Inspection on 19/07/07 for St Kitts

This inspection was carried out on 19th July 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 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 Kitts 25/07/06

St Kitts 09/02/06

St Kitts 10/05/05

St Kitts 14/12/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

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 Revelstoke 88 Promenade Bridlington East Yorkshire YO15 2QL Lead Inspector Diane Wilkinson Key Unannounced Inspection 19th July 2007 10:15 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 Revelstoke DS0000062592.V346600.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. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Revelstoke Address 88 Promenade Bridlington East Yorkshire YO15 2QL 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 678253 Pennine Care Services Ltd. Mrs Julie Thomson Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users admitted for respite care in the category (DE(E)) and OP is limited to a maximum of four (4) service users at any one time. 25th July 2006 Date of last inspection Brief Description of the Service: Revelstoke is a care home that is owned by a small private company; it is registered to provide care and accommodation for a maximum of 22 older people, including four people at any one time for respite care. It is situated close to the seafront at Bridlington, in the East Riding of Yorkshire and is close to local amenities including transport, shops, health care and leisure facilities. Private accommodation is provided in eighteen single and two shared rooms; six of these have en-suite facilities. Communal accommodation is provided in a large lounge and a dining room, and there is a patio area at the front of the property. Some private accommodation consists of two rooms, one that is used as a bedroom and one that is used as a sitting room. This enables service users to spend their day in their private accommodation if they choose to do so. All areas of the home are accessible to service users via the provision of a passenger lift and ramps. Information about the home is provided in a statement of purpose and a service user’s guide; these inform service users and others about the scope and nature of the care and facilities on offer. The registered manager informed the inspector that fees charged are between £310.20 and £355.00 per week, and that chiropody, hairdressing, transport and outings are not included in this fee. Revelstoke DS0000062592.V346600.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 Key Inspection of the home on the 25th July 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.15 am and ended at 4.30 pm. On the day of the site visit the inspector spoke with four residents, a member of staff and the registered manager on a one to one basis, and chatted to other service users, staff and the registered provider. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The manager submitted information about the service in advance of the site visit by completing and returning an annual quality assurance assessment. Survey forms were sent out prior to the inspection; two were returned from relatives. Comments from returned surveys and from discussions with service users, staff and others were mainly positive, such as, ‘the food is excellent’ and ‘staff cannot do enough to help’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. A random inspection was undertaken on the 22nd June 2007 following receipt of a complaint about the home. The findings of this inspection are included in this report. The registered provider was sent a report following the random inspection and requirements and recommendations were made; the report will be made available on request to members of the public and other enquirers. What the service does well: Service users are assessed prior to their admission to the home and only admitted if their assessed needs can be met. Staff were seen to talk to service users sensitively regarding personal care needs and when offering assistance with eating and drinking. Service users are supported to retain their independence and encouraged to maintain their chosen lifestyle. Meal provision at the home is good; this was confirmed by service users on the day of the site visit. The home is clean, well maintained and comfortably furnished. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 6 The home is well managed; the registered manager listens to suggestions about how to make improvements to the home and acts upon any requirements made. Health and safety is promoted at the home by the systems in place and via staff training. What has improved since the last inspection? What they could do better: Medication is not currently stored in a secure area of the home, where the temperature can be controlled; medication must be stored at a temperature that meets the Royal Pharmaceutical Society guidelines. Not all staff that administer medication have had accredited training. This is needed to ensure that they are able to undertake this task safely. Recruitment and selection of staff is not robust and this could leave service users in a vulnerable position. Service users are not currently provided with a lockable facility in their bedroom; this would ensure that they can hold their own money securely. Please contact the provider for advice of actions taken in response to this Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 7 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. Revelstoke DS0000062592.V346600.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 Revelstoke DS0000062592.V346600.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): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: The inspector checked the care records for three service users, including those for a service user that was recently admitted to the home. It was observed that a thorough assessment of needs is completed for service users prior to their admission to the home. This assessment includes risk assessments for pressure care, nutrition, safety, moving and handling plus a risk assessment for the service user’s bedroom. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 10 The home is registered to take a maximum of four service users for respite care and records and discussions with service users and staff evidence that this service is provided on a regular basis; many service users return to the home to have subsequent respite stays. Some service users who decide to live at the home on a permanent basis have previously had respite care at the home. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are met in a way that respects their privacy and dignity. Medication practices at the home are improving but are still not robust and do not fully protect the safety of service users. EVIDENCE: The inspector examined the care records of three service users; all of these included a photograph of the service user to assist new staff with identification and to assist the emergency services should a service user become missing from the home. Care plans seen by the inspector were based on the assessment undertaken by the home and, in some instances, community care assessments/care plans provided by care management. Care plans for service users funded by a local authority had been reviewed formally by care management, and records evidenced that service users attended their review if they wished to do so. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 12 Those service users that are privately funded had not had a formal review of their care plan and the registered manager agreed that these reviews would be introduced. Both relatives that returned a survey said that they are kept informed of important issues affecting their relative and that the care home meets the needs of their relative. Two of the care plans examined by the inspector included written risk assessments in respect of the risk of falls, moving and handling, pressure care and nutrition. The care plan for a newly admitted service user had these documents in place but they had not been completed by staff. Service users are weighed as part of nutritional screening and weights are recorded in individual care plans. Staff record a daily account of the care provided to service users. Visits from health care professionals, including the reason for the visit and any outcome, are recorded in individual care plans. Care plan records evidence that any concerns regarding pressure care are recorded and that continence care is promoted. One care plan included a blood pressure monitoring chart, as this was an area of concern for the individual service user. The Commission for Social Care Inspection (CSCI) pharmacist inspector undertook a random inspection following the receipt of a complaint regarding the administration of medication. Since this inspection some improvements have been instigated by the registered provider, i.e. separate storage and recording documentation for controlled drugs, checks on the administration of medication by the registered manager and recording on medication administration records. The inspector observed the administration of medication on the day of the site visit and noted that service users were provided with a drink with which to take their medication. The medication administration records have been divided to improve security and there is a photograph of each service user to aid identification. The inspector noted that medication administration records were signed as medication was taken from the cabinet and not when it was actually taken by service users. Medication administration records should signed as evidence that service users have taken their medication. Also, medication was left on the dining table for service users to take with their meal; this is unsafe practice as other service users could take this medication in error. This was discussed with the registered manager on the day of the site visit and she agreed that staff would be informed of the importance of these issues. Other than this, medication administration records had been completed in a satisfactory manner. The medication trolley is attached to the wall in one of the lounges; this should be relocated to a safer area where the temperature of the environment can be monitored and to improve security. Since the random inspection, controlled drugs have been removed from the medication trolley and are stored in a Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 13 secure, locked area – there is also a separate system for recording the administration of controlled drugs; the inspector observed that records included two staff signatures and a ‘running total’ of medication remaining. There is no separate fridge for the storage of medication that requires a cool temperature, such as antibiotics. A separate fridge must be provided for the storage of medication; temperatures would have to be taken and recorded on a daily basis. The inspector examined the records for medication returned to the pharmacist and these were found to be satisfactory. However, the pharmacist does not currently provide the home with a copy of the returns form and the registered manager agreed to request this in future. Records seen on the day of the site visit evidence that staff had some medications training in March 2005. There is no evidence that this was accredited training. The registered manager agreed that all staff that administer medication would have refresher training that is accredited. Sample signatures are held for staff that administer medication to enable administration records to be checked. Since the random inspection of the home, the registered manager has started to carry out audits of the medication system. She observes members of staff whilst administering medication and checks all associated records. These checks are recorded on a monitoring form; monitoring forms were seen by the inspector at the time of the site visit. The inspector observed that staff respected the privacy and dignity of service users. They used the service user’s preferred name, and knocked on doors before entering. Staff were seen to talk to service users sensitively regarding personal care needs and when offering assistance with eating and drinking. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 14 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to make choices about their day-to-day lives and are encouraged to retain their level of independence. Meal provision at the home is good with a choice of meal being provided at all mealtimes. EVIDENCE: Care plans record the previous lifestyle of service users, including leisure and social interests and likes and dislikes. Daily diary sheets record activities undertaken by service users, such as visitors seen, visits outside of the home and ‘sitting in the sunshine on the patio’. When asked, ‘Does the care service support people to live the life they choose’, both relatives that responded in a survey said ‘Usually’. Two people that use the service told the inspector about trips out of the home to do shopping and go to the pub. One person told the inspector about their key worker and their role, in this instance, taking care of laundry and repairing clothing. A friend of one of the residents drives the home’s mini bus and takes those service users that like to go out on regular trips. Another member of staff takes service users out in her car as part of her day to day duties. Key workers record a monthly summary of events in each Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 15 care plan. The inspector observed on the day of the site visit that staff spend one to one time with residents on their chosen activities, including chatting. Discussion with service users and information seen in care plans evidenced that those service users that have friends and relatives are supported to remain in contact with them, and that their visitors are made welcome by staff at the home. Details about advocacy services are made available to services users and visitors in the information booklet displayed in the entrance hall. Service users are able to make choices about where and how to spend their day and where to take their meals, and are encouraged and supported to retain their level of independence. Some service users have a bedroom and a small lounge, and use their accommodation more like a flat than a bedroom. Service users are encouraged to bring some of their personal items into the home. The inspector observed the serving of lunch on the day of the site visit. A three-course meal is provided each lunchtime and the meal provided looked appetising; service users told the inspector that they had enjoyed it. A relative recorded in a survey, ‘The food is excellent’ and a resident told the inspector that the food is excellent and that they are always offered a choice. Another resident told the inspector that they have a cooked breakfast every morning, and that they thoroughly enjoy it. There was no menu on display; a menu would encourage service users to become involved in meal provision at the home and may encourage conversation. All service users had their lunch in the dining room on the day of the site visit and they chatted to each other and to staff. The inspector noted that service users were offered appropriate assistance with eating and drinking, and observed that an ample supply of drinks was made available during the day. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 16 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about how to make a complaint is provided but staff should ensure that this is fully understood by service users and others. There are appropriate policies and procedures in place on safeguarding adults and the training undertaken by staff has increased awareness of safeguarding adult’s procedures and reduced the risk of abuse occurring. EVIDENCE: The home’s complaints procedure is displayed in the entrance hall. There is a complaints log in place but this has no entries, as no complaints have been made to the home. One complaint has been made to the CSCI since the last inspection of the home. A random inspection of the home was undertaken to investigate the complaint, and action has been taken by the registered manager to rectify some of the areas of concern that were identified. More information is included in the ‘Health and Personal Care’ section of this report. Of the two relatives that completed a survey, one said that they were aware of the complaints procedure and the other said that they were not. Residents told the inspector that they were not aware of the complaints procedure, but that they would have no hesitation in speaking to the registered manager or Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 17 other members of staff if they did have a concern or a complaint. Two residents told the inspector that they had never had any need to complain, but that they were confident that any complaints would be dealt with in a satisfactory manner. The registered manager should ensure that service users and others are made aware of the complaints procedure and how to use it. There are appropriate policies and procedures in place on safeguarding adults, and training records seen by the inspector evidence that all staff, including the registered manager, have undertaken training on safeguarding adults. Some of this training was undertaken a few years ago and the registered manager should consider arranging refresher training. A member informed the inspector that they would not hesitate to tell the manager if they observed any inappropriate behaviour or practices from colleagues. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 18 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, 21, 23, 24 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides comfortable and homely accommodation. The home is maintained in a clean and hygienic state but is compromised by the lack of hand washing facilities in the laundry room. EVIDENCE: There is no maintenance programme in place but there is a maintenance book in use; staff record any repairs that need to be done and the maintenance person undertakes these repairs and records when the work has been completed. All areas of the home are decorated in a homely and comfortable fashion with good quality furnishings and fittings, and service users are encouraged to bring small items of furniture and photographs and ornaments from home. One service user told the inspector that they thought their Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 19 bedroom was due for redecoration. There is a patio area at the front of the building and service users enjoy sitting out. One relative commented that the open plan design of the home is not ideal for service users, and that service users complain of ‘draughts’ – the relative felt that doors should be re-hung to prevent this. They also commented that, when the boiler broke recently, it took a long time to be repaired. The registered provider should note these comments. Accommodation at the home is provided over three floors and there is a passenger lift to enable access for service users. All bedrooms have en-suite facilities and some of these include the provision of a shower. Service users told the inspector that this promoted their independence, as well as privacy and dignity. There is a small sitting/dining room on the first floor of the property that is sometimes used when service users have a relative staying to have a meal with them. Private accommodation for some service users is provided as a bedroom and a small sitting room. This enables service users to use their accommodation as a flat, and suits the needs of some service users, especially those having respite care at the home. Laundry facilities are situated in the cellar and the equipment provided in the laundry room is satisfactory. However, facilities need to be provided so that staff can either wash or disinfect their hands. There were no offensive odours on the day of the site visit and all areas of the home were clean. Domestic and catering staff are employed at the home and this enables care staff to concentrate on personal care duties; this helps to control the risk of cross infection. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 20 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home employs sufficient care and ancillary staff to fulfil the care needs of service users. The recruitment and selection of staff is not robust and this leaves service users in a vulnerable position. Staff have attained qualifications and undertaken training programmes, although induction training is not completed within recommended timescales. EVIDENCE: There is a staff rota in place and this evidences that there are always two care staff plus the manager or the deputy manager on duty at the home up to 5.00 pm. There are two staff on duty from 5.00 – 10.00 pm and throughout the night. There is a cook (who also works as a senior carer) on duty most days and a domestic assistant on duty six days per week. The registered manager was advised to add the hours worked by the manager or the deputy manager to the staff rota so that there is always a full record of the actual staff on duty. Staff recorded on the rota were seen to be on duty on the day of the site visit. Eleven care staff are employed at the home and over 50 of care staff have achieved NVQ Level 2 in Care. There is a training and development matrix in place at the home; this evidences that all staff have undertaken health and safety and moving and handling training, and those staff that have worked at the home for some years have had refresher training. The registered manager Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 21 informed the inspector that six staff are undertaking infection control training and that nine staff are due to attend fire safety training on the 23rd July 2007; this was confirmed by staff on the day of the site visit. The training and development matrix records that all staff have undertaken Induction training. A new member of staff confirmed that they had undertaken in-house ‘orientation’ training and had done a ‘shadowing’ shift with a senior carer prior to commencing work at the home, and that they are due to commence Skills for Care induction training shortly. The registered manager should note that staff should undertake induction training within six weeks of commencing work. The recruitment records for a new member of staff were examined by the inspector. These indicated that the member of staff had commenced work prior to a POVA first check being received, and that a CRB check had still not been received. Two written references had been obtained for this employee, but one had arrived after their start date at the home. This is unsafe practice and could place service users at risk of harm. Two written references and a satisfactory CRB check must be in place prior to staff commencing work at the home. POVA first checks should only be used in exceptional circumstances, and staff must be supervised at all times until a full CRB check is received. An application form is used and copies of any training courses undertaken prior to employment are requested and retained by the home. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 22 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 and 38 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. The home is well managed and suggestions made to the registered manager to improve the service are acted upon. Quality monitoring systems allow service users and others to affect the way in which the service is operated. The health, welfare and safety of service users is protected although some improvements need to be made to financial systems to improve the security of service user monies. EVIDENCE: The registered manager has the qualifications, experience and skills to carry out her role. All service users spoke highly of the registered manager and other staff at the home. Staff said that they felt well supported by the manager, and records evidence that they receive regular supervision and Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 23 appraisals. Following the recent random inspection of the home, the registered manager quickly actioned suggested changes to the medication system to ensure that the health and safety of service users is protected. Those requirements not yet actioned have been considered by the registered manager and there are plans in place to carry out the required work and changes to systems. The registered manager keeps her practice up to date by attending in-house training courses alongside staff. The home has recently achieved QDS Part 1 (the local authority’s quality scheme) and are planning to apply for Part 2. A residents and relatives survey was distributed in June 2007 – the registered manager plans to complete a ‘residents/relatives satisfaction survey analysis form’ and to talk to service users on a one to one basis about the outcome of the survey, and any actions taken. A chart displayed on the office wall records that residents, care staff, senior carers and managers have a meeting six times per year – this was confirmed by service users and staff on the day of the site visit. An agenda is circulated and minutes of the meetings are recorded and distributed. The inspector recommends that the outcome of any surveys undertaken should be published so that all participants and interested parties are made aware of the outcome of the survey and any actions taken as a result. The registered manager informed the inspector that service user monies are paid into Pennine Care Services Limited account, and personal allowances are withdrawn and held at the home; this has been agreed with the local authority that commissions the service although it does not meet guidance issued by the Commission. Personal allowances and associated records were examined by the inspector and found that there were minor discrepancies. It was discovered that this was because ‘small change’ is returned to the safe, rather than being retained by service users. The inspector recommends that, once cash has been handed to service users, any change from this is held by service users; service users must be provided with a lockable facility in their bedroom to hold money safely. Records held include money paid in, money withdrawn, a running total and signatures, and receipts are retained. Some service users have quite large amounts of money in the homes safe – the registered manager agreed to make enquiries about opening an individual bank account for these service users. All health and safety documentation was examined by the inspector on the day of the site visit; there is evidence that the fire alarm system, the passenger lift and the bath hoist have been serviced appropriately. In-house tests of the fire alarm system and monthly tests of the call system take place consistently, and there is a fire risk assessment in place. Water temperatures are tested on a regular basis in bathrooms but not in bedrooms – the registered manager informed the inspector that the boiler is set to 43°C for all bedrooms and that there are hot water signs in place. The inspector recommends that water outlets in bedrooms are tested (and recorded) on a regular basis to assist in controlling the risk of scalding for service users. There has been no test of the Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 24 water system to detect the presence of Legionella present and the registered manager agreed to ensure that the water was tested. The electrical installation was tested in December 2004 and related documentation records that this is due for a further test after 5 years. Accident recording meets the needs of the Data Protection Act but the inspector noted that the registered manager notifies the CSCI of deaths but not accidents and incidents at the home. It was agreed that the CSCI would be notified of any accidents that require medical intervention. The registered manager must take more care to ensure that all recruitment documentation is in place prior to staff commencing work at the home. The registered manager has provided a written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments. Training records evidence that most staff have undertaken health and safety training. Documentation is in place on the Control of Substances Hazardous to Health (COSHH) and staff have had appropriate training. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 25 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 3 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 3 X 3 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 4 X 3 X 2 X X 3 Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement The registered person must ensure that all staff authorised to handle and administer medicines have been appropriately trained and assessed as competent so that they can handle and record medicines safely. Previous timescale not met. The registered person must ensure the medication policy and procedures are updated regularly so that staff are always working to current good practice guidance. Previous timescale not met. The registered person must ensure that all medicines are stored securely at the temperature recommended by the manufacturer so that they are safe to use. Previous timescale not met. Two written references and a satisfactory CRB check must be in place prior to staff commencing work at the home. Service users must be provided with a lockable storage facility to DS0000062592.V346600.R01.S.doc Timescale for action 31/10/07 2. OP9 13(2) 30/09/07 3. OP9 13(2) 30/09/07 4. OP29 18/19 19/07/07 5. OP35 16 31/08/07 Revelstoke Version 5.2 Page 27 6. OP38 37 enable them to hold money safely. Any accidents that require medical intervention should be reported to the CSCI. 19/07/07 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. Refer to Standard OP7 OP9 OP9 Good Practice Recommendations A formal review of the care plan for privately funded service users should be held. A copy of the returns form for medication returned to the pharmacist should be retained by the home. Staff should sign administration records when service users take their medication, not when it is taken from the medication trolley. Medication should not be left on the dining table for service users to take, as there is a danger that this could be taken by other service users. A menu should be displayed to encourage independence and to promote conversation. There should be a complaints log in place, and service users and others should be made aware of how to make a complaint. The registered manager should consider arranging refresher training for staff on safeguarding adults. Hand washing or disinfecting facilities should be provided in the laundry room to promote infection control. The hours worked by the registered manager and the deputy manager should be recorded on the staff rota so that there is a full record of the actual staff on duty. Staff should complete Induction training within 6 weeks of commencing work at the home. The outcome of satisfaction surveys, and any action taken as a result, should be published. Bank accounts should be opened for service users that have large amounts of money in the homes safe. ‘Small change’ should not be returned to the safe but retained by service users to ensure that financial records held at the home are correct. Water temperatures at outlets in bedrooms should be DS0000062592.V346600.R01.S.doc Version 5.2 Page 28 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. OP15 OP16 OP18 OP26 OP27 OP30 OP33 OP35 OP35 OP38 Revelstoke tested to control the risk of scalding for service users. The water system within the home should be tested to detect any presence of Legionella. Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 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 Revelstoke DS0000062592.V346600.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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