CARE HOMES FOR OLDER PEOPLE
St Marthas Residential Home 17 Thornhill Park Sunderland SR2 7LA Lead Inspector
Mrs Irene Bowater Unannounced Inspection 09:30 14 November 2007
th 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 Marthas Residential Home DS0000015725.V346194.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. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Marthas Residential Home Address 17 Thornhill Park Sunderland SR2 7LA 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) 0191 565 6443 0191 565 6411 Ms Gwendoline Swalwell ** Post Vacant *** Care Home 24 Category(ies) of Dementia (8), Mental disorder, excluding registration, with number learning disability or dementia (4), Old age, not of places falling within any other category (24) St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th September 2006 Brief Description of the Service: St Martha’s is a care home that provides personal care for up to 24 older people, some of who may have dementia or mental health needs. Nursing care is not provided. A day care service, meals at home, and a domiciliary care agency are operated from a designated area of the building. The house is a Victorian semi-detached property that has been converted to a care home and extended. It is over three floors and most of the bedrooms are on the upper floors. A passenger lift is provided. There is a large front garden with a paved terrace where residents and visitors can sit. The home is located in a quiet tree lined street in a residential area. It is a short walk into Sunderland City Centre where there are a range of amenities and shops. The current weekly fees range from £381 to £394 for residents funded by the Local Authority or who are privately funded. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • • • • • Information we have received since the last visit on 26th and 27th September 2006. How the service dealt with any complaints and concerns since the last visit Any changes to how the home is run The provider’s view of how well they care for people The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on date 14 November 2007 During the visit we: • Talked with people who use the service, relatives, staff, the provider and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit. • We told the provider what we found. What the service does well:
The owner and staff make sure that residents and their families are involved in the admission process. Bedrooms are redecorated and highly personalised before residents move into the home. The staff have formed good relationships with the residents and make sure their rights to privacy and dignity are met. They work hard to promote residents independence at all times. Visitors are made welcome and there are good links with the local community. There is a range of social events including a yearly pilgrimage to Lourdes, which many of the residents say, “is the best thing in the year”. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 6 The home is a pleasant, warm and comfortable place to live. Communal rooms are nicely furnished and decorated. Bedrooms are all individual in style and highly personalised to reflect residents’ preferences and religious beliefs. A number of staff have worked together at the home for a long time. They are enthusiastic and have created a positive and happy atmosphere in the home. Good staffing levels are provided to meet the needs of the residents in the home. Residents are protected by the recruitment processed and safeguarding training. Comments from relative surveys include: “Moving to care has been a very positive for both X and ourselves. X is now content, secure (physically & psychologically) and can enjoy life-which couldn’t happen at home!!” “I have not had to raise many concerns but if I have they have been dealt with very professionally.” “Staff treats everyone as individuals and respects dignity” “They are very aware of every ones needs.” “They always welcome visitors.” “They have an awareness of what is important to A. Family, personal appearance, privacy have lifted her mood amazingly since came in to care. She is a different woman!!” “My mother has been a resident in St. Marthas for 8 years now and during that time she has built up a trust in the carers and sees them all as her friends. I visit my mother everyday and I am always made very welcome. I work very closely with the manager and carers to ensure all my mothers needs are met. I take my mother home often and the home is very supportive of this. If I have had any concerns, they have always been handled professionally and treated with urgency. I am more than happy with all aspects of my mothers care & wish St. Marthas every success in the future”. Residents’ surveys said: “My daughter and sister visited St. Marthas prior to myself moving in. My family were shown around and all questions were answered fully. All information was transferred to me and I was able to make an informed choice” “On any occasion when I require support the staff are always available. I also have an alarm in my room in case I need help.”
St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 7 “Staff always listen if I say I am not feeling very well this is attended to and my doctor is notified or appropriate action taken.” “If I don’t want to go on a day trip or out anywhere they will listen to me.” “The home is cleaned everyday” What has improved since the last inspection? What they could do better:
The Service User Guide needs to be updated to make sure residents and their representatives have easy to understand information about the care and services provided in the home. The contract needs to set out the rights and obligations of both parties. Further work is needed on the care plans so that they are clear and detailed about the care provided. Detailed risk assessments must be in place to prevent falls, promote continence and make sure residents nutritional needs are met. Information about residents’ previous lifestyles and choices need to be written down so that staff can continue to support them. Improvements are needed to the record keeping for medication. A planned programme of refurbishment and redecoration of the external fabric of the building needs to be in place with timescales for completion. Improvements are needed to the sluice and laundry area to make sure infection control procedures are followed. Develop a plan of how the quality of the service is checked and then improved. Make sure that there are two signatures on all resident transactions. Detailed risk assessments need to be in place for all safe working practices. Further training in safe working practices is needed to make sure staff remain up to date. Wardrobes must be secure to make sure there are no toppling incidents. Water temperatures must be checked weekly with records kept.
St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 8 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. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 9 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 Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 10 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. Standard 6 is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents are not given up to date written information about the service provided. The rights and obligations of self-funding residents parties are not clear to enable them to make informed choices. The admission assessments and procedures ensure the residents care needs will be met. EVIDENCE: A Statement of purpose and service user guide is in place and is accompanied with a brochure of the home. This is available to give out to anyone who makes an enquiry about the home.
St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 11 The Service User Guide is not in a style, which those who have a dementia type illness could understand. The provider is aware that it contains some out of date information and it is going to be reviewed. Case tracking of three residents showed that both the home and care managers authority complete assessments in order to ensure that their needs could be met in the home. The home also involves the resident and their relatives during the admission process. Terms and conditions of residency for those funded by local authority are available .Any resident who is self funding does not have a contract which clearly sets out all of their rights including how fee rates are increased. Resident survey’s said: “My daughter and sister visited St. Marthas prior to myself moving in. My family were shown around and all questions were answered fully. All information was transferred to me and I was able to make an informed choice.” St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10. Quality in this outcome area is adequate This judgement has been made from evidence gathered both during and before the visit to this service. The care planning systems do not provide staff, residents and their representatives with the information they need to make sure residents individual needs are met. Health and personal care is well met so that the care people receive is based on their individual needs. Adequate systems for the administration of medicines are in place. Further improvements will make sure that residents receive their medication safely. A good level of personal support is in place, which promotes peoples rights to privacy and dignity. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 13 EVIDENCE: Each resident has a care plan which follows information received from the care managers and the homes own assessments. The information in the care plans was difficult to follow as risk assessments, daily recording and evaluations were not up to date nor person centred. When reviews are completed the detail is good. Information about what they prefer to do for themselves and how staff are to assist is available. This is not then put into a care plan for staff to follow. Risk assessments are not clear about how residents are to be assisted with their daily lives including moving and assisting, bathing and continence care. Their was only limited evidence to show that social care plans have been developed nor were there detailed care plans available to show how staff assisted those who have a dementia type illness. Care plans did record residents personal choices, likes and dislikes and religious preferences and this was positive Daily progress records are variable although fluid and food charts are clearly set out. The care plan records do not show the good care practices that were carried out by all staff on the day of the site visit. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s including, opticians and chiropody services. Advice and support is available from other healthcare professionals when required such as the district nursing services and mental health professionals. The senior staff administer medication to residents and they have completed a “Safe Handling of Medicines” course. Procedures for the safe handling of medicines are available. Records are in place for all medicines administered and disposed of. Medicine Administration Records (M.A.R.) showed no discrepancies. Staff do have sight of all prescriptions coming into the home but they do not record the amount of medication received from the pharmacy. This means a clear audit trail could not be carried out. Handwritten directions did not have any witness signatures, which would make sure there had been no error in transcribing.
St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 14 Not all of the printed directions on the M.A.R. sheets were clear, for example “ give as directed”. There are no Controlled Drugs in the home and no one self medicates. Residents spoken to felt that they are treated with respect and their right to privacy is upheld. Residents spoke about their personal wishes and preferences, which are respected by staff. Examples include locking their bedroom doors, receiving their mail, being addressed by their preferred name and being able to go wherever they wish inside and where possible, outside of the home. Comments from resident surveys included: “Staff always listen if I say I am not feeling well. This is always attended to and my doctor is notified or appropriate action is taken.” “I always receive my medication and if I am poorly I am monitored. I know the staff will look after me.” “There are alarms in the toilets which enables me to go to the toilet independently knowing that help will come if I need it. This maintains my independence.” Comments from relatives included: “Its gorgeous” “X is safe and looked after really well” “They treat everyone as individuals. And respects everyone’s dignity. Staff are very aware of everyone’s needs. Visitors are always welcome”. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A range of social and religious activities is provided which offer stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with good opportunities to maintain their previous lifestyles. Residents are well supported to make choices and take control over their lives. Choices of nutritious and appetising meals are available to ensure individual dietary needs and preferences are met. EVIDENCE: An activities coordinator is involved in arranging a number of activities for the residents many of which include craftwork and making items for the home.
St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 16 Other activities include spending time on a one to one basis with residents who prefer to stay on their room, manicures, armchair aerobics, tombola, board games and sing a longs. Other events include themed nights including an Italian night, trips to the theatre and tea dances. Both residents and relatives were extremely satisfied with the events held in the home especially the yearly pilgrimage to Lourdes, which is the highlight of the year for many of them. There is an open visiting policy and residents can choose who they wish to see. Visitors are usually received in the resident’s bedroom, the dining room outside of mealtimes, or outdoors in the summer months. Residents are supported to make use of nearby amenities such as the ‘Over 60’s’ club in a local church hall, shops, garden centre, and going for walks in the area. Local clergy visit individuals and hold religious services in the home on a regular basis. Residents are encouraged to continue to manage their own finances, and for relatives to provide assistance where needed. Management do not take responsibilities for individuals’ finances, other than the safe keeping of cash for personal spending. Information is available to residents on advocacy services. The extent of personal possessions to be brought into the home is agreed with new residents before admission. There is a menu, which offers choices and variety. Menus are changed seasonally and residents’ personal preferences are taken into account. This includes providing a daily vegetarian and soft diet menu. Residents can choose to have a full English breakfast although in practice they generally have the lighter option of cereals, toast with butter and preserves, juices and tea or coffee. Residents’ said they preferred this so they had “plenty of room for a good lunch”. The dining tables were nicely set for the lunchtime meal. This consisted of mince and dumplings or sausages and Yorkshire pudding with cauliflower, carrots, mashed potatoes and gravy. Dessert choices included fresh fruit, freshly made strawberry mouse with fresh strawberries and double cream or ice cream. Residents were able to have a combination of all choices as they wished. Juice was readily available throughout the meal. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 17 Staff were attentive and offered assistance to those who needed it, in a discreet, courteous and unhurried manner. The environment and the atmosphere were sociable and pleasant. Comments from residents included: “There are lots of activities to take part in I choose which ones I want to do, if I want to do them” “If I don’t want to do anything I don’t have to”. “The food is good” “Meals are always nice” “I have plenty to eat” St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 18 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): 16,18. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The complaints procedures are clear. However without accurate records no one can be sure that all resident and relative views are listened to and acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: There are complaints policies and procedures, which are displayed, in the home. All of the residents and relatives spoken to said they would be able to use the procedure and knew “things would be sorted straight away”. The owner said that all complaints are taken very seriously and action is always taken .The complaints book was not available and records of all complaints are not written down with timescales, outcomes and action taken. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 19 Policies and procedures on safeguarding adults and ‘whistle blowing’ (informing on bad practice) are available in the home. The staff have completed protection of vulnerable adults training and have regular updates. There have been no Safeguarding Alerts or complaints made to either Local Authority or to the Commission for Social Care Inspection. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 20 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): 19,20,21,24,26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The building is clean, warm and homely offering residents a pleasant environment in which to live. EVIDENCE: This is a Victorian semi-detached property that has been converted to a care home and extended. The lounges and dining areas are mainly on the ground floor with another large lounge upstairs Bedrooms are available on all floors. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 21 The home does not have a planned programme of routine maintenance, renewal and redecoration. The owner is aware that external repairs are needed to the brickwork and stonework around the windows but has prioritised the refurbishment of the inside of the home A bedroom next to the kitchen is being changed to provide more kitchen space. The owner confirmed that building regulations and requirements of the fire officer were being carried out. A bedroom opposite is being refurbished to provide further office space. All of the lounges and dining rooms are nicely decorated and furnished. The bedrooms all vary in layout and design. All were clean, decorated and furnished to a good standard. None of the wardrobes were secured to the walls. The pipe work under the sinks was exposed. Many of the residents have brought small items of furniture and keepsakes with them making the rooms highly individualised. They reflect residents’ previous lifestyles and religious beliefs. Time and effort has been taken by the owner to make sure that rooms are redecorated ready for residents to move straight into. The bathrooms and toilets are close to resident areas and are fitted with appropriate aids and adaptations. The laundry and sluice facilities are combined in one room separate from resident areas. This results in commode pots being cleaned in the same area as soiled and clean laundry. Commode pots are stacked on a draining board to dry when they have been washed and cleaned out manually. Staff do not have immediate access to goggles, gloves and aprons when carrying out this task and liquid soap and paper hand towels were not provided in the laundry/sluice for staff to effectively wash their hands The washing machines are domestic in style and have no specific programme to make sure disinfection standards are met. All bins including clinical waste bins do not have suitable lids. On the day of the site visit the home was well lit, clean, tidy and fresh smelling. The owner agreed to look at how the laundry/sluice area could be improved to reduce as far as possible any risk of infection. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The current staffing levels is sufficient to meet the residents’ needs. A training programme is in place to make sure staff have the competence to care for the residents needs. There are robust recruitment policies in place, which makes sure residents, are protected from harm. EVIDENCE: The home benefits from a stable staff team, many of whom have worked in the home for twenty years or more. Currently there is not a registered manager employed. The owner carries out the management of the home, delegating some management jobs to the senior staff. Staffing levels are maintained at three during the day and two staff overnight.
St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 23 In addition there is an activities organiser, part time administrator, chef, kitchen assistants, maintenance and domestic staff. Senior staff are trained to level 3 National Vocational Qualifications (NVQ) in care and all staff are completing NVQ level two training. Four staff files showed that job descriptions and roles are clear and each file had an application form completed. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, and proof of identity. Two of the files did not have two references. This was because they have been employed in the home since 1989. There is evidence that previously a planned training programme was in place. Training in safe working practices was not up to date for this year. The staff have received training in Safeguarding Adults, safe administration of medicines and positive dementia care. There are plans for further training to be carried out and two senior staff to complete NVQ level 4. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 24 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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service The owner is currently managing a staff team who ensure the home is run in the best interests of people using the service. Without clear systems for consultation and quality monitoring residents cannot be sure that their views are sought and acted upon. Residents personal accounts are managed to ensure their best interests are protected. Without up to date training and clear record keeping the staff cannot be sure that residents are fully protected St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 25 EVIDENCE: The home currently does not have a registered manager. The owner has assumed full responsibility for the day-to-day management of the service. Senior staff help in decision making and their views are used for forward planning and day to day running of the home. Feedback from residents meetings, questionairs and meetings with families are used as tools for quality assurance. This has not been done recently. The owner is responsible for all the insurance policies being in place, financial planning and running of the business. There is a financial administrator/ business partner to assist with the smooth running of financial affairs and budgets. The home handles only small amounts of money on behalf of residents although families generally handle their own relatives’ money. Transactions were appropriately recorded but did not have two signatures. Receipts are kept to verify purchases. A check of a sample of residents’ balances and cash found no discrepancies. Risk assessments for safe working practices (fire safety, moving and handling, food hygiene, first aid, and infection control) need to be developed. Some staff still need to be provided with training in health and safety and aspects of safe working practices. Records of accidents are kept and these include action taken by staff but not the outcome. There is no analysis of trends to find out what could be done to minimise the risk to individuals. Staff received training from the fire officer on the 10 October 2007. Night staff are to receive training three monthly and day staff six monthly. The owner is to make sure that the actions required following the fire officers’ visit are carried out In house maintenance checks are carried out as required. Water temperatures are not checked on a weekly basis. St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 26 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 2 3 3 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4,5 Requirement Timescale for action 01/04/08 2 OP2 5 3 OP7 14 The registered person must make sure that the Service User Guide is reviewed and a copy provided to current and prospective residents. The registered person must 01/03/08 make sure that a copy of the terms and conditions of residence be issued to each resident. A copy of this document must also be kept on each residents file. Timescales of 27/12/06 not met. The registered person must 01/03/08 make sure that care plans set out in detail the action to be taken by care staff to ensure all aspects of health, personal and social care needs of residents are met. Detailed risk assessments need to be available for moving and handling, nutrition and promotion of continence. Care plans must be reviewed at least monthly and updated to reflect the changing needs of individual residents. Timescale of 27/03/07 not
DS0000015725.V346194.R01.S.doc Version 5.2 St Marthas Residential Home Page 28 4 OP9 13 5 OP16 17,22 6 OP19 23 7 OP19 23(2) 8 OP26 16(2)(j) 9 OP26 13, met. The registered person must make sure that all medicines received into the home are checked, recorded, dated and signed by staff. All handwritten directions on the Medicine Administration Record (M.A.R.) must have two signatures. All directions on the M.A.R. must be clearly set out. The registered person must make sure that a record of all concerns and complaints is kept. Details of investigations, action and timescales must be included. The registered person must progress with plans for the repair of the exterior of the building Timescale of 8/02/06 and 27/12/06 not met. A programme of maintenance, renewal and decoration must be devised that includes the building and hygiene issues detailed in this report. Timescale of 27/12/06 not met. The registered person must make sure that liquid soap and paper hand towels be provided in the laundry/sluice for staff hand washing. Lidded bins must be provided in the kitchen and toilets, and separate bins used for clinical waste. Timescale of 27/09/06 not met The registered person must provide a washing machine that has specified programming ability to meet disinfection standards. Protective aprons, gloves and goggles must be provided when staff are dealing with body fluids.
DS0000015725.V346194.R01.S.doc 01/02/08 01/02/08 01/09/08 01/04/08 01/03/08 01/02/08 St Marthas Residential Home Version 5.2 Page 29 10 OP31 9 11 OP33 24 12 OP35 12 13 OP38 13(3)(4) 14 OP38 13 The registered owner must progress with the employment of a suitable person to manage the care home. The registered person must develop an annual quality assurance system, which is based on seeking the views of the residents with records kept. The registered person must make sure that all transactions of residents’ personal accounts have witness signatures. Risk assessments must be devised for safe working practices: moving and handling, fire safety, first aid, and food hygiene and infection control. Timescale of 27/12/06 not met. The registered person must make sure that all water temperatures are checked weekly with records kept. All wardrobes must be secured to the wall to prevent toppling incidents. Exposed piping must be boxed in. 01/06/08 01/06/08 01/02/08 01/03/08 31/12/07 St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 30 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 OP7 Good Practice Recommendations (a) Validated assessments should be used to identify and monitor changes to resident physical and mental health needs. (b) Day and night reports should be regularly recorded. Sitting scales should be provided to ensure residents weight gain or loss is recorded. Health and safety audits should be introduced. 2 3 OP8 OP38 St Marthas Residential Home DS0000015725.V346194.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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