Inspection on 19/06/06 for St Leonards

This inspection was carried out on 19th June 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 12/01/06

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 Unannounced Inspection 19th June 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.V290802.R01.S.doc Version 5.1 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.V290802.R01.S.doc Version 5.1 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 N/A Colley Care Limited (Trading as B & M Care) 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.V290802.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 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 residents. Fees range from £400.00-£650.00 per week. Additional charges are made for hairdressing chiropody, newspapers and toiletries. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took place on June 12 2006. Prior to the fieldwork visit previous information about the home was reviewed and the outcome of previous inspections noted. Comment cards were received from two residents, four relatives and one care manager. Residents and those family members who were visiting on the day of the fieldwork were interviewed. Overall they were happy with the care provision. A tour of the premises was undertaken and care records were examined. The care of five residents was ‘case tracked’ from their original contact with the home to the care that they are now receiving. Care practices and the home’s approach to quality and diversity issues were observed. What the service does well: What has improved since the last inspection? An external trainer recently facilitated training in COSHH, health and safety and dementia. Some care staff had commenced a distant learning training course in the safe handling of medication to improve their knowledge in the administration and recording of medication. Two care staff have achieved national vocational qualification (NVQ) in direct care at level 2 and 3. General waste bins of the swing top type in areas of the building had been replaced with the foot pedal type to prevent the spread of cross infection. Protocols had been developed for those residents who have been prescribed for Warfarin medication to ensure that it is administered appropriately. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 6 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.V290802.R01.S.doc Version 5.1 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.V290802.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home ensures that a pre-admission assessment is undertaken for all prospective residents before they are admitted to the home. However, the home needs to develop a system to ensure that information from placing authorities is obtained prior to the individual’s assessment and admission taking place to ensure that all identified needs would be fully met. EVIDENCE: The home ensures that a pre admission assessment is undertaken for all prospective residents prior to admission. The manager or a senior member of staff undertake assessments. The manager described the assessment process for the most recent admission to the home. It involved meeting the resident in their own environment. The paper work seen had some information to ensure that the staff team would be able to meet the individual’s needs. However, it was noted that information from the placing authority was not submitted to the home until after the resident had been admitted, this was unfortunate. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 9 Obtaining as complete a picture as possible of a residents care needs prior to admission will ensure all needs can be met from the outset of the individuals stay. The manager described inviting prospective residents or their representatives to view the home before admission. This is deemed as good practice. A formal review process of a residents placement normally takes place to ensure that the resident is happy with their new environment. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Further work is needed in the recording of care plans, moving and handling risk assessments and individuals’ health sheets to ensure that there is a clear and consistent recording system in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. This should be supported by staff training. Persistent poor medication administration and record practice could potentially place residents at risk. EVIDENCE: Five care plans were examined. It is acknowledged that there has been an improvement in the detail of some identified needs in the care plans seen relating to residents’ food preferences. The home has again changed its format of the care plans and staff were described by the project manager as working extremely hard to develop these documents. The new care plans were not in operation and detail in the old format was relevant. It was not apparent that all staff had been given adequate training to support the new care planning process. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 11 In some care plans examined the personal details were incomplete. Residents’ ethnicity and religion was not always recorded. Their signatures or those of their representatives were not always evident to confirm their involvement in the development of the care plan. Care plans examined did not describe fully the level of assistance and support needed. Information was not detailed and would not enable a new member of staff or an agency staff member to care for the residents adequately. For example, an entry recorded in a particular resident’s care plan indicated that the resident was allergic to wasp and bee stings. However, there was no action plan in place detailing what action staff should take in the event of the resident sustaining a sting. A behavioural chart was noted in a particular resident’s care record. There was no care plan in place relating to the individual’s behaviour to support this good practice. It was noted that a particular resident was being cared for in bed. There was no information recorded to describe how the resident’s social and emotional needs were being met. It was noted that the resident had refused to have a pressure- relieving mattress to prevent the risk of tissue damage. This information was not documented in the care records. It was recorded in the care plan for a particular resident with type two diabetes that the individual often helped herself to the sugar bowl from the tea trolley. This has the potential to place the resident at risk and must be supported by a clear action plan to minimise any risk. This matter was discussed with the manager. It was noted that a particular resident’s weight was recorded on admission in stones and pounds. Subsequent recordings were in kilograms. Staff should ensure that they are consistent when recording residents’ weights to facilitate accurate recording. It is acknowledged that care plans examined had clear pen pictures of residents. This is deemed as good practice. One of the care plans examined had been recently reviewed. However, the process of recording reviews was inconsistent. The care plan for a newly admitted resident was not completed. It is acknowledged that work was in progress to complete the plan. Clarity in the daily report sheets was compromised by scribbled out and written over entries. Care should be taken to ensure entries are always legible. Entries seen in the daily log placed an emphasis on the recording of a residents fluid and food intake. This is an important issue but daily records of a residents well being should relate to the care plan content including any social and emotional needs identified. It is acknowledged that some entries did refer to visitors. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 12 There was some evidence that the manager had started to audit the care plan content. She was able to identify similar shortfalls to those identified by the inspectors. Completing the audit process should provide the manager with the information she needs to train her staff in appropriate care plan content and recording practice. The home has a range of assessment documentation in place including one titled ‘ability’ and ‘lifting and handling’ assessment. The word ‘lifting’ could be misleading and it is recommended that the wording on the documents be changed. The format of the form also provides limited space for staff to record the assessment details e.g. ‘assist into chair in the event of a fall’. This was discussed with the manager. Identified risks should be supported by a care plan. Residents are registered with five general practitioner surgeries. The general practitioner would visit residents as and when required. There was evidence in the files that the district nurse visits the home. Those residents with continence problems are assessed for aids and equipment to manage their incontinence. Information recorded in the pre-inspection questionnaire highlighted that there were no residents in the home with tissue damage. Physiotherapy, audiology and the services of a CPN can be accessed via the GP. It is recommended the manager reviews the homes current practice of managing residents oral health needs. As part of the case tracking process the inspector met with a resident who for a number of years had been cared for in her room. It is recommended that residents with more complex needs such as anyone being cared for in bed should have regular reviews to ensure all identified needs are met. It is acknowledged that following the inspection visit a review for this resident has been held. It was noted that health care records were described in the new care plan format as ‘an appointment sheet.’ However, some appointment sheets were noted as blank. The home had a good system in place previously. Staff had an overall understanding of the needs of people with dementia and were seen to be patient and kind when interacting with them. Visitors spoken to confirmed this. The medication and administration record (MAR) sheets were examined and eleven omissions were found without explanation. In one instance the medication cassette was checked and it was noted that the tablet was in the cassette. However, the code to denote the reason for omission was not used. Some sheets were sticky and it was difficult to read the printed information on those sheets. Scribbled over entries were noted on MAR sheets. Three residents were taking controlled drugs and the controlled drugs register was completed correctly. It was noted that a record was being maintained for St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 13 stock drugs and staff are expected to sign when drugs are taken from the cupboard. This is deemed as good practice. There was no written evidence that MAR sheets were being monitored. The manager said that poor recording of medication is discussed at senior staff meetings. The management of medication must be improved in line with guidance issued by the British Royal Pharmaceutical Society. Staff spoken to confirmed that their competencies had been assessed. Residents spoken to felt that their privacy was respected and that staff were sensitive when they needed help with personal care and supported them to promote their independence. Resident’s preferred term of address was recorded in care plans examined. Medical examinations are carried out in private in residents’ bedrooms. It was noted that residents were dressed appropriately with attention to detail. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that residents’ social, recreational and dietary needs were being adequately met. EVIDENCE: Residents spoken with confirmed that the home’s daily routine was flexible and matched their expectations. One particular resident commented that it was just like “home from home”. Residents said that they felt very much in control of their own lives. They felt free to go out for daily walks. One particular resident often takes the bus to the town centre unescorted. The home employs two part-time activity organisers. One of the activity organisers was on leave and the second activity person works two days a week. There is an activity programme in place that consists of reminiscence, musical quiz, karaoke, general knowledge quiz, crosswords, bingo, arts and craft. Residents are able to participate with outings in the wider community. These trips usually take place during the summer period to the seaside or places of interests. One particular resident expressed a wish to have more trips to the seaside. It was noted that a small group of residents attend St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 15 swimming at the local pool. Some residents assist with maintaining the sensory garden. Staff spoken to were able to describe the activities that are provided in the home. Residents are encouraged to maintain contact with family and friends and the local community. Relatives spoken to confirmed that staff were approachable, and made them feel welcome when they visit. One visitor said, “Staff always make me and dad a tray of tea and biscuits.” From discussions with residents it was evident that the staff team supported them to exercise choice, take risks and have control over their lives. Residents were encouraged to look after their finances for as long as they are able to. Some residents’ bedrooms were personalised with their own furniture, which confirmed that residents are made aware of their entitlement to bring some personal possessions if they wished to. There were no residents using the services of an advocate because the service had been withdrawn because of reduced local funding. Lunchtime was observed on both units. There were sufficient cutlery and condiments to use and a choice of drinks was available. The dining areas were inviting. Staff were observed offering assistance to those residents who needed assistance with feeding and prompting in a sensitive and discreet manner. Mealtime was a relaxed and social event. Some residents spoken to enjoyed the flexibility of being able to eat in their bedrooms if they wished to. It was noted that the choices on offer at lunchtime was not reflected on the menu that was displayed. It became apparent that the menu had been changed and residents were consulted about the change. Lunch consisted of the following choices: cottage pie, salads and jacket potato with various fillings. Residents spoken to said that overall meals were tasty and portions were adequate. The chef is made aware of residents’ special dietary needs. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has a complaints procedure in place. However, a record of all verbal complaints needs to be recorded to ensure that they are acted on. The home’s recruitment procedure needs to be more robust to protect residents from any potential harm or abuse. EVIDENCE: The home has a complaints procedure in place. Some residents spoken to said that they were familiar with the procedure. They all said that if they had a problem about their care they would discuss it with the manager. The home does not appear to record verbal concerns. All verbal concerns should be recorded, this will enable the manager to identify and address any problem areas. Since the last inspection no complainant has contacted the Commission with information concerning a complaint made to the service. During the inspection one relative mentioned that their relative had money go missing on three occasions. It is acknowledged that the home followed this up in the best interests of the resident. However, this should have been reported under Vunerable Adults Proceedures. The home has a policy and procedure in place for dealing with allegations of abuse. Staff spoken to had a basic understanding of the action to be taken if an allegation was made but there were some gaps in their knowledge of this subject. Staff confirmed that they had had training in abuse in the form of a video. Further training would be beneficial to staff. Recruitment records St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 17 indicate that the home’s recruitment procedure needs to be more robust to better protect residents. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a safe and well maintained environment. However, several residents’ bedrooms had an odour, which detracted from an otherwise pleasant environment. 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 There is a secured garden to the rear that is accessible to the residents. All bedrooms are single with en suite facilities. Bedrooms were personalised with personal items of furniture, family pictures and mementoes, which reflected the individual characters of residents. All residents spoken to said that they liked their bedrooms, and most were happy with the facilities in the home. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 19 The home was recently inspected by the local fire service and all safety matters were considered satisfactory. There was an odour of urine in eight bedrooms. Steps need to be taken to address this problem in the short term and a more permanent solution found for the longer term. It was noted in some residents’ bedrooms that supplies of incontinent pads were stored at the bottom of residents’ beds. This had the potential to compromise residents privacy and dignity and be a trip hazzerd. More discrete and safe storage of such items should be found. Standards of housekeeping in the home generally and in particular in the communal areas was satisfactory. The laundry room is situated away from the kitchen and was clean and tidy. The floor and walls of the laundry room are impermeable. There is a red bag system for separating soiled laundry to reduce the risk of cross infection. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home’s recruitment practice needs to be strengthened to ensure that residents are protected from any potential harm. Records relating to staff training need to be maintained to ensure that training is current. EVIDENCE: There is a staff rota that shows the number of staff on duty. The home ensures that there are seven care staff on duty covering the morning and afternoon shift and four staff covering the night shift. This is in addition to kitchen and domestic staff. Agency workers cover sickness and annual leave. Members of staff spoken to said that they had adequate time to care for residents. Relatives spoken to during the inspection referred to the staff team as being ‘good and excellent.’ One relative said, “Staff keep me informed of any changes with mother’s care.” The home employs a total of forty carers which includes a number of bank staff. From the information provided by the home, of the 40 staff listed, 17 have a qualification of NVQ level 2 or above. This is slightly below the 50 required under NMS 28. However, seven further members of staff are to enrol for this qualification in the near future. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 21 The recruitment records of four staff members were examined. All had completed an application form and had two references and an enhanced criminal record bureau (CRB) clearance in place. However, references were not authenticated and were not obtained from the employees’ previous employers. Of the four files examined only one had a recent photograph of the individual to confirm proof of identity. It was noted that a CRB clearance had not been obtained for the hairdresser. Arrangements must be made for one to be obtained. The staff training folder was examined the information recorded appeared very muddled and it was difficult to assess what training staff had undertaken. The manager confirmed that staff had undertaken training in moving and handling, COSHH, health and safety and dementia. This was not reflected in the training folder seen. It was evident that the folder needed to be updated. New staff are inducted into their specific roles. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Quality assurance systems need to be fully developed to ensure that the home is run in the best interests of residents. Health and safety records need to be consistently maintained to ensure that residents’ safety and welfare are promoted. EVIDENCE: The manager has several years experience working in a supervisory capacity for social services homecare services and has also managed staff in a retail store. She is in the process of submitting her application to the Commission to become registered. She has achieved the national vocational qualification (NVQ) training in direct care at level 2 and has commenced training in the registered manager’s award (RMA) qualification. It was noted that the deputy manager’s position had recently become vacant and arrangements were being made to recruit to the vacant position. Staff confirmed that the manager was St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 23 approachable. The practice in the home in relation to staff supervision is that staff receive three group supervision sessions as well as three individual sessions. Staff confirmed that regular staff meetings are arranged. An annual quality assurance survey was recently undertaken and was waiting to be analysed. A senior member of the organisation carries out monthly quality assurance visits to the home. The home has policies and procedures in place however, it was not evident if they are regularly updated, as there was no implementation or review date recorded on the pre-inspection questionnaire. The manager stated that the home does not act as an agent or appointee to residents’ pensions neither do they manage residents’ money. Residents are invoiced monthly for any additional charges incurred. Information recorded on the pre-inspection questionnaire indicated that regular maintenance of equipment is undertaken. The fire log was seen and evidenced that fire checks had been undertaken. Accidents are recorded appropriately and the home has been proactive by submitting a monthly list of all accidents that occur to the Commission. However, more detailing of action taken needs to be recorded to ensure that staff are fully compliant with first-aid guidance and the home’s health and safety policy. It was noted that there were gaps in the food temperature record in the main kitchen. Records must be maintained daily to ensure that food is served at the appropriate temperature range. The fridge and freezer temperature record indicated that the freezer temperature was slightly above the normal range and needed to be monitored to ensure that the freezer was working satisfactorily. Checks on the temperatures of hot water outlets are maintained. Staff are reminded of the need to record the temperature range and dates on which the readings were taken. It was noted that the cover for the bin in the satellite kitchen was broken and needed to be replaced in line with the food standards guidance. St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 18(1)(c) (i) Requirement The manager must ensure that staff undertake further training in care planning and report writing. (Previous timescale of 30/06/06 not met) The manager must ensure that residents’ care plans are detailed and that they describe fully the level of support and assistance required. Care plans must be regularly audited. The manager must ensure that medication administration record sheets be completed fully and reasons why a resident has not taken the medication should be recorded. The manager must ensure that the practice of scribbling over entries on MAR sheets ceases. (Previous timescale of 15/02/06 not met) The manager needs to address the problem of unpleasant odours in bedrooms both in the short and long term. Timescale for action 31/10/06 2 OP7 24(1)(a) (b) 15(1) 30/10/06 3 OP9 13(2) 31/07/06 4 OP9 13(2) 31/07/06 5 OP19 16(k) 31/07/06 St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 Page 26 6 OP29 19(1) 7 OP29 19(1) Schedule 2 The manager must ensure that a criminal record bureau clearance is obtained for all members of staff. The manager must ensure that weaknesses identified in the home’s recruitment policy are addressed. (Previous timescale of 15/02/06 not met) 31/07/06 31/07/06 8 OP38 13(4)(c) The manager must ensure that 31/07/06 daily food temperatures be maintained to ensure that food is served at the appropriate temperature range. 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 OP3 Good Practice Recommendations It is recommended that the manager should ensure that information be obtained from placing authorities before prospective residents are admitted to the home. It is recommended that staff be reminded of correct recording practices in care records. It is recommended that the manager should ensure that there is written evidence MAR sheets are being audited with details of any action taken. It is recommended that the manager should ensure that verbal concerns be recorded along with any action taken. It is recommended for reasons of safety and privacy that alternative storage facilities are found for incontinence materials. It is recommended that the training folder be updated to better reflect the training undertaken by staff. It is recommended that the current practice of managing residents oral health needs is reviewed. 2 3 4 5 6 7 OP7 OP9 OP16 OP19 OP30 OP7 St Leonards DS0000023023.V290802.R01.S.doc Version 5.1 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.V290802.R01.S.doc Version 5.1 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. 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