Inspection on 01/05/07 for St Judes

This inspection was carried out on 1st May 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 Judes 17/04/08

St Judes 23/10/07

St Judes 14/02/07

St Judes 18/05/06

St Judes 02/02/06

St Judes 29/09/05

St Judes 10/05/05

St Judes 21/10/04

St Judes 17/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Judes 89 Cardigan Road Bridlington East Yorkshire YO15 3JU Lead Inspector Diane Wilkinson Key Inspection 1st May 2007 10:00 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 Judes DS0000019726.V338494.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 Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Judes Address 89 Cardigan Road Bridlington East Yorkshire YO15 3JU 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) 01262 674129 Mrs Patricia Elizabeth Lewis Mrs Patricia Elizabeth Lewis Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14) of places St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2007 Brief Description of the Service: St Judes is a privately owned care home that is registered to provide care and accommodation for fourteen service users (male and female) who are over 65 years of age, including those with dementia. The home currently accommodates six service users, two of whom are having respite care at the home. Information about the home is provided to service users and others in the home’s statement of purpose and service user guide. Fees paid range from £286.80 - £366.00 per week. Accommodation at the home is provided in single and twin rooms, with ensuite facilities in three of the nine bedrooms. In addition to private accommodation, there are two lounges (one with a dining area) and a small lounge that is used by staff and service users. There is a small garden at the rear of the property. Most areas of the home are accessible via the provision of a passenger lift and ramps, but the second floor is only accessible via the use of stairs. The home is required to undertake a risk assessment to evidence that any service users using the stairs to the second floor are safe to do so. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit on the 1st May 2007. The pre-inspection questionnaire was not returned by the registered person (as requested) so this information could not be used as part of the inspection process. This unannounced site visit is part of a key inspection and was undertaken by one inspector over one day; the site visit commenced at 10.00 am and finished at 4.00 pm. The site visit consisted of a tour of the premises and examination of documentation, including all six care plans. On the day of the site visit the inspector spoke on a one to one basis with two service users, two members of staff and the registered person, as well as chatting to other service users and staff. Surveys were sent to all staff prior to the day of the site visit; at the time of writing this report, three had been returned. Surveys were sent to two relatives and to 5 GP’s following the day of the site visit; none had been returned at the time of writing this report. Comments from service users and staff, both from one to one discussions and from surveys, will be included throughout the report. The inspector would like to thank service users, staff and the registered person for their assistance on the day of the site visit, and to everyone who spoke to the inspector or responded to a survey. What the service does well: Meal provision at the home is good; this was confirmed by service users on the day of the site visit. There is a choice at all meal times and the individual requirements of service users are met. One service user told the inspector, ‘they do very good meals’. Daily records are a thorough record of the care needs of service users and how these are met by staff. Staff have undertaken training to equip them to carry out the tasks needed to care for service users effectively. A member of staff recorded in a survey, ‘Management have been very supportive to me over training’. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has been providing a service for which it is not registered; this is a breach of regulation. Some service users now have a signed contract in place with the home. The assessment process does not always include a meeting with the prospective service user and this results in an incomplete assessment taking place. EVIDENCE: There are now contracts in place between service users and the home; some of these still require agreement and a signature from service users or their representative. The registered person had previously agreed that any assessments undertaken for prospective service users would be shared with the Commission for Social St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 9 Care Inspection (CSCI) to ensure that appropriate admissions were being made. Since the key inspection in February 2007 there have been two admissions to the home; copies of these assessments have not been sent to the CSCI as agreed with the registered person. In addition to this, although a relative of one of the new service users visited the home prior to admission, no-one from the home visited this service user to commence the assessment process and to determine if their assessed needs could be met by the home. The inspector observed in care planning documentation that the home has been providing a domiciliary care service to one of these service users since their discharge home. The registered person was informed that this must cease immediately, as it is a breach of regulation; they agreed to do so. The home must be registered with the CSCI if they wish to offer a domiciliary care service. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are met in a way that respects their privacy and dignity but arrangements for continence care, the administration of medication and care planning are not currently robust. EVIDENCE: Care plans already in place at the home are being maintained in a satisfactory manner, and a care plan has been developed for a new permanent resident. However, care plans are not being compiled for those service users that are having respite care at the home. This results in staff not having the information they need to offer appropriate care to meet the assessed needs of these service users. Most service users have had a formal review of the care provided by the home and monthly reviews of the care plan are recorded. There are risk assessments in place for mobility, the risk of pressure sores and the use of bed rails. There has been some improvement in the signing and St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 11 dating of written entries made in care plans, but there is still little evidence that service users are involved in the care planning process. Another service user has been accommodated on the second floor of the home and a risk assessment has not been undertaken about the use of the stairs. The inspector recommends that this service user should be offered alternative accommodation on the ground floor or first floor of the home. Daily records are a thorough record of care provided by staff and include details of contact with health care professionals, food and fluid intake, any visitors seen and activities. A separate record is kept of contact with all health care professionals, including the reason for the contact and any outcome. Staff at the home continue to use bathing charts and bowel charts – these may be useful if used consistently, but staff are using them spasmodically and the documents therefore have no relevance to the person’s care. Accidents and the need for pressure care are recorded appropriately, and these records cross reference to information recorded in daily diary sheets. The inspector had concerns about the continence care for one service user; there was a very strong odour of urine in the service user’s bedroom and the registered person was informed that this must be dealt with as a matter of urgency. See recording in outcome group Environment. The inspector examined medication administration records on the day of the site visit and all were found to be satisfactory. None of the current service users have been prescribed controlled drugs and none have requested to hold their own medication. Medication is stored securely and no excessive stock is held on the premises. Unused medication has been returned to the Pharmacist, although there is no record of this in the returns book. The registered person has not yet completed accredited medications training and must do so within agreed timescales. A new member of staff has responsibility for administering medication – there was no sample signature available to allow records to be checked, and there was no evidence that this person has completed accredited medications training. A letter was sent to the registered person following the site visit requiring this information to be sent to the CSCI within 28 days. The inspector observed that service users are treated sensitively by staff regarding assistance with personal care, and that their right to privacy is respected. There is a small room available should service users wish to see health and social care professionals and visitors in private, and some service users have a single room. There are screens available to be used in shared rooms to promote dignity for service users. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to make choices about their day-to-day lives, within their capabilities, but would benefit from more one to one support from staff to enhance their leisure and social lives. Meal provision at the home is good and includes a choice at all mealtimes. EVIDENCE: In most instances, care plans record the leisure and social interests of service users. Daily diary sheets record activities undertaken by service users, such as watching TV, chatting or being taken out by relatives. The registered person recorded in the improvement plan that was sent to the CSCI on the 5th February 2007 that activities now take place on a regular basis and that these are recorded on the notice board in the lounge. This was observed on the day of the site visit, and the inspector noted that an activity took place in the morning. There is evidence that those service users that have friends and relatives are supported to remain in contact with them, and with the local community. One service user has regular visitors and the inspector was told St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 13 by staff that the visitors are invited to stay for lunch or tea; this was confirmed by the service user concerned. Other service users have very few visitors and the inspector recommends that these people should be taken out by staff, even if this is only for a walk around the garden. Staff have taken one service user out on a couple of occasions, and it is evident that they have enjoyed this individual attention. Staff recorded in surveys that they felt they had enough time to spend with service users. There are only six service users accommodated at the home (including two having respite care) and there is little evidence that one to one time is spent with them. Details about advocacy services are available for services users and visitors to the home. Service users are able to make some choices within their capabilities. However, the inspector observed that choices offered are very limited. For example, service users can choose to remain in their bedroom or to spend time in the lounge, and are able to choose from a variety of meals on offer. On the day of the site visit the meal provided looked appetising and service users told the inspector that they had enjoyed it. Records at the home evidence that a choice of meal is offered at all meal times, and this was confirmed by service users. There was no menu on display; a menu would encourage service users to become involved in meal provision at the home and may encourage conversation. The inspector observed that an ample supply of drinks was made available during the day and that service users are encouraged to drink. The inspector noted that service users were offered appropriate assistance with eating and drinking. One service user told the inspector, ‘they do very good meals’. The inspector observed on the staff rota that there is no longer a kitchen assistant employed at the home. On the day of the site visit the senior carer was preparing lunch in addition to undertaking care duties. This arrangement could leave service users at risk due to the lack of supervision by staff, and increases the risk of cross infection. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about how to make a complaint is now provided to each service user. The risk of abuse occurring is reduced by the policies and procedures that are in place at the home, and by staff training. EVIDENCE: There is a complaints policy and procedure in place at the home; the inspector observed that there is now a copy of this in each bedroom. There is a complaints log in place but no entries have been made. No formal complaints have been received by the CSCI or the home since the last key inspection so the inspector has not been able to assess whether the registered person’s capability when investigating complaints has improved. The registered person informed the inspector that any minor complaints or concerns are now recorded in daily diary records. Staff comments in surveys evidence that they understand the complaint procedure in operation at the home. One complaint has been received by CSCI since the last inspection of the home; this was that the home was short staffed and poorly managed. This was investigated as part of this site visit to the home and via sending out staff surveys. See comments recorded in outcome groups Staffing and Management and Administration. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 15 Three members of staff have undertaken training on safeguarding adults. Most staff have achieved NVQ Level 2 or 3 in Care or are undertaking this training – this also includes information about adult protection. There are suitable policies and procedure in place, including whistle blowing, management of violence and restraint; all staff should have continuous updates on this topic. Comments in staff surveys evidence that staff understand the safeguarding adults procedures that are in place at the home, including whistle blowing. The local authority Social Services Department has received one allegation of abuse since the last inspection of the home. This was that a service user had been admitted to hospital in a ‘poor state’, that night staff ‘drink on duty’ and that a new member of staff has had no CRB check. Care Management staff investigated the allegation about the service user being admitted to hospital ‘in a poor state’ and concluded that service users at the home are well cared for and have not been placed at risk. The other allegations were investigated as part of this site visit to the home. The inspector observed that there was a CRB check in place for the member of staff that it was alleged did not have one in place. There is no evidence that night staff are drinking on duty although the registered person is reminded that all staff should be made aware that this would be a dismissible offence. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 16 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, 24, 25 and 26 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some further improvements need to be made so ensure that the home is safe, hygienic and well maintained, and that service users are provided with all of the facilities they require. EVIDENCE: There is no maintenance programme in place and no records of maintenance that is carried out on a day-to-day basis. However, the premises appeared to be well maintained on the day of the site visit, and the call system had been serviced. The premises are comfortably furnished and offer access to sunlight – there is a door from one of the lounges into the garden. The improvement plan prepared by the registered person records that she would be implementing some changes that are designed to improve the quality of life for St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 17 residents, including signposting around the home to assist with their orientation. No progress has been made towards this. A hand washbasin has still not been fitted in the downstairs bedroom. The registered person has recorded in the improvement plan that this work will be included in the annual development plan; there is no annual development plan in place as yet so no timescale has been identified for this work to be undertaken. As it is not acceptable for this service user to have to use the communal toilet and washbasin situated next door, the inspector has identified a reasonable timescale for completion of this work; this timescale has not expired. The work to ensure that water temperatures are controlled in hand washbasins in bedrooms and bathrooms is still to be completed. However, there are some safeguards in place such as notices to alert people to hot water, and ‘push down’ style taps. Information was received by the CSCI stating that the washing machine had been out of order for two weeks. The registered person informed the inspector that this was because parts had to be ordered by the contractor to repair the machine. In the interim period, soiled washing was taken to the launderette or staff took washing home; there was no backlog of dirty laundry at any time. Staff confirmed this on the day of the site visit. A new service user had been given a questionnaire to complete and this recorded that the laundry service at the home was excellent. The registered person is reminded that the sink in the laundry room cannot be used for sluicing and for staff to use to wash their hands. Six care staff have undertaken training on infection control and there are appropriate policies and procedures in place. There was a very strong odour of urine in one bedroom. The mattress and bed linen were stained and the registered person was informed that the mattress would have to be replaced, as no mattress cover had been in use. The registered person agreed to this. The registered person was also advised that advice regarding continence equipment should be sought for the person who occupied this room to alleviate such problems in the future. A letter was sent to the registered person following the site visit to require them to inform CSCI within 28 days of the action they have taken about this issue. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff have accessed various training opportunities and some have achieved NVQ Level 2 or 3 in Care but induction training is inconsistent. Recruitment and selection procedures and recording on the staff rota should be more robust to ensure the safety of service users. EVIDENCE: There is a staff rota in place but this is not a true reflection of the actual staff on duty and does not record the role of the person on a particular shift; some staff have dual roles. There is usually a record of the carer who will be working night duty, but not always a record of the person who will be ‘sleeping in’. Catering staff are no longer employed so the two care staff on duty are responsible for the preparation of meals and some cleaning duties. This poses a risk of cross infection. A new member of staff has been recruited recently. An application form was completed by this person but no record of the interview process has been retained. A POVA first check has been obtained for this person but only one written reference. Staff must not commence work at the home until two written references have been received. The registered person was sent a St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 19 letter following the day of the site visit to require her to forward a copy of a second reference to the CSCI. Due to recent staff changes, 50 of the staff group have not achieved NVQ Level 2 or above. There must be an action plan in place to evidence how this will be achieved. The registered person recorded in the improvement plan that they are reviewing the training for staff to ensure that they receive thorough induction training. However, the records seen for a newly appointed member of staff (and discussion on the day of the site visit) evidence that staff do not receive appropriate induction training. This could result in staff not being fully equipped to carry out their role and to meet the assessed needs of service users. There is a training and development plan in place, in addition to individual training records for each employee. Records evidence that all staff have now completed ‘on line’ health and safety training; the inspector saw certificates to evidence this. Some staff are currently undertaking Dementia care training. Fire safety training was provided for staff in October 2006. A member of staff recorded in a survey, ‘Management have been very supportive to me over training’. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 and 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered person does not hold the necessary care and management qualifications and staff do not receive regular supervision; this results in a lack of a clear sense of direction for staff, and could impact on the quality of service provided to service users. The quality monitoring system should be fully developed to ensure that service users are able to affect the way that the home is operated. There is no evidence that the home is currently a viable business and the finances of service users are not managed safely. Health and safety systems have improved although in-house fire tests are not maintained consistently. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered person has many years experience in the caring profession but she has made no progress towards achieving NVQ Level 4 in Care and Management. She has made some progress with training to keep her practice up to date; she has completed health and safety training and has almost completed accredited medications training. There is a lack of clear leadership from the registered person and this results in some confusion for staff regarding care practices and systems. This could impact on the quality of the service provided to service users and must be addressed by the registered person. The requirement remains that there must be a registered manager in place that has achieved NVQ Level 4 in Care and Management. In the improvement plan received by the CSCI on the 5th February 2007 the registered person recorded that questionnaires have been sent out to residents and relatives, and that their responses will be included in the service user guide, and will be used to inform future developments; this will be recorded in the annual development plan. There is no evidence that this work has taken place and there is no annual development plan in place as yet. The registered person also recorded in the improvement plan that regular quality audits will become part of internal management arrangements at the home; these have not yet been instigated. On the day of the site visit the inspector saw a copy of one quality survey that had been completed by a new service user. This was in the person’s care plan and there is no evidence that any action has been taken as a result of this survey. If any other surveys have been completed, these were not available on the day of the site visit. There is no evidence that there has been a staff meeting, a service user meeting or a relative meeting at the home for many months. The quality monitoring system must be further developed so that service users and others have an opportunity to affect the way that the home is operated. The registered person is reminded that, as part of the quality monitoring system, policies and procedures should be updated to reflect current practices and any changes in legislation. The registered person has been asked on numerous occasions to provide the CSCI with details of the bank holding her business account so that enquires can be made about financial viability. In the improvement plan the registered person recorded, ‘any consideration of the financial viability of the home should not be in question, after taking into account the substantial financial investment and time I have given and am continuing to give over many years towards this end’. However, financial viability has been an area of concern for some time; there are few service users accommodated at the home and this has put a strain on the financial situation. On the day of the site visit the registered person was informed that this information must be received by the CSCI within 28 days. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 22 There have been ongoing concerns about the safe handling of service user monies. The inspector observed on the day of the site visit that the recording on monies managed for one service user ceased at the end of December 2006. The monies of this service user continue to be held in the business account of the registered person. In the improvement plan, the registered person recorded, ‘I am currently investigating an alternative method of looking after a particular resident’s personal allowances, that with your agreement, may involve me being appointed custodian of these monies’. The inspector recommended following the inspection of the home in February 2007 that a bank account should be set up for this service user and that the registered person should have no involvement in these financial arrangements. The registered person has not taken any action to meet this requirement. The registered person recorded in the improvement plan, ‘Further staff supervision sessions will be used to reinforce the importance I place upon the homes philosophy of providing the best possible care for residents. It will also focus upon the career needs of staff’. The inspector observed that some staff supervision has taken place but that this is spasmodic. A programme should be developed to ensure that staff receive formal one to one supervision six times per year. This will ensure that staff have the opportunity to talk to their manager in private and will enable a staff member’s effectiveness in their work role to be monitored. Fire safety records were examined on the day of the site visit; these evidenced that a weekly fire test has not taken place since 8.4.07 and that a monthly fire drill had not taken place since 7.3.07. An immediate requirement notice was left at the home stating that both of these must take place by 4.5.07 and the registered person notified the CSCI that this action was taken. These must now be undertaken consistently. There is a fire risk assessment in place and an annual fire alarm and equipment test by a qualified contractor has taken place. Testing of the electrical installation is now overdue and the registered person should arrange for this work to take place. The call system has been serviced as required at the last inspection of the home. Portable appliances, hoists and the passenger lift have also been serviced, and there is a gas safety certificate in place. Water temperatures are tested in bathrooms and bedrooms but these tests are not consistent. Records at the home evidence that water temperatures are too high at some of these outlets and action must be taken to alleviate this risk to service users, as recorded in previous inspection reports. A senior carer has completed a record of safe working practices, including risk assessments, for all health and safety areas. All staff have now undertaken health and safety training but there should be more evidence that induction training for staff includes information about all health and safety topics. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 23 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 1 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 17 18 3 X X X X 1 2 1 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 1 1 2 X 1 3 X 3 St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 Requirement The home must not provide a service for which they are not registered. In this instance, the home is not registered with the CSCI to provide a domiciliary care service. The registered person agreed to stop providing this service immediately. There must be a care plan in place for all service users living at the home, including those having respite care. Previous timescales of 15/11/06 and 14/02/07 not met. The registered person must complete accredited medications training. Previous timescale of 31/3/07 not met. The registered person is required to send the CSCI evidence that the new member of staff that is administering medication has completed accredited training. A hand washbasin must be provided in the ground floor bedroom. Previous timescale of 13/12/06 not met. Current timescale has not yet expired. DS0000019726.V338494.R01.S.doc Timescale for action 01/05/07 2. OP7 15 01/05/07 3. OP9 13 and 18 30/06/07 4. OP9 13 and 18 29/05/07 5. OP24 16 31/05/07 St Judes Version 5.2 Page 25 6. OP25 23 7. OP26 16 8. OP29 19 9. OP34 25 10. OP35 20 11. OP35 20 Thermostatic valves (or some other form of control) should be fitted in all bedrooms used by service users to control the risk of scalding. Water temperatures should continue to be tested and recorded. The home must be kept free from offensive odours. A notice was sent to the registered person informing them that work to alleviate this problem must be completed within 28 days. Staff must not commence work at the home until two written references have been received. A notice was sent to the registered person informing them that a copy of the second reference received for the new recruit should be sent to the CSCI within 28 days. The registered provider is required to provide the CSCI with details of the bank used by the home to enable information about financial viability to be obtained. Previous timescales of 01/08/06, 31/10/06,15/11/06 and 21/02/07 not met. Enforcement action will now be taken regarding this issue. Records for monies held on behalf of service users must be kept up to date. A notice was sent to the registered person requiring them to bring the accounts up to date for an identified service user within 28 days. Alternative means must be found for the holding of service user monies; monies must not be held in the business account of the registered person. Previous timescale of 31/03/07 not met. A notice was sent to the registered person requiring them DS0000019726.V338494.R01.S.doc 30/06/07 29/05/07 29/05/07 29/05/07 29/05/07 29/05/07 St Judes Version 5.2 Page 26 12. OP38 23 to bring the accounts up to date for an identified service user within 28 days. In-house tests of the fire alarm 04/05/07 system and fire drills should take place consistently. An immediate requirement notice was left at the home requiring them to undertake a fire test and a fire drill by 4.5.07. The registered person contacted the CSCI to inform us that this had been actioned. 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. 2. Refer to Standard OP2 OP3 Good Practice Recommendations All service users should have a contract or statement of terms and conditions in place with the home that has been signed by the service user or their representative. The assessment of prospective service users should include a visit to meet them, so that the assessment process can commence prior to their admission to the home. Service users should be involved in the care planning process. Arrangements for continence care for service users should meet their individual assessed needs. If it is considered that charts need to be used to record baths and bowel movements, these must be used consistently. The documentation to record any medication returned to the Pharmacist should be signed and dated by the Pharmacist. Staff should spend more one to one time with service users in an attempt to maintain their social skills and levels of memory impairment. A menu should be displayed to encourage service users to become involved in daily meal provision and to encourage conversation. The registered person should pay particular attention to the risk of infection control due to staff DS0000019726.V338494.R01.S.doc Version 5.2 Page 27 3. 4. OP7 OP8 5. 6. 7. OP9 OP12 OP15 St Judes 8. 9. OP19 OP27 10. 11. 12. 13. OP28 OP30 OP31 OP33 14. 15. OP36 OP38 undertaking both care and catering duties. There should be a maintenance programme in place. The staff rota should be a true reflection of the actual staff on duty and a full record of the actual staff on duty. The role of each member of staff should be recorded on the rota. There should be an action plan in place to record how the home will meet the requirement for 50 of staff to have achieved NVQ Level 2 in Care, or above. Staff should receive appropriate induction training to ensure that they are equipped to carry out their role and meet the assessed needs of service users. There must be plans in place for a registered manager to be in post who has achieved NVQ Level 4 in Care & Management. There should be a quality monitoring system in place that gives service users and others the opportunity to affect the way in which the home is operated. The system should include an annual development plan and the updating of policies and procedures. The staff supervision system that has been developed must become fully operational to ensure that staff receive adequate one to one supervision. Testing of the electrical installation is overdue and the registered person should arrange for this work to take place. St Judes DS0000019726.V338494.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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