Inspection on 18/05/06 for St Judes

This inspection was carried out on 18th May 2006.

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 14/02/07

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 18th May 2006 09:30 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.V293858.R01.S.doc Version 5.1 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.V293858.R01.S.doc Version 5.1 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.V293858.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 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. Fees paid range from £286.80 £366.00 per week. The home currently accommodates seven service users. 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 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.V293858.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken by one inspector over one day; the inspection commenced at 9.40 am and finished at 5.40 pm. The inspection report is based on information gained during and prior to the site visit to the home and as a result of a meeting held with the registered provider/manager on the 17th May 2006. The pre-inspection questionnaire was not returned to the Commission for Social Care Inspection (CSCI) as requested so information supplied by this route could not be included in this inspection report. The site visit consisted of a tour of the premises and examination of documentation, including four care plans. The inspector spoke on a one to one basis with three residents, three visitors to the home and two staff, as well as the registered provider/manager. Surveys were sent to six relatives and four health and social care professionals. Four were returned from relatives and three were returned from health and social care professionals. Comments from one to one discussions and from completed surveys will be included in the report. An additional inspection visit was made on the 10th March 2006. On this occasion the registered provider/manager agreed to an action plan to address several specific areas of shortfall. Some of these areas have been actioned. A complaint concerning staff recruitment and induction practices at the home is currently being investigated by the registered provider/manager. This has not been investigated within required timescales and no outcome had been shared with the complainant or the CSCI at the time of writing this report. A letter was sent to the registered provider/manager immediately following this inspection to ensure that she was clear about those matters requiring urgent attention. The inspector would like to thank service users, staff, visitors and the registered provider/manager for their assistance on the day of the inspection. What the service does well: Care plans continue to be well maintained by staff at the home, although some records that should be retained in the care plan have been ‘filed away’, for example, life histories and previous lifestyles. Staff interviewed by the inspector felt that there is now a good team of staff working at the home. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 6 One service user said ‘the staff are very kind’ and another service user said ‘the staff are very good and the food is very good’. Visitors at the home on the day of the inspection said that the food is good, that service users are well cared for and that the home is clean. Agency staff are included in some in-house training sessions. What has improved since the last inspection? What they could do better: The recording of controlled drugs does not fully ensure the safety of service users. The registered provider/manager must undertake accredited medications training. A service user’s assessed care needs are not continually reviewed and health professionals are not appropriately consulted about a service user’s changing needs. The registered manager has not made a commitment to undertaking 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 staff rota does not evidence that there are sufficient staff on duty to meet the needs of service users accommodated at the home. Recruitment and selection practices are not sufficiently robust to ensure the safety and well-being of service users. Health and safety practices, including the notification of incidents at the home and the testing of water temperatures to control the risk of scalding, are not adequately monitored. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 7 There is no system in place to measure the satisfaction of service users and others with the service provided by the home. Staff do not receive formal one to one supervision so they do not have the opportunity for a private meeting with their manager. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 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.V293858.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are now assessed prior to their admission to the home to ensure that individual care needs can be met. Service users do not have a contract so they have no written information confirming the terms and conditions of their residence. EVIDENCE: All service users have a copy of the service user guide in their bedroom. A contract between the home and the service user is attached. However, the inspector was informed that none of the contracts had been completed and signed by service users or their representatives. The registered provider/manager agreed to have these in place by the 29th May 2006. The records for a newly admitted respite service user were seen by the inspection. These included a full assessment of care needs, a risk assessment and a care plan. Detailed diary sheets had been recorded. The registered St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 10 provider/manager informed the inspector that a copy of the assessment had been sent to the Commission for Social Care Inspection (CSCI) as requested, but it had not been received. The service user and their family visited the home prior to the date of admission and it was decided that the service user’s needs could be met by the home. The registered provider/manager was reminded that service users must be informed (in writing) that their assessed current care needs can be met by the home. Staff have undertaken training on dementia awareness and the protection of vulnerable adults from abuse. This has prepared them to work with vulnerable service users and those with dementia. There needs to be more evidence that staff are able to care for service users with mental health concerns, physical disabilities and sensory impairments. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Care plans do not currently address the health and social care needs of service users to ensure that they are fully met. Service users are not fully protected by the medication administration procedures that are in place. Staff respect the privacy and dignity of service users. EVIDENCE: Care plans include details of any assistance required by service users, a daily living profile (including a service user’s weight and details of hairdressing and chiropody appointments and any visitors seen) and appropriate risk assessments. Diary sheets that are completed during the day are quite detailed, but those during the night are brief and do not record the frequency of checks made by staff or details of any assistance given with care needs. Some care plans do not include details of a service user’s life history or previous lifestyle. Some care plans had been updated but these changes were not dated so were not useful when monitoring a service user’s care needs. Monthly monitoring does take place, but annual reviews had not taken place St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 12 for some service users. There is little evidence that service users are involved in the care planning process. Care plans include details of contact with general practitioners and other health professionals. Details of any pressure care needs and continence care needs are also recorded. One health/social care professional commented that the overall care provided by staff has improved recently, although there were concerns that staff do not have the skills to recognise when a service user’s needs are not being met. Some care plans do not include information about a person’s previous medical history and this results in an incomplete record of health care needs that could lead to these not being met. There is little evidence that the psychological health of service users is monitored and that medical advice is sought when psychological health deteriorates. There is no risk assessment in place for the service user who uses the stairs to access a bedroom on the second floor. The registered provider/manager was required to undertake this task by Friday 26th May and this was achieved. However, the risk assessment does not record full details of identified risks and how these are controlled to safeguard the service user. The four senior carers at the home have undertaken accredited medications training but the registered provider/manager still needs to undertake this training. Controlled drugs are stored appropriately but records need to be improved to ensure that new stock and a running total of stock held is recorded. The medications policy at the home is brief but does now include information about the administration and storage of controlled drugs. Service users confirmed that their privacy and dignity are respected by staff at the home. One service user has a telephone in their bedroom. The inspector observed that service users wear their own clothes at all times. Visitors to the home and health/social care professionals stated that they are able to see service users in private if they wish to do so. Lack of provision of induction training for new staff is a concern and there is little evidence that new staff are instructed on how to treat service users with respect at all times. However, the inspector observed that service users were treated with respect on the day of the inspection. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported to make choices about their day-to-day lives, within their capabilities. Meal provision at the home is good and includes a choice at all mealtimes. Visitors are made welcome at the home. Service users would benefit from some one to one support from staff. EVIDENCE: Some care plans do not include details of a person’s previous lifestyle, interests and preferences. It is therefore not possible to assess whether these continue to be met by the home. Service users are supported to access library services and listen to ‘talking books’. Staff assist service users to care for their pets. The inspector observed that staff respond inappropriately to the behaviour of some service users. For example, one service user was constantly told to ‘sit down’ rather than staff spending time with her to find out what was troubling her or assessing whether she could be better occupied. This could be due to low staffing levels or the lack of skills of the staff group in this specific area of work. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 14 Relatives and visitors to the home state that they are always made welcome. Some relatives correspond with the registered provider/manager and relationships would appear to be good. Service users are able to see relatives, friends and health/social care professionals in a private area of the home. One relative said ‘Meals and drinks are always readily available for any visitors’ and ‘the staff themselves are all friendly and I can feel at ease with any one of them to discuss anything’. Details about advocacy services are available for services users and visitors to the home. Service users are able to make choices within their capabilities. 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. There is evidence that the specific religious needs and wishes of service users are met by the home. One health/social care professional commented that food at the home is poor. On the day of the inspection the meal provided looked appetising and was enjoyed by service users – a choice was offered and accepted by some service users. A visitor commented ‘the food at the home is very good – we are often offered home made cakes’. There is a menu on display that includes a choice of meal and the menu was adhered to on the day of the inspection. Diabetic meals can be catered for. The inspector observed that an ample supply of drinks were 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. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are not investigated in a satisfactory manner and are not recorded appropriately. Any risks of abuse are reduced by the staff training and policies and procedure that are in place. EVIDENCE: There is a complaints policy in place and this is displayed in the home. There is a complaints log in place but this contains no entries. There have been no complaints made to the home over the last year, but complaints have been made to the CSCI that led to investigations under the protection of vulnerable adults procedures, and these are not recorded in the complaints log. The complaint that the registered provider/manager has recently been asked to investigate has not been investigated within required timescales, was not recorded in the complaints record and the complainant is still waiting for an outcome. Three members of staff have undertaken training on the protection of vulnerable adults from abuse. 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. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 16 St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is maintained in a safe and clean condition but more care must be taken to alleviate strong odours. EVIDENCE: There is a maintenance programme in place – the registered provider/manager was reminded that this must be kept up to date. The home was well maintained on the day of the inspection, although the inspector noted that the carpet in the dining room is beginning to show signs of ‘wear and tear’. The garden is enclosed and would benefit from making safe so that service users could spend time in the garden with minimal assistance. An assessment of the premises has now been undertaken by an occupational therapist, whose report states that the home ‘has a good supply of moving and handling and pressure care equipment’. Some equipment needed minor St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 18 repairs and the inspector agreed to check this work had been undertaken at the next inspection. On the day of the inspection one service user who was spending the day in their bedroom did not have access to the nurse call system – this was rectified at the request of the inspector. Some service users have ‘sensor’ mats at the side of the bed so that staff are made aware when they get out of bed so that their safety can be monitored. This must not be used as an alternative to adequate staffing levels. The maintenance programme records that locks are due to be fitted to bedrooms doors so that service users can be offered a key to their door. The registered provider/manager confirmed that this work is due to take place shortly. Screening is available in shared rooms to ensure privacy. Small safes are available for service users on request to enable money, valuables and medication to be stored safely (although none of the current service users are able to manage their own medication). Water temperatures are tested in bathrooms – these are recorded in the bathing records of service users. Tests commenced on water temperatures in washbasins in bedrooms but these ceased in March 2006 and should be reinstated to ensure any risk of scalding is monitored. The laundry room is situated away from the living areas and kitchen area of the home and contains suitable equipment to meet the laundry needs of service users. There are no separate hand-washing facilities for staff in the laundry room. Some cleaning products and equipment are stored in the laundry room – this was locked on the day of the inspection to ensure that service users do not have access. Service users and visitors confirmed that the clothing that belongs to service users is kept clean. The home was clean on the day of the inspection but there was a strong smell of urine in two bedrooms. The staff rota does not identify the hours dedicated to domestic duties. Some staff have recently undertaken training on infection control. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The staff rota does not evidence that there are enough staff on duty to meet the needs of service users. Staff have accessed various training opportunities and have achieved NVQ Level 2 or 3 in Care but induction training is inconsistent. Recruitment and selection procedures are not robust and do not protect service users from the potential to be abused. EVIDENCE: The inspector observed that there was no staff rota in place for the days following the inspection, and the rota was not fully covered for the actual day of the inspection. The registered provider/manager was required to have a rota in place for week commencing the 29th May by Friday 26th May – this was actioned by the required date. However, the rota forwarded to the CSCI did not identify the hours dedicated to catering/domestic duties or the hours worked by the registered provider/manager on managerial duties. It also recorded a shortfall of care staff hours on some occasions. The inspector identified that there have been occasions when there has been no ‘sleep in’ night staff and occasions when a volunteer has been used to in place of a member of staff. The inspector was assured that this would no longer occur. The inspector is concerned about the high number of hours worked by the registered provider/manager covering care shifts – this should not exceed 40 hours per week counted on the rota. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 20 There is evidence that some staff do not undertake appropriate induction training prior to them commencing work at the home. Staff have undertaken several training courses recently, including moving and handling and infection control. However, moving and handling training is still an identified need – this view was supported by a health and social care professional spoken to by the inspector. Most staff have now achieved NVQ Level 2 or 3 in Care. There is a training and development programme in place and some training records for individual members of staff. Some of the training records do not include dates so it is difficult to ascertain if staff training is kept ‘up to date’. An agency worker is occasionally used by the home and this person has been included in some in-house training – this is good practice. There is one member of staff who is primarily employed as a domestic assistant but occasionally works a care shift - appropriate health and safety training has now been undertaken. Recruitment and selection procedures at the home continue to be a cause for concern. Staff have commenced work prior to a CRB check (or a POVA first check) and two written references being in place and this could leave service users open to the risk of abuse. A complaint was received by the CSCI about the recruitment of a new member of staff and this has yet to be reported on by the registered provider/manager. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The home is not well managed and 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. There is no quality monitoring system in place to allow service users and other to express their satisfaction with the service provided by the home. Staff do not receive formal supervision with a manager and this could result in them feeling unsupported. There is a business and financial plan in place that evidences that the home is currently not a viable business, although the finances of service users are managed safely. Health and safety systems, such as the testing of water temperatures and induction training, need to improve to fully protect service users. EVIDENCE: St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 22 The registered provider/manager has many years experience in the caring profession but she has made no progress towards achieving NVQ Level 4 in Care and Management. The registered provider/manager is responsible for the administration of medication on some occasions and has not yet completed accredited medications training, although this is planned. There is no evidence that practice is being kept up to date. One health and social care professional commented ‘the level of care is poor with no leadership from the owner’. The lack of clear leadership from the registered provider/manager 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 provider/manager. There has been no progress made towards establishing a quality monitoring system at the home. The home has developed a survey to be sent out to service users and others but this has not been used to date. The registered provider/manager was advised on how to progress the quality systems at the home in order to measure the level of satisfaction with the service provided. This should result in an annual development plan. Staff meetings continue to be held – a record is kept of staff meetings and these evidence that staff are able to make suggestions that contribute towards the well-being of service users and the running of the business. There is now a business and financial plan in place at the home, although this had to be requested by the CSCI on several occasions before the request was complied with. This plan evidences that the business is currently not viable without financial input from the registered provider/manager. It is anticipated that this situation will not improve until more service users are admitted to the home. The business and financial plan must be reviewed annually and must be available at all times for inspection. There was no current insurance certificate in place on the day of the inspection. The registered provider/manager contacted the insurance company whilst the inspector was at the home to confirm that the home is adequately insured. The registered provider/manager agreed to forward a copy of the insurance certificate to the inspector but this has not been received. Financial transactions made on behalf of service users are now recorded in a satisfactory manner. These are held on a database and a running total of money held on behalf of service users is included. The registered provider/manager does not act as appointee for any service users. The previous acting manager devised a satisfactory staff supervision system but this had not been continued by the registered provider/manager. The registered provider/manager showed the inspector documentation recording one supervision session per staff member – these were not signed by either party and were not dated. Staff spoken to informed the inspector that they have not had one to one supervision with the registered provider/manager. A programme must be developed to ensure that staff receive formal one to one St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 23 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. Some health and safety checks had not been undertaken consistently, for example, the testing of water temperatures in bedrooms, the testing of water temperatures at the boiler (to control the risk of Legionella) and the general health and safety check. Safe working practice topics are in place for bathing and the use of the kitchen. These should be extended to include all safe working practice topics. The nurse call system was tested in July 2003 but there is no record of a test since then. 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 these are still current. The fire risk assessment needs to be updated. An annual fire test (including servicing of the fire extinguishers) took place in September 2005. Records show that in-house weekly fire alarm tests and monthly fire drills are being maintained on a regular basis. Fire training last took place in August 2005. There is a current gas safety record in place and bath hoists and the passenger lift have been appropriately maintained. Some health and safety training has taken place over the last few months but arrangements for induction training must improve. Accidents are recorded appropriately but the CSCI are not notified of incidents under Regulation 37 of the Care Homes Regulations 2001 as is required by legislation. The inspector agreed to send information about the need to notify the CSCI of incidents that affect the well-being of service users to the registered provider/manager again. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 1 3 2 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 3 X X 3 X 2 2 1 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 3 2 X 1 St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 25 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 OP2 Regulation 5 Requirement Each service user must have a contract or statement of terms and conditions in place with the home. There must be a risk assessment in place for any service users that use the stairs. Formal reviews of care plans must take place for all service users, including those who are self-funding. There should be evidence that service users are involved in the care planning process. Care must be taken with the dating of records. All staff who administer medication must undertake accredited medications training. Controlled drugs must be recorded correctly. Previous timescale of 31/12/05 not met. The registered person must adhere to the complaints procedure in place at the home. All complaints must be recorded in the complaints log. The outstanding complaints investigation must be concluded and the complainant must be DS0000019726.V293858.R01.S.doc Timescale for action 29/05/06 2. 3. OP7 OP7 15 15 26/05/06 18/05/06 4. OP9 13 and 18 31/08/06 5. OP16 22 26/05/06 St Judes Version 5.1 Page 26 6. OP26 16 7. OP27 18 8. OP29 18 and 19 9. OP38 18, 23 and 37 10. OP38 18, 23 and 37 informed of the outcome. The home must be kept free from offensive odours. The laundry room must include handwashing facilities for staff. There must be a satisfactory staff rota in place that records all staff on duty each day, and in what capacity they are employed. There must be sufficient staff on duty at all times to ensure the safety of service users. Two written references and a satisfactory CRB check (or POVA first check) must be obtained prior to staff commencing work at the home. This includes volunteer staff. Volunteers must not be used to replace staff. Previous timescale of 10/03/06 not met. The Commission must be informed about incidents at the home that affect the well-being of service users. All staff must receive health and safety training as part of their induction to the home. The call system must be serviced and the electrical installation must be tested. There must be an updated fire risk assessment in place and evidence of this must be forwarded to the CSCI. 18/05/06 26/05/06 18/05/06 18/05/06 30/06/06 St Judes DS0000019726.V293858.R01.S.doc Version 5.1 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. Refer to Standard OP4 Good Practice Recommendations Service users should be informed in writing that their care needs can be met by the home. There should be evidence that staff are able to assist those service users with mental health concerns, sensory impairments and physical disabilities. More care should be taken with the monitoring of health care needs for service users, and health/social care professionals should be involved appropriately. Information about a service users medical history must be included in care plans. Staffing levels should allow for staff to spend one to one time with service users. Records should include details of a person’s previous lifestyle and hobbies/interests. There must be sufficient staff on duty to ensure that the preparation of meals does not leave service users at risk due to the lack of supervision. Bedroom doors must be lockable and service users must be offered a key to their bedroom door. The system in place to record water temperatures in washbasins must be consistently maintained. New staff must undertake induction training that meets Skills for Care specifications. Training records should be dated so that the training achievements and needs of staff are accurately monitored. 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 by the home is measured. There should be an annual development plan in place and evidence that policies and procedures are regularly reviewed. The business and financial plan must be reviewed annually and must be open to inspection at all times. A copy of the current insurance certificate must be forwarded to the Commission for Social Care Inspection. The staff supervision system that has been developed DS0000019726.V293858.R01.S.doc Version 5.1 Page 28 2. OP8 3. 4. 5. 6. 7. OP12 OP15 OP24 OP25 OP30 8. 9. OP31 OP33 10. OP34 11. St Judes OP36 12. OP38 must become fully operational to ensure that staff receive adequate one to one supervision. The work undertaken to provide written statements about the organisation of safe working practices should continue until all safe working practice topics are included. St Judes DS0000019726.V293858.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Judes DS0000019726.V293858.R01.S.doc Version 5.1 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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