Inspection on 26/09/06 for St Martha's Residential Home

This inspection was carried out on 26th September 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 Martha's Residential Home 12/11/08

St Martha's Residential Home 14/11/07

St Martha's Residential Home 08/02/06

St Martha's Residential Home 15/09/05

St Martha's Residential Home 05/10/04

St Martha's Residential Home 10/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Marthas Residential Home 17 Thornhill Park Sunderland SR2 7LA Lead Inspector Elaine Malloy Key Unannounced Inspection 09:50 26 to 27 September 2006 th 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 DS0000015725.V309243.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. DS0000015725.V309243.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 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) DS0000015725.V309243.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 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 £359 to £374 for residents funded by the Local Authority or who are privately funded. DS0000015725.V309243.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. It was carried out over 2 days and took 9 hours. Standards were inspected through discussion with the manager, staff and residents, examining the home’s records and touring the building. Surveys were made available to residents to get their views on the service. Two completed surveys were received and comments from these are included in the report. Each of the areas that needed improvement from the previous inspection was checked with the manager. What the service does well: What has improved since the last inspection? What they could do better: Action needs to be taken on the requirements of previous inspections to: DS0000015725.V309243.R01.S.doc Version 5.2 Page 6 1. Make sure all residents have a contract in place for their care at the home. 2. Make further improvements to how residents care needs are recorded in care plans. 3. Decorate and carry out work to the outside of the building. Other improvements needed from this inspection are: Assessments to identify resident needs and monitor changes. Forward plan social activities and keep records of all activities that are provided. Introduce new menus that provide a varied range of meals and meet the nutritional needs of older people. Draw up a programme for maintaining the building and improve hygiene in the kitchen and food storage areas, laundry, and toilets. Provide staff with further training that is relevant to caring for older people, and make arrangements for more staff to complete care qualifications. Develop a plan that shows how the quality of the service is checked. Record two signatures to entries for resident personal finances. Meet health and safety requirements by assessing risks, arranging training and checking fire equipment. 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. DS0000015725.V309243.R01.S.doc Version 5.2 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 DS0000015725.V309243.R01.S.doc Version 5.2 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): 2 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. All residents must have a contract from the Local Authority that funds their care, or a privately funded contract. New residents have their care needs assessed before admission to the home is agreed. EVIDENCE: At previous inspections the home has been required to make sure all residents have contracts of their terms and conditions of residence. A sample of resident files was examined. Contracts were not present for each person. One resident who completed a survey said they had a contract, and another was uncertain whether they had. Both indicated they received enough information about the home before moving in. One lady commented “I attended St Martha’s day care unit before I came in as a resident which made making the decision a lot easier. I knew I was coming into a nice, friendly home”. DS0000015725.V309243.R01.S.doc Version 5.2 Page 9 The care records of the last two residents admitted to the home were examined. Pre-admission assessments of care needs had been carried out. A Social Work assessment was also obtained for a lady whose place at the home is funded by the Local Authority. The assessment information was used to draw up care plans so that staff are aware of the care and support new residents require. DS0000015725.V309243.R01.S.doc Version 5.2 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 and 10. Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Plans that show how resident care needs will be met do not have enough detail and require further improvement. Arrangements are in place for residents to access health care professionals. The home needs to improve how care is assessed and planned for moving and handling, nutrition and weights, and continence needs. Residents are protected by the home’s system for medication and staff who deal with medication have received training. Resident privacy and dignity is respected. EVIDENCE: The home does not currently use any validated assessment tools to identify and monitor changes to residents physical and mental health needs. Those assessments that were in place were not always dated. This made it difficult to establish individual’s current needs. DS0000015725.V309243.R01.S.doc Version 5.2 Page 11 At previous inspections the home was required to develop the recording of resident care plans. A sample of resident care records was examined. The previous manager had made some improvements, however the plans specify to target only 2 or 3 objectives. This has resulted in not all care needs being addressed in care plans. The majority of plans were not specific and lacked sufficient detail of the assistance needed from staff and what the resident can do independently. There was no evidence of care plans being evaluated; this must be introduced and completed at least monthly. Day and night reports need to be recorded with greater frequency to provide an ongoing record of care provided and to assist with evaluations. It was suggested that the reports could be numbered to correspond to care plans. Residents said they receive the medical support they need. One lady commented, “I feel very safe here”. Residents use a range of local GP practices and have access to District Nursing Services. Mental health professionals provide services to individual residents. Arrangements are in place for visits from optician, dentist and chiropodist. All visits and appointments with medical professionals are recorded separate to daily reports. The home does not use an assessment to determine residents moving and handling needs. This must be introduced and lead to clear moving and handling care plans being drawn up. There was evidence of assessment of risks. Details were recorded of how to minimise or manage risks, for example risk of falls. The District Nurse assesses residents with continence needs. Care plans for continence management lacked basic details. For example, how often the resident should be assisted to go to the toilet and aids that are used. Resident weights were not being routinely monitored. The home does not have sitting weighing scales and therefore not all residents can be weighed. A sample nutritional assessment and information on nutritional needs of older people was sent to the home following the inspection. Staff who give out medication have completed relevant training. No residents currently self-administer their prescribed medication. Medication charts were examined. These had photographs of residents for identification, and were appropriately recorded with no gaps to signatures. Codes were recorded on occasions to show the reasons why medication was not given. Some preprinted directions for medication were unclear. The Manager agreed to follow this up with the supplying pharmacist and where necessary add handwritten directions. No residents at present are prescribed Controlled Drugs. DS0000015725.V309243.R01.S.doc Version 5.2 Page 12 All personal care and medical examination/treatment takes place in the privacy of the resident’s bedroom. Two bedrooms are currently shared and curtain screening is provided to afford privacy. Residents are asked the name they wish to be addressed by and this is recorded on their initial assessment. During the course of the inspection staff were seen to address residents in a courteous manner. Residents praised staff and said they are “very good” and “respectful”. The home employs all female care staff. Some residents have their own telephones in their bedrooms. There is a telephone available in the hall for resident use, or they can use a portable telephone to make or receive calls in private. Mail is given directly to residents unopened, or staff/relatives provide support. Residents clothing is labelled and there is named shelving in the laundry to make sure clothing is returned to the right person. The manager agreed to purchase individual wash bags for tights, stockings and socks. DS0000015725.V309243.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Residents are provided with a fair range of social activities and outings and most said life in the home meets their social needs. Supported is offered to maintain contact with relatives, friends and the local community. Residents are encouraged to make choices and decisions in daily living. The home’s menus need to be revised to offer residents a variety of nutritious meals. EVIDENCE: During the inspection residents were sitting outside in the sun talking with one another and staff, and music was playing. A group of residents were also seen playing dominoes. The home employs an Activities Co-ordinator. A photograph album is maintained of residents taking part in seasonal events and themed social evenings. A diary is kept of social activities provided and which residents have participated. This showed a fair range of activities including armchair exercises, ball games, knitting, dominoes, and reminiscence. There were also DS0000015725.V309243.R01.S.doc Version 5.2 Page 14 recordings of activities and outings with individual residents. Care staff were not recording activities provided when the Activities Co-ordinator is on days off or leave. There is not a forward planned programme of daily activities; this should be considered and provided to residents for their information. One resident said she would like access to books. This was discussed with the manager who agreed to make arrangements for a mobile library service. The home has use of two mini-buses and outings are arranged. Ideas for outings had been discussed at a recent resident meeting. Some residents had been on an annual pilgrimage to Lourdes. Some residents told the inspector they liked being able to sit outside and go on trips. One resident who completed a survey said there is always activities arranged that they could take part in. She commented, “We have just been on a trip to Lourdes in France and we have recently been to the Empire to a show. We have lots of special nights, like the Italian Night and the Cowboy Night. We also do exercises and play bingo”. The other resident surveyed said activities are never arranged and commented, “St Martha’s has a very vigilant and caring management and staff. The carers are great, always ready to help and listen to any worries that one may have. The only area that could improve would be to have entertainers coming in on a regular basis to give fun and stimulation to residents”. 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 when the weather is fine. 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. 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 policy on resident access to personal care records. The manager agreed to discuss with staff how this could be put into practice. The home has a 4-week cycle of menus. Breakfast consists of cereals, porridge and toast. Cooked breakfasts were not offered daily. There is a choice of main meal and dessert at lunch, and choice of lighter meals for tea. Snacks and milky drinks are served for supper. Two weeks of the menu were examined. These showed a fair amount of repetition of meals. The manager said she was discussing the menus with the catering staff, and agreed to consult residents about meals and mealtimes. Those residents spoken with confirmed they were given choice of meals and said they could take meals in their bedroom if they wished. Some residents said they enjoyed the food whilst others said it was DS0000015725.V309243.R01.S.doc Version 5.2 Page 15 ‘okay’. Residents who completed surveys said they ‘always’ or ‘usually’ liked the meals. One day commented, “The meals are lovely and we always get a choice”. Themed food had been provided on social evenings such as St Patrick/Irish, Country and Western and Italian nights. Menus were now being displayed in the dining room, as previously recommended. Residents are asked their preference for meals on the day. Nutritional needs of older people were discussed with the manager, including fortification of food, and information was sent to the home. No residents require special diets. One resident who was currently in hospital had been provided with blended food. Residents are encouraged to eat independently with prompts and support from staff. DS0000015725.V309243.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents are aware of how to make a complaint and any complaints received are taken seriously and investigated. Procedures are in place to protect vulnerable adults from abuse and staff training is organised. EVIDENCE: Residents who spoke to the inspector, and who completed surveys confirmed that they would know how to make a complaint. One lady commented, “I have a good relationship with all the staff but I would speak to the manager if I was not happy”. Two complaints had been received in the past year. Both were about missing laundry and were resolved when items were located. The manager said that she was intending to combine compliments and complaints records, and continue resident meetings to get feedback on the service. There are policies and procedures on prevention of abuse, protection of vulnerable adults and ‘whistle blowing’ (informing on bad practice). ‘Whistle blowing’ had been discussed at a recent staff meeting. 50 of the staff team have completed protection of vulnerable adults training. The remainder are booked to attend this training soon. There have been no allegations of abuse in the period since the last inspection. The home does not advocate use of DS0000015725.V309243.R01.S.doc Version 5.2 Page 17 restraint. Some residents present challenging behaviour due their mental frailty. The manager agreed to make sure that this is recorded explicitly in care plans. DS0000015725.V309243.R01.S.doc Version 5.2 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 and 26. Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. A programme to maintain the building is needed and hygiene methods need to be improved. EVIDENCE: At the previous inspection a requirement was made to decorate the exterior of the building, carry out pointing to the brickwork and remedial work to stonework around windows. The manager said that estimates had been taken up for the work, however a start date was not yet agreed. Communal lounges, the dining room and those resident bedrooms seen were suitably decorated and furnished and looked comfortable. Many residents had brought in possessions from home to personalise their rooms. The manager agreed to make sure prescribed creams, toiletries, disposable razors and bathing procedures are removed from bathrooms. DS0000015725.V309243.R01.S.doc Version 5.2 Page 19 The home does not have a programme of routine maintenance, renewal and redecoration. This needs to be drawn up following a thorough audit of the building and prioritise work. The programme must also take into account the following: • The laundry and sluice facilities are combined in one room. This results in commode pots being cleaned in the same area as soiled and clean laundry. Consideration must be given to creating separate laundry and sluice rooms. • Pipe work under sinks in bedrooms is not boxed in. • Damage to paintwork of doors and skirting. • All bedrooms to have bedside lights and call systems within reach of the bed for resident safety. During the inspector’s tour of the building the following issues were also identified: • Food storage: Opened dried food was not date labelled. Spilt food not cleaned up in kitchen store. Food being kept in dirty conditions in the cellar, including being stored on the floor. Some out of date food in the chest freezer. An Environmental Health Officer had visited the previous day. • Liquid soap and paper hand towels were not provided in the laundry/sluice for staff hand washing. • There were bins without lids in the kitchen and toilets. An open bin was being used for clinical waste in one toilet. Residents who spoke to the inspector or completed surveys said they were happy with their surroundings, and the home is always fresh and clean. Many residents commented positively on using the outside sitting area in fine weather. Other comments included, “My room has just been decorated and it is lovely. It gets cleaned every day. All the rooms are lovely and very clean. The home is lovely and well looked after”. DS0000015725.V309243.R01.S.doc Version 5.2 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 and 30. Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. There are good staffing levels to meet the needs for the number of residents. Progress needs to be made towards meeting the standard for the number of staff who have care qualifications. The home operates a generally robust recruitment process. Staff training needs have been identified and courses are to be arranged. EVIDENCE: The home continues to provide staffing levels of 3 carers across the waking day and 2 carers at night. Additional to these staffing levels are the hours worked by the manager, the Activities Co-ordinator, and a part-time Administrator. There is a designated senior member of staff in charge of each shift. All seniors are over 21 years of age and all care staff are aged over 18. There is a total of 97 weekly catering hours. Two cooks and a kitchen assistant are employed to cater for the residents of the home, up to 10 day care service users and up to 30 ‘meals at home’ each day. 80 domestic and laundry hours are provided weekly. There is a full-time maintenance person. Residents who completed surveys said they always received the care and support they need. They said staff listen and act on what they say, and are DS0000015725.V309243.R01.S.doc Version 5.2 Page 21 available when they need them. One resident commented, “The staff are very friendly and caring”. One lady told the inspector she was able to maintain her independence and receive the support she needs. Another lady said she was very well cared for. The home does not currently meet the standard for at least 50 of care staff to have achieved qualifications in care. 13 carers including seniors are employed. To date 3 senior staff have completed National Vocational Qualifications (NVQ) in care. The manager was making arrangements to enrol further staff on NVQ training. A sample of staff personnel files was examined. Appropriate recruitment information was maintained, including photograph, proof of identification, application form, references, Criminal Records Bureau checks and medical questionnaires. Further staff was being recruited to fill vacancies and new interview formats were being introduced. Staff undertake induction training that includes shadowing experienced staff. This was verified during the inspection. A new carer was being introduced to residents and was being supervised by another worker. In the past year there had been training in protection of vulnerable adults, falls prevention and health and safety. Fire safety and moving and handling training was planned for October 2006. The new manager had recently audited staff training records. From this she had identified the need for further staff to have training on caring for people with dementia, medication, health and safety, first aid, and food hygiene. DS0000015725.V309243.R01.S.doc Version 5.2 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 and 38. Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. A new manager has been appointed who has care and management experience and is qualified. A clear plan on how the quality of the service is monitored needs to be introduced. Personal finance recording needs to be made safer by being checked and signed by two staff. Health and safety is to be improved by providing further staff training, assessing risks, checking fire equipment and introducing audits of the building. DS0000015725.V309243.R01.S.doc Version 5.2 Page 23 EVIDENCE: The current manager previously managed the company’s domiciliary care agency and has recently taken up post as manager of the home. She has been involved with the family care business for over 20 years. She has completed NVQ qualification Level 4 in Care and Management. She is applying to become the home’s Registered Manager. A development plan for how the quality of the service is monitored needs to be introduced. The inspector gave advice including introduction of audits and measurable standards. Feedback about the service is currently obtained through holding resident meetings and questionnaires with residents. The manager said she was planning to develop questionnaires for residents and relatives with questions on staff, food, activities, the running of the home, and privacy and dignity. There will also be space to record additional comments. The manager agreed to include findings and comments in the home’s Service User Guide. She was also looking towards introducing a monthly newsletter for the home. The home holds personal cash for safekeeping in a safe. Resident personal finances were checked. 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 was carried out; this was correct. The home has a health and safety policy and associated procedures. Maintenance and servicing arrangements for amenities and equipment are in place. There is no system for routinely checking the building other than staff reporting any repairs, hazards or maintenance needed. The inspector suggested that health and safety audits should be introduced. 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. Fire safety records were examined. Checks and tests of fire alarms and emergency lighting were being carried out at the required frequency. Fire fighting equipment was not being checked monthly. Fire instructions were being provided to day staff on a six monthly basis, and three monthly for night staff. The manager agreed to reintroduce records that forward plan instructions. DS0000015725.V309243.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 2 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 DS0000015725.V309243.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Requirement (Outstanding Requirement) A copy of the terms and conditions of residence must be issued to each resident. A copy of this document must also be kept on each residents file. (Outstanding Requirement) Residents care plans must continue to be developed. There must be care plans for all identified care needs; with sufficient details of the action to be taken by staff to meet needs; and plans must be evaluated at least monthly. Resident moving and handling, and nutritional needs must be properly assessed. Resident continence needs must be addressed in specific care plans. The home’s menus must be revised to provide a varied range of nutritious meals. (Outstanding Requirement) The exterior of the premises must be decorated and all remedial works as discussed during the (previous) inspection DS0000015725.V309243.R01.S.doc Timescale for action 27/12/06 2. OP7 14 27/03/07 3. OP8 14(2) 15 29/11/06 4. 5. OP15 OP19 16(2)(i) 23 27/11/06 27/12/06 Version 5.2 Page 26 6. OP19 23(2) 7. OP26 16(2)(j) 8. OP30 18(1) 9. 10. OP38 OP38 23(4) 13(3)(4) must be addressed (pointing to brickwork and remedial work to stonework around windows). A programme of maintenance, renewal and decoration must be devised that includes the building and hygiene issues detailed in this report. (a) Food must be appropriately stored in clean conditions. (b) Liquid soap and paper hand towels must be provided in the laundry/sluice for staff hand washing. (c) Lidded bins must be provided in the kitchen and toilets, and separate bins used for clinical waste. Confirmation must be submitted to the CSCI that identified training courses have been booked for caring for people with dementia, medication, health and safety, first aid, and food hygiene. Fire fighting equipment must be checked monthly. Risk assessments must be devised for safe working practices: moving and handling, fire safety, first aid, and food hygiene and infection control. 27/12/06 27/09/06 27/11/06 27/09/06 27/12/06 DS0000015725.V309243.R01.S.doc Version 5.2 Page 27 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. (a) Resident weights should be regularly monitored. (b) Sitting weighing scales should be provided. (a) Social activities that take place in the absence of the Activities Co-ordinator should be recorded. (b) Daily activities should be forward planned and information circulated to residents. The home should continue to make progress towards meeting the standard of care staff with NVQ qualifications and confirm further enrolment to the CSCI. An annual development plan for monitoring the quality of the service should be introduced. Two signatures should be recorded to verify all resident personal finance transactions. Health and safety audits should be introduced. 2. 3. OP8 OP12 4. 5. 6. 6. OP28 OP33 OP35 OP38 DS0000015725.V309243.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Shields Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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