Inspection on 05/07/07 for St Lawrence Residential Home

This inspection was carried out on 5th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Lawrence Residential Home 06/07/06

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 St Lawrence Residential Home 102-104 Oswald Road Scunthorpe North Lincs DN15 7PA Lead Inspector Janet Lamb Key Unannounced Inspection 5th July 2007 09:50 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 DS0000065182.V346020.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. DS0000065182.V346020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Lawrence Residential Home Address 102-104 Oswald Road Scunthorpe North Lincs DN15 7PA 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) 01724 847082 01724 845327 Ajay Kumar Jebodh Priscilla Devi Jebodh Sharon Shaw Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places DS0000065182.V346020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 Brief Description of the Service: St Lawrence Residential Home is situated close to the town centre of Scunthorpe within easy reach of local amenities. It is registered to provide care and support to twenty-four service users in the category of older people. The home consists of two Edwardian brick built houses extended over two floors, serviced by a through floor lift and stairs. The home has ten single and seven shared bedrooms, all with en-suite facilities. There are two bathrooms with toilets, both of which are assisted, and a walk-in shower room. In addition there is a single toilet facility. All are strategically placed for ease of access to service users. There is a large lounge separated into three individual sections incorporating one large and one small seating area and a dining area. The latter has four separate dining tables to seat four to six people at each. Leading on from the larger seating area is a conservatory with easy chairs and coffee tables and an additional staff room. There is a small well-maintained garden to the rear of the building and car parking space for approximately eight cars. Overall the home has a comfortable, homely feel and is generally well maintained. According to information received from the home on 05/07/07 their weekly fees are between £327.00 and £345.00. Items not included in the fee are toiletries, hairdressing, chiropody and transport. Information about the services the home provides is kept in each of the service users bedrooms. DS0000065182.V346020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of St Lawrence Residential Home has taken place over a period of time and involved making a request for information in May 2007 concerning service users and their family members, as well as staff and details of the home’s policies, procedures and practices. The manager obtained the Commission’s ‘annual quality assurance assessment’ form from their web site and sent the completed form and information electronically to the Commission in June 2007. Unfortunately survey questionnaires were not sent out to service users and their relatives in time to return them before the site visit and so these, along with staff questionnaires, were taken to the home on the day of the site visit. This took place on 05/07/07. Service users, visitors and the home manager were interviewed. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with all bedrooms, though not all service users’ permission was obtained. The manager and two service users were interviewed, and the registered provider, three staff and four visitors were briefly spoken to, to obtain information and opinions of the service provided in the home. Staff practices in moving and handling, administration of medication and assisting service users at lunchtime were observed, as was the interaction between service users and service users and staff. Questionnaires were handed out although non were received until after the site visit. All of the information obtained during the year and running up to the site visit, as well as afterwards in one service user’s and four relatives’ questionnaires was used to make a judgement on what it must be like living in the home. What the service does well: Service users are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication well and staff are appropriately trained in medication administration. DS0000065182.V346020.R01.S.doc Version 5.2 Page 6 Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. Service users enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. Service users are confident their complaints will be listened to and acted upon. Service users are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. Service users experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the needs of service users. The manager runs the service in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? What they could do better: DS0000065182.V346020.R01.S.doc Version 5.2 Page 7 The service could obtain ways of monitoring the weight of service users unable to stand so that all service users’ health is monitored and they know their needs are being met. The service could continue to encourage staff to undertake the recognised training or equivalent to achieve more than 50 with the award, so service users know they are in safe hands. The service could make sure all staff have completed annual mandatory training and any other identified training and that the record of training shows names and dates, so that service users know they are cared for by trained and competent staff. The service could make sure staff use the lifting equipment to assist all those service users identified and risk assessed as requiring it when assisting them to move, so service users know their health, safety and welfare is promoted and protected. 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. DS0000065182.V346020.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 DS0000065182.V346020.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 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their individual and diverse needs well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. EVIDENCE: Service users and the manager spoken to and viewing of files with service users’ permission reveals placing authorities carry out assessments of need before service users become resident in the home, and the manager carries out a second assessment once they are resident. Areas covered take into consideration religion, culture, race, sexuality, gender, disability etc. DS0000065182.V346020.R01.S.doc Version 5.2 Page 10 Service users said, “Yes, I can remember having a social service assessment done, but I don’t know about a care plan. I was in hospital when details were taken.” Another said, “My assessment was done a long time ago, I’ve been here almost eleven years.” Both were happy for their files to be viewed. Two files seen contained one community care assessment document for one service user and nothing else. The manager explained that the person admitted eleven years ago had the original assessments archived some years ago, and the person with one assessment document was admitted in an emergency and the manager was not in post at that time. Two more service users’ assessment documents were viewed as evidence that the process is followed. These people were admitted since the manager has been in post. Service users or relatives had signed documents that were seen in agreement with their content. The home has a service user guide and a statement of purpose, which are held in service users’ rooms and given to prospective service users. One relative that filled out a questionnaire thinks the information held in these is a little scattered and needs to be more compact. The manager explains that the service user guide is to be reviewed. Perhaps this opinion can be considered when it is reviewed. On the day of the site visit there were three people visiting to view the home before they decided on agreeing to have their mother admitted from hospital. The prospective service user had already spent a respite stay in the home. Family visiting were relieved to have a place for their mother, rather than have her stay in hospital. The manager spent time with them and answered their questions about the home. DS0000065182.V346020.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 receive good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so their overall quality of life is good. EVIDENCE: Discussion with service users and the manager, and viewing of care plans reveals service users continue to have their personal and health care needs well represented in a care plan, which is carefully followed by the carers, and shows how needs are met. Care plans take into consideration any special differences because of religion, disability etc. that have already been assessed. DS0000065182.V346020.R01.S.doc Version 5.2 Page 12 There is a comprehensive list of areas that are covered within the care plan, including personal care, mobility, nutrition and weight, medication, social and mental needs, communication, finances etc. which is reviewed every month and review notes recorded. There is a daily diary record maintained and service users’ documents contain signatures where possible. The home is still unable to weigh those service users that cannot stand so the requirement set at the last key inspection remains a requirement of this key inspection. There is a medication administration policy and procedure for staff to follow and this includes self-medication. Service users say they are happy with the medication arrangements, which involve the home ordering, receipting and administering of drugs to them. One service user said, “I take lots of medicines. I don’t look after them, but I’m very happy with that. I’ve just finished taking two lots of antibiotic, and still use some cream. I do that myself.” Systems are robust for ensuring service users are safe with the medication arrangements, there are risk assessments in place and staff follow the procedure and instruction given in training. The home uses a pre-prescribed card administration system. Staff were observed administering drugs and practice was good. The staff training record shows staff have undertaken a safe handling of medication course with Grantham College and Lloyds Pharmacy within the last 10 months and new staff completed this in February 2007. Medication administration record sheets seen were accurately completed and were only signed after the drugs had been administered to service users. All service users spoken to or observed during the site visit say and show that they feel their privacy and dignity is being upheld. Staff observed were discreet wherever possible and they demonstrate good understanding of service users’ needs and preferences. Service users said, “Staff help bath me and do it how I like,” and “I don’t need much help with care, but what help I do get is alright. I just can’t bath myself. The staff are good really.” No relatives or service users made adverse comments about any of these areas related to health and personal care. Outcomes in this section are good and standards are well met. DS0000065182.V346020.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 good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users enjoy flexible routines, good contact with relatives and friends, good opportunities to be self-determining, and highly satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Discussion with service users and the manager and viewing of daily diary notes and records relating to activities etc. reveal service users’ daily lives are as busy as they want them to be and according to their choice and preference. Service users spoken to explain they are able to make choices about rising, going to bed and whether or not they want to engage in activities, etc. One said, “I help fold napkins for meal times, I like knitting and talking to my friend. We’re knitting blanket squares for a puppy dog at the moment, and we’ve done some Scunthorpe United scarves. The hairdresser calls every week and I get visits from my family. I’ve just had a new granddaughter delivered.” DS0000065182.V346020.R01.S.doc Version 5.2 Page 14 They have the opportunity to undertake social pastimes in the home and out in the community. Service users say they enjoy watching the weddings that take place at the church across the road, take walks into town shopping, go to the local cemetery, watch television, do quizzes and discuss the past with staff. The manager had purchased an activity CD-Rom from which games, puzzles etc could be printed. Service users also do bingo in the home and enjoy birthday parties and other seasonal occasions. Those less mobile or with cognitive difficulties are less active but still join in with such as group quiz as was seen on the day of the site visit. Television is a constant feature in the lounge, but seems to provide more of a background noise than a meaningful activity. There is an open day planned for the end of July and the theme is to be ‘St Trinians,’ where staff and visitors can dress up if they wish. An entertainer is also booked for the event. Contact with relatives and friends is encouraged and they are made welcome when they do visit the home. One service user said, “I go out with my family in the wheelchair and I like going shopping best.” One relative was observed visiting and appeared to be enjoying the visit and the semi-privacy she had in the lounge. There was no issue around having the visit in front of other service users. Service users’ diary notes show that their social and community interests are undertaken at their own choosing and according to their preferences. Meal provision is generally to the liking of service users. They say they find the food to be “not bad, but not particularly brilliant either,” although some say they do get foods of their choice and that deviate from the typical English cuisine. There are no service users of a different nationality living in the home at the moment, but the manager gave assurances that foods would be provided to any diverse culinary needs that service users have, if at all possible. One service user said, “We get good food here, I like curry and had that yesterday. We also get foods like spaghetti Bolognaise and I like that as well.” There were no adverse comments on questionnaires about food provision and everyone observed at the mid-day meal appeared to enjoy the quiche, mashed potatoes, mixed vegetables and gravy or the bacon option and fruit sponge and custard at lunch time. One service user was given a second pudding on request, and two were assisted with their food at the second meal sitting. Mealtime is a social event, all service users sitting around one large, long dining table close to the kitchen, and those requiring help being provided with it discreetly after the rest. The manager and the cook compile the menus after seeking likes etc. from service users and asking their opinion of what should be provided. DS0000065182.V346020.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 good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so service users are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: Discussion with service users and the manager and viewing of the home’s complaint and safeguarding adults’ records show the policies and procedures and practices of the home are well followed. Service users spoken to and relatives in questionnaires express the view that they know how to complain, know who to talk to and feel confident their views will be listened to and acted on. One service user said, “If I were unhappy about anything I would tell Sharon the boss. She’s a good boss.” Another said, “If I had a complaint I would go to Sharon, I don’t worry about telling anyone.” Staff were observed to be dealing with service users’ care needs and minor problems as they arose. DS0000065182.V346020.R01.S.doc Version 5.2 Page 16 The complaint record shows only one complaint in the last twelve months because of spoiled clothing in the laundry. This was dealt with appropriately. Two anonymous complaints received at the Commission in August 2006 were about two staff being ‘off-hand’ with a named service user. An investigation by the local authority revealed no service users felt they had been poorly treated or spoken to. On the day of the site visit the Inspector observed two care staff lifting a nonweight bearing service user without the aid of the hoist. See the section on ‘Management and Administration.’ The safeguarding adults’ record in the home shows no allegations over the last twelve months, but discussion with the manager established that one staff has been dismissed and another is likely to be dismissed because of their actions. The manager was fearful that NL Council would find nothing for this staff member to answer to and that the person would return to work. There have been a number of anonymous complaints and allegations in May and June 2007, which imply that service users are being physically abused because of poor attitude to their needs and because of rough handling. These issues were passed to NL Council to investigate and to consider as safeguarding adults’ issues. The outcome of these allegations was checked with an officer at NL Council, soon after the site visit and the following was established. There was no evidence available or detected to show any of the allegations had taken place. DS0000065182.V346020.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 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have a well-maintained, safe, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: Discussion with service users and viewing of some parts of the home reveals the premises is satisfactory for its stated purpose of providing care and accommodation to older people and everywhere is clean, comfortable and well maintained. Communal areas of the home were viewed and all sixteen bedrooms were seen, but not all with service users’ permission. These are satisfactorily DS0000065182.V346020.R01.S.doc Version 5.2 Page 18 furnished and decorated and are very personalised. There are 10 single rooms and 6 double rooms. Bathrooms, toilets and the hairdressing room were also seen and these are satisfactory in respect of cleanliness and maintenance. Service users spoken to are satisfied with the cleanliness of the home, their rooms and the opportunities they have to mix with different people in the lounge/dining room. Meal times are a social event. Equipment such as grab rails, lifting belts, sliding sheets. Kitchen tools etc. are in place to enable those service users with mobility and disability problems to remain independent. There is a passenger lift and a mobile lifting hoist available to staff and service users. There are also grab rails and ramps and personal equipment such as frames, sliding sheets etc. On the day of the site visit the Inspector observed two carers lifting a service user without use of the hoist equipment. See the section on ‘Management and Administration.’ DS0000065182.V346020.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 good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users are cared for by well-recruited, well-trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy an excellent service of care. EVIDENCE: Discussion with the manager, viewing of staff files with their permission and inspection of records and documents kept reveals there are sufficient staff on duty, they are appropriately recruited and they are satisfactorily trained. The calculated Residential Staffing Forum figures requires 399.97 hours per week for 3 high, 3 medium and 11 low dependency service users. One roster shows there are 434 care hours provided each week. Staffing hours are satisfactory and there are sufficient staff employed to meet the needs of service users. Of the 14 care staff employed in the home two have achieved the required qualification at level 2 and five are completing it. The two staff with level 2 are also doing level 3. Another two staff will begin the course in September 2007. This gives the home exactly 50 of care staff with or nearly with the DS0000065182.V346020.R01.S.doc Version 5.2 Page 20 recognised training. One staff has completed a Teaching Certificate and is soon to take up the role of staff trainer. There is a recruitment and selection policy and procedure for the management to follow. Staff files contain the documents required in regulation 19, schedule 2, in respect of identification of staff, a security check and their references and declarations of fitness and health. Files also contain such as contracts, interview checklists, job descriptions and induction records etc. Staff training has recently been audited and a new matrix is in place to cover courses to be updated and to do anew. These include moving and handling refresher as well as the Mental Capacity Act and Employment law awareness, which will be new to staff. A training record shows that over the last twelve months staff have done fire awareness, first aid, moving and handling, health and safety, food hygiene, safe handling of medication, vulnerable adults, loss and bereavement, dementia, care planning and infection control. Unfortunately the record does not show which staff has completed which training or exactly when. This needs to be recorded in greater detail showing which staff did which training and on what date. DS0000065182.V346020.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 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service, and where their financial interests are safeguarded and their health, safety and welfare are usually well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with the manager reveals she has achieved the NVQ level 4 Registered Manager’s Award and has three years experience as the manager of the home. DS0000065182.V346020.R01.S.doc Version 5.2 Page 22 The home maintains a quality assurance system, which involves surveying service users, relatives, staff and health care professionals that visit. Information is collated and formatted in graphs. The systems have yet to be reviewed so no report has been written or sent to the Commission yet. The standard is met. The home has the council’s Gold Award Standard. Discussion with service users and the manager and viewing of records held on finances reveals service users are satisfied with the arrangements for the handling of their finances. Most have family members that take the responsibility and ensure service users have a nominal amount of money held in the home, which is recorded in and out of safekeeping and a running total maintained. Receipts are kept against any expenditure. Two checks were undertaken with permission from service users, though one did not have anything in safekeeping, the other had, and this was correctly recorded and balanced against the record. Discussion with the manager and viewing of records, documents and certificates reveals there are safe measures in place to maintain service users’ and staff safety. Areas sampled were fire drills/safety equipment tests and systems, passenger and hoist lifting equipment, COSHH regulations and water temperature controls and legionella check. The home has a quote for the installation of new fire safety detection equipment and new smoke detectors, requested by the last fire safety inspection, are to be fitted over the next few months. Chubb last maintained the systems in February 2007, and there are risk assessment documents on different areas of the home, which are reviewed annually. The main fire risk assessment was reviewed in March 2007. Weekly system checks are carried out and monthly fire drills are held. These are recorded. Staff have completed fire awareness training, to be reviewed and updated, as the record does not show actual dates and which staff completed it. There is a passenger lift in the home and hoist lifting equipment, which were last maintained in June 2007 and May 2007. Certificates are available. Practice was observed, which did not comply fully with manual handling regulations, and a service user was assisted to move without the aid of the hoist. Two care staff assisted the service user, but the person was unable to weight bear and clearly needed the hoist for safe moving. This was pointed out to the manager who requested staff review the risk assessment of his person and set up the use of the hoist for her. It is important that this continues and that all staff are informed of the change in risk assessment and practice for lifting this person, especially in view of the complaint made on 15/05/07 about the moving and handling practices of one staff member. The manager must also specifically monitor the moving and handling of all service users for a determined length of time to make sure all staff are following DS0000065182.V346020.R01.S.doc Version 5.2 Page 23 procedure, that safe working practices are carried out and that the safety of service users is promoted and protected. The home has a file containing all details concerning the cleaning materials used and a risk assessment document for each one. Staff are aware of their health and safety responsibilities. There are monthly checks on the hot water outlets, which are recorded and a legionella test was carried out 17/11/06. Evidence is available. DS0000065182.V346020.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 4 X 3 X 3 X X 2 DS0000065182.V346020.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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 OP8 Regulation 12 Requirement The registered person must obtain ways of monitoring the weight of service users unable to stand so that all service users’ health can be monitored and they know their needs are being met (previous timescale of 30/11/05 not met). This has still not been met due to funding of a seated weigh scales sill not being available. New and last timescale set. Timescale for action 30/11/07 DS0000065182.V346020.R01.S.doc Version 5.2 Page 26 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 OP28 Good Practice Recommendations The registered provider should continue to encourage staff to undertake NVQ level 2 (and 3) or equivalent to achieve more than 50 with the award, so service users know they are in safe hands. The registered provider should make sure all staff have completed annual mandatory training and any other identified training and that the record of training shows names and dates, so that service users know they are cared for by trained and competent staff. The registered provider should make sure staff use the lifting equipment to assist all those identified and risk assessed as requiring it when assisting them to move, so service users know their health, safety and welfare is promoted and protected. 2. OP30 3. OP38 DS0000065182.V346020.R01.S.doc Version 5.2 Page 27 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 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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