CARE HOMES FOR OLDER PEOPLE
St Mark`s Nursing Centre 110 St Marks Road Maidenhead Berkshire SL6 6DN Lead Inspector
Christine Sidwell Unannounced Inspection 23rd October 2007 10.00 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 DS0000062781.V346563.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. DS0000062781.V346563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Mark`s Nursing Centre Address 110 St Marks Road Maidenhead Berkshire SL6 6DN 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) 01628 582800 01628 582899 mitchsus@bupa.com ANS Homes Ltd Susan Mitchell Care Home 80 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (80) of places DS0000062781.V346563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Up to 20 service users from the age of 50 may be admitted to the rehabilitation unit. 25th May 2006 Date of last inspection Brief Description of the Service: St Marks Care Centre is purpose built and was completed in 2005. The decoration and furnishings are of good quality and provide a very attractive environment. The home is built next door to the local hospital and is accessed via the hospital grounds. The home is arranged in four wings, one is a recently registered dementia care unit, one is a rehabilitation unit, provided under contract to the Primary Care Trust and two are care home with nursing units, offering care to a mixture of privately funded service users and service users funded by the local authority. All rooms are spacious and have en-suite facilities of a toilet, hand basin and shower. All four units have their own communal lounge and dining room, as well as a smaller lounge for private use. The home is arranged over two floors. There are gardens with seating arranged round the home. A separate, securely fenced garden is provided for the dementia unit. The home is close to the centre of Maidenhead, with a large shopping centre and other community facilities. St. Mark’s provides accommodation for up to 80 service users (20 per unit). The fees, at the time of the inspection, were in the range of £494 to £900 per week depending on the type of placement. Additional charges are made for services such as direct dial telephone, hairdressing and newspapers. DS0000062781.V346563.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was conducted over the course of four days and included a two day unannounced visit to the home. The key standards for older people’s services were covered. Information received about the home since the last inspection was taken into account in the planning of the visit. Prior to the visit, an annual quality assurance self-assessment was sent to the manager and surveys were distributed to service users, relatives and visiting professionals. Twelve residents or their families and four healthcare professionals returned the questionnaires. Residents and families were also spoken to on the days of the unannounced visit. Discussions took place with the manager, nursing, care and ancillary staff. Care practice was observed. A tour of the premises and examination of some of the required records was also undertaken. The homes approach to equality and diversity was considered throughout. What the service does well:
There is information available to potential residents and their diverse care needs are identified with them, prior to their move to the home, to ensure that they can be met. The information describes how residents cultural and spiritual needs could be met. There is good multidisciplinary teamwork in the rehabilitation unit, supporting residents’ individual goals for rehabilitation to maximise their individual abilities. One family member said ‘they encourage my mother and treat her as an individual’. Residents’ personal, healthcare and medication needs are met. The care plans are comprehensive, updated regularly and are developed with residents and their families. Residents’ individual needs are identified. ‘Life maps’ give staff a good insight into residents’ life history, their likes and dislikes and their diverse backgrounds. There is good liaison with the local Primary Care Trust and the local health and social care teams. One family member said ‘I couldn’t fault the care’ and another that ‘I am always kept informed about my relatives care’. The home offers a flexible lifestyle, in line with resident’s expectations and abilities and supports their autonomy. There is a variety of activities available and residents have a choice as to whether they participate or not. Families and friends are encouraged to visit and are made to feel welcome. The meals are of a high standard. The menu is varied and menus to meet residents’ health and cultural needs are available. Food is freshly prepared and a cooked breakfast, choice of main meals and a ‘night bite’ service is available. DS0000062781.V346563.R01.S.doc Version 5.2 Page 6 Residents said that they enjoyed their meals and mealtimes were a sociable occasion. There are complaints policies and procedures in place and most residents and their families were aware of these. A record of complaints is kept and there is evidence to show that action is taken is response to complaints. There are safeguarding policies and procedures in place and most staff have now had safeguarding training. The Commission for Social Care Inspection is aware of two complaints and two safeguarding incidents at the home, both of which had been responded to appropriately. The home is purpose built and all rooms have ensuites. There is programme of ongoing decoration and services and equipment is maintained regularly. The gardens are accessible to people with disabilities. There are infection control policies and procedures in place and the home has contacted the environmental health officer about a recent outbreak of a skin infection amongst residents. There were no offensive odours and the home smelt clean and fresh. Staffing levels are adequate to meet the needs of residents although staff training could be improved. Families and residents commented that ‘staff make you feel welcome, are cheerful, caring and helpful’. One said that they ‘ make my Nan feel special and important and encourage her even when she doesn’t feel like doing much’. There are health and safety policies and procedures in place to provide a safe environment for residents and staff. Staff have training in moving and handling and hoists are available to assist those who cannot move unaided. What has improved since the last inspection? What they could do better:
There is a need to ensure that all residents, irrespective of their funding source, have a statement of their individual fee arrangements and the terms and conditions of their stay. Although there is an good activities programme in place it could be developed further if the activities’ coordinators were to have training in their role and in
DS0000062781.V346563.R01.S.doc Version 5.2 Page 7 particular training in the provision of therapeutic activity for people with dementia. The senior management team in the home should undertake external safeguarding training, preferably offered by the local authority which is the lead agency in safeguarding matters. Staffing levels should be monitored carefully to ensure that not only are their sufficient staff but that continuity of carer is improved for residents who feel more comfortable with a carer they know. Staffing allocations should also be monitored carefully to ensure that staff are available at busy times. Care staff should be offered the opportunity to gain National Vocational Qualifications in Care at level 2 or above and all staff should have food hygiene training and infection control training. Where in house training videos are used, carers should be supported and their learning assessed. 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. DS0000062781.V346563.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 DS0000062781.V346563.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): 1, 2, 3 and 6 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There is information available to potential residents and their care needs are identified with them, prior to their move to the home, to ensure that they can be met. There is good multidisciplinary teamwork in the rehabilitation unit, supporting resident’s individual goals for rehabilitation. There is a need to ensure that all residents, irrespective of their funding source, have a statement of their individual fee arrangements and the terms and conditions of their stay, to ensure clarity and transparency for all residents. EVIDENCE: The home has an up to date statement of purpose and service users’ guide, entitled ‘Welcome to St Marks’. All but one of the residents, or families, who returned the questionnaire, said that they had received information about the home and a copy of the welcome pack was seen in residents’ rooms. All residents who fund their own care have a contract and these were seen in their files. The manager and administrator stated that those residents funded by
DS0000062781.V346563.R01.S.doc Version 5.2 Page 10 the Primary Care Trust or Social Services do not have contracts or statements of their terms and conditions. This should be addressed and all residents should have a statement of their terms and conditions. There was evidence in residents’ files that a comprehensive assessment of their needs is undertaken prior to their move to the home. The assessment documentation prompts staff to consider the diverse needs of residents and their cultural and spiritual wishes, which were recorded. The home manages a rehabilitation unit conjunction with the local Primary Care Trust. There was evidence that multidisciplinary assessments are undertaken for all residents, many of whom go home after a period of rehabilitation. There is dedicated space and equipment for rehabilitation. Individual’s needs are reassessed if they subsequently need long-term care. DS0000062781.V346563.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Residents’ personal, healthcare and medication needs are met, promoting their dignity and wellbeing. EVIDENCE: The care of six residents was followed through. The home has recently introduced a new care planning system, which has been implemented thoroughly. There was evidence that both residents and families are involved in planning their care. The files contained comprehensive care plans and the staff spoken to were knowledgeable about residents’ care wishes. The care plans had been reviewed regularly and updated when appropriate. The residents who returned the questionnaires and those spoken to on the day of the unannounced visit said that they were involved in planning their care and that the staff were responsive to their wishes. The risk of residents acquiring pressure damage due to immobility is assessed and in general appropriate equipment is made available. The home has recognised that they have a need for more height adjustable beds and specialist airflow mattresses, which are on order. Some members of staff said that thy felt that they needed more pressure-relieving seat cushions, which will be a recommendation of this
DS0000062781.V346563.R01.S.doc Version 5.2 Page 12 report. The file of one resident with pressure damage was examined. The resident had been assessed and appropriate specialist advice had been sought. The records were good and the wound was healing. The resident had been provided with appropriate pressure relieving equipment. Continence assessments are undertaken and the Primary Care Trust, (PCT) provides appropriate aids. Nutritional risk assessments had been undertaken. The staff and chef were aware of residents’ dietary needs and could provide special diets to meet residents’ health and cultural needs if necessary. The chef was aware of the need to provide some people who suffer from dementia with a high calorie diet. Residents are weighed regularly and those residents whose care was followed through had maintained their weight on moving to the home. Residents register with the local general practitioner who visits the home weekly. He returned the questionnaire and said that the home communicated clearly with him and that any specialist advice was incorporated into the resident’s care plan. There was evidence that falls assessments are undertaken and the advice of the local Primary Care Trust specialist falls prevention team is taken where necessary. Residents have access to additional private physiotherapy. There are medication management policies and procedures in place and the staff spoken to were aware of these. Storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were accurately completed. Controlled drugs were stored satisfactorily and all entries to the controlled drug register were signed. A contract is held for the disposal of unused medication. The registered nurses spoken to said that medication was not administered covertly. If a resident refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make to the decision, the doctor and family would be informed and a way forward agreed. The staff were aware of the fact that medication should not normally be crushed before administration and a multidisciplinary team meeting had been held to agree that this could happen for one particular gentleman. This was recorded in his care plan. There is an incident reporting system in place and two medication errors had been notified to the home manager. She had taken appropriate action to ensure that the resident did not come to harm, their families were notified and to ensure that the nurses concerned were given additional training and their practice supervised for a period. The staff were observed to be respectful towards residents with and to protect their dignity. All care is given in residents’ rooms. The general practitioner said that he saw residents in their rooms. Residents said that they enjoyed the privacy of the home and the fact that they could use the facilities, for DS0000062781.V346563.R01.S.doc Version 5.2 Page 13 instance the activities room, communal lounges or dining rooms when they wished. DS0000062781.V346563.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home offers a flexible lifestyle, in line with resident’s expectations and abilities and supports their autonomy. The meals are of a high standard and meet resident’s nutritional and social expectations. EVIDENCE: The home has two activities coordinators in post. They arrange a programme of activities, which run twice a day. There is a separate activities room, which is very homely. The residents who chose to participate in the activities on the day of the unannounced visit were clearly enjoying themselves. The activities coordinators said that they undertake group activities and one to one activities with people in their own rooms if they wish. They are both relatively new in post and have not had previous experience in providing activities for older people. It is recommended that they undertake training, particularly in providing therapeutic activities for older people with dementia. Three of the residents spoken to said that they had been able to attend church. Families and friends were seen to be coming and going throughout the day. Those spoken to said that they were always made welcome and all those who returned the questionnaires said that the home always or usually helped their relative to keep in touch with them. The residents spoken to said that the staff
DS0000062781.V346563.R01.S.doc Version 5.2 Page 15 were polite and addressed them by the name that they preferred and that they had a choice as to how they spent their day. There is a varied menu and residents have the opportunity to influence the menu at residents meetings. A cooked breakfast is available and a choice of menu is available at the main meal and at supper. There is a ‘night bite’ service whereby residents who may be hungry in the evening can have an additional hot snack if necessary. Food is freshly prepared and cakes were being prepared for afternoon tea on the day of the unannounced visit. The residents spoken to said that they enjoyed the meals. The dining rooms were well laid and mealtimes were observed to be a sociable occasion. There are additional snacks for people with dementia and finger food is available to ensure that those who lack the concentration to complete a full meal receive enough calories. The care staff were observed to be assisting those who required help discretely and sensitively. DS0000062781.V346563.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The complaints and protection policies and procedures work well, giving residents, and their families, confidence that their concerns will be addressed and any safeguarding issues will be addressed, in conjunction with the local authority. EVIDENCE: There are complaints policies and procedures in place. A complaints log is kept and action was seen to be taken in response to concerns and complaints. All the residents who returned the questionnaires said that they knew who to speak to if they were unhappy. The residents spoken to said that they had never had to make a formal complaint and that if they were unhappy with any aspect of the service it would usually be dealt with immediately. The home is aware of the local multi agency strategy for the protection of vulnerable adults. Most staff have now had safeguarding training and those spoken to said that they would have no hesitation in reporting any concerns about residents welfare. The Commission for Social Care Inspection is aware of two complaints, which have been made to the organisation, one of which was anonymous. The other complaint was investigated and addressed by the manager. The information raised in both these complaints was considered as part of the planning of this inspection. There have been two safeguarding allegations since the last inspection both of which were responded to appropriately by the manager and were investigated under the local authorities safeguarding procedures. The action plan agreed with the local authority has been implemented.
DS0000062781.V346563.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 available evidence, including a visit to this service. The home is purpose built, clean and well maintained providing a comfortable and safe home for residents. EVIDENCE: The home is purpose built. There is a programme of ongoing maintenance and redecoration. A full time handyman is in post who responds quickly to resident’s wishes regarding their rooms. The maintenance records showed that services and equipment are serviced on a regular basis. The grounds are tidy and attractive and are accessible to people with disabilities. There are control of infection policies and procedures, which have been updated in the last year. All rooms and clinical areas have liquid soap and hand towels available to staff. Alcohol hand gel is also used to help prevent cross infection. Residents have individual hoist slings. There has been a recent outbreak of a skin infection in the home, which was not diagnosed immediately and is currently being investigated. The home has sought the advice of the
DS0000062781.V346563.R01.S.doc Version 5.2 Page 18 local environmental health officer as to the best way to address this to prevent any further outbreak. The laundry is clean and well managed. It is situated away from the kitchen. There are washing machines with the appropriate sluicing cycles and a ‘red bag’ system is in place for soiled laundry to prevent cross infection. Residents’ clothes are washed, ironed and repaired regularly. The laundry team was aware of the importance of this in maintaining residents’ dignity and self esteem. The home was clean and tidy and staff said that there is a regular programme of carpet cleaning. There were no offensive odours. DS0000062781.V346563.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 adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There are sufficient staff, recruited to a good standard, to meet the needs of residents. Care staff should be supported to undertake National Vocational Qualifications in Care to give them the knowledge and skills that they need to meet the needs of older people. EVIDENCE: There are four units in the home, each with up to twenty residents. The manager stated that she aimed to have five members of staff including a registered nurse on duty in the morning, four in the afternoon and two at night in the frail elderly units and the rehabilitation unit. An additional member of staff is on duty on each shift in the dementia care unit. The staff rotas confirmed this. If the number of permanent staff available falls below this, agency staff are used. Residents and families expressed concerns about the use of agency staff in the questionnaires and when spoken to on the day of the unannounced visit. They were concerned about the continuity of care not only when agency staff were used but also when staff were moved from unit to unit. One said ‘I can’t fault the care if my mother’s regular carers are on duty but, like today, the carers do not know her’. The staff on the rehabilitation unit also felt that their morning staffing levels were sometimes insufficient to ensure that everyone was ready for their scheduled rehabilitation sessions or that staff were able to give residents the time to care for themselves which was part of their programme. However all residents spoken to and those who completed the questionnaires said that staff always or usually met their needs
DS0000062781.V346563.R01.S.doc Version 5.2 Page 20 and that they did not have to wait long for their bells to be answered. Housekeeping, catering, maintenance and administrative teams also support residents. Eight of the forty carers hold the national Vocational Qualifications in Care at level 2 and above, which amounts to twenty percent. A further eight wish to undertake the course. The home does not yet meet the standard that fifty percent of carers hold this qualification and must develop a clear plan to enable staff to undertake this course, if it is to meet the standard. The recruitment files of four recently appointed members of staff were examined and all had the required records. All had submitted an application form, which showed their work history, and any gaps in this had been explored. Criminal Records Bureau disclosures and two references had been sought before the member of staff commenced work. The training records were examined. These showed that, since the last inspection, all new staff had commenced an induction programme. Training records had been established to record mandatory training and to help ensure that all staff had up to date mandatory training in safe working practices. Not all staff had had the required training but a plan was in place to address this. Staff in the dementia care unit have also undertaken an in-house course in dementia care to give them the insight that they need to care for people with dementia. Training has also been available in specialised procedures for nursing staff. DS0000062781.V346563.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 available evidence, including a visit to this service. The home is well managed and there are quality assurance systems in place to ensure that residents receive a high standard of care and that their views are taken into account in the running of the home. EVIDENCE: There is an experienced manager in post who has registered with Commission for Social Care Inspection. She holds the National Vocation Qualifications in Management at level 4. There is also a Head of Care and a Unit Manager in each unit. The lines of accountability within the organisation are clear. The residents spoken to said that the manager was approachable and responsive to their needs. The home has a quality assurance system in place. Regular resident and family meetings are held. The organisation also undertakes an annual survey,
DS0000062781.V346563.R01.S.doc Version 5.2 Page 22 the results of which are collated and shared with residents, potential residents and other stakeholders on request. The previous survey indicated that the level of activities offered by the home was poor at the time. This was recognised by the organisation and action taken to improve this with the appointment of two activities coordinators. Regular audit of processes takes place. Care plans, medication and recruitment files have been audited recently. No requirements were made at the last inspection and two out of the three recommendations have been implemented. The third related to staff training and has not yet been implemented. The home does not manage residents’ financial affairs. Residents may wish to place a small personal allowance with the home for safekeeping. These daily expense accounts are managed by the administrator and cover items such as daily papers, hairdressing and chiropody. Records are kept and receipts are given for all monies given to the home for safekeeping or spent on residents’ behalf. There are health and safety policies and procedures in place. The information sent prior to the visit showed that service and maintenance records are up to date. Most staff have had moving and handling training and fire safety training. There is a need to ensure that more staff undertake food hygiene and infection control training. The use of in-house videos for training purposes should be supervised and staff learning assessed. Fire safety checks were up to date and regular fire drills are undertaken. The staff spoken to were aware of the fire evacuation procedures. DS0000062781.V346563.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X 3 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 3 14 3 15 4 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 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000062781.V346563.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5A Requirement All service users, irrespective of their funding source, should have a statement of their terms and conditions. Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP8 OP12 Good Practice Recommendations The organisation should review whether it has sufficient pressure relieving chair cushions to minimise the risk of residents developing pressure damage. The activities coordinators should undertake training for their role to give them additional skills and insight when providing therapeutic activity for older people, in particular those with dementia. The senior team should undertake safeguarding training preferably at a course offered or recognised by the local authority, to ensure that residents are fully protected from harm. Staffing levels and continuity of staff allocation should be monitored carefully to ensure that residents’ needs are met in a timely way and that someone that they know
DS0000062781.V346563.R01.S.doc Version 5.2 Page 25 3 OP18 4 OP27 5 6 7 8 OP28 OP30 OP38 OP38 cares for them. Fifty percent of care staff should hold the National Vocational Qualifications in Care at level 2 Vocational Qualifications in Care at level 2 or above. Staff should be supported when in house video training is offered and their learning should be assessed. All staff should have infection control training. All staff who handle food should have food hygiene training. DS0000062781.V346563.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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
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