Inspection on 14/02/07 for St Judes

This inspection was carried out on 14th February 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 01/05/07

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 Unannounced Inspection 14th February 2007 10:15 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.V330699.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.V330699.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.V330699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2006 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. 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. St Judes DS0000019726.V330699.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, from information obtained whilst undertaking the four random inspections that have taken place since the last inspection of the home and from the site visit on the 14th February 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 10.15 am and finished at 3.15 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 a service user, a member of staff and the registered person, as well as chatting to other service users and staff. Three surveys were sent to staff following the day of the site visit. At the time of writing this report, none had been returned. 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: What has improved since the last inspection? Contracts or statements of terms and conditions have now been drawn up between service users and the home. However, most of these still need to be signed by service users or their representative. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 6 There are now risk assessments in place for service users that use the stairs to the second floor of the home and for the use of bed rails. Controlled drugs are now recorded effectively at the home. There is a staff rota in place but this is still sometimes not a true reflection of the actual staff on duty. There are arrangements in place to record safe working practices, including risk assessments, to ensure the safety of service users and staff. Action is being taken to control water temperatures to protect service users from the risk of scalding. What they could do better: There must be a care plan and records for medication administered in place for all service users, including those that are newly admitted to the home. Staff do not spend one to one time with service users, even though there are currently only five permanent residents at the home. All bedrooms do not include the facilities that are required by legislation to meet the needs of service users. The registered manager has made no progress towards achieving NVQ Level 4 in Care and Management and there are no plans to appoint another manager who would be suitable for registration with the CSCI. The system to measure the satisfaction of service users and others with the quality of the service provided by the home is not fully operational. The registered person persistently declines to provide the CSCI with information needed to confirm the financial viability of the business, as requested. Service user monies are not held in a satisfactory manner, i.e. they are held in the business account of the registered person. Financial records for monies held on behalf of service users are not kept up to date. Staff do not receive formal one to one supervision so they do not have the opportunity for a private meeting with their manager. The staff call system is not serviced annually, as recommended by the manufacturer. There has been no recent test of the electrical installation. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 7 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.V330699.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 Judes DS0000019726.V330699.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 and 3. Standard 6 was not assessed as there is no intermediate care provision at the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are now assessed prior to their admission to the home but most do not have a contract in place that defines the terms and conditions of their stay. EVIDENCE: Some progress has been made towards service users having a contract in place with the home. Contracts have been written up and one has been signed by a service user. The registered person informed the inspector that the remaining contracts have been sent to relatives requesting their agreement and signature. However, this has been the situation for the past few months. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 10 Since the key inspection in May 2006 there has been one inappropriate admission made to the home; on that occasion no care needs assessment was completed by the home. More recently, progress had been made on ensuring that all service users are fully assessed prior to their admission to the home to evidence that their care needs could be met. The registered person had previously agreed that any assessments undertaken would be shared with the Commission for Social Care Inspection (CSCI) to ensure that appropriate admissions were being made. Recently a service user was admitted to the home and a care needs assessment was undertaken by the registered person; this was forwarded to the CSCI within five days of the person being admitted, as agreed. St Judes DS0000019726.V330699.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 poor. 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 the administration of medication and care planning are not currently robust. EVIDENCE: A new service user has been admitted to the home. Although a care needs assessment has been undertaken for this service user and information is being recorded on daily diary sheets by staff, there is no care plan and no risk assessments in place. This leaves the service user in a vulnerable position, as there is no record of the actions that need to be taken by staff to ensure that the service user’s care needs are met. There were care plans in place for all other service users and these were examined by the inspector. The inspector observed that daily records are a St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 12 thorough record of the care provided to meet the needs of service users, and that these are maintained consistently. An annual review had taken place for two of these service users, but there were no records of a recent review for the remaining service users; the registered person should arrange an annual review for those service users that are privately funded and contact Care Management to remind them that a review is overdue for the other service users (or obtain minutes of the review meeting if it has already taken place). There is no evidence that service users are involved in the care planning process. There are appropriate risk assessments in place, including those for the use of bed rails and the stairs to the second floor. The registered person is reminded that all documentation should be signed and dated so that it can be determined when reviews should take place. Monthly summaries of the care plan are recorded and any necessary changes are made to care plans. The inspector observed that bed rails are checked periodically to ensure that they are safe. The inspector was concerned about one frail service user who had regular bed rest. The registered person informed the inspector that this person is very frail but not unwell; the inspector recommends that this person should be seen by a GP or other health care professional to establish that their current care needs are being met by the home. There is evidence that a record is held of any contact made with health care professionals and the reason for this contact. Bathing records and ‘bowel movement’ records are included in care planning documentation. These evidence that service users have very irregular baths and bowel movements. The inspector was informed by the registered person that staff have forgotten to record information on these forms. The inspector advised that, if such forms are intended to be used by staff, they must be used consistently otherwise they create the impression that the care needs of service users have been neglected. Some, but not all, service users are weighed as part of nutritional screening. Some service users are quite frail and the inspector recommends that more detailed information is recorded about the food and fluid intake of service users, in addition to regular weighing. The inspector was informed in the improvement plan that was forwarded to the CSCI on 5.2.07 that some new documentation was to be introduced to care plans, i.e. a ‘skin’ map to record any injuries or pressure areas. These were seen on the day of the site visit. Two new monitoring forms have also been introduced; one records any changes in the behaviour of service users and records, ‘to enable staff to minimise the instance of hostile events’. The other records any incidents or accidents concerning service users; one care plan included a record of a recent accident suffered by a service user. Pressure care equipment is obtained for service users as needed, and appropriate continence equipment is provided. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 13 There has been an on-going issue since the inspection in May 2006 about the recording of controlled drugs. This improved at one stage, but at the most recent random inspection recording had deteriorated again, and the inspector noted that medication that should have been returned to the Pharmacist was still held in the home. At this site visit, the inspector was informed that a controlled drugs book is now being used; this was seen by the inspector and was being used correctly. The registered person informed the inspector that all unused drugs had been returned to the Pharmacist and this was confirmed on the day of the site visit. A sheet recording all items was shown to the inspector – this had been signed by staff at the home but had not been signed by the Pharmacist. The registered person informed the inspector that she had almost completed accredited medications training; she agreed that this would be completed by 31/3/07. All other staff that administer medication have completed this training. All medication administration sheets examined by the inspector were completed accurately. However, the inspector observed that medication was held for the new service user (in a blister pack prepared by a different Pharmacist) and that administration of this medication was not been recorded by the home. 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.V330699.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. Service users are supported to make choices about their day-to-day lives, within their capabilities, but would benefit from some 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, but these are primarily watching TV, chatting or a record of visits by friends or 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 a quiz took place in the afternoon, as recorded on the notice board. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 15 Some of the service users have very few visitors and the inspector recommends that these service users should be taken out by staff, even if this is only for a walk around the garden. There are only six service users accommodated at the home and there is still no evidence that one to one time is spent with them. Staff should spend some one to one time with service users in an attempt to maintain their social skills and levels of memory impairment. 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. 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 – an alternative meal was offered and accepted by some service users. 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 the kitchen assistant works for four days per week and on other days, care staff have to prepare meals. This arrangement could leave service users at risk due to the lack of supervision by staff. However, on the day of the site visit the inspector noted that service users were offered appropriate assistance with eating and drinking. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Information about how to make a complaint is now provided to each service user, but any complaints made are not recorded or acted upon in a satisfactory manner. Risks of abuse are 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 recorded in the improvement plan received by the CSCI on 5.2.07 that, ‘I am aware that some staff may not have been recording all the complaints made by residents, and that some concerns may have been seen as trivia, and not worth recording. I have addressed this matter at a recent staff meeting, and have encouraged all staff to act as advocates on behalf of residents in this respect’. On the day of the site visit, there was no evidence that such a meeting had been held, and there was no ‘grumbles’ book St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 17 in operation. The success of this change of policy will be better assessed at the next inspection of the home. Three members of staff have undertaken training on adult protection. Most staff have achieved NVQ Level 2 or 3 in Care or are undertaking this training – this includes information about the protection of vulnerable adults from abuse. 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. There have been no recorded allegations or incidents of abuse at the home since the last key inspection. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 18 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, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements need to be made so ensure that the home is safe and well maintained, and that service users are provided with all of the facilities they require. EVIDENCE: On the day of the site visit the inspector toured the premises; it was observed that the bedroom carpet that was due to be replaced has not been. However, the carpet had been cleaned and the odour noticed at previous inspections was much reduced. There is no maintenance programme in place but there is a weekly health and safety checklist in place; this had not been completed since August 2006. This checklist records, ‘Entered in repairs and maintenance file’ St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 19 against any entries that indicate a repair is required. However, the repairs and maintenance file could not be found on the day of the site visit. The premises are comfortably furnished and offer access to sunlight – there is a door from one of the lounges into the garden. On the day of the site visit, the inspector observed that a new carpet and curtains had been fitted in the dining room. The inspector noted that the premises were only just warm enough. However, there is a gas fire in the living room used by most service users to provide additional heating. The improvement plan prepared by the registered person records that she will be implementing some changes that are designed to improve the quality of life for residents, including signposting around the home to assist with their orientation. No progress has been made towards this. A hand washbasin has not been fitted in the bedroom that does not currently have one, as required. 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. The improvement plan also records that ‘action has been taken to ensure that the water temperatures in the first floor bathroom and one bedroom are distributed at 43°C to ensure the safety of residents’. This work has not yet been carried out. However, the taps in the bedroom concerned are of a ‘push down’ style and this offers some protection to service users. There is also a notice alerting people that water supplied at the tap is hot. As an additional safety precaution, a pressure mat has been placed at the side of the bed to alert staff that the service user is out of bed. The bath and washbasin in the bathroom on the first floor are rarely used; the registered person informed the inspector that a plumber has checked both of these and will be fitting thermostatic control valves shortly. Laundry facilities remain satisfactory and, on the day of the site visit, the premises were clean and free from offensive odours. 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. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Staff have accessed various training opportunities and most 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 now a staff rota in place; this does not consistently record the actual staff on duty, the correct time of the shift or the role of the person on duty. For example, one member of staff works day shifts and night shifts, and another works as a care worker and a domestic assistant. The staff rota should record the role that staff are undertaking on each occasion they are recorded on the rota, and all occasions when staff are absent from their shift should be recorded on the rota. Staff at the home stated that they had enough time to spend with service users. There have been no staff employed since the last key inspection of the home. The registered person informed the inspector that she is considering reemploying a former employee, and that she has obtained a POVA first check for this person. However, no application form has been completed as yet by St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 21 the applicant, and no references have been requested. There must be an application form in place that records the applicants employment history, and two written references must be obtained prior to the prospective employee commencing work at the home. The registered person is reminded that a CRB check should be obtained prior to staff commencing work, and that POVA first checks are only to be used in exceptional circumstances. 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 and over 50 of care staff employed at the home have achieved NVQ Level 2 or 3 in Care. There continues to be little evidence that new staff at the home undertake appropriate induction training; the registered person recorded in the improvement plan that she is reviewing the training for staff to ensure that they receive thorough induction training. A member of staff informed the inspector that they had undertaken food hygiene, first aid, health and safety, infection control, moving and handling and fire training. The staff are now more equipped to care for the service users accommodated at the home. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 and 38 Quality in this outcome area is poor. 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 and now provide protection to service users and staff. EVIDENCE: St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 23 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. Residents/relatives meetings are held spasmodically. Staff meetings are held but not on a regular basis. 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. 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 was shown a copy of the quality audit that has been distributed to residents and relatives; this is the quality audit form that has been in place at the home for some time but never previously used. The inspector will be able to assess the success of the quality monitoring system at the next inspection of the home. The registered person informed the CSCI that she has started to compile an annual development plan that is based on consultation with residents and relatives. The inspector was informed at the time of the site visit that no progress has been made with the compilation of an annual development plan. 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. There have been issues in the past about the home not being warm, about low food provisions and about accounts not being paid. The inspector discussed these concerns with the registered person, who agreed to forward these details to the CSCI by the 21st February 2007; this information has not been received. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 24 There have been ongoing concerns about the safe handling of service user monies. The recording of these had improved, but the inspector observed at the most recent site visit to the home that these monies are not recorded consistently, and that the monies of one 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 recommends that a bank account be set up for this service user and that the registered person should have no involvement in these financial arrangements. The registered person informed the inspector that the financial affairs of four of the remaining service users are managed by a relative or a solicitor. 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. The staff call system was tested in July 2003 but there is no record of a test since then. The inspector contacted the company that supplied the call system and was informed that they recommend an annual service. The electrical installation was tested in March 2004 and should have been retested after one year. These tests must be undertaken as soon as possible and evidence must be sent to the CSCI. Portable appliances have been tested and do not need testing again until March 2007. The fire risk assessment was reviewed in October 2006. An annual fire test (including servicing of the fire extinguishers) took place in September 2006 and fire extinguishers were serviced in February 2007. Records show that inhouse weekly fire alarm tests and monthly fire drills are being maintained on a regular basis. Fire training last took place in October 2006. There is a current gas safety record in place and bath hoists and the passenger lift have been appropriately maintained. 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.V330699.R01.S.doc Version 5.2 Page 25 Wooden door wedges were seen on the day of the site visit, although they were not being used to hold doors open at the time. The registered person is reminded that door should never be held open by unauthorised means. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 26 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 1 1 2 X 2 St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement There must be a care plan in place for all service users living at the home, including those having respite care. Previous timescale of 15/11/06 not met. There must be medication administration records in place for all medication administered by staff at the home. The registered person must complete accredited medications training by 31/3/07, as agreed. A hand washbasin must be provided in the ground floor bedroom. Previous timescale of 13/12/06 not met. 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 and 15/11/06 not met. 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. DS0000019726.V330699.R01.S.doc Timescale for action 14/02/07 2. OP9 13 and 18 14/02/07 3. 4. OP9 OP25 13 and 18 16 31/03/07 31/05/07 5. OP34 25 21/02/07 6. OP35 20 31/03/07 St Judes 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. 2. Refer to Standard OP2 OP7 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. All service users should have their care plan reviewed on a formal basis annually. Any changes to care plans should be signed and dated. Service users should be involved in the care planning process. If it is considered that charts need to be used to record baths and bowel movements, these must be used consistently. Nutritional screening should be more robust. A health care professional should be contacted regarding the identified frail service user. The documentation to record any medication returned to the Pharmacist should be signed and dated by the Pharmacist. Staff should spend some 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. All complaints or ‘grumbles’ made by service users should be recorded and there should be evidence that these have been dealt with. 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 staff rota should be a reflection of the actual staff on duty, including their role and the time of the shift. There should be an application form, two written references and a satisfactory CRB check in place before staff commence work at the home. POVA first checks should only be used in exceptional circumstances. There must be an appropriate induction training programme in place for new staff. DS0000019726.V330699.R01.S.doc Version 5.2 Page 29 3. OP8 4. 5. 6. 7. 8. OP9 OP12 OP15 OP16 OP25 9. 10. OP27 OP29 11. OP30 St Judes 12. 13. OP31 OP33 14. 15. OP36 OP38 There must be plans in place for a registered manager to be in post who has achieved NVQ Level 4 in Care & Management. The quality monitoring systems that have been developed must now be actioned to evidence that the quality of the service offered is measured by the home. There should be an annual development plan in place as well as evidence that policies and procedures are regularly reviewed. The staff supervision system that has been developed must become fully operational to ensure that staff receive adequate one to one supervision. The call system should be serviced annually and the electrical installation should be serviced as stated by the contractor. St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI St Judes DS0000019726.V330699.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!