Inspection on 02/02/06 for St Judes

This inspection was carried out on 2nd February 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 18/05/06

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 2nd February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Judes DS0000019726.V280381.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.V280381.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.V280381.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 2005 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. Accommodation at the home is provided in single and shared 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 smokers lounge. There is a garden at the rear of the property, which is safe and secure. 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.V280381.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of seven hours, including preparation time for the inspector. The inspection included a tour of the premises and examination of documentation, including care plans. The inspector spoke to several service users, the staff on duty and the registered manager. There are currently seven service users accommodated at the home. What the service does well: What has improved since the last inspection? What they could do better: Recruitment practices must become more robust to ensure the safety of service users. There must be a formal staff supervision system in place to give staff the opportunity to have a one to one meeting with a manager. The testing of water temperatures should be ‘risk assessed’ to ensure that the risk of scalding is controlled. Monthly fire drills must take place every month. St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 6 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.V280381.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The lack of a full assessment of needs prior to admission could result in a service user’s current care needs not being met by the home. Staff training and experience indicate that the current needs of service users can be met. EVIDENCE: There have been no new service users admitted to the home since the last inspection. Current care plans include a daily living profile, appropriate risk assessments, task sheets (these record what tasks a service user can do unassisted and what they need help with) and a care plan. More staff training has been taking place at the home than in previous inspection periods. Medications training has been undertaken by all staff and several care workers now achieved NVQ qualifications. Two staff have undertaken first aid training and all care staff have undertaken training on the protection of vulnerable adults from abuse. Staff are now better equipped to meet the needs of prospective and current service users. The registered manager was reminded that new service users should be informed in writing that their current care needs can be met by the home. St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 9 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 and 9 Service users need to be more involved in the care planning process to ensure that their wishes are recorded and carried out. Care plans evidence that the health, personal and social care needs of service users are met. The systems for the administration of medication are good but some improvements are needed to policies and procedures to ensure consistency. EVIDENCE: Each service user has an individual care plan in place. These set out in detail the care needs of service users and the level of assistance needed from staff. Care plans include risk assessments that are appropriate to the service user and include the risk of falling, pressure care and ‘mood swings’. Monthly summaries of care plans are now been recorded. There is no evidence of formal reviews being held for service users to fully reassess the care plans that are in place. There is no evidence that service users are aware of their care plan, although some relatives are aware– a relative has written the life history for one service user. There is evidence that care plans are updated when changes are made, for example, changes in medication. Some other changes are not recorded – one service user used to spend the day in the bedroom but now spends most of the day in one of the lounges – this change had not been St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 10 recorded in the person’s care plan. Care plans have been obtained from the commissioning authority. Some documentation that is in place in care plans has not been completed, for example, weight charts and details of personal assistance required. All contacts with GP’s and other health professionals are recorded, including any outcomes. The risk of developing pressure sores is risk assessed and any equipment that is needed is provided. Appropriate continence care is provided by the home. Daily diary sheets record a person’s food and fluid intake and how the service user has spent their day. Staff that administer medications have either completed or are undertaking accredited training – one carer has achieved the award, two carers are waiting for their results and two care staff are in the process of enrolling. All staff have undertaken the ‘Safe Handling of Medicines’ training with the pharmacist. There is a medications policy in place but this does not include information about controlled drugs. There is a policy in place for self-medication and this includes a risk assessment. There is a medications fridge at the home but it is currently not in use. St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 11 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): None EVIDENCE: St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 12 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 There is a procedure in place that is readily available to service users and visitors to enable them to complain. Staff are aware of and follow policies and procedures that are in place to protect vulnerable service users from abuse. EVIDENCE: There is a satisfactory complaints policy and procedure in place. This is included in the hallway and in the service user guide, which is placed in each service user’s bedroom. There is a complaints log in place and this records that there have been no complaints since the last inspection. There are suitable policies and procedure in place that are designed to protect service users from abuse, such as whistle blowing, management of violence, restraint, gifts and hospitality and the protection of vulnerable adults from abuse. The latter two of these policies have been discussed at a staff meeting - this is evidenced in meeting minutes. Four staff attended training on the protection of vulnerable adults from abuse on the 8th December 2005 and the remaining care staff are due to attend. St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 13 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): 22, 24 and 25 A specialist assessment of the premises is needed to confirm that the premises are suitable for the service users accommodated. Work is being undertaken to ensure that service users can be offered a key to their bedroom door to promote privacy and independence. Service users are not sufficiently protected from the risk of scalding. EVIDENCE: There has been no assessment of the premises by a suitably qualified person but the manager has agreed to arrange this. Moving and handling equipment has been provided, both in communal and private areas of the home. Pressure mats are provided for some service users so that staff are alerted when they get out of bed – this enables staff to monitor service users during the night who are at risk of falling. Service user’s bedrooms are personalised to suit their wishes and are furnished to meet their individual needs. The maintenance programme records that locks are being fitted to bedrooms doors in bedrooms so that new and existing St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 14 service users can be offered a key to their bedroom – this work is expected to be completed by the end of February 2006. Screening is available in double rooms to ensure privacy. There are small safes available for service users should they wish to hold money, valuables or medication in their bedroom. Rooms are centrally heated and heating can be controlled in a service user’s own room. All radiators are covered to protect service users from the risk of burning. All bedrooms have opening windows and allow access to fresh air and sunlight. A test to detect the presence of Legionella in the water system was carried out in September 2005 and the result was negative. Water temperatures are tested in bathrooms each time someone is assisted with a bath but similar tests do not take place in washbasins in bedrooms. All service users require assistance with washing and bathing so it is unlikely that they would use the washbasins unaided. Some of the taps have to be pressed down to work and only a short jet of water is released. The provider needs to undertake a risk assessment to evidence that the risk of service users scalding themselves is controlled and minimised. There is now a maintenance person employed at the home. St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 15 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 There are sufficient staff on duty to meet the needs of service users living at the home. Staff are trained and competent to do their jobs. The home’s recruitment practices must be more robust to ensure that the safety of service users is protected. EVIDENCE: The staff rota records all staff on duty, including ancillary staff. The role of each worker is recorded. The rota evidences that there are sufficient staff on duty to meet the needs of service users. One of the domestic workers ‘acts up’ as a care worker – there must be evidence that this person has undertaken Skills for Care induction training and moving and handling training within two months from the date of the inspection. She has already attended training on fire safety and food hygiene. There are six care staff employed at the home – two care staff have achieved NVQ Levels 2 and 3 in Care and three care staff have achieved NVQ Level 2 in Care. Another care worker has enrolled for NVQ Level 2 in Care training. The requirement for 50 of care staff to achieve NVQ Level 2 in Care has been met. Recruitment and selection at the home falls short of current requirements. The recruitment records for a new staff member were examined by the inspector. These evidence that a POVA first check has been applied for but not yet received. The staff member concerned had a CRB check undertaken at her St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 16 previous post in December 2005. There was no evidence of two written references being received. The application form in use by the home records a person’s employment history and details of training and qualifications achieved by the applicant. There is no evidence that information is obtained by the home and then retained (such as copies of passports and birth certificates) to confirm identification. There is now an effective training and development plan in place. Induction training is arranged for new staff at the home. NVQ training is promoted and this has resulted in 50 of staff achieving NVQ qualifications. Four staff attended vulnerable adults training on the 8th December, 2005 and five staff have either completed or are undertaking accredited medications training. All care staff have attended a basic medications training course. All staff have an individual training record and training certificates are retained by the home. St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 17 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, 33, 34, 35, 36 and 38 The home is being managed effectively but consideration needs to be given to the requirement for managers to hold appropriate qualifications. The quality assurance system needs to be further developed to enable service users and other stakeholders to affect the way in which the home is operated. The lack of a business and financial plan makes it difficult to assess financial viability. Health and safety practices need to improve to ensure that the wellbeing and safety of service users is protected. EVIDENCE: The registered provider is also registered as the manager of the home. She is skilled and experienced but has not achieved NVQ Level 4 in Care or Management. A new member of staff has been appointed as the proposed register manager. She has commenced training at NVQ Level 4 and has many years experience of working in the caring profession. The registered provider St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 18 needs to arrange for this employee to apply to the Commission for Social Care Inspection for registration in due course. There is a quality assurance policy in place and staff meetings are held. Quality audits and questionnaires have been developed ready to distribute to service users and visitors. These systems have now to be put into practice to enable the quality of the service provided by the home to be measured internally. There should also be an annual development plan in place. Some new policies and procedures have been developed but there should be evidence that existing policies and procedures are reviewed regularly to ensure that they remain relevant. There is no business and financial plan in place at the home. Following a meeting with East Riding of Yorkshire Council, the Commission for Social Care Inspection (CSCI) and the registered provider, a business and financial plan was requested. This has yet to be forwarded to the CSCI. Without this, it is difficult to assess the financial viability of the home. Records are now held for financial transactions that take place on behalf of service users. These need to be improved so that a ‘running total’ is included and must be kept up to date. The registered manager agreed that financial transactions for the month of January would be up to date by 17.2.06. A staff supervision system was developed by the previous manager but these meetings have lapsed. There must be a formal staff supervision system in place to enable staff to have a one to one meeting with a manager six times per year. Ancillary staff should also be offered formal supervision – the frequency of these meetings should be decided by the registered manager. Risk assessments for safe working practice topics have commenced but these should continue until all safe working practices are recorded. There is appropriate documentation in place to enable this task to be undertaken. Fire training took place in July 2005. In-house tests on the emergency lighting system and fire alarm system are up to date. An annual inspection of the fire alarm system and fire equipment was undertaken by a qualified contractor in September 2005. There is a fire risk assessment in place. The last monthly fire drill took place in June 2005. An immediate requirement notice was left at the home stating that a fire drill must take place by 4.2.06. A weekly health and safety checklist has been devised – this has not yet been put into use. St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 19 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 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X 2 X 3 2 X STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 1 2 1 X 1 St Judes DS0000019726.V280381.R01.S.doc Version 5.1 Page 20 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 OP29 Regulation 18 & 19 Requirement Two written references and a satisfactory CRB check (or POVA first check) must be obtained prior to staff commencing work at the home (previous timescale of 29/09/05 not met). There must be a business and financial plan in place at the home that is open to inspection and reviewed annually (previous timescale of 31.12.05 not met). There must be a formal staff supervision system in place that includes supervision for ancillary staff. Monthly fire drills must take place every month. An immediate requirement notice to this effect was left at the home. Timescale for action 02/02/06 2. OP34 25 03/03/06 3. OP36 17 31/03/06 4. OP38 23 02/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. St Judes Refer to Good Practice Recommendations DS0000019726.V280381.R01.S.doc Version 5.1 Page 21 1. Standard OP3 2. 3. OP4 OP7 4. 5. 6. 7. 8. 8. 9. OP8 OP9 OP22 OP25 OP27 OP31 OP33 10. 11. 12. OP35 OP36 OP38 There must be evidence that prospective service users are assessed prior to their admission to the home - this assessment should be based on information gained from care management and/or the homes own assessment. The home should confirm to new service users that their current assessed needs can be met. Formal reviews of care plans must take place for all service users, including those who are self-funding. All documentation included in the care plan should be filled in. There should be more evidence that service users are involved in the care planning process. Weighing service users and recording their weight would add to the effectiveness of nutritional screening. Policies and procedures for the administration of medication should include information about controlled drugs. The registered person should demonstrate that an assessment of the premises has been carried out by a suitably qualified person. A risk assessment must be carried out to evidence that water temperatures are controlled to minimise the risk of scalding. The domestic assistant should undertake Skills for Care training and moving and handling training to ensure that she is equipped to work care shifts. 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 and evidence that policies and procedures are regularly reviewed. Financial records for service users must be kept up to date. These need to be expanded to include a ‘running total’. The staff supervision system that has been developed 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.V280381.R01.S.doc Version 5.1 Page 22 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. 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