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Inspection on 29/11/07 for St Judes Residential Home For The Elderly

Also see our care home review for St Judes Residential Home For The Elderly for more information

This inspection was carried out on 29th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The registered provider completes a detailed pre-admission assessment, which includes information from healthcare professional where necessary, to ensure that peoples` needs are met at the home, and their admission is well planned. People are well supported in the home by the care staff and healthcare professionals when required. Staff know peoples needs well and treat them as individuals in a caring family run home. The people living in the home enjoy taking part in the local `Golden Age ` club activities and feel part of the local community. The home provides activities and encourages village people to join them. Home cooked food is provided, including a variety of food, which people said they liked. Special diets are provided as required and alternatives to the planned menu are available. The staff group has not changed for many years, providing a stable, experienced and well trained care staff to support people.

What has improved since the last inspection?

The care plan format has changed since the last inspection and is now type written and reviewed monthly. This is easier for people living in the home to read and understand. Since the last inspection the home has been decorated internally, most of the flooring has been replaced and the replacement of windows in the home is complete. The home has new security light outside. The home has started quality assurance monitoring by providing people with questionnaires to find out what they like about the home or want to change.

What the care home could do better:

The care plans are completed on the home`s computer and are regularly reviewed. Minor changes to the recording would ensure that all needs are recorded, all risk assessments are complete and monthly reviews are more meaningful. Medication must be handled with more care, and safe and clean storage provided to ensure safe handling and administration. The communal areas need to be improved to provide more space for people and to maintain a clean environment. The health and safety policy requires updating to help ensure that all people are protected.

CARE HOMES FOR OLDER PEOPLE St Judes Residential Home For The Elderly Front Street Nympsfield Nr Stonehouse Glos GL10 3TY Lead Inspector Kate Silvey Key Unannounced Inspection 29th November & 7th December 2007 11:30 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 Residential Home For The Elderly DS0000016586.V350056.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 Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Judes Residential Home For The Elderly Address Front Street Nympsfield Nr Stonehouse Glos GL10 3TY 01453 860682 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) Mr Paul Anthony Morgan Mrs Winifred Morgan Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate 1 named service user for category LD(E). Condition to be removed when service user leaves the home. 19th April 2006 Date of last inspection Brief Description of the Service: St. Judes is a small, family run care home providing personal care for older people. The accommodation is on two floors. The home does not have a lift so people living on the upper floor must be mobile. All but one room is single occupancy and the majority have en-suite facilities. There are bathrooms on each floor with the ground floor bathroom offering an electric bath hoist to assist with bathing. The communal areas consist of a lounge and dining room. The outside area is accessible, however, service users who have limited mobility will require assistance from the staff in the home to access the steps to the terrace. The fees range for this home is £340.00 to £440.00, this information is available in the Service User Guide. Extras not included this price are newspapers, hairdressing and chiropody. St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The inspection took place over two days with one inspector. All the people accommodated were seen and most were spoken to during the inspection. A visitor was spoken to and staff were interviewed and observed. The accommodation and grounds were seen, including the kitchen and laundry facilities. Records were looked at, which included care plans, medication, recruitment, staff training, and fire safety. The Commission received one completed service user’s survey, two relatives’ surveys, one from the Village Agent and two staff surveys’. An Annual Quality Assurance Assessment (AQAA) of the home completed by the registered provider was sent to the Commission. What the service does well: What has improved since the last inspection? St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 6 The care plan format has changed since the last inspection and is now type written and reviewed monthly. This is easier for people living in the home to read and understand. Since the last inspection the home has been decorated internally, most of the flooring has been replaced and the replacement of windows in the home is complete. The home has new security light outside. The home has started quality assurance monitoring by providing people with questionnaires to find out what they like about the home or want to change. What they could do better: 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 Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 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 Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A detailed pre-admission assessment is completed before admission and healthcare professionals are contacted, where required, to ensure that peoples needs can be met and that the home is well prepared for them on arrival. EVIDENCE: Examples of two pre-admission assessments were seen the records were good covering all the areas for assessment in this standard. It was evident that the registered provider had recorded sufficient detail to include how needs would be met in the home and the person’s lifestyle and preferences. The provider had been in contact with a healthcare professional before one admission and had also contacted CACD to discuss the placement. The provider or manager visits the person to be admitted and also invites them to the home before St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 9 admission to join in with meals and activities enabling them to make an informed choice about living in the home. The home had installed satellite television in one person’s room before admission, as this was a particular enjoyment. The person was spoken to and agreed this was an asset to his life in the home and had been pleased that it was provided before he was admitted. The information regarding fees charged was seen in the current Service User Guide and the provider stated that this information is changed when the fees change. Any extras charged for are added to the information in the Guide. The registered provider agreed to add information to the Statement of Purpose about the two people from the new sheltered accommodation, owned by the provider, accessing the care home facilities during the day for meals or recreation. The provider stated that he had verbally informed recent new service users of the arrangements. St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have a care plan, which is reviewed monthly, and have appropriate healthcare professional support as required to help ensure that their need are identified and met. The homes medication procedures, policies and storage are not good enough to ensure that people are protected. EVIDENCE: Two care plans were looked at in detail and the people were spoken to about their care. The care assessments seen were detailed and risk assessments had been completed, however, hot surfaces had not been included. The provider agreed to review this and include in individual risk assessments. There was evidence that a hot pipe had been covered in one bedroom. St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 11 The format for care plans has been changed and is completed on the home’s computer. All areas of assessment had information on what the persons needs are, there could be more detailed information of how the needs are met for example; continence care should record what type and size continence pads are used and how often people need to be checked or taken to the toilet in some cases (this was raised in the last inspection report). Another example would be caring for an indwelling urinary catheter; this requires more detailed actions particularly regarding infection control. The district nurse has overall responsibility for any catheters, but recorded actions should include when to seek professional advice and what to look for. It is recommended that the manager seeks advice from the district nurse regarding the care plan actions/observation. The AQAA stated that the doctor checks people at the home every three months, a chiropodist visits every six weeks and the district nurse visits weekly. People living at the home said the optician visited the home and they could see a dentist when required. One person spoken to had an appointment for a new digital hearing aid to be fitted. The care plans are reviewed monthly and changes are recorded and a complete new plan printed as part of the review process. It is recommended that the review should record if the care plan actions are working and where changes have been made so that progress or deterioration can be seen and acted upon if required. This was discussed with the provider who helps to complete the care plans with the registered manger. There were good records of what activities people take part in each day and their daily personal hygiene care. The record of health care professional visits was detailed and provided a good picture of what support and treatment people had received. Both people spoken to about their care plans said they were well looked after by kind staff and liked living in the home, but were unaware they had a care plan. The medication is administered using dosette boxes filled by the supplying pharmacist. The home produces their own computerised medication administration records and the details are transcribed from the dosette boxes. The records should be signed by whoever completes the transcribing. There is a clear record of the amount of medication delivered weekly to the home to enable an audit. The administration records had been completed correctly, the home should consider the use of a key for recording for example; refused medication. Any ‘as required’ medication must have a care plan to describe for example in what circumstances it should be given, how many doses, for how long and when the doctor should be informed if required. Medication was left in people’s bedrooms, which included a bottle of tablets and prescribed creams. The prescribed tablets found could be self-medicated, however, there was no lockable storage in the bedroom. The provider agreed to provide the storage to enable the person to self-medicate safely and to keep St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 12 it under review. The creams found were applied by the staff and must be safely stored. A monthly audit should be recorded to check compliance and safe handling and administration of medication that would highlight any poor practice. The latest medication reference book could not be found as the inspector was informed a member of staff had taken it to complete NVQ level 3 studies. It is recommended that information on all medication used in the home is kept in an accessible folder for reference, as good practice. The medication procedure completed in the year 2005 needs reviewing and should include the use of homely remedies. It was recommended that the manager obtain a copy of the Royal Pharmaceutical Society’s Guidance, which can be downloaded from their website. The doctor must agree homely remedies administered and a protocol must be recorded for administration. The medication cupboard was very untidy and required cleaning. Internal and external medication was not stored separately; this must be rectified to ensure safe and hygienic administration. Dirty, named medication pots were found which indicates that administration is not completed correctly. Medication must be taken to the person in the original container and given directly to them, the home may need to provide a secure carrying case for transporting around the home from the medication cupboard with the record of administration. All staff that administer medication have completed an ASET training course the certificates were seen by the inspector. Clearly staff need to be reminded and supervised to ensure the safe handling and administration of medication. St Judes Residential Home For The Elderly DS0000016586.V350056.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 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people living in the home are part of the local community and enjoy outings and activities with the villagers. The home meets people’s social and religious needs and enables them to make choices in how they spend their day. Dietary needs are met providing people with home cooked appetising food, which they enjoy. EVIDENCE: The people living in the home are part of the village community and join in with entertainment and trips provided by the local ‘Golden Age’ club. This includes outings to the seaside and the theatre. Two people attend weekly bingo at a local club. The information provided in the AQAA states that some trips are shortened for people with greater needs to enjoy without any inconvenience. Regular exercise classes take place in the home. Some people go shopping with the staff and one man likes to accompany staff to the local tip. Some evening’s staff buy people a fish and chip supper, which they enjoy. People spoken to said they enjoyed the activities provided in the home and felt St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 14 part of the community, as local people also join them in some of the homes activities. People enjoy regular religious services in the home and it was felt by the provider and the people spoken to that spiritual needs were being met. People spoken said they spend their day how they choose and that visitors were always made welcome in the home. The Village Agent, funded by a government agency, had recently helped people in the home as an advocate dealing with any correspondence when required. It was observed that people are treated with respect and affection by caring staff. The home is hoping to provide more trips out when a mini-bus can be purchased and are also looking into hiring a minibus through a scheme run by the local authority. Since the last inspection a ‘Sky’ dish has been installed so that people in the lounge and another person in his own room can access satellite television programmes. The provider stated there is room with this installation for two more people to have individual satellite access in their rooms if they wish. The meals provided are home cooked and samples were seen of appetising dishes cooked by the staff. Special diets are catered for which currently includes a diabetic diet. The new menus were seen, which cover a two-week period and are rotated. Any changes provided are recorded in the diary, as alternatives are available and people likes and dislikes are known. The size of meals and any dietary requirements are recorded in the care plans. Two people said they have a cooked breakfast. The home also provides meals for two people living in the sheltered accommodations within the grounds. Everyone spoken to were satisfied with the food provided and said for example ‘ I like the food here’ and’ the food is nice and staff will always get me something else if I want’. The provider has a copy of the Commissions report called ‘Highlight of the day’, about improving meals for older people in care homes. The dining room was cluttered and there was only room for six people to eat comfortably. It is recommended that additional dining room seating is provided to enable everyone to eat at the same time if they wish. The room should be tidy and free from clutter to avoid accidents and provide a relaxing room for people to enjoy their meals. During the second day of the inspection the provider had started to organise the dining space. St Judes Residential Home For The Elderly DS0000016586.V350056.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples concerns are listened too and procedures are in place and staff have the knowledge to help safeguard them from abuse. However, some procedures require updating to ensure that current information is available. EVIDENCE: The home has not had any complaints since the last inspection. The surveys said people know how to complain and discussions with people said that the staff deal with concerns straight away. There is a complaints procedure, which requires updating with the correct information about the Commission, and everyone should have their own copy in the Service User Guide, or easy access to one. The home has a policy on the protection of adults from abuse, which includes ‘whistle blowing’; the telephone number for the local Adults at Risk Unit at Shire Hall Gloucestershire should be added to the procedure. It is recommended that the home obtain a copy of the Department of Heath ‘Whistle Blowing’ guidance. The home had a copy of the ‘Alerters’ Guide’ produced by Gloucestshire County Council. The registered provider has completed training in adult protection and passed the information onto staff, he was aware of how abuse can affect people, and St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 16 was able to explain the help given to a person, abused elsewhere, to become more confident in the home. Staff spoken to knew about the need to protect people from abuse. It is recommended that all staff go on the free adult protection training provided by GCC. St Judes Residential Home For The Elderly DS0000016586.V350056.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained but an improvement in the space for people in the communal areas should be addressed. Some areas require additional cleaning to help ensure that people are protected and their dignity is respected at all times EVIDENCE: Since the last inspection the home has been decorated internally, most of the flooring has been replaced, and the replacement of windows in the home is complete. There are also plans to replace the kitchen and cooking appliances soon. The communal areas are cluttered and untidy, and people commented at the last inspection that the home was untidy. As mentioned in Standard 15 the dining area required tidying. The removal of a folding bed for night staff from the dining room to the lounge during the St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 18 inspection did not improve space in the lounge as the homes computer is situated there. The provider agreed to create more space in the lounge as two people from the sheltered accommodation in the grounds often shared the communal rooms. This means that there must be at least twelve easy chairs to accommodate everyone in the lounge. Bedrooms were well personalised, however, one conservatory area leading from a bedroom was piled with belongings and equipment and looked unsightly. A double room requires permanent privacy curtains to help maintain dignity for the two people accommodated there, particularly when using their commodes at night. There were some areas that required an improvement in the cleaning, and they were identified to the registered manager and the provider during the inspection. There were no complaints from people about the cleanliness of their bedrooms. Internal glass in the landing area was dirty as were many windows. Keeping the communal rooms tidy and all areas clean shows respect for peoples dignity and health and welfare, and must be completed correctly. The provider was beginning to make some changes to the environment before the inspection was completed and was positive about continuing to improve the environment for people in the home. People spoken to appeared happy to share their home with the two people accommodated in the sheltered housing. This arrangement must be managed well to ensure that people have control and are consulted about changes that take place in their home. St Judes Residential Home For The Elderly DS0000016586.V350056.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable staff group of experienced and well-trained carers, which help to ensure that people needs are well met. Recruitment checks are completed to help safeguard people. EVIDENCE: There is a stable staff group as all but one person is a family member. The staff rota was not available on the first day of the inspection and the provider was advised that it is a regulatory requirement to maintain a rota. Subsequently a rota was provided, however, this was not a true reflection as on the second inspection day staff were not available as indicated on the rota. During the day there are at least two staff on duty which includes the registered provider or manager, and for the majority of the day from 9.0015.00 hours there are three staff on duty. Some evenings there is only one person on duty, which should be regularly reviewed to ensure that needs can be met at peak times of activity. There is one sleeping night staff who ensures everyone is checked at least twice during the night. There are no ancillary staff as the care staff undertake all cleaning, laundry and catering duties. The staff who complete catering duties have basic food hygiene training, and one carer has relevant catering experience. St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 20 There are seven staff which includes the registered provider and manager who have both completed NVQ level 4 in care and management. One carer has completed NVQ level 3 and another carer is working towards NVQ level 3. There have not been any new staff recruited, and all current staff have an enhanced CRB check. St Judes Residential Home For The Elderly DS0000016586.V350056.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): 31,33,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The experienced management team help to ensure that the home is well run and people are safeguarded. People live in a safe environment, however, health and safety policies require updating to ensure this continues. EVIDENCE: The registered provider is taking over most of the management duties and it is recommended that he becomes the registered manager. A completed application will be required to the Commissions’ Central Registration Team. The home provides questionnaires for the residents and their relatives to complete. Improved menus have arisen from this and the minutes from the St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 22 Golden Age club are distributed and people are able to comment on what activities are included. It was recommended that the positive comments from visiting healthcare professionals be recorded as part of quality assurance information. The registered provider has made many improvements to the record keeping in the home and has updated several policy and procedures seen by the inspector. The registered provider is the appointee for only one person with regard to obtaining personal monies and handles personal monies for one other person. The monies were correct, however, two signatures are recommend when transactions are completed in the home to protect people. Formal staff supervision is not recorded yet, but daily meeting ensure information is passed to staff and training needs are identified in this small staff group. It is recommended that meetings are recorded as part of supervision. The health and safety policy requires updating, as there has not been a review since 2003. It is recommended that each room is individually assessed for risks to each person, and the risk to anyone from hot surfaces is recorded or the risk removed. The fire risk assessment had been completed by agreement with the fire officer’s recommendations, and fire safety records were well maintained including staff training. The home has new security light outside. The provider stated there are no outstanding requirements from Environmental Health. St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 X 3 St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4 Requirement The registered provider must ensure that The Statement of Purpose is kept up to date with information regarding the use of the homes facilities by people in the sheltered accommodation. The registered person must ensure that medication is managed safely and hygienically to ensure that people are protected and can manage their own mediation safely if they wish. The registered person must ensure there is sufficient communal space in the lounge and dining room to meet people’s needs and the areas are kept clean and tidy. The registered provider must ensure that a staff duty rota is maintained correctly. Timescale for action 31/01/08 2 OP9 13 (2) 15/01/08 2. OP19 23 (2) 31/01/08 3. OP27 17 (2) schedule 4 31/01/08 St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 25 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 OP7 Good Practice Recommendations It is recommended that more detailed information is recorded in the care plans to provide good up to date information for care staff and that changes made at reviews can be traced to identify progress made. It is recommended that the complaints procedure is updated to include the correct information about the Commission. It is recommended that all care staff have protection of vulnerable adults training, and that the home has the DoH information on ‘whistle Blowing’. It is recommended that permanent privacy curtains are provided in the double bedroom for peoples dignity at all times It is recommended that the registered provider becomes the registered manager as he has taken over most of the management duties. It was recommended that the positive comments from visiting healthcare professionals be recorded as part of quality assurance information. Two signatures are recommended when personal money transactions are completed in the home, to protect people. It is recommended that staff meetings are recorded as part of supervision. The health and safety policy requires updating, as there has not been a review since 2003. It is recommended that each room is individually assessed for risks to each person, and the risk to anyone from hot surfaces is recorded or the risk removed. 2. OP16 3. OP18 4. OP24 5 OP31 5. OP33 6. 7. 8. OP35 OP36 OP38 St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Judes Residential Home For The Elderly DS0000016586.V350056.R01.S.doc Version 5.2 Page 27 - 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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