Inspection on 15/02/07 for St Martins Care Home for the Elderly

This inspection was carried out on 15th February 2007.

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 Martins Care Home for the... 03/02/08

St Martins Care Home for the... 21/08/07

St Martins Care Home for the... 22/05/06

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

CARE HOMES FOR OLDER PEOPLE St Martins Care Home for the Elderly 22 Feckenham Road Headless Cross Redditch Worcestershire B97 5AR Lead Inspector Nic Andrews Unannounced Inspection 19 & 20 February 2007 09:15 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 Martins Care Home for the Elderly DS0000065811.V329922.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 Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Care Home for the Elderly Address 22 Feckenham Road Headless Cross Redditch Worcestershire B97 5AR 01527 544592 F/P 01527 544592 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) St Martins Care Home for the Elderly Ltd Post Vacant Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (12) St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There were no conditions of registration apart from those referred to on the previous page. Date of last inspection 17th November 2006 Brief Description of the Service: St Martins is situated in a residential area close to local shops and other amenities. There is a small car parking area at the front of the premises and an enclosed garden at the rear. An extension is being built in the rear garden in order to provide an additional three single bedrooms. The home is registered to provide personal care for a maximum of twelve older people over the age of 65 years. The home is also registered to provide care for older people who may have a physical disability and/or a dementia illness. The people who use the service are accommodated on the ground floor and first floor of the building. There are eight single bedrooms and two double bedrooms. Two of the single bedrooms have an en suite facility. The home has a stair lift to enable service users to gain access to the first floor. The communal space consists of a dining room, a front lounge, a smaller rear lounge and a conservatory. The home’s stated purpose is to provide an environment that seeks to support people for the remainder of their lives. The fees ranged from £1372.00 to £1420.00 per month. St Martins Care Home for the Elderly DS0000065811.V329922.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 that took place over two days. The home was inspected against the key National Minimum Standards. The inspection included time spent with the new acting manager and the proprietor. The home’s response to the requirements and recommendations that were made as a result of previous inspections was assessed. Various records and documents were examined. Individual discussions were held with two service users and three members of staff. Parts of the premises were also inspected. As part of the inspection ‘Comment Cards’ were issued to the relatives/visitors of the service users. Three Comment Cards were completed and returned. The comments that were made are reflected in this report. What the service does well: What has improved since the last inspection? What they could do better: St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 6 Improvements were needed to various aspects of the home’s written documentation and administrative procedures including the service users’ guide, contracts, care plans, risk assessments and record keeping. The acting manager needed to be relieved of some of her caring duties in order to be able to devote more time to her managerial and administrative responsibilities. Staff training was needed in different areas including medication and the protection of vulnerable adults. The number and deployment of staff needed to be improved. The correct staff recruitment procedures must be followed in order to ensure the safety and protection of the service users. The system for monitoring the quality of the service must be more thorough and effective. The acting manager said that there was a need to review the food provided for the service users and the home’s policies and procedures. The acting manager also said that there was a need to do some work on ‘team building’. 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 Martins Care Home for the Elderly DS0000065811.V329922.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 St Martins Care Home for the Elderly DS0000065811.V329922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. The quality outcome in this area was poor. This judgement has been made using available evidence including a visit to this service. The statement of purpose must be updated and the service users’ guide did not give clear information about the home. Not all of the service users had been issued with a contract and not all of their care needs had been fully assessed. EVIDENCE: A requirement was made as a result of previous inspections that the home’s statement of purpose must be amended. The contents of the statement of purpose had improved. However, the requirement had not been fully implemented and still stands. The statement of purpose included details of the former acting manager and other former members of staff that were no longer working at the home. The statement of purpose did not include the address of the registered provider, a clear statement that the home was not registered to provide nursing care or details of the associated emergency procedures as a result of fire e.g. the arrangements for the care and accommodation of the service users in the event of a temporary closure of the home. A copy of the service users’ guide was made available for inspection. The acting manager stated that a copy of the service users’ guide had been placed in all of the service users’ bedrooms. However, the requirement that was made as a result St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 9 of the previous inspection regarding amendments to the service users’ guide had not been implemented and still stands. The service users’ guide was poorly written and did not include all of the required information. The service users’ guide also included details of the former acting manager and other former members of staff that were no longer working at the home. The service users’ guide must be reviewed and amended appropriately. The two service user files that were inspected did not include a copy of a statement of the terms and conditions of residence (contract). The acting manager confirmed that not all of the service users had been issued with a contract. A contract that includes all of the issues referred to in Standard 2.2 must be issued to all of the existing service users and to all new service users at the point of moving into the home. The acting manager confirmed that the needs of all the service users had been assessed. A requirement was made as a result of the previous inspection in regard to Standard 3. The requirement was that the home must provide one, clear form for the specific purpose of assessing the care needs of the service users. The form must include a reference to all of the issues listed in Standard 3.3 and be referred to correctly as an assessment form. A copy of the form that was used to assess the needs of the service users was made available for inspection. The requirement had not been implemented. The wording of the requirement has been amended and is repeated in this report. It was noted that the form used for assessing the needs of one service user did not include any reference to foot care, personal safety and risk or carer and family involvement and other social contacts/relationships. Prospective service users were given the opportunity to visit the home before they were admitted. However, this practice was not always followed. The acting manager stated that this was because social workers said that it was not always possible to do this. The acting manager was given advice on this matter. The first four weeks following admission were regarded as a trial period. The home did not normally accept new service users in an emergency. St Martins Care Home for the Elderly DS0000065811.V329922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. Each service user had a care plan and access to health care services. The service users’ privacy and dignity were respected. However, some aspects of the care planning and the administration of medication needed to be improved in order to ensure that all of the service users’ needs were fully met. EVIDENCE: Two requirements were made in regard to Standard 7 as a result of the previous inspection. The first requirement was that the care plans must cover all aspects of care as set out in Standards 7.2 and 3.3 including risk assessments and must contain clear, specific guidance for the safe delivery of care. A copy of the care plan used by the home was made available for inspection and several completed care plans were inspected. The care plans covered all of the aspects of care referred to in Standards 7.2 and 3.3. It was also pleasing to note that risk assessments on falls, pressure sores and nutrition had been carried out. However, the care plans still needed to be more specific in regard to the action to be taken to ensure that all of the service users’ needs were met. This aspect of the requirement has been reworded and still stands. It was also noted that a risk assessment had not been carried out and recorded in respect of one service user with epilepsy. The St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 11 acting manager stated that she would address this matter immediately. The second requirement was that all service user care plans must be reviewed by care staff at the home at least once a month and be agreed and signed by the service user whenever capable and/or representative (if any). It was confirmed that all of the service user care plans had been reviewed on a monthly basis. However, not all of the service users had signed their care plans. The acting manager said that this was something that could be encouraged. This aspect of the requirement still stands. All of the service users were registered with one of five local GP practices. It was confirmed that none of the service users had a pressure sore. However, one service user used a pressure relieving mattress and cushion. Another service user had a cushion. The district nurse provided these items. The continence adviser had recently carried out an assessment of the service users. The acting manager stated that none of the service users required the help of an occupational therapist or psychiatrist. The acting manager intended to make arrangements for music and movement sessions to be introduced in order to help the service users to remain active. The chiropodist visited once a month. The service users received appropriate dental treatment and ophthalmic care. A training session had been arranged for the staff with the dental health educator. Two previous requirements that were made were about the need to carry out risk assessments on all of the service users regarding nutritional screening and falls. Both of these requirements had been implemented. Two other requirements had also been made about risk assessments. These were regarding tissue viability and the use of a stoma bag. The two service users to whom these requirements applied were no longer living at the home. Therefore, the two requirements have been deleted. The home used the Boots monitored dosage system for administering medication. Photographs of the service users were attached to the Medication Administration Records (MAR charts). The arrangements for the storage of medication were satisfactory. The home had a lockable medicine trolley that was secured to the wall when not in use. The medication that required cold storage (eye drops) was kept in a lockable box in a fridge in the kitchen. The medication that required cold storage did not include insulin. Therefore, these arrangements were satisfactory. A record of the daily temperature of the fridge was maintained. None of the service users were in receipt of a controlled drug. However, the home had a controlled drug cupboard. It was confirmed that the home did not have any ‘overspill’ drugs. Access to the medication was restricted. The senior member of staff on duty held the keys to the medication trolley. The home should have an up to date list of the signatures of all the staff that are involved in the administration of medication. Five requirements had been made as a result of the previous inspection. Three of the five requirements were about being able to complete an audit of medication, recording the receipt of medication accurately and recording the strength of Warfarin tablets on the medicine charts clearly. These three requirements had been implemented. The other two requirements were about St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 12 the provision of a policy and procedure on the administration of medication and accredited training for the staff. The first of these two requirements had not been fully implemented and still stands. The home had a copy of a commercially produced policy that needed to be adapted in order to reflect the circumstances and procedures followed by the home. The name of the home should be included and the references to registered nurses, nursing homes and dual registered homes that are not applicable should be deleted. The second of these requirements had also not been implemented and still stands. The staff had undertaken basic awareness training in medication on 7 December 2006. However, none of the staff had undertaken the accredited training. Two recommendations were made as a result of the previous inspection. One was about checking and signing the MAR charts. The other was about an amendment to the home’s policy and procedure on the administration of medication. The first of the recommendations had not been implemented and still stands. The second recommendation was implemented during the inspection by a hand written amendment to the policy. However, the policy and procedure on the administration of medication needed to be reviewed and retyped correctly. The staff with whom discussions were held understood the importance of respecting the service users’ right to privacy. It was confirmed that the principles regarding privacy outlined in Standard 10 were carried out in practice. The service users with whom discussions were held confirmed that the staff treated them with respect and that their privacy was maintained. The service users had access to a mobile handset to enable them to make and receive calls in private. The two double bedrooms had screening. It was confirmed that medical examinations and treatment were carried out in private. The acting manager stated that the previous requirement that was made about making sure the service users were always dressed appropriately had been implemented. However, the previous recommendation that staff supervision meetings should include discussions about privacy and dignity had not been implemented and still stands. St Martins Care Home for the Elderly DS0000065811.V329922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users were able to exercise choice in regard to their daily routines, maintain contact with their relatives and friends and to express their preferences in regard to food. However, a more individual approach to social and leisure activities needed to be developed. EVIDENCE: Various social and recreational activities were provided. These included television, music, sing a longs, flower arranging and colouring. Bingo was held twice a week. The service users received a manicure once a week and a singer visited once a month. A carol service had been held before Christmas. A recommendation was made as a result of the previous inspection that the range of social and recreational activities should be extended in order to meet the service users’ individual needs and interests and a record maintained. The acting manager confirmed that the recommendation had been implemented. An activities schedule was maintained on behalf of each service user. One of the service users said that she would ‘like more outings’. The acting manager stated that it was intended to take the service users out for a meal in groups of two or three. The staff resources needed to be increased in order to allow more time for individual activities and stimulation. There were no set bedtimes. The service users could choose to eat their meals in their bedrooms if they wished. Members of the local church held a service at the home every St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 14 month. Information about activities was displayed on the notice board. The relatives of the service users were sent invitations to attend the Christmas party. There were no unreasonable restrictions in regard to visiting. The acting manager stated that she had removed the notice that had been displayed on the front door asking visitors not to come at meal times. She said that, since removing the notice, the level of visiting had increased and the visitors tended to stay for longer. The service users with whom discussions were held confirmed that they were able to see their visitors in private and that their visitors were made welcome and offered a cup of tea. A recommendation was made as a result of the previous inspection that relatives, friends and representatives of service users should be given written information, preferably in the service users’ guide, about the home’s policy on maintaining relatives and friends involvement with service users at the time of an admission to the home. The recommendation had not been implemented and still stands. It was confirmed that the service users were able to exercise choice in regard to the food they ate, the clothes they wore, hairdressing and their daily routines. The service users with whom discussions were held confirmed that they were able to get up and go to bed when they wished. Two recommendations were made in regard to Standard 14 as a result of the previous inspection. The first recommendation was that information regarding the service users’ right of access to the records held about them by the home and information about how to contact external agents e.g. advocates, who will act in their interests should be included in the service users’ guide. The recommendation had not been implemented and still stands. The second recommendation was that a clear statement that prospective service users are entitled to bring personal possessions with them, the extent of which will be agreed prior to admission, should be included in the service users’ guide. The recommendation had not been implemented and still stands. Meals were provided at appropriate intervals and drinks and snacks were available throughout the day. The record of the food provided was satisfactory. The meal that was observed being served to the service users was wholesome and appetising. The service users with whom discussions were held made positive comments about the food. They confirmed that they were consulted about the food and that they were provided with an alternative meal if they did not like what was offered. One service user said, ‘The food is marvellous. The cook is wonderful. She’s out of this world’. Another service user said, ‘It’s good, plain food, cooked well and nicely presented’. The cook, who had worked in the home for five years, was aware of the service users’ personal preferences. The recommendation that was made as a result of the previous inspection that details of the service users’ food preferences should be kept in the kitchen had been implemented. The acting manager said that a wider variety of food was gradually being introduced in order to improve the nutritional content of the service users’ diet. New tablecloths had been St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 15 provided for the dining room. A record of the food, fridge and freezer temperatures was maintained. The cook confirmed that all of the kitchen equipment was in good working order. The service users were asked to sign a statement about eating soft-boiled eggs. A cleaning schedule was maintained. St Martins Care Home for the Elderly DS0000065811.V329922.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. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The home had a clear complaints procedure and the service users felt confident about making a complaint. However, the policy and procedure needed to be amended in order to ensure that the service users were fully protected. EVIDENCE: The home had a satisfactory complaints procedure. A copy of the complaints procedure was displayed near to the main entrance. A record had been made of a complaint dated 7 April 2006. A complaint was made against the home and investigated by the CSCI in November 2006. The complaint was about personal care, staff recruitment and health and safety checks. No record of this complaint had been made by the home. A record of all complaints made against the home must be maintained. The service users with whom discussions were held said that they felt confident about making a complaint. They also felt that any complaint that was made would be dealt with quickly and appropriately. They said that the proprietor and the staff were approachable. A recommendation was made in regard to Standard 17 as a result of the previous inspection. The recommendation was that information regarding the service users’ legal rights should be included in the service users’ guide. The recommendation had not been implemented and still stands. A requirement was made as a result of the previous inspection that procedures for responding to suspicion or evidence of abuse or neglect (including whistle blowing) must be drawn up in accordance with the Public Interest Disclosure St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 17 Act 1998 and the Department of Health guidance ‘No Secrets’. A copy of the home’s policy and procedure on ‘The Protection of Vulnerable Service Users’ was made available for inspection. The policy had been purchased by the home from a commercial organisation and was an extract from a care practice manual. The policy needed to be reviewed and, where necessary, amended in order to reflect the particular circumstances of the home. The policy should also include the name of the home, the name and telephone number of the Adult Protection Coordinator and the address and telephone number of the local office of the CSCI. The requirement had not been fully implemented and still stands. The home also had a whistle blowing policy. The policy was amended during the inspection in order to include the address and telephone number of the CSCI. No incidents of abuse had been reported to the acting manager or had otherwise come to her attention. The acting manager said that she had discussed indicators of abuse with the staff at a recent staff meeting. It was also confirmed that a copy of a leaflet called ‘Reporting abuse or mistreatment of vulnerable adults-guidance for staff’ produced by the Worcestershire Vulnerable Adults Protection Committee had been issued to all members of staff. It was stated that the staff had undertaken basic abuse awareness training. However, the acting manager had not undertaken training in the protection of vulnerable adults from abuse at an appropriate level for a manager of a care home. The acting manager said that she had had no reason to refer any member of staff for possible inclusion on the POVA register. The home did not have a policy to help staff understand or respond appropriately to physical and/or verbal aggression. The recommendation that was made as a result of the previous inspection regarding the introduction of a policy about service users’ money and financial affairs had not been fully implemented. The recommendation still stands. The acting manager said that the home did not keep any personal valuables on behalf of any of the service users. However, the home had adequate facilities to do this, if necessary. St Martins Care Home for the Elderly DS0000065811.V329922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service provides a homely environment. However, some improvements were needed to ensure that the standards of maintenance and hygiene were maintained. EVIDENCE: The home was located in a mainly residential area near to shops and other amenities. The home was accessible to people in wheelchairs. The home did not have a passenger lift. However, a stair lift had been provided to enable the service users to access the accommodation on the first floor more easily. The home was comfortable and homely. The home provides eight single bedrooms and two double bedrooms. However, the home did not have a programme of routine maintenance and renewal of the fabric and decoration of the premises. A single storey extension was being built at the rear of the premises that would accommodate a further three service users in single rooms. The proprietor said that the extension would be completed in June 2007. The proprietor was aware that an application would have to be submitted to and approved by the CSCI before the new accommodation could be used. The proprietor gave an assurance that work would be undertaken to St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 19 improve the condition of the garden when the building work had been completed. It was stated that the Fire Safety Officer and the Environmental Health Officer had not made a recent visit to the home. The proprietor was advised to ask the Fire Safety Officer to inspect the premises and the changes to the environment and to confirm that the fire safety precautions and the home’s fire risk assessment were satisfactory. The proprietor was aware that this would need to be done before an application was made to the CSCI for a variation in the conditions of registration. Two requirements and two recommendations were made in regard to Standard 26 as a result of the previous inspection. The first requirement was that the risk assessment for the handling of soiled linen within the home must be fully completed. This requirement had been implemented. The second requirement was that a policy and procedure for the control of infection that includes the issues referred to in Standard 26.5 must be provided. The requirement had not been implemented and still stands. The first recommendation that consideration should be given to the provision of a washing machine that has a built in sluicing facility had not been implemented and still stands. The second recommendation was that the home’s policy and procedure for the control of infection should be revised in accordance with the ‘Guidelines for Infection Control in Care Homes’ produced by the Herefordshire and Worcestershire Local Health Protection Unit. The recommendation had not been implemented. The recommendation has been combined with the requirement referred to above. The proprietor confirmed that, in the near future, a new floor covering would be provided in the laundry and that the laundry walls would be repainted. The staff cleaned manually the commode pots that are used. The home did not have appropriate facilities to carry out this task and manual cleaning is not the recommended method of decontamination. Disposable commode pots should be used. There were no unpleasant odours in the home. However, it was noted that the floor covering in toilet 2 on the ground floor was badly stained. The floor covering must be thoroughly cleaned or replaced. It was also noted that there was no liquid soap dispenser in toilet 2. The service users with whom discussions were held confirmed that their bedrooms and their clothes were kept clean. St Martins Care Home for the Elderly DS0000065811.V329922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users were generally satisfied that the care they received met their needs. However, there were some areas that needed attention including the recruitment, training and deployment of staff. EVIDENCE: In addition to the acting manager, the home employed a part-time deputy manager, two senior care assistants, seven care assistants and a cook. One of the senior care assistants carried out sleeping-in duties. The other senior care assistant, deputy manager and seven care assistants worked a total of 145 hours per week (days). One waking member of staff and one member of staff asleep and on call were on duty at night. The cook was employed for 30 hours per week. The home had three vacant posts. One vacancy was for a weekend cook (12 hours per week). One vacancy was for a part time housekeeper (20 hours per week) and one vacancy was for a part time care assistant (20 hours per week). When the part time care assistant vacancy is filled the number of care hours provided during the working day will be 165 hours per week. Two recommendations were made as a result of the previous inspection. The first recommendation was that the acting manager and deputy manager should work some separate shifts in order to spread the management cover for the home. The recommendation had not been implemented and still stands. The second recommendation was that the registered provider should give consideration to increasing the level of staffing in anticipation of the proposed increase in the number of service users. Since the previous inspection there had been no increase in the number of staff. The acting manager was working St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 21 hard to address all of the issues arising from previous inspections of the home. However, the amount of time that she was able to devote to the management and administrative tasks was limited. This was because the acting manager spent three days each week providing ‘hands on’ care. It is accepted that in a relatively small home the manager will, from time to time, be expected to become involved in caring duties. However, the manager’s primary task is to manage the home. In order to enable the acting manager to fulfil her primary responsibility the number of care assistant hours must be increased by the equivalent of one full time member of staff, that is an additional 35 hours per week. This would increase the number of care assistant hours from 145 to 180 hours per week (days). Therefore, the recommendation has been deleted and replaced with a requirement for the staffing levels to be increased. The service users with whom discussions were held spoke positively about the staff. One of the service users described them as ‘very helpful and very friendly’. The same service user said, ‘I’m very happy here, it’s much nicer than living alone’. Another service user described the staff as, ‘angels’ and said, ‘You couldn’t fault any of the staff. They’re all grand. You can’t choose between them. They come within seconds when you ring for them’. The Comment Card completed by the relative of one service user stated, ‘Friendly atmosphere. My mother appears very happy with her care’. Another respondent stated that the priorities of the proprietor were the ‘residents and staff’ and that all the staff were ‘very caring people’. The same respondent said, ‘Nothing is too much trouble and they go to great lengths to keep the residents happy and comfortable. They are an efficient cheerful crowd’. The acting manager was undertaking the NVQ level 4 training with Solihull College. She was also undertaking the Registered Managers’ Award training. The acting manager hoped to complete both aspects of training later in the year. The deputy manager had obtained the NVQ level 4. The two senior care assistants and one care assistant had obtained the NVQ level 2. Therefore, the number of care staff that had completed training at NVQ level 2 or above was still below the 50 target set by the National Minimum Standards. The requirement that was made about this matter as a result of the previous inspection still stands. It was pleasing to note that two other staff were undertaking NVQ level 2 training. The home was in the process of recruiting three new members of staff to fill the three vacant posts. The acting manager confirmed that references would be sent for and an application for a CRB check had been made for each of the prospective members of staff. The application form that had been used did not include a declaration of any convictions/cautions. The acting manager gave an assurance that the three prospective staff would be asked to sign a declaration about any convictions/cautions before they were appointed. An assurance was also given that a declaration of convictions/cautions would be included as an integral part of the job application form in the near future. It was noted with concern that no references had been obtained in respect of one member of staff that had been appointed a few months before the new acting manager St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 22 had commenced working at the home. The acting manager confirmed that she would apply for the references as a matter of priority. The acting manager had introduced a new reference request form and a new reference request letter. A new care assistant job description had also been introduced. However, it was noted with concern that, since the previous inspection and before the new acting manager had commenced working at the home, a person had been employed as a weekend cook. The person had not completed an application form. The home had also not obtained two written references in respect of the same person. The member of staff had not completed his probationary period successfully and, therefore, his employment had been terminated. A requirement had been made as a result of the previous inspection that the positive disclosure result from the CRB in respect of a member of staff must be fully investigated and recorded. The proprietor confirmed that the requirement had been implemented. However, no written evidence was made available to confirm the outcome. Since the previous inspection the member of staff had left the home. Therefore, the requirement was no longer applicable and has been deleted. The proprietor stated that he kept all of the information relating to the recruitment of the acting manager at home. All of the records that the home is required to maintain including information on staff must be maintained at the home available for inspection. The acting manager stated that all of the staff had been issued with a copy of the code of conduct and practice set by the General Social Care Council. The acting manager said that a contract may not have been issued to all of the staff. A contract should be issued to all of the staff. The home did not have a formal induction programme that met the Skills for Care standard. However, the acting manager was aware of the need to provide a suitable induction for new staff. She also knew how to access the appropriate information. The acting manager intended to introduce her own ‘in-house’ induction training that included fire safety, infection control and other relevant issues. It was confirmed that all of the staff had received three paid days training per year. It was also stated that each member of staff had an individual training and development assessment and profile. However, the training profiles needed to be brought up to date. Two requirements were made as a result of the previous inspection. The first requirement was that all the staff must undergo all of the relevant core training. It was noted that all the members of staff except two had undertaken basic first aid training on 15 January 2007. It was also noted that food hygiene training had been arranged for 9 March 2007 and that infection control training had been arranged for 12 March 2007. Moving and handling training had taken place on 5 July 2006 and further training had been arranged for July 2007. Fire awareness training had been arranged for 27 February 2007. Therefore, the requirement was regarded as having been implemented. The acting manager said that training in palliative care had not yet been undertaken. The second requirement was that all of the care staff must undertake appropriate training in key working and person centred planning. The acting manager confirmed that the St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 23 requirement had been implemented and that all the staff had undertaken the training on 24 January 2007. St Martins Care Home for the Elderly DS0000065811.V329922.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, 36 and 38. The quality outcome in this area was poor. This judgement has been made using available evidence including a visit to this service. The home had an acting manager who was endeavouring to improve the management aspects of the home. The arrangements for the safekeeping of the service users’ money were satisfactory. However, the absence of an effective quality assurance system, regular staff supervision and risk assessments do not ensure that the service users are fully safeguarded. EVIDENCE: In September 2006 the Care Standards Tribunal upheld a decision of the CSCI to refuse an application by the previous acting manager to be the registered manager of the home. The home had a new acting manager who had been in post for approximately three months. She had commenced working in the home on 13 November 2006. A requirement had been made as a result of the previous inspection that the acting manager must make an application to the CSCI to become the registered manager. The acting manager had not obtained her CRB check. Therefore, her application had not been completed St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 25 and the requirement had not been fully implemented. The requirement still stands. A recommendation was made as a result of previous inspections that the registered manager’s job description should be amended. The recommendation had not been implemented and still stands. The Comment Card from the relative of one service user stated that the current manager had ‘created a much improved atmosphere’. A recommendation was made in regard to Standard 32 as a result of the previous inspection that evidence should be provided to show that management planning and practice encourage innovation, creativity and development. The acting manager said that work had been carried out to develop the home’s policies and procedures and to improve the home’s environment in the form of the new extension. However, it was accepted that further work needed to be done in order to fully implement the recommendation. The requirement and three recommendations that were made in regard to Standard 33 as a result of previous inspections had not been implemented. They are repeated again in this report. It was confirmed that the home had purchased a commercially produced quality assurance system from Sovereign Healthcare Development Ltd (SHDL) on 10 August 2006. However, the system was not yet fully operational and the home still needed to develop a full and effective quality assurance system. The acting manager said that she was in the process of developing questionnaires for service users, relatives and other stakeholders in the community. It was intended that this work would be completed by the end of March 2007. The acting manager confirmed that no one connected with the running of the home acted as an agent or appointee on behalf of any of the service users. However, money was held for safekeeping by the home on behalf of all the service users. The money was kept in individual envelopes in a lockable cabinet in a lockable office. A written record of transactions was maintained in respect of the service users’ individual accounts. Receipts were also kept. New forms had been introduced to enable monthly audits to be carried out of the money held in safekeeping. The money and accounts kept on behalf of two service users was checked at random. The money and accounts were correct. The acting manager confirmed that no valuables were kept on behalf of any of the service users at the present time. An independent audit of the service users’ money should be undertaken approximately every three months. A requirement was made as a result of the previous inspection that safeguards must be introduced to ensure that the money that is held in safekeeping on behalf of the service users is accurately maintained at all times. The requirement was regarded as having been implemented. A requirement was made in regard to Standard 36 as a result of the previous inspections. The requirement was that care staff must receive formal supervision at least six times a year that includes all of the issues referred to in St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 26 Standard 36.3. The requirement had not been implemented and still stands. The acting manager found it difficult to carry out staff supervision meetings because of the amount of time that she had to spend carrying out personal care tasks. However, it was stated that the staff supervision forms had been revised and that a new staff appraisal form had been introduced. Two requirements and one recommendation were made in regard to Standard 37 as a result of the previous inspection. The first requirement was that the accident forms must be completed in full and checked by a senior member of staff at the time of the accident. The second requirement was that the Commission must be notified without delay of any serious injury, illness, accident or event that affects the wellbeing of any service user. Both requirements had been implemented. The recommendation that a statement should be included in the service users’ guide informing service users of the opportunities to help maintain their personal records had not been implemented and still stands. Five requirements and one recommendation were made in regard to Standard 38 as a result of the previous inspection. The first requirement was that risk assessments must be carried out and recorded for all safe working practice topics. This requirement included a fire risk assessment. The requirement had not been fully implemented and still stands. The second requirement was that a fire alarm test and fire drill must be carried out and recorded by 24/05/06 and, thereafter, at the frequency recommended by the Fire Safety Officer. The weekly fire alarm tests had been maintained. However, the last fire drill was held on 18 August 2006 when only some of the staff attended. The acting manager said that she would ensure that all the staff attended a fire drill by 6 March 2007. The third requirement was that moving and handling training must be undertaken by all the staff by 20/07/06 and, thereafter, at least every twelve months. The requirement had been implemented. The fourth requirement was that the boiler and central heating system must be serviced at least annually and copies of the servicing certificate retained at the home and made available for inspection. The requirement had been implemented. The fifth requirement was that all of the records, policies and procedures that the home is required to keep must be checked for grammatical and typographical errors, amended where necessary, signed and dated. The requirement had not been fully implemented and is repeated in this report as a recommendation. The recommendation that was made as a result of the previous inspection about keeping a record of all the PAT tests had been implemented. A record was made available to show that PAT tests had been carried out on 30 December 2006. There were no reports made by the proprietor in accordance with Regulation 26 available for inspection. St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 27 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 1 2 2 X 2 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 1 St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 28 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 Requirement The statement of purpose must be amended so that it includes all of the information detailed in Regulation 4 and Schedule 1 and in accordance with the guidance in this report. (Previous timescale 31/07/06 not met). The service users’ guide must be amended to include all of the information detailed in Regulation 5 and Standard 1 and in accordance with the guidance given in this and previous reports and copies given to all current, and any prospective, service users. (Previous timescale 31/07/06 not met). A statement of terms and conditions of residence (contract) that includes all of the details referred to in Standard 2.2 must be issued to all of the current service users and to all new service users at the point of moving into the home and a copy of the contract signed by the service user and/or their representative retained on their individual file. DS0000065811.V329922.R01.S.doc Timescale for action 30/06/07 2 OP1 5 30/06/07 3 OP2 5 31/03/07 St Martins Care Home for the Elderly Version 5.2 Page 29 4 OP3 14 5 OP7 15 6 OP7 15 7 OP9 13 8 OP9 13 9 10 OP16 OP18 22 12,13 The registered person must ensure that an assessment that includes all of the issues listed in Standard 3.3 has been undertaken of all service users by a suitably qualified or trained person, that a copy of the assessment has been obtained and that he has confirmed in writing to the service user that the home is suitable for the purpose of meeting their health and welfare needs. The service users’ care plans must set out in detail the specific action to be taken by the staff to ensure that all aspects of the service users’ needs are met. (Previous timescale 31/07/06 not met). All service user care plans must be agreed and signed by the service user whenever capable and/or representative (if any). (Previous timescale 31/07/06 not met). A policy and procedure for the receipt, recording, storage, handling, safe administration and disposal of medication must be drawn up and implemented. (Previous timescale 01/07/06 not met). All staff must undertake accredited training in the administration of medication that includes basic knowledge of how medicines are used and how to recognise and deal with problems in use and the principles behind all aspects of the home’s policy on medicines handling and records. (Previous timescale 30/09/06 not met). A record of all complaints made against the home must be maintained. The home’s policy and DS0000065811.V329922.R01.S.doc 30/04/07 30/06/07 30/04/07 30/04/07 30/04/07 31/03/07 30/04/07 Page 30 St Martins Care Home for the Elderly Version 5.2 11 OP18 18 12 OP18 12,13 13 OP26 13 14 OP26 13,23 15 OP27 18 16 OP28 18 procedures for responding to suspicion or evidence of abuse or neglect (including whistleblowing) must be amended in accordance with the Public Interest Disclosure Act 1998, the Department of Health guidance ‘No Secrets’ and the guidance in this report. (Previous timescale 31/07/06 not met). The acting manager must undertake training in the protection of vulnerable adults from abuse at an appropriate level suitable for a manager of a care home. A policy to help staff understand and respond appropriately to physical and/or verbal aggression by service users must be introduced in accordance with Standard 18.5. A policy and procedure for the control of infection that includes the issues referred to in Standard 26.5 and reflects the ‘Guidelines for Infection Control in Care Homes’ produced by the Local Health Protection Unit must be provided. (Previous timescale 31/07/06 not met). The floor covering in toilet 2 on the ground floor must be thoroughly cleaned or replaced and a liquid soap dispenser provided. The home must employ additional care staff in accordance with the guidance given in this report in order to ensure the health and welfare of the service users. Arrangements must be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent. (Previous timescale 31/12/06 DS0000065811.V329922.R01.S.doc 30/06/07 30/04/07 31/05/07 31/03/07 30/04/07 30/09/07 St Martins Care Home for the Elderly Version 5.2 Page 31 17 OP29 19 18 OP29 19 19 OP29 17,19 20 OP30 12,18 21 OP31 8,9 22 OP33 24 23 OP36 18 24 OP38 12,13 25 OP38 13,23 26 OP38 26 not met). All prospective staff must complete an application form that includes a declaration of any convictions/cautions before they commence working at the home. Two written references must be obtained before appointing any member of staff and any gaps in employment records must be explored. All of the staff records, including those relating to the acting manager, must be kept at the home available for inspection. All staff must receive induction training to National Training Organisation specification within 6 weeks of appointment to their posts. The acting manager must make an application to the CSCI for registration. (Previous timescale 31/12/06 not met). A quality assurance system must be introduced in accordance with the requirements Regulation 24 and Standard 33. (Previous timescale 31/07/06 not met). Care staff must receive formal supervision at least six times a year that includes all of the issues referred to in Standard 36.3. (Previous timescale 30/09/06 not met). Risk assessments must be carried out and recorded for all safe working practice topics covered in Standards 38.2 and 38.3. (Previous timescale 31/05/06 not met). All the staff must attend a fire drill by 06/03/07 and, thereafter, at the frequency recommended by the Fire Safety Officer. (Previous timescale 24/05/06 not met). The registered provider must DS0000065811.V329922.R01.S.doc 31/03/07 31/03/07 31/03/07 30/04/07 31/03/07 30/06/07 30/09/07 30/04/07 06/03/07 31/03/07 Page 32 St Martins Care Home for the Elderly Version 5.2 prepare a written report every month on the conduct of the home and supply a copy to the manager in accordance with Regulation 26. 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 OP5 Good Practice Recommendations All prospective service users should be given the opportunity to visit the home before admission. Only in very exceptional circumstances should this practice not be followed. The service users should be given the opportunity to undertake appropriate exercise and physical activity. The home should have an up to date list of the signatures of all the staff who are involved in the administration of medication. Two staff should check the record of the hand written medicine charts against the original prescription and both staff should sign the chart to confirm the accuracy. The supervision records should contain evidence to show that the staff have received guidance and instruction during their individual supervision meetings to ensure that the service users’ privacy and dignity is respected at all times in accordance with Standard 10.1. Relatives, friends and representatives of service users should be given written information, preferably in the service users’ guide, about the home’s policy on maintaining relatives and friends involvement with service users at the time of an admission to the home. Information regarding the service users’ right of access to the records held about them by the home and information about how to contact external agents e.g. advocates, who will act in their interests should be included in the service users’ guide. A clear statement that prospective service users are entitled to bring personal possessions with them, the extent of which will be agreed prior to admission, should DS0000065811.V329922.R01.S.doc Version 5.2 Page 33 2 3 4 5 OP8 OP9 OP9 OP10 6 OP13 7 OP14 8 OP14 St Martins Care Home for the Elderly 9 10 OP17 OP18 11 12 13 14 15 16 17 18 OP19 OP26 OP26 OP26 OP27 OP29 OP30 OP31 19 20 21 22 23 24 25 OP32 OP33 OP33 OP33 OP35 OP37 OP38 be included in the service users’ guide. Information regarding the service users’ legal rights should be included in the service users’ guide. A policy should be developed and implemented regarding service users’ money and financial affairs, ensuring safe storage of valuables, consultation on finances in private, advice on personal insurance and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be introduced and implemented with records kept. Consideration should be given to the provision of a washing machine that has a built-in sluicing facility. New floor covering should be provided in the laundry and the laundry walls should be re-painted. Disposable commode pots should be used. The acting manager and deputy manager should work some separate shifts in order to spread the management cover for the home. All of the staff should be issued with a copy of their terms and conditions of employment (contract). The individual staff training and development assessments and profiles should be brought up to date. The job description for the post of registered manager that will enable the acting manager to take responsibility for fulfilling all of the duties under the Care Standards Act should be revised in accordance with the guidance given in the inspection report dated 8 November 2005. Evidence should be provided to show that management planning and practice encourage innovation, creativity and development. The home should demonstrate a commitment to lifelong learning and development for each service user linked to the implementation of their individual care plans. The views of family, friends and stakeholders in the community should be sought on how the home is achieving goals for service users. The results of the Development Plan and the effectiveness of the action taken to improve the outcomes for service users should be kept under constant review and recorded. An independent audit of the service users’ money should be undertaken periodically. A statement should be included in the service users’ guide informing service users of the opportunities to help maintain their personal records. All of the records, policies and procedures that the home is DS0000065811.V329922.R01.S.doc Version 5.2 Page 34 St Martins Care Home for the Elderly required to keep should be checked for grammatical and typographical errors, amended where necessary, signed and dated in order to ensure that the contents of these is interpreted, understood and implemented correctly. St Martins Care Home for the Elderly DS0000065811.V329922.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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