Inspection on 23/10/07 for St Judes

This inspection was carried out on 23rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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

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 23rd October 2007 10:30 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.V354164.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.V354164.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.V354164.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st May 2007 Brief Description of the Service: St Judes is a privately owned care home that is registered to provide care and accommodation for fourteen service users (male and female) who are over 65 years of age, including those with dementia. Four 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. The home is required to undertake a risk assessment to evidence that any residents using the stairs to the second floor are safe to do so. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home on the 1st May 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 10.30 am and ended at 4.00 pm. On the day of the site visit the inspector spoke on a one to one basis with a member of staff and the registered provider/manager, as well as chatting to all residents and other available staff. Inspection of the premises and close examination of a range of documentation, including four 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 as required by regulation. Survey forms were not used on this occasion; the inspector spoke to health and social care professionals involved with the home to discuss their opinion of the care provided there. Anonymised comments from discussions with residents, staff and health care professionals will be included throughout the report. Two random inspections were undertaken in August 2007; the first was undertaken to follow up information received by the CSCI from Social Services that resulted in a Safeguarding Adults strategy meeting being held. The second was a follow up inspection. Information obtained at both of these inspections will be referred to in this report. What the service does well: Meal provision at the home is good; this was confirmed by service users on the day of the site visit. There is a choice at all meal times and the individual requirements of service users are met. One service user told the inspector, ‘they do very good meals’. Daily records are a thorough record of the care needs of service users and how these are met by staff. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Medication policies and procedures are not adhered to by staff at the home, and some staff that administer medication have not had appropriate training. This leaves residents at risk of harm from errors I the administration of their medicines. Bruising and other marks seen on residents are not investigated and the appropriate authorities are not informed of these observations; this leaves residents vulnerable to the risk of abuse. There is a risk that potential abuse would not be investigated. Staff do not spend sufficient one to one time with service users undertaking leisure activities. 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 that is in place is not a true reflection of the actual staff on duty and there is no evidence that the home is always fully staffed. 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. Some experienced staff have left the home and there is no evidence that new 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 did not return the Annual Quality Assurance Assessment form, as required by regulation and there is no staff supervision system in place. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 7 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. Records required by regulation were not available at the time of the site visit to the home. These included a record of admissions and discharges, recruitment records and training records. The registered person did not know what information these records contained. 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. 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.V354164.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.V354164.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. People have a current assessment of needs in place that is updated monthly. Poor recording results in there being no current record of people admitted to the home. EVIDENCE: The registered person informed the inspector that no new residents have been admitted to the home since the last random inspection in August 2007. The book used to record new admissions and discharges could not be found on the day of the site visit – the manager said that this had been taken by the Police as part of an investigation, and that they had not started a new record. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 10 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 all residents have a current contract in place between themselves and the home. When a person’s care is being funded by the local authority, community care assessments and care plans are obtained from care management as part of the assessment process. New assessments have been undertaken for the four residents living at the home; these are a thorough record of a person’s strengths, needs and care requirements. These assessments had been reviewed every month since August 2007. St Judes DS0000019726.V354164.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 poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are maintained in a satisfactory manner but 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: There are care plans in place for all residents and care plans had been reviewed each month up to August 2007; the registered person must ensure that care plans are reviewed consistently. Care plans are based on the home’s own assessment and any assessment received from care management. There is no evidence that residents are involved in the care planning process, although they have attended care plan reviews that have been arranged by care management. Care plans include a record of any contact with health care professionals, including the reason for the visit and any outcome. Pressure care and St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 12 continence care are areas covered in the home’s assessment, and there is evidence that appropriate equipment is obtained for people when needed. No record of a person’s weight was seen by the inspector on the day of the site visit, although the registered person contacted the inspector afterwards to inform us that there was a record of a person’s weight in all care plans. This is used as part of nutritional screening. No fluid or food intake charts are in use but daily records do sometimes record the food and fluid intake of residents. Each care plan includes a ‘body map’ to record incidences of bruising, scratching etc. The inspector noted that there are regular entries for some residents and asked the registered person if these could be as a result of poor moving and handling practices by staff. This was denied but, when asked, the registered person could not produce records of moving and handling training for staff. The inspector examined medication administration records and noted that one person had not received prescribed medication for over a week and that there were some gaps in recording. The registered person was not able to offer an explanation as to why this was the case. There is a record of sample signatures for those staff that have responsibility for the administration of medication but there is no evidence that some of these staff (including the registered person) have undertaken accredited training. According to the staff rota, there have been some days recently when none of these people have been on duty yet medication records are still signed. The inspector was informed at the last inspection that one new member of staff that has not completed accredited medications training no longer has responsibility for the administration of medication. However, on the day of the site visit the inspector noted that this member of staff had recorded in daily diary notes that they had given someone two paracetamol tablets. On checking, the inspector found that this resident was not prescribed paracetamol by their GP, and there is no record of how these tablets were obtained. An immediate requirement notice was issued to the registered person following the site visit in respect of breaches of regulation regarding the administration of medication. The inspector observed on the day of the site visit that residents were treated with respect by staff and that their right to privacy was upheld. Staff were seen to speak to residents in a sensitive way about personal care needs and to knock on doors before entering. St Judes DS0000019726.V354164.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 have sufficient time or inclination to assist residents to participate in social activities, especially trips out of the home. EVIDENCE: The new 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. Any visitors seen by residents are also recorded in care plans, although visitors to the home are infrequent. On the day of the site visit a member of staff had brought some nail varnishes into the lounge; one person had already had their nails painted and another declined to have their nails painted. The inspector suggests that this activity should be expanded to include other aspects of hand care, i.e. to have a hand massage or hand cream applied. Two residents were in need of seeing a hairdresser; the inspector was told that staff now take people out to have their St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 14 hair done as the hairdresser no longer visits the home. No diary entries were seen to support this. Details about advocacy services are available for services users and visitors to the home; these were displayed in the entrance hall. Service users are able to make some choices within their capabilities. However, the inspector observed that choices offered are very limited. For example, service users can choose to remain in their bedroom or to spend time in the lounge, and are able to choose from a variety of meals on offer. The inspector asked residents what they were going to be having for lunch and one person said that ‘they never knew’ but that ‘the food is always good’. On the day of the site visit there was no menu on display and the inspector observed that there is no standard menu in place; 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. The inspector observed that residents are offered appropriate assistance with eating and drinking. There is no cook employed at the home so care staff have to prepare meals. 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 meal was chicken tikka masala with cabbage, cauliflower and mashed carrot, followed by fresh fruit or yoghurt. The registered person told the inspector that the menu for tea was going to be macaroni cheese, sandwiches and buns. St Judes DS0000019726.V354164.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 result in residents being protected from harm. EVIDENCE: The complaints procedure is displayed in the entrance hall and the registered person told the inspector that there is a complaints form in every bedroom. The complaints log could not be found on the day of the site visit. The registered person did not return the AQQA form as requested, so there is no record of how many complaints have been received since the last key inspection of the home. No complaints have been received by the CSCI since the last inspection of the home. On the day of the site visit a Social Worker visited the home to discuss with the registered person an allegation that they had received. This was an allegation made by a visitor to the home that a resident had an ‘unexplained’ black eye. The inspector examined care records and noted that the black eye had been recorded but that no-one had informed Social Services, the person’s relative or their GP of this unexplained injury. The registered person informed the inspector that she believed that this resident had caused the injury herself by ‘holding her head in her hands’ - the inspector observed this behaviour on the day of the site visit and did not believe that it could cause such an injury. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 16 One other allegation has been investigated since the last key inspection of the home. This resulted in a strategy meeting under safeguarding adult’s protocols being arranged by Social Services. The outcome of the strategy meeting resulted in daily monitoring of the home by Social Services staff. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 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. 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: The inspector toured the premises and observed that the resident that occupied a room on the second floor has moved to the first floor, so no longer has to use the stairs. One bedroom carpet was very stained and needs to be replaced, and there were slight odours in two bedrooms. There is no maintenance programme in place but there is now a repairs and maintenance record in use; this records minor repairs that have been undertaken. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 18 One of the lounge areas has a door that opens into the garden. However, 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 cold, apart from in the main lounge, where the gas fire was in use. All residents were seated it the main lounge so they were keeping warm. However, to enable people to move around the home comfortably, all areas of the home should be maintained to an adequate temperature. A hand washbasin has still not been fitted in the downstairs bedroom. The registered person has recorded in the improvement plan that this work will be included in the annual development plan; there is no annual development plan in place as yet so no timescale has been identified for this work to be undertaken. The work to ensure that water temperatures are controlled in hand washbasins in bedrooms and bathrooms is still to be completed. However, there are some safeguards in place such as notices to alert people to hot water and ‘push down’ style taps, so people cannot be exposed to prolonged contact with hot water. Laundry facilities provided by the home are satisfactory. 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. Those staff that were present on the day of the site visit told the inspector that they had not had this training. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 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. 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 evidence that staffing levels at the home are sufficient to care for and protect residents. There is no plan in place to show how National Vocational Qualification (NVQ) qualifications will be achieved, and recruitment and training records were not available for inspection. This results in there being 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: The staff rota was examined by the inspector; this is an incomplete record and does not evidence that there are always two staff on duty. Shifts worked by the registered person, the care manager and the prospective provider are not always recorded on the rota and these people do not complete a time sheet; this makes it impossible to check their attendance at the home. 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 new staff have been recruited. Some of the new members of St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 20 staff are unqualified and this has resulted in the home no longer meeting the requirement for 50 of staff to have achieved NVQ Level 2 or above in Care. Recruitment records were not available for new staff employed so the inspector could not check their training achievements or qualifications. Because recruitment records were not held at the home, the inspector was not able to check that application forms had been completed, that two written references had been received and that a satisfactory Criminal Records Bureau (CRB) check (or POVA first check, in exceptional circumstances) had been obtained for all new staff employed. The registered person was told that recruitment records must always be held at the home. The absence of training records and recruitment records resulted in the inspector 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.V354164.R01.S.doc Version 5.2 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. 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 or demonstrate competence and staff do not receive regular supervision; this results in a lack of a clear sense of direction for staff, and could impact on the quality of service provided to service users. The quality monitoring system is not fully developed so does not allow service users the opportunity to affect the way that the home 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.V354164.R01.S.doc Version 5.2 Page 22 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 at the home. The registered person is intending to sell the home and the prospective purchaser and prospective manager are currently working at the home on a voluntary basis. The registered person was reminded that she is responsible for all management decisions until the prospective provider goes through the registration process with the CSCI and becomes the registered person. The registered person did not return the AQQA form 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 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. No progress has been made towards opening a bank account for the person whose personal allowance is currently being paid into the business account of the home. The timescale for completion was 29/05/07 and this has now expired. No new financial records have been kept for transactions made on behalf of residents since the records were seized by the Police; new records should have been started from this date. The registered person told the inspector that she is currently not able to invoice relatives for purchases made on behalf of service users due to the lack of written records. She 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 a 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 inspector noted that one resident had died since the last inspection of the home. The CSCI had not been notified of this death under Regulation 37 of the Care Homes Regulations 2001. In this instance it was important for the St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 23 CSCI to be informed, as there had been a post mortem. Other records that are required by regulation were not available at the home, such as recruitment records, training records and financial records. The inspector asked to see accident records; these records met with the needs of the Data Protection Act but were not held in a person’s care plan. Accident records should be held in a person’s care plan so that there is a full record of a person’s needs in one place. It was noted that there were about ten recent accident records for one resident and the inspector suggested that the registered person should be seeking further advice about this person’s care. 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 fire equipment at the home has been tested by a qualified contractor. 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 determine if new staff were recruited in a safe way, or whether they did training on health and safety topics at the time of their Induction. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 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 1 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 1 1 2 1 2 St Judes DS0000019726.V354164.R01.S.doc Version 5.2 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. 2. Standard OP3 OP37 OP8 OP18 Regulation 13, 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. The registered person must put safe systems in place for ensuring medicines are only given to people for whom they have been personally prescribed and only then strictly according to the directions of the prescriber. An immediate requirement notice has been sent to the home on 26/10/07 in respect of this breach of regulation. DS0000019726.V354164.R01.S.doc Timescale for action 23/10/07 23/10/07 3. OP9 13 and 18 30/11/07 4. OP9 13 and 18 23/10/07 St Judes Version 5.2 Page 26 5. OP9 13 and 18 6. OP9 13 and 18 7. OP24 16 8. OP25 23 9. 10. OP27 OP29 17 Schedule 4 19 11. OP29 19 All staff that administer medication must first undertake accredited training. An immediate requirement notice was sent to the home on 26/10/07 in respect of this breach of regulation. Medication that has been prescribed by a GP must be given to residents. If this is refused by a resident, further advice must be sought. A hand washbasin must be provided in the ground floor bedroom. Previous timescales not met. There must be some form of temperature control on hot water outlets in all bedrooms used by residents to control the risk of scalding. Water temperatures should continue to be tested and recorded. Previous timescales not met. 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. Recruitment and selection records must be available at the home for inspection at all times. DS0000019726.V354164.R01.S.doc 23/10/07 23/10/07 30/11/07 30/11/07 23/10/07 23/10/07 23/10/07 St Judes Version 5.2 Page 27 12. OP30 18 & 19 13. OP33 24 14. OP34 25 15. OP35 20 16. OP35 20 17. OP37 17 Schedules 3&4 18. OP37 37 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. 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 not met. Enforcement action will now be taken regarding this issue. Alternative means must be found for the holding of service user monies; monies must not be held in the business account of the registered person. Previous timescale of 31/10/07 not met. Records for monies held on behalf of service users must be recorded and these records must be kept up to date. Records required by regulation 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. The CSCI must be notified of any deaths that occur at the home. 30/11/07 23/10/07 30/11/07 31/12/07 23/10/07 23/10/07 23/10/07 St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Refer to Standard OP2 OP7 OP7 OP9 OP9 OP12 OP15 OP16 OP19 OP26 OP26 OP27 OP28 OP30 OP31 OP33 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. Service users should be involved in the care planning process. Care plans should be reviewed consistently. There should be a sample signature held for each person that is trained to administer medication to enable records to be checked. More care should be taken to ensure that there are no gaps in recording on medication administration records. 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 complaints log in use and this should be available for inspection at all times. There should be a maintenance programme in place. The home should be free from unpleasant odours. 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 should be an action plan in place to record how 50 of staff will achieve NVQ Level 2 in Care. There should be a training and development plan in place and this should be available for inspection at all times. There must be plans in place for a registered manager to be in post who has achieved NVQ Level 4 in Care & Management. There should be a quality monitoring system in place that gives service users and others the opportunity to affect the way in which the home is operated. The system should include an annual development plan and the updating of policies and procedures. DS0000019726.V354164.R01.S.doc Version 5.2 Page 29 St Judes 17. 18. 19. OP36 OP38 OP38 The staff supervision system that has been developed must become operational to ensure that staff receive adequate one to one supervision. Testing of the electrical installation is overdue and the registered person should arrange for this work to take place. Staff should receive health and safety training at the time of their Induction. St Judes DS0000019726.V354164.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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