Inspection on 17/04/08 for St Judes

This inspection was carried out on 17th April 2008.

CSCI found this care home to be providing an Poor service.

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 23/10/07

St Judes 01/05/07

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

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Hawkhills

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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 Unannounced Inspection 17th April 2008 12:00 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.V362773.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.V362773.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.V362773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2008 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. Three people are currently accommodated at the home. Information about the home is provided to residents and others in the home’s Statement of Purpose and Service User’s 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 (both with a dining area) and a small lounge that is used by staff and residents. 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.V362773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 23rd October 2007 including information gathered during a site visit to the home. This unannounced site visit was undertaken by one inspector over one day. It began at 12.00 noon and ended at 2.00 pm. On the day of the site visit the inspector spoke on a one to one basis with one of the residents, the two care staff on duty and the registered provider/manager. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered provider/manager did not submit information about the service in advance of the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. These forms have been requested on two occasions and have not been returned. Survey forms were not used on this occasion. Since the last key inspection we have undertaken three random inspections at the home due to our concerns and the concerns of others about the care provided for residents, staffing levels and management issues. These visits have also enabled us to check on any compliance towards requirements and recommendations by the registered person. The findings of these inspections will be included in this report. What the service does well: What has improved since the last inspection? St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 6 Water temperatures are now tested and recorded at outlets accessible to residents. This helps to protect them from the risk of scalding. Risk assessments are undertaken on the safe use of bed rails and the safety of bed rails are now checked on a regular basis. What they could do better: Some staff that administer medication have not had appropriate training. This leaves residents at risk of harm from errors in the administration of their medication. Staff do not spend sufficient one to one time with service users undertaking leisure activities. There is an unpleasant odour in one bedroom and the carpet is stained. This has not been replaced, as required. All bedrooms do not include the facilities that are required by the National Minimum Standards to meet the needs of service users. The staff rota is covered on a day-to-day basis; this could result in the home being understaffed and puts residents at risk of harm. The lack of domestic and catering staff results in a risk of cross infection, as care staff have to perform these functions as well as providing personal care. There is no training and development plan and a lack of any training records so it is not possible to assess whether staff have the skills and experience to care for people living at the home. Management of the home continues to be poor; there is a lack of leadership and sense of direction. The registered person has not returned any of the Annual Quality Assurance Assessments as required by regulation and improvement plans have not been returned to the CSCI as requested. 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. Staff do not receive formal supervision. This does not give residents and staff the opportunity to affect the way in which the home is operated. Records required by regulation are not in place and are not made available for inspection. This includes a record of admissions and discharges, recruitment records and training records. Records should be kept on the premises and should be available for inspection at all times. Records of monies held and financial transactions made on behalf of residents are not held; this leaves them vulnerable to the risk of abuse. St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 7 There is no evidence that staff are recruited safely; this leaves residents vulnerable to the risk of abuse. 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.V362773.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.V362773.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. 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. Appropriate records, such as admission and discharge information and contracts, are not in place. People living at the home therefore have no record of what their fee does and does not include. EVIDENCE: There is a Statement of Purpose and a Service User’s Guide in place that could be given to any prospective residents or enquirers. There is no evidence that residents have a current contract in place between themselves and the home. The registered person informed us that there have been no new admissions to the home since the last key inspection, including respite care and day care. There continues to be no admissions or discharges book in use. One resident St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 10 has died since the last key inspection of the home so there are currently three residents accommodated there; one person is in hospital and the home were informed on the day of this site visit that they would not be returning to St. Judes. St Judes DS0000019726.V362773.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. 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. Daily entries in care plans are thorough but monthly reviews are not consistent, and there is no evidence that residents are involved in the care planning process. Administration of medication at the home places people at risk of harm. EVIDENCE: We examined care plans for the three residents living at the home. Care plans are based on the homes own assessment and any assessment received from care management. Daily recording is thorough and up to date. There are systems in place to update care plans and risk assessments on a monthly basis but these have not been adhered to. However, one resident has recently had major surgery and new care plan areas had been added to the individual care plan; these included information for staff on how to provide care for the individual concerned. Social Services staff have undertaken formal reviews of the care plan for residents funded by them. There is no evidence that residents who are privately funded have had a formal review of their care plan. St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 12 Information recorded about any contact with GP’s and other health care professionals is good. However, daily notes record information about people’s physical and emotional well-being that should have been discussed with health or social care professionals, and there is no evidence that these concerns have been followed up. People have been weighed as part of nutritional screening and daily notes record the food and fluid intake of residents. Pressure care equipment is obtained where this is needed by residents, and following advice given at a previous inspection, bed rails are now checked on a regular basis. There is only one member of staff at the home who has undertaken accredited medications training. The registered person continues to administer medication even though she has been advised that she must undertake accredited training and should not administer medication until this has been achieved. On the day of this site visit to the home, the registered person was on duty in the morning with a care worker, and two care staff were on duty in the afternoon; neither have had accredited training. The registered person told us that she would contact the trained member of staff to ask her to administer tea-time and evening medication, but this had not been done by the time she left the home after lunch. Medication administration records had been signed daily apart from on the day of our site visit; the registered person told us that this had been an oversight on her part, and she updated the records in our presence. We noted that medication administration records are not completed when ‘as required’ medication is not given to residents. Signing these records evidences that people have been asked if they want or need this medication and that they have declined. None of the current residents are prescribed controlled drugs but there are suitable storage and recording arrangements should this change. Medication is stored securely. We observed on the day of the site visit that staff spoke to residents in a sensitive way about personal care needs. Residents are accommodated in single rooms so are able to see visitors and health/social care professionals in their own room. St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. 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. People enjoy the meals provided by the home but staff do not spend one to one time with residents or arrange any trips out. There are very few visitors to the home but those that do visit are made welcome. EVIDENCE: The needs assessments record a person’s previous life history and the reason for their admission to the home. Daily records evidence that some activities take place. However, these are minimal and most entries record that residents spend their day watching the TV or videos or listening to music. There are only three residents living at the home and there are always two staff on duty, so it should be possible for residents to benefit from some one to one attention or a trip out of the home. We noted at the two random inspections and this key inspection that residents are spending a lot of time in their bedrooms. Social Services staff have also expressed this concern to us. Any visitors seen by residents are recorded in care plans, although visitors to the home are infrequent. No evidence was seen that a hairdresser visits the home or that residents are taken out to the hairdressers. Care plans record a St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 14 person’s religious beliefs but there is no evidence that a minister visits the home to undertake a service or speak to residents, or that residents are supported to visit a church. Details about advocacy services are available for services users and visitors to the home; these were displayed in the entrance hall. Residents are able to make some choices within their capabilities. However, we observed that choices offered are very limited. For example, residents 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. We noted that residents are able to bring some possessions into the home to personalise their bedrooms. Residents are not supported to handle their own financial affairs. On the day of the site visit there was no menu on display but we saw the menu for the previous day. There is no standard menu in place and decisions are made about the provision of meals on a day-to-day basis. A menu should be displayed to encourage service users to become involved in daily meal provision and to encourage conversation. There is no cook employed at the home - extra care should be taken regarding infection control, as care staff are providing personal care as well as undertaking domestic and catering duties; this poses a risk of cross infection. On the day of the site visit the registered person told us that the meal was meatballs or omelette with vegetables, followed by rice pudding or fresh fruit. We saw this being served to residents and noted that they were offered appropriate assistance with eating and drinking. St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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. Arrangements in place for the investigation of complaints and safeguarding adults do not offer residents protection from harm. EVIDENCE: The complaints policy and procedure was not on display on the day of this site visit; at other visits it has been found under a pile of papers in the reception area. On some of our recent visits to the home the complaints log could not be found. On this occasion the complaints log was located – it records that there have been no complaints since the last key inspection of the home. No complaints have been received by the CSCI since the last key inspection of the home. We are not confident that, should a complaint be made, staff or the registered person would deal with this according to the home’s policies and procedures, and that it would be recorded appropriately. There have been no recorded allegations or incidents of abuse since the last key inspection. There are no training records at the home – the registered person told us that these are still being held by the Police. The training records for new staff have not been retained centrally so there is no record of whether or not the current staff group have attended training on safeguarding adults, dementia care or challenging behaviour. St Judes DS0000019726.V362773.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. Residents are not provided with all of the facilities they require and some shortfalls in hygiene practices and maintenance result in an unsafe environment for residents. EVIDENCE: On the day of this site visit we found that one bedroom had an unpleasant odour; the carpet was very stained and must be replaced. A hand washbasin has still not been fitted in the downstairs bedroom. There is no maintenance programme in place but there is now a repairs and maintenance record in use to record minor repairs that have been undertaken. However, this has not been used for several months. St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 17 One of the lounge areas has a door that opens into the garden, although this area is rarely used by residents and there is no evidence that residents are encouraged to use the garden. Bedroom accommodation does offer access to sunlight; some bedrooms have pleasant views from the window. The inspector noted that the home was only just warm enough to provide residents with a comfortable environment. The inspector was informed at the random inspection of January 2008 that thermostatic valves have been fitted to washbasins in bedrooms. The water that we tested in one washbasin was very hot and the member of staff on duty was advised to contact the plumber to arrange for the thermostatic valve to be checked or re-set. They were also advised that water temperatures should be tested and recorded to evidence that water at outlets accessible to residents is at around 43°C. On the day of this site visit the inspector noted that water temperatures are being recorded. Laundry facilities provided by the home are satisfactory, although we noted that the door to the laundry room is not locked. The domestic assistant is currently working as a care assistant, so care staff are having to undertake domestic and catering duties as well as personal care tasks. This poses a risk of cross infection and the registered person should take particular care in ensuring that good hygiene practices are followed by staff. Training records were missing on the day of the site visit so the inspector could not check if staff had undertaken training on infection control. St Judes DS0000019726.V362773.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 poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is no plan in place to show how National Vocational Qualification (NVQ) qualifications will be achieved, and recruitment and training records are not available for inspection. Consequently, there is no evidence that staff have been recruited in a safe way, or that they have the skills and knowledge to care for residents appropriately. EVIDENCE: There was no staff rota in place on the day of this site visit and only the registered person was on duty when we arrived at the home; we were told that the other care worker had just gone to the shops and they did arrive shortly with some shopping. Discussion with the registered person and staff evidenced that shifts are covered at very short notice and this results in staff not knowing what shifts they will be working during the next days or weeks. This could result in there being insufficient staff on duty to provide a safe service for residents. Some long-standing members of staff have left the home in the past few months, and no new staff have been recruited. We were told that the home no longer meets the requirement for 50 of staff to have achieved NVQ Level 2 or above in Care, and there are no real plans in place for this to be achieved. St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 19 No new staff have been recruited since the most recent random inspection of the home, so it was not possible to check if recruitment practices have improved. At the random inspection undertaken in January 2008 we noted that POVA first checks had arrived several weeks after care staff had commenced work at the home. The absence of training records and recruitment records resulted in us not being able to assess the training needs and achievements of staff. The registered person was informed that a training and development plan and a record of individual training needs and achievements for staff should be in place, and that these should be available for inspection at all times. St Judes DS0000019726.V362773.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, 37 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 residents. The lack of a quality assurance system means that there is no way for residents and staff to affect the way in which the service is operated. There is no evidence that the home is currently a viable business and that the finances of service users are managed safely. Health and safety systems have improved with the exception of staff recruitment and staff training. St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home continues to be poorly managed. The registered person has not achieved NVQ Level 4 in Care or Management and does not intend to undertake this training. There are no clear lines of accountability within the home. The registered person was hoping to sell the home but the sale has ‘fallen through’. She informed us on the day of this site visit that she intends to close the home and will be giving residents 28 days notice. The registered person has been sent two AQAA forms in preparation for previous inspections and neither has been returned as requested; this is a breach of regulation and is an indication of poor management practice. There is no operational quality assurance system at the home. There have been no staff meetings for some time and resident meetings are not held. No surveys are distributed to staff, residents or others and this means that people are not involved in influencing how the home is operated. Policies and procedures are not updated to reflect changes in legislation or best practice guidelines. There is no evidence that the home is financially viable and information requested by the CSCI from the registered person has not been provided. However, there have been no further suggestions that food is in short supply or that there are insufficient funds to maintain essential equipment. The registered person informed us at the most recent random inspection that they have opened a bank account for one of the residents. The bank account is in the name of the registered person and there are no corresponding accounts held at the home. The registered person told us that she has paid a sum of money into this account, but said that this was not based on any accounts, ‘it was just a round figure’. No new financial records have been kept for transactions made on behalf of residents since the original records were seized by the Police; new records should have been started from this date. The registered person told the inspector that she had arranged for new clothes to be purchased for one resident and receipts had been kept; these clothes still had labels on them and had not been handed to the resident. Staff at the home do not have formal supervision with the manager; this does not give them the opportunity to discuss any concerns about residents or issues such as individual training requirements. This could result in a staff group that lacks motivation and a sense of direction. The home has recently being informing CSCI of any accidents or adverse incidents in the home that affect the well being of residents, under Regulation 37 of the Care Homes Regulations 2001. Accident records are now held in a person’s care plan so that they can be cross-referenced to daily records. Other St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 22 records that are required by regulation were not available at the home, such as recruitment records, training records and financial records. Fire safety records were examined on the day of the site visit; these evidenced that weekly fire tests and monthly fire drills now take place on a regular basis. There is a fire risk assessment in place and the registered person told us that there has been an annual test of the fire alarm system. No evidence of this could be found and an immediate requirement notice was left at the home requiring the registered person to forward evidence of this test to CSCI by the 24th April 2008; this has not been received. Testing of the electrical installation is now overdue and the registered person should arrange for this work to take place. Portable appliances, hoists and the passenger lift have been serviced, and there is a gas safety certificate in place. A senior carer has completed a record of safe working practices, including risk assessments, for all health and safety areas. Recruitment or training records were not available on the day of the site visit so it was not possible to assess whether staff have undertaken training on health and safety topics. St Judes DS0000019726.V362773.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 X 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 1 2 X X X X 2 1 1 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 1 1 2 1 2 St Judes DS0000019726.V362773.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 OP3 Regulation 17, Schedule 3 13 Requirement Any admissions to or discharges from the home should be recorded. Any incidences of bruising or other signs of injury must be explored, and appropriate people must be informed. An immediate requirement notice was sent to the home on 26/10/07 in respect of this breach of regulation. The registered person must complete accredited medications training or cease administering medication. Previous timescales of 31/3/07 and 30/06/07 not met. A hand washbasin must be provided in the ground floor bedroom. Previous timescales not met. There is an unpleasant odour in one bedroom and the carpet is stained. The carpet must be replaced. DS0000019726.V362773.R01.S.doc Timescale for action 23/10/07 2. OP8 23/10/07 3. OP9 13 and 18 30/11/07 4. OP24 16 30/11/07 5. OP26 16 31/05/08 St Judes Version 5.2 Page 25 6. OP27 17, Schedule 4 19 The staff rota must be a true reflection and a full record of the actual staff on duty. Staff must not commence work at the home until two written references and a satisfactory CRB check (or POVA first check in exceptional circumstances) have been received. A person’s employment history as recorded on an application form should also be checked. The registered person agreed that this information would be forwarded to the CSCI but at the time of writing this report it has not been received. An immediate requirement notice was sent to the registered person on 26/10/07 in respect of this breach of regulation. There must be a training and development plan in place, as well as an individual record of the training achievements and needs of all staff. This must be available for inspection at all times. Improvement plans must be returned to the CSCI within given timescales. The Annual Quality Assurance Assessment (AQAA) must be completed by the registered person as requested, and returned to the CSCI within given timescales. 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 DS0000019726.V362773.R01.S.doc 23/10/07 7. OP29 23/10/07 8. OP30 18 & 19 30/11/07 9. OP31 24A 03/12/07 10. OP33 24 23/10/07 11. OP34 25 30/11/07 St Judes Version 5.2 Page 26 not met. Enforcement action will now be taken regarding this issue. 12. OP35 20 Alternative means must be found 31/12/07 for the holding of service user monies; monies must not be held in the business account of the registered person. Previous timescale of 31/10/07 not met. Records for monies held on behalf of service users must be held and these records must be kept up to date. 23/10/07 13. OP35 20 14. OP37 17Schedul Records required by regulation es 3 & 4 must be kept at the home, including admission/discharge records, recruitment records, resident’s financial records and a duty rota. These must be available for inspection at all times. 23 There must be evidence that the fire alarm system has been serviced by a qualified contractor. An immediate requirement notice was left at the home in respect of this breach of regulation. 23/10/07 15. OP38 24/04/08 St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 27 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. 3. 4. Refer to Standard OP2 OP7 OP7 OP9 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. Monthly reviews of care plans and risk assessments should take place consistently. Service users should be involved in the care planning process. There should be a sample signature held for each person that is trained to administer medication to enable records to be checked. Medication administration records should be signed when residents refuse ‘as required’ medication to evidence that this has been offered to them. 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. There should be a maintenance programme in place. The registered person should pay particular attention to the risk of infection control due to staff undertaking both care and catering duties. The role of each member of staff should be recorded on the rota. There must be plans in place for a registered manager to be in post who has achieved NVQ Level 4 in Care & DS0000019726.V362773.R01.S.doc Version 5.2 Page 28 5. OP9 6. OP12 7. OP15 8. 9. OP19 OP26 10. 11. OP27 OP31 St Judes Management. 12. OP33 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. Staff should receive formal supervision so that they have the opportunity to discuss their concerns and training opportunities with a manager. Testing of the electrical installation is overdue and the registered person should arrange for this work to take place. Staff should receive health and safety training at the time of their Induction, and then on an on-going basis. 13. OP36 14. OP38 15. OP38 St Judes DS0000019726.V362773.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V362773.R01.S.doc Version 5.2 Page 30 - 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. 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