most of the time. In circumstances such as these there must be evidence that the individual has had some one to one staff time. Daily records for the people living in the home did not show how the individuals’ in the home were spending their time and that their social needs were being met. Daily records did show when the people living in the home were having visitors and there were no restrictions on this. Visitors were seen to come and go throughout the course of the inspection and were made welcome by the staff. The people living in the home appeared to be encouraged to exercise choice and control over their lives in such things as choosing what they did during the day, what to wear, when to get up and go to bed and what to eat. Care plans included details as to what extent they could self care and could direct their own personal care and of their preferred waking and retiring times. One of the files sampled included very good detail of how it appeared that one person living in the home was making choices for another individual. It detailed how staff were to discourage this and ask the individual themselves about every day issues such as choices of food, what to wear and when to go to the toilet as the person was able to make these decisions. The people living in the home had been encouraged to personalise their rooms to their choosing and personal effects were seen in all the bedrooms. There had been no changes to the menus in the home since the last inspection apart from some amendments that had been written on them. It was evident from the food records that the menus were not always followed and that there was some repetition, for example, the same meal had been served on the 21st and the 24th of July. The comments received about the food were generally good these included: ‘The food is good I eat it all.’ ‘Well prepared food.’ ‘There are a lot of things I cannot eat due to allergies and the cook will always make me an alternative.’ The inspector had lunch with the people living in the home. The meal was generally well cooked and presented apart from the meat which was a little tough. There were nine people eating in the dining and six of these had their meal served on small tea plates, others had dishes as these were easier for St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 16 them to manage. Due to the plates being very small there was no room for people to move the food around on their plates and also the portions for some appeared quite small. Two of the people eating in the dining room ate all their lunch and pudding and one was actually scraping their plate to get all the gravy however neither were offered any more to eat. Staff must ensure that all individuals have enough to eat at meal times. It was also evident that the table manners of one of the people living in the home was upsetting for another person sitting at the same table. This issue was discussed with the manager and it was suggested the individual was spoken with and that if necessary the seating arrangements were reviewed. The food records did not evidence that any diets were being catered for. It was also evident that staff were recording foods as given that people did not like, for example, one person did not eat pork and on one occasion was detailed as having this for lunch. The cook stated the person had actually had lamb. The food records needed to be true reflection of what people were eating. Alternative ways of recording meals served were discussed with the manager. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had appropriate complaints and adult protection procedures. People living in the home were able to raise any issues that may arise. Staff training in adult protection issues needed to be ongoing to ensure staff were aware of how to recognise and report any issues that may arise. EVIDENCE: The complaints and adult protection procedures were not viewed at this inspection as they had been seen at the last inspection and the required amendments had been made. The home had not logged any complaints since the last inspection and none had been lodged with the Commission. It was evident throughout the course of the inspection that the people living in the home had good relationships with the staff and the manager and were very at ease in their presence. This would give them the confidence to raise any issues. Comments received appear to confirm that individuals have ways of raising any issues and that they would be acted on. ‘Son would know how to make a complaint.’ ‘Would speak to the manager but all carers are very helpful.’ ‘My son would deal with it if I had any complaints.’ St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 18 ‘I have no complaints.’ The training records seen evidenced that some staff had received adult protection training but his needed to be ongoing to ensure all staff were included. Staff had undertaken challenging behaviour training as required following the last inspection. No adult protection issues had been raised since the last inspection. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home was well maintained and provided an adequate level of comfort to the people living there. Further improvements were planned which will add to the facilities available for the people living in the home. EVIDENCE: A tour of the home was undertaken and some bedrooms were sampled. The home was generally well maintained, safe and comfortable. Discussions with the manager indicated that the home had been given a grant by the City council to improve the facilities available for the people living in the home. Planned improvements included decorating the lounge and fitting new carpet, redecoration of the dining room and improving the lighting, having a floor level shower installed and changing one of the bathrooms so that it was St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 20 an assisted facility. The grant was time limited and all improvements had to be completed by the end of October. As at the last inspection there was adequate communal space at the home comprising of a large lounge and a dining room. Both were adequately furnished. Both rooms were to be redecorated with the grant money from the City Council. The lounge carpet was badly stained this was also planned to be replaced and needed to be done as soon as possible. There were adequate numbers of toilets throughout the home and some had had hand or grab rails installed. There were two bathrooms on the first floor of the home, one with a medic bath, which was due to be changed to a floor level shower which will give the people living in the home the choice of either a bath or a shower. The other bathroom had a domestic style bath. This was not used but was to be changed to an assisted facility. One of the toilets on the first floor had been removed since the last inspection. This room had had a commode pot washer installed however only the electrical work had been completed and it still needed to be plumbed in. The proprietor was having some difficulties getting this work completed. There was one large bathroom on the ground floor that had a bath hoist fitted. The flooring in this room was quite old and would not clean properly and needed to be replaced. The mobile hoist was being stored in this room an alternative storage area should be considered. There had been no changes to the aids and adaptations in the home these included, shaft lift, portable ramp for going into the garden, mobile hoist and wheelchairs. There were no handrails in any of the corridors. As at the last inspection there had been no changes to the bedrooms which varied in size and the majority of the required furnishings and fittings were in place. Some of the bedrooms seen were in need of redecoration. 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 discussed with the occupants to ascertain if they are happy with their rooms. All rooms had a lockable piece of furniture and the people living in the home were able to have keys to their bedroom doors if they wished. Bedrooms were personalised to the occupant’s choosing. The improvements in the infection control procedures noted at the last inspection had been sustained and further improved, for example, there was liquid soap and disposable towels available in the laundry. The home was clean and odour free. The kitchen was clean and tidy and appropriate food labelling and temperature recordings were in place. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A stable staff team was maintaining appropriate staffing levels. It could not be evidenced that all staff had undertaken all the necessary training to ensure they could care for the people living in the home. The recruitment process was robust and protected the people living in the home. EVIDENCE: The manager was not on duty when the inspector arrived as it was her day off. On duty were a senior care, two care assistants, domestic assistant and a cook. Staffing levels seemed appropriate for the numbers and needs of the people living in the home. The manager was contacted and came in. She confirmed these were the usual staffing levels. There had been very little staff turnover since the last inspection which was good for the continuity of care of the people living in the home. The files for two staff employed at the home since the last inspection were sampled. The files included all the required information in relation to recruitment and all the required checks had been undertaken prior to them commencing their employment, for example, POVA first checks. One of the employees had only been resident in this country for a short time and it was recommended that in these instances the staff were asked for some verification of their good character from their country of origin. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 22 There was evidence on the files that were sampled for care staff that they had received induction training in line with skills for care specifications however one of the records had not been signed off as completed. The file for an ancillary worker was also checked to ensure there had been some induction training as this had been a requirement at the last inspection. This had been undertaken. All staff had individual training records and these were sampled. The records showed that staff had undertaken training in fire procedures, tissue viability and challenging behaviour. Some staff had also undertaken training in adult protection, manual handling, food hygiene, health and safety and infection control. It could not be evidenced that all staff had undertaken all these training topics. The home needed to have a dated training matrix to identify which staff had undertaken the required training and shortfalls needed to be addressed. The information received prior to the inspection showed that six of the eighteen staff employed had completed their NVQ level 2 or the equivalent. This is below the required fifty percent. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. The health and safety of the staff and the people living in the home were well managed. The home needed to have a development plan in place, based on seeking the views of the people living there, that showed how the service was to be improved. EVIDENCE: A new manager had been appointed at the home since the last inspection and she had been registered with the Commission. On the day of the inspection it was her day off but when contacted she attended the home as she wanted to be present this being her first inspection at this home. The manager had a lot St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 24 of experience of caring for older people, had the NVQ level 4 in care and had enrolled on the Registered Manager’s Award. There had been quite a few improvements in the home since the manager was appointed, for example, care planning, risk assessments and the management of the medication system. Other areas required further development, for example, activities for the people living in the home. Throughout the course of the inspection the manager was very receptive to the comments and suggestions made and showed a commitment to improving the service offered where possible. There were good relationships between the manager, staff and the people living in the home. Comments received from the people living in the home included, ‘Jackie is lovely’ and ‘Jackie is very nice.’ As at the two last inspections there were some systems in place for monitoring the quality of the service offered at the home, for example, meetings with the people living in the home, staff meetings and regulation 26 visit reports by the responsible individual, questionnaires for the people living in the home and their relatives. However the registered manager needed to further develop some formal methods for monitoring the quality of the service offered at the home based on seeking the views of the residents with a view to continuous improvement. The outcome of any quality system should be an improvement plan for the home that details how the home will improve the service offered. The home was managing some of the personal allowances for the people living in the home. The records kept were sampled and found to be generally appropriate. However it was noted that the hairdresser was signing the individual records for money received. These records are personal and the hairdresser should not have access to them. Receipts needed to be obtained for any expenditure made on behalf of the people living in the home. The manager was undertaking staff supervision but was finding it difficult to complete the appropriate number of sessions for all staff. Health and safety at the home were well managed. The majority of the staff had received training in safe working practices and the systems in place for infection control had improved further since the last inspection. There was evidence on site of the regular servicing of equipment and that the water system had been checked for the prevention of legionella. The in house checks on the fire system were being carried out and fire drills were being carried out at the required frequency. An outside contractor had recently carried out a fire risk assessment. The outcome of this was very good and there were very few issues that needed to be followed up. The incident and accident recording and reporting in the home were good. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 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 3 17 X 18 2 2 2 2 2 X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 3 St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 12(1)(a) Requirement The daily records for the people living in the home must include details of their general well being and the care being given. This will provide evidence that the needs of the people living in the home are being met. Food records must be an accurate record of the food the people living in the home have eaten and include details of any specific diets being catered for. (Previous time scale of 31/10/06 not met.) Staff must ensure that the portions of food being served to the people living in the home are adequate. This will ensure the nutritional needs of the people living in the home are met All staff must receive training in adult protection issues. This will ensure the people living in the home are safeguarded. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 27 Timescale for action 31/08/07 2. OP15 12(1)(a) (b) 16(2)(i) 31/08/07 3. OP18 13(6) 01/10/07 4. OP19 23(2)(b) (d) All areas of the home must be kept reasonably decorated. The carpet in the lounge must be replaced. 31/10/07 5. OP21 23(2)(b) This will ensure the home is kept to an acceptable standard for the people living there. The flooring in the ground floor 31/10/07 bathroom must be changed. This will ensure it can be cleaned effectively and improve the infection control in the home. The registered person must 01/11/07 ensure that all staff have completed the appropriate training in safe working practices to include: Manual handling Food hygiene Health and safety Infection control. This will ensure the safety of the people living in the home. The home must have a system in 01/10/07 place for monitoring the quality of the service offered based on seeking the views of the people living there. (Previous time scales of 1/06/06 and 01/12/06 not met.) This will ensure there is a plan in place for continually improving the service for the benefit of the people living there. The registered must ensure that the personal financial records of the people living in the home are kept confidential. This will ensure the privacy of the people living in the home is upheld. 6. OP30 18(1)(a) 7. OP33 24(1)(a) (b) 8. OP35 12(4)(a) 31/08/07 St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 28 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 OP7 Good Practice Recommendations It is strongly recommended that the manager introduces read and sign sheets with the individual service statements and risk assessments that showed staff had read, understood and agreed to follow them. To enable staff to monitor the weight of all the people living in the home consideration should be given to purchasing some sit on scales. There should be evidence that the outcomes of the meetings held with the people living in the home in relation to activities have been acted upon and that the activities available are suitable for the people living in the home. Daily records should include details of how the people living in the home are spending their time to evidence their social needs are being met. The seating arrangements in the dining room should be reviewed to ensure all the people living in the home can enjoy meal times. Alternative storage space should be found for the mobile hoist to avoid issues of infection control and the bathroom becoming cluttered for the people using it. Handrails should be installed in the corridors wherever possible to help those people living in the home with any mobility difficulties negotiate their way around the home. The bedrooms should be audited for furnishings and fittings against the National Minimum Standards and any shortfalls discussed with the occupants to ascertain if they are happy with their rooms. To ensure staff have all the knowledge and skills they need to care for the people living in the home fifty percent should be qualified to NVQ level 2 or the equivalent. To ensure the people living in the home are fully safeguarded consideration should be given to asking staff who have not been resident in this country for very long for some verification of their good character from their country of origin. The home should have a dated training matrix to identify which staff had undertaken the required training. All staff should have supervision six times a year to ensure DS0000064278.V341791.R01.S.doc Version 5.2 Page 29 2. 3. OP8 OP12 4. 5. 6. 7. 8. OP12 OP15 OP21 OP22 OP24 9. 10. OP28 OP29 11. 12. OP30 OP36 St Josephs their performance is overseen and discussed with them and training needs are identified. This will ensure the people living in the home receive care from the appropriate people. St Josephs DS0000064278.V341791.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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