Inspection on 12/01/06 for St Leonards

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Leonards 15/05/08

St Leonards 15/05/07

St Leonards 19/06/06

St Leonards 05/07/05

St Leonards 04/01/05

St Leonards 30/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Leonards 86 Wendover Road Aylesbury Bucks HP21 9NJ Lead Inspector Joan Browne Announced Inspection 12th January 2006 09:30 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 Leonards DS0000023023.V266890.R01.S.doc Version 5.0 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 Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Leonards Address 86 Wendover Road Aylesbury Bucks HP21 9NJ 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) 01296 337765 01296 339529 Colley Care Limited (Trading as B & M Care) Ann Marshall Care Home 45 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (22) of places St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: St. Leonards is a purpose built care home providing personal care and accommodation for 45 older people who are elderly frail and elderly mentally infirm. It is divided into two units. One unit caters for older people with physical frailties, the other for older people with mental frailties. It is owned by B & M Care , which is a private care organisation. The home is located on the outskirts of Aylesbury town, close to shops, pubs, the post office and other amenities. Public transport is easily accessible. The home was registered on the 19th April 2000 and consists of two floors. All bedrooms are single with en suite facilities. There is a passenger lift. The home has a secured garden to the rear that is accessible to the residents. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection of the home, which took place on 12 January 2006 from 09.30 am to 18.30 pm. The lead inspector was Ms Joan Browne who was accompanied by Mrs Gill Wooldridge (Inspector). The inspection consisted of discussions with residents, relatives, staff, examination of care documentation and records. The requirements and recommendations from the previous inspection were discussed. Comment cards were received from residents, relatives and health and social care professionals. Overall they were happy with the care, which was being provided. A tour of the communal areas, general kitchen and bedrooms was carried out. Feedback was given to the management team on the findings of the inspection. What the service does well: What has improved since the last inspection? The home now employs a night team leader who works three nights weekly. Regular night staff meetings take place. Night staff work sheets have been introduced. Night care staff are expected to review two care plans nightly. The manager stated that there has been a reduction in the use of agency staff. There has been a reduction in complaints. An advocate representative from Age Concern conducts regular meetings with residents. The medication system has been changed to the Nomad monitored dose system. A new care plan format has been developed. The manager stated that recording systems St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 6 had been developed further to enhance on the service delivery. An in-house training package for staff had been introduced. Some bedroom carpets had been replaced. Opened packets of food and sauces stored in the refrigerator are now being dated and labelled. Opened packets of biscuits are now stored in airtight containers. A cleaning schedule is in place to ensure that ceiling lights are cleaned regularly. A monitoring system for medication administration record ((MAR) sheets have been developed. Latex gloves and pads are stored in cupboards out of view. 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. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 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 Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 All residents are assessed before moving into the home. However, the preadmission assessment tools need to be audited to ensure that clear and detailed information is recorded. EVIDENCE: All residents have to undergo a pre-admission assessment before moving into the home. The home has a detailed pre-admission assessment tool in place that consists of the following heads: mobility and personal safety, mental state and cognition, dressing and undressing, continence, personal hygiene, eating and drinking, special diets, oral hygiene, foot care, communication, ethnic monitoring, sociability and behaviour, social relationship, sight, hearing medication, skin viability and funding. The pre-admission assessments for five residents were examined. It was noted that dates were not always recorded on assessment sheets and scribbling out entries were noted. It was not evident that an audit of the process of assessments undertaken was in place. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 There has been some improvement in the recording of care plans. However, further work is needed to ensure that more detailed information is recorded, and plans interrelate with risk assessments. There is a medication system in place. However, inconsistencies by staff members identified in the body of the report persist, which has the potential to place residents at risk. Systems are in place to ensure that residents are treated with respect and their right to privacy is upheld. EVIDENCE: Five care plans were examined and it is acknowledged that there has been an improvement in the detail of some identified needs in the care plan. However, further improvement is required. The personal details on some care plans examined were incomplete. For example, telephone numbers of next of kin were not always recorded. Residents or their representatives’ signatures were not recorded. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 10 Two particular care plans identified that the individuals required assistance with washing and dressing. However, the information recorded was as follows: “Some assistance”, “staff to encourage”. The information was not detailed and would not enable a new member of staff or an agency staff member to adequately care for the residents. In some care plans eating and drinking preferences were not recorded. Toileting regimes needed to be described more fully. In a particular resident’s care plan it was noted that the district nurse was supporting the care of the resident. Records indicated that a pressure mattress was in place. The care plan indicated that the resident’s skin was ‘vulnerable and needs monitoring.’ However, information on the individual’s skin care was not detailed in the care plan. In the daily report sheets there were scribbled out entries and tippex paper was noted on one entry. However, there was a good recording of the district nurse’s visit. It was not apparent that residents with dementia were orientated as to time and place as would be expected in individuals’ care plans for staff to refer to. However, some good practice was noted. For example, ‘staff need to familiarise Mrs X within the unit. Show communal areas, put a picture on her door to enable her to find her bedroom.’ Some entries recorded were contradictory. Examples of these were highlighted and discussed during the inspection. It was evident that reviews of residents’ care plans were taking place and the manager described her actions to address any concerns raised. It was noted that there is physiotherapy support to the home. However, care plans and risk assessments need to inter-relate. The home’s monitored dose medication system was changed to the Nomad system. It is acknowledged that the assistant manager had put in a lot of effort to ensure a smooth transition of the system. An improvement had been made in the recording of medication. The medication administration record (MAR) sheets were examined and no gaps were noted. However, some inconsistencies were noted such as, scribbled over entries and a bottle of eye drops that was in use did not record the date when it was opened. Evidence was in place that the MAR sheets were regularly monitored and the daily fridge temperature was being recorded. Risk assessments were in place for those residents who self medicate. It was discussed with the assistant manager how risk assessments could be improved further by ensuring that more regular spot checks are undertaken. It is acknowledged that there was a written declaration in place for those residents who self medicate. There was evidence in place that staff’s competencies in the administration and recording of medication were regularly assessed. The manager stated that St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 11 poor practice in the administration and recording of medication was being addressed. The controlled drug register was checked and balances in the register corresponded with tablets in bottles. A discussion was held on the storage of Aspirin in the Nomad Cassettes and its administration. A requirement is made in this report that scribbled over entries on MAR sheets must cease. Entries recorded in error should have a line drawn through and an explanation recorded at the end or the back of the sheet. Opened bottles of eye drops must be dated. Individual’s risk assessments for self- administration of medication should be reviewed to include more frequent spot checks. It was noted that some residents who were self-medicating had signed a disclaimer. However, staff are reminded of their duty of care if the resident is unwell. Staff should continually assess whether the resident is able to self-medicate. Protocols should be developed for those residents who have been prescribed for Warfarin medication. Individual PRN management plans should also be developed. Residents and relatives spoken to confirmed that staff treat residents with respect and dignity. Relatives praised staff for providing a high standard of care. It was noted during the inspection that staff interaction with residents was good. Residents’ preferred term of address was recorded in their care plans. The general practitioner commented that medical examination and treatment are provided in residents’ bedrooms. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 There is a good activity programme in place to ensure that residents’ social and recreational needs are met. Arrangements are in place to ensure that residents maintain contact with their family and friends. Residents are given the opportunity to be supported by an advocate this would ensure that they exercise their own choice and have full control over their lives. EVIDENCE: Residents spoken with who were able to articulate their views confirmed that the home was meeting their expectations. The home’s daily routine and activities that were being provided were varied and flexible. However, not all residents choose to participate in activities. It was noted that residents’ activity interests were recorded and evaluated monthly. The manager praised the activity organiser for her dedication and commitment and commended her for her support to the residents. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 13 Residents are encouraged to maintain contact with family and friends and the local community. Relatives spoken to confirmed that staff were approachable, open and transparent and they were made to feel welcome by staff when they visit. The manager stated that relatives of residents who have passed on have established relations with other residents and often they volunteer their services and escort residents on outings and shopping trips. Staff encourage those residents who are able to exercise choice, and control over their lives to maintain their independence. One particular resident stated that staff allow her to have the use of the kitchen whenever she wishes to. Sometimes she would assist staff with washing cups and saucers. Residents confirmed that they were aware whom to approach if they needed to discuss a concern. On the day of the inspection no residents were managing their own financial affairs. Meetings with the local age concern advocacy representative were taking place on a regular basis. Residents are made aware of their entitlement to bring in personal possessions such as, small pieces of furniture or electrical equipment if they wished to. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a complaints policy in place to ensure that residents and their relatives are listened to. EVIDENCE: The home has a complaints record folder in place. It was noted that there had been a reduction in the number of complaints made by relatives. However, since the last inspection the Commission for Social Care Inspection had received one anonymous written complaint, which the home was made aware of. As part of the inspection process the manager requested to discuss anonymous complaints that have been forwarded to the Commission. Relatives spoken to during the inspection confirmed that they had no concerns to raise. They were satisfied with the care provision. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 & 26 The appearance of the home creates a comfortable and safe environment for residents living there. However, minor shortfalls identified in the body of the report and odour control would need to be addressed to ensure a suitable and pleasant environment is provided for residents. EVIDENCE: The home’s environment is safe and well maintained. It has been designed with reference to current legislation and is accessible to meet the needs of residents living in the home. The grounds and garden were well maintained. The manager confirmed that requirements made from the recent fire safety officer’s visit had been actioned. The environmental health officer recently inspected the premises and work was in progress to ensure that the requirements and recommendations were being addressed. There are adequate toilets and bathroom facilities, which are sufficient in numbers and well maintained. In one bathroom a mural was displayed on the wall, which gave it a homely feel. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 16 It was noted that an insert from a toilet roll holder was missing in one of the toilets and needed to be replaced. Some bedrooms were personalised with personal items of furniture, family pictures and mementoes, which reflected the individual characters of residents. Some residents were happy to show off their bedrooms and said that they felt safe living in the home. There was an odour in three bedrooms. It is required that an increase in the cleaning of carpets in these bedrooms is carried out to remedy this problem. It was noted in a particular resident’s bedroom that there was a three -way pin adaptor. It is required that a risk assessment is developed or the adaptor is replaced with a wall mounted device with an on and off switch. On the day of the inspection the home was bright, clean, hygienic and free from odours in the communal areas. Fresh flowers were displayed in the lounges. The walls and floor in the laundry room were clean and free from dust. It was evident that a cleaning schedule was in place and being maintained. It was noted that some bins in the toilets, bathrooms and other areas were not of the foot pedal type. It is required that bins are replaced with the foot pedal type to prevent the spread of cross infection. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Residents’ dependency levels need to be assessed to ensure that they are adequate staffing levels provided to meet their needs. Arrangements are in place to ensure that staff are adequately trained and competent to care for residents. The organisation of staff’s files needs to be improved. Weaknesses identified in the home’s recruitment procedure has the potential to put residents at risk EVIDENCE: Staff spoken to were able to describe clearly how they were caring for the residents. However, this information was not always reflected in residents’ care plans. Staff were doing themselves an injustice by not incorporating their good practice in the care plans. A two-week rota was forwarded to the Commission, which indicated that the total weekly care hours that the home was providing to meet the needs of the residents were approximately 852 care hours. The dependency levels of residents’ needs had not been calculated. It was agreed that this information would be forwarded to the Commission. On receipt of this information the staffing hours required would be calculated fully using the Department of Health Guidance tool taking into consideration key factors such as residents’ needs and the size and layout of the building. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 18 A discussion with some staff members highlighted that there were occasions when the need for an extra staff member would be beneficial to meet residents’ needs. This was discussed with the manager who stated that staff were not always forthcoming to ask for help and to report that the needs of residents had change. It was noted that some residents’ needs were recently re-assessed and as a result the home was no longer able to meet their needs. A more appropriate placement was being sought. The process was carried out sensitively with the involvement of individuals’ relatives and other professionals. There was evidence in place that 40 of the care staff team had achieved National Vocational Qualification (NVQ) in direct care at level 2 and 3. Work was in progress for the remainder of the staff team to achieve NVQ status. Thirteen staff files were randomly chosen and examined. With the exception of one staff member who had been working at the home for sometime Enhanced Criminal Record Bureau (CRB) Clearances were obtained. However, it was noted that two written references were not always obtained. Gaps in dates of employment did not appear to have been explored at interview or otherwise be followed up by the manager. The status of some references was unclear. For example, no information available on the status of the referee, or if references were obtained from the employer, the authority of the person providing the reference. The organisation of files was not good. POVA first checks were not always evident. Staff starting dates and POVA first checks did not always correspond, this has the potential to put residents at risks. A training matrix listing staff’s names with mandatory training undertaken had been developed. Staff had undertaken the following training: protection of vulnerable adults, abuse in the care home, emergency first aid, food handling and hygiene, fire awareness, health and safety infection control, moving and handling and managing challenging behaviour. It was noted that the home had invested in an in-house training package consisting of approximately eighteen videos. All staff would be expected to undertake training on a regular basis. Staff members spoken to confirmed that they had undertaken training. Two staff members had recently undertaken update training in food handling and hygiene. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Arrangements were in place to ensure that the new manager and deputy manager understand their roles to be able to discharge and delegate responsibilities fully. The home is developing systems to ensure that residents and staff benefit from the ethos leadership and management approach of the home Some work in reviewing the home’s performance has taken place. However the home needs to regularly seek the views of residents to find out if their interests and expectations are being met. The home’s policy on personal allowance for residents needs to be kept under review and checked against staff’s practice to ensure that residents’ financial interests are safeguarded. Supervision training for all senior staff needs to be undertaken to ensure that the supervision framework is fully implemented and all staff are adequately supervised as per National Minimum Standards. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 20 Systems are in place to protect residents’ safety however, some systems need to be reviewed to ensure that residents’ safety is not compromised. EVIDENCE: A new manager has been appointed to the home. She initially worked as the home’s administrator and deputy manager. To date she has not applied to the Commission to be registered as the manager. She has several years experience working in a supervisory capacity for social services homecare services and has also managed staff in a retail store. The manager has achieved NVQ training in direct care at level 2 and has commenced training in the registered manager’s (RMA) award. She would need to fully understand her own accountability in this new role and be able to discharge and delegate her responsibilities fully to other members of the staff team. It was also noted that a new deputy manager had been recently appointed. The manager described the ethos of the home and her leadership and management approach of the home as being open and transparent. Staff meetings take place regularly. Management record systems have been put in place to enable staff to deliver a quality service to residents and to enhance their performance. All staff are issued with a copy of the General Social Care Council code of practice and are expected to work to the guidelines outlined in the code. The home developed a quality questionnaire for relatives, which was well responded to and acted upon. Further development of quality assurance needs to be developed to ensure that residents’ views are sought in all areas of their care. The manager described looking after a significant amount of personal allowance for one resident. She explained that the resident’s solicitor has power of attorney. A senior staff also described lending money to a resident. This is not a good practice and the manager must ensure that systems are in place for residents to access their money as they wish. It is required that the home’s policy on holding personal allowance for residents is checked against staff’s practice. The home has a supervision and appraisal system in place and work is in progress to ensure that staff have six supervision sessions for the year as St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 21 outlined in the National Minimum Standards. The manager stated that to date all staff had received two supervision sessions and most staff had been appraised. However it was noted that senior carers had not undertaken supervision training to support this practice. It is required that senior carers undertake this training. The home’s training matrix identified that staff have had training in moving and handling and fire safety. Staff spoken to during the inspection also confirmed that they had undertaken update training. The first aid box on the ground floor was checked. A list was not evident to check that the contents in the box were correct. However, there were adequate plasters and dressings in the box. It is recommended that a list be kept also a record of when the box was checked should be kept. Opened packets of food and sauces stored in the refrigerator in the main kitchen were dated and labelled. The food storage cupboard was neat and tidy and it was evident that a stock control system was in place. Equipment and cupboards were free from grease and dust. Food, freezer and refrigerator temperatures were being recorded and up to date. Staff’s knowledge in food hygiene and handling was sound. The portable appliance test (PAT) for electrical equipment used in the home was up to date. There was evidence that the portable hoists are regularly serviced. The recent service of hoists was undertaken on 18 July 2005. There was evidence that the passenger lift was serviced on the 3 January 2006. The engineer recommended that some minor work needed to be carried out on the lift door. The manager stated that work was in progress to action the recommendation. Records relating to the hot water storage tank were in place. However, the dates on two reports were illegible and it was difficult to ascertain if the records were up to date. There was evidence that the hot water temperatures for taps in residents’ bedrooms and other areas of the building were checked monthly and were within the normal range. Evidence available relating to legionella test indicated that checks were carried out on 25 March 2005. There were no dates available to confirm that the service record for the boiler and central heating system was up to date. There was no evidence that the hard wiring electrical certificate for the premises was up to date. The manager agreed to submit a copy of the certificate to the Commission. At the time of writing the report this was not yet received. Labels on fire extinguishers indicated that they were recently services and the next service was due on 6 June 2006. Generic risk assessments and COSHH assessments were in place and up to date. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 22 A record is kept of all accidents sustained by residents. It was noted that there has been an improvement in the detail of information recorded on accident sheets. Accidents are monitored monthly and where falls are sustained frequently by individuals’ professional support is obtained. This can be either a referral by the general practitioner to the physiotherapist or the falls clinic. It was noted that Regulation 37 reports were not always completed when residents’ condition had deteriorated and needed hospitalisation. This was discussed during the inspection and it was clarified that reports should be completed for all serious illnesses and serious accidents sustained by residents. St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 2 2 X 2 St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 18(1)(c) (i) Requirement The manager must ensure that staff undertake further training in care planning and report writing. Care plans and preassessments must be monitored. The manager must ensure that scribbled over entries on MAR sheets must cease. Opened bottles of eye drops must be dated. The manager must ensure that the missing toilet roll insert be replaced. The manager must ensure that there is an increase in the cleaning of carpets in the 3 bedrooms identified with odours during the inspection. The manager must ensure that a risk assessment is developed for the three-way pin adaptor in the resident’s bedroom as discussed during the inspection. Alternatively the adaptor must be replaced with a wall mount device. The manager must ensure that weaknesses identified in the home’s recruitment policy must DS0000023023.V266890.R01.S.doc Timescale for action 30/06/06 2 OP9 13(2) 15/02/06 3 4 OP21 OP24 23(2)(b) 16(k) 15/02/06 15/02/06 5 OP24 13(4) 15/02/06 6 OP29 19(1) 15/02/06 St Leonards Version 5.0 Page 25 7 OP26 16(2)(k) 8 OP35 10(1) 9 OP36 18(2) 10 OP38 13(6) be addressed. The manager must ensure that swing top waste bins are replace with foot pedal bins to prevent the spread of cross infection. (Previous timescale of 30/08/05 not met.) The manager must ensure that the home’s policy relating to resident’s personal allowance is checked against staff’s practice. The manager must ensure that all senior staff undertake supervision training to facilitate the process of all staff receiving a minimum of six supervision sessions yearly. The manager must ensure that a record be kept of dates when the boiler and central heating system is serviced. 15/02/06 31/03/06 30/06/06 15/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that the manager should ensure that risk assessments for individuals who self-administer medication be reviewed to include more frequent spot checks. It is recommended the manager should ensure that protocols be developed for those residents who have be prescribed for Warfarin medication. Individual PRN management plans should also be developed. It is recommended that the manager should ensure that the quality assurance system is further developed to ensure that residents’ views are sought in all areas of their care. It is recommended that the first aid box contain a list to check that the contents in the box are correct. A list should also be kept of when the box was checked. DS0000023023.V266890.R01.S.doc Version 5.0 Page 26 2 OP9 3 OP33 4 OP38 St Leonards St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Leonards DS0000023023.V266890.R01.S.doc Version 5.0 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!