Inspection on 21/08/07 for St Martins Care Home for the Elderly

This inspection was carried out on 21st August 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... 15/02/07

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 Andrew Spearing-Brown Unannounced Inspection 10:00 21 August and 18 September 2007 st th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Martins Care Home for the Elderly DS0000065811.V336758.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.V336758.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.V336758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2007 Brief Description of the Service: St Martins is situated in a residential area close to local shops and other amenities. There are limited car parking facilities at the front of the premises and an enclosed garden at the rear. At the time of the inspection an extension was being built in the rear garden in order to provide an additional three single bedrooms. The home is currently registered as a care home 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 in eight single bedrooms and two double bedrooms. Two of the single bedrooms have an en suite facility. The home has a stair lift to assist people to gain access to the first floor. The communal space consists of a dining room, a front lounge and a smaller rear dining room. The current Statement of Purpose states that the fees ranged from £345.00 to £360.00 per week. Additional charges are made for hairdressing and chiropody. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector based at the Worcester office of the Commission for Social Care Inspection (CSCI) undertook this unannounced key inspection. This inspection was conducted over a period of a number of days within the home. At the time of this inspection the home had one vacancy. This inspection takes into account information received by the CSCI in relation to the home since the previous inspection as well as the visits to the home. Since the last key inspection, which took place during February 2007, the manager designate has resigned and a new manager designate has come into post. Prior to this inspection a Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the us within a given timescale. The former manager designate completed some of this document while others parts were completed by the registered provider. The document was not returned to us by the date given. As part of the inspection process a number of questionnaires were sent to a sample number of people using the service, their relatives and health care professionals. A number of completed questionnaires were returned to us and these are taken into account as part of the inspection. Both the manager designate and the registered provider were present throughout this inspection. Discussions took place with some members of staff, and some people using the service. A significant amount of time was spent with people who live in the home and observations were made during this inspection. A look around the home took place which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records, some policies and procedures and staffing records. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection we are able to see some improvement towards fully meeting the necessary standards. The amount of training which has taken place since the last inspection is noted. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 7 What they could do better: Following the last inspection a meeting was held at our office in Worcester with the registered provider and the former manager designate. At that meeting it was accepted that St. Martins had some way to go before they were able to fully meet the requirements of The Care Homes Regulations. Since that meeting the then manager designate has left the home and a new manager designate is in post. Despite some improvements the above statement remains and improvements are necessary in a number of places. Improvement is necessary regarding both care planning and risk assessments. Care plans need to be an accurate account of current care needs in order to give guidance to care staff. Some risk assessments were in place however these were not always reviewed as needed. The recording of medication administration and medication removed from the home needs to be improved. The medication policy needs to be reviewed. The safeguarding adults procedures needs to be improved and some staff need training in relation to safeguarding. A full review of staffing levels needs to take place. Care staff currently have to carry out domestic tasks on some occasions as well as having to cover the laundry and final preparation of tea. Recruitment procedures need to be improved to ensure that suitable staff are working within the home. The manager designate needs to make an application to us to become the registered manager. No progress has taken place regarding the introduction of a quality assurance system and staff supervision. A number of health and safety concerns were discussed as part of this inspection including matters relating to the fire risk assessment. Unmet requirements from the previous inspection have been revised and are now grouped into a more limited number in line with our policy. Therefore the number of requirements is reduced, however this does not necessarily indicate an improvement in the associated standards. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Information is available for people to enable them to assess whether the service provided is suitable to their needs, this does however need to be reviewed. Pre admission assessments are taking place in order that care needs can be identified prior to arrival at the home. EVIDENCE: Since the last inspection the registered provider has compiled a revised Statement of Purpose and Service User Guide. Both documents now contain the name of the manager designate who was appointed in July 2007. The Service Users Guide should provide people with information about the home and the care that can be provided, which should help individuals decide whether the home is likely to be suitable for them. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 11 Although the information within these documents is extensive further amendments are needed. Additional information is needed upon how the home is able to provide suitable care for people with a dementia type illness. The documents do not make any reference to person centred care and do not contain any views of people already using the service. On a questionnaire sent to a representative sample of relatives, carers or advocates we asked whether people had received enough information about the home to assist in making decisions. We received 8 questionnaires back on which 6 answered ‘Always’ and 2 answered ‘Usually’. Contracts or terms and conditions are in place although the content was not assessed against the associate standard on this occasion. Contracts therefore need to be fully assessed as part of a forthcoming inspection. The file of an individual who used the service on a short stay basis was viewed. Initially no pre admission documentation could be sought however both an assessment carried out by a social worker and an assessment done by a representative of the home were later found. The initial assessment contained sufficient information in enable a care plan to be drawn up. St Martins does not provide and has no plans to provide intermediate care. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although staff were able to verbally evidence knowledge of care needs the documentation was not sufficient in detail and could potentially result in people using the service not having their care needs fully met. Medication systems were generally satisfactory although some improvement is needed. EVIDENCE: Individual care plans are in place for all people using the service. A representative sample of care plans were viewed and assessed as part of this inspection. It was encouraging to see that care plans contained information regarding life history. This can assist with caring for people with a dementia type illness as well as recognising the person as an individual. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 13 The information within the care plans was at times scant and did not give sufficient guidance to care staff in order to ensure a consist delivery of care. Under the National Minimum Standards care plans need to be reviewed in line with changing care needs on at least a monthly basis. It was evident that care plans are reviewed however they were not always capturing all the information included within the daily notes and were therefore not a full and accurate reflection of peoples current care needs. Improvements are required in relation to risk assessments especially nutritional and pressure care. It was noted on some risk assessments that they had a review date upon them however these reviews had not always taken place. Although the information within the documents was not sufficient care staff had a good knowledge of the care needs of people residing within the care home. On the questionnaire to relatives we asked whether people felt that the care home meets the care needs of their friend/ relative. All 8 respondents answered ‘Always’. We received a number of questionnaires prior to this inspection from medical practitioners who have patients at St. Martins. Although no additional comments were added to any of these questionnaires none of them raised any concerns regarding the care provided at the home. As part of the first visit to the service the management of medication was assessed. The majority of the current months MAR (Medication Administration Record) sheets were viewed and the security of medication assessed. It was noted that a photograph was in place to aid recognition of each person using the service. Medication was signed into the home appropriately. It was evident that when a variable dose is prescribed staff record the actual dose given. An audit of some painkillers balanced correctly. The vast majority of MAR sheets contained the correct amount of signatures however a few gaps were noted. It was of some concern that it was evident that staff may be signing MAR sheets in advance as on occasions staff had over signed their original signature with a code for why medication was not administered. At the time of this inspection nobody within the home was prescribed any ‘controlled medication’. The CDR (Controlled Drugs Register) was checked and it was discovered that it stated medication was held. As the named individual was no longer residing within the home it was assumed that the medication St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 14 was taken from the home at the time of discharge but this was not recorded. It was also noted that staff were not signing with a full signature within the CDR. The medication trolley was suitably secured and in good order. Procedures for the handover of keys are in place. Some staff have not undertaken accredited medication training. Some medication was stored the kitchen fridge. These arrangements would not be sufficient in the event of somebody needing insulin. The medication policy was insufficient and lacking details in areas such as managing errors. Information held upon who is able to administer mediation was out of date. The manager designate was not able to locate a copy of the guidance issued by the Royal Pharmaceutical Society of Great Britain. Staff were seen to be addressing people using the service appropriately and respectfully. People using the service appeared to be appropriately dressed taking into account gender and the weather conditions. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Stimulation is provided within the home by means of social and recreational activities. People using the service are able to maintain contact with family and friends. The food provided appeared appetizing and in line with peoples expectations. EVIDENCE: The majority of responses to questions on the questionnaires sent to people using the service returned to us before this inspection were positive. One question was: Are there activities arranged by the home that you can take part in? The responses were as follows: Always Usually 3 6 DS0000065811.V336758.R01.S.doc Version 5.2 Page 16 St Martins Care Home for the Elderly Sometimes Never 2 0 It was reported that activities take place each afternoon. Staff consulted were able to give an indication regarding the activities individual people using the service were likely to partake in. Records regarding activities were not sufficient and need to be improved however recent events included a visit to a safari park. Religious care needs are meet by means of in house services. During this inspection visit a number of people were busy colouring in. Some staff assistance was given as needed. The television set was on throughout the period of time we spent in the lounge. The picture was fairly poor however the subtitles were on to aid people who may have a hearing impairment. There were no unreasonable restrictions in regard to visiting. Information about visiting is included within the Service Users Guide. One relative wrote on a questionnaire returned to us ‘Excellent home cooked food, which my **really appreciates. .’ Other positive comments were received as part of the inspection process regarding the food served at St Martins. The menu on the first day of this inspection consisted of chicken and mushroom pie, mixed vegetables, sprouts and boiled potatoes with gravy. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People using the service have access to a suitable complaints procedure although the recording of any concerns and complaints needs to be improved to ensure that these are dealt with effectively. It is recognised that training regarding safeguarding adults has taken place for some staff. All other staff need to attend this training in order to ensure everybody has this knowledge. Policies and procedures need to be developed further to promote the protection of people living within the home. EVIDENCE: The complaints procedure is held within both the Statement of Purpose and the Service Users Guide. This procedure is satisfactory and makes reference to our local office in Worcester. The previous report states that the procedure was displayed near to the main entrance; this was not the case on this occasion. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 18 The complaints log was seen as part of this inspection. The log did not contain any new entries. The previous report noted that an earlier complaint was not recorded within the complaints log. It was noted that this information remains unrecorded. It was evident from the replies we received to the questionnaire sent to relatives, carers and advocates that the vast majority of people are aware of the homes complaints procedure. Nobody living within the home raised any concerns about their ability to complain during the course of this inspection. A policy and procedure on safeguarding (adult protection) was available dated August 2006. It would seem likely that this procedure is the same as the one seen during a previous inspection as the shortfalls identified as part of the last inspection remain. The procedure is a commercially produced one and therefore does not include any local information such as how to contact the local safeguarding coordinator. Some information regarding Worcestershire Adult Services procedures was available such as a poster and leaflets for staff. However a copy of the Vulnerable Adults Procedures produced by Worcestershire was not available. A procedure for the management of aggressive behaviour, that may include the need for physical restraint of an individual needs to be developed. No incidents, which need to be recorded as safeguarding, have been brought to the attention of the manager designate and no such incidents have been reported to us. Training records showed that a number of staff received training in relation to safeguarding during July 2007. A number of staff need to undertake this training in the future. The manager designate undertook safeguarding training as part of her previous post. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although building work is currently taking place which needs to be taken into account regarding the risks people living within the home are generally provided with a homely and comfortable place to reside. EVIDENCE: St Martins care home is located in a mainly residential area near to shops and other amenities such as a public house. The home is accessible to people in a wheelchair as a ramp is provided however many corridor areas are narrow. The home does not have a passenger lift however a stair lift is provided to enable access to the first floor. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 20 The home was found to be comfortable and homely. The décor within communal areas is adequate. The upstairs bathroom floor is carpeted which could be a concern regarding the ability to keep it hygienically clean. The stair carpet was showing signs of wear and tear. Radiators throughout the home were covered to prevent accidental scalding with the exception of one in the upstairs bathroom. Bedroom accommodation consists of eight single bedrooms and two doubles. There is no programme of refurbishment although bedrooms were well maintained. The wardrobe in one bedroom viewed was not secured to the wall to prevent accidental toppling. Work is currently underway to provide an additional three bedrooms in a ground floor extension. The registered provider is aware that an application must be made to us and approved before these rooms can be used. Due to the building work the back garden is currently untidy and could be a health and safety concern were people using the service to gain access to it. It was reported that an officer from Redditch Council had recently undertaken an Environmental Health visit and that no concerns were raised. The report from this visit will be viewed as part our next inspection. Information regarding fire safety and the fire risk assessment is included within the management section of this report. Since the previous inspection a policy and procedure regarding infection control had been drawn up. The previous report brought to the attention of the registered provider the need to have a suitable washing machine in place. During the course of this visit a machine with a sluice facility was fitted and the registered provider was making good the flooring. The registered provider is aware that a wash hand basin is needed within the laundry area and stated that one would be fitted. Commodes are cleaned in a bath using a sterilising tablet. This arrangement remains to be unsatisfactory and needs further reviewing. It was noted that antibacterial soap was available within communal areas of the home. No unpleasant odours were detected. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Training provided has increased since the previous inspection to ensure that staff have the necessary skills and knowledge to care for people safety and effectively. The number of staff on duty needs to be reviewed and recruitment procedures need to be improved to ensure that care needs are met and that people using the service are safe. EVIDENCE: Since the previous inspection further changes have taken place regarding the person employed as manager of the home. It was stated that the manager designate is now provided with additional ‘management hours’ therefore reducing the time spent working as a carer. The deputy manager who works as part of the care team covers day shifts. It was reported that during the morning shift two carers are on duty. For a couple of hours during the afternoon it was stated that one carer and the manager designate are on duty, which conflicts with the above statement. Two carers cover the evening shift while one wakeful carer and one carer sleeping in cover the night shift. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 22 A housekeeper works four days per week. Carers have to perform domestic duties on the remain days (Tuesday, Saturday and Sunday). Nobody is employed within the laundry therefore carers have to undertake this duty. Catering staff are employed each morning although carers have to undertake the final preparation of tea. This is a concern due to the reduction of staff available to provide care to people living within the home as well as the risk of cross infection. It is of further concern that two members of staff do not hold a basis food hygiene certificate. This training shortfall needs to be addressed. Staffing levels within St Martins need to be reviewed to ensure that the identified care needs of people using the service can be met. The current extension to the home will entail additional persons living within the home therefore again raising the need to increase staffing levels. No agency staff are used within the home and no relief care staff are employed. The manager designate reported that she hoped to commence her NVQ (National Vocational Qualification) level 4 shortly. The deputy manager holds a level 3 NVQ. At the time of this inspection four carers held a level 2 NVQ. It was stated that additional carers are about to start their NVQ training however at the time of this visit the percentage of qualified staff was less than 50 . It is noted that staff training has improved since the previous inspection visit. It was stated that the ‘majority’ of staff have undertaken dementia care training. Staff files were generally up to date regarding the training they had undertaken. Other training recently undertaken includes moving and handling and basic food hygiene. Some gaps were noted regarding the training undertaken by some members of staff which need to be addressed especially those relating to health and safety matters. Induction training was not assessed as part of this visit. Training will be assessed further as part of a forthcoming inspection visit. The files of three recently appointed employees were viewed. The information held was insufficient in some places and areas for improvement were noted. Details on one application form did not tally with information on a reference. There was no evidence that this conflicting information was checked out or verified. One file contained evidence that the PoVA (Protection of Vulnerable Adults) first check was received the day after employment had commenced. No evidence could be found of a full CRB (Criminal Records Bureau) disclosure. The manager designate was aware of some shortfalls with staffing files and stated that she was going to sort them out. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. An application to become registered needs to be made to us without delay. Quality Assurance systems need to commence to assist in the development of the home. A number of health and safety shortfalls were noted which could potentially place people using the service at risk. EVIDENCE: At the time of the previous inspection (February 2007) a manager designate was managing the home following a decision made by the Care Standards Tribunal to uphold our refusal to register a former manager designate. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 24 The manager designate in place at the time of the previous inspection completed some elements of the Annual Quality Assurance Assessment (AQAA) document and the improvement plan from that inspection. Both of these documents needed to be returned to us within a certain timeframe. The AQAA was not fully completed on time and following the departure of the manager designate the registered provider compiled the remaining parts of this document. The registered provider recently informed us that he had successfully appointed another manager designate. The latest manager designate was on duty throughout this inspection. It was stated that the registered provider has increased that number of hours whereby manager designate has dedicated time to perform management responsibilities. We were informed that the current manager designate has almost completed the Registered Managers Award (RMA) and that she intended to commence upon her National Vocational Qualification (NVQ) level 4 in management in September 2007. At the time of this inspection the newly appointed manager designate had not applied to us to become the registered manager. This application must be made without any undue delay. The previous inspection report stated that although a commercially produced quality assurance document was purchased during August 2006 it was not in operation. No progress has been made and the need to implement a quality assurance system remains. The manager designate confirmed that no one connected with the running of the home acts as either an agent or appointee on behalf of anybody using the service. A small amount of money is held in safe keeping on behalf of some people using the service. The balance held was checked in relation to a random sample of people and found to be in order. It was confirmed that no valuables are held on behalf of individuals. The manager designate is aware that formal staff supervision needs to be implemented within the home. Policies and procedures were generally not viewed as part of this inspection. The manager designate is aware that these need to be reviewed to ensure that they are an accurate reflection of the practice within the home. The manager designate is aware that under Regulation 37 of the Care Homes Regulation we have to be informed about certain events that have happened within the home. The previous inspection report highlighted the need to have a fire risk assessment carried out. A comprehensive fire risk assessment dated March St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 25 2007 was viewed. The report made a number of recommendations needed to ensure that that the home is compliant with current fire safety legislation. Many of the recommendations were reported to now be met. A random sample of these recommendations were checked and we found that suitable action had taken place. A number of recommendations do however remain outstanding and need to be actioned. In one section the report stated: ‘In order to ensure fire safety and health and safety of all persons in the premises all wedges should be withdrawn and replaced with approved hold open devises connected to the fire alarm system or (named type of devise).’ Devises are now fitted to some fire doors to ensure that they close in the event of the fire alarm sounding. Some doors continue to have wedges in place. It is appreciated that people using the service need to be able to freely access all areas of the home however the holding open of doors by means of wedges is a concern. It was of some concern that the action plan compiled regarding the fire risk assessment was not an accurate reflection of the action which has taken place. This action plan therefore needs to be reviewed and needs to be factual. Staff did not have knowledge regarding the location of emergency cut off taps for gas and water in the event of an emergency. Certificates regarding gas safety (boilers), electrical hard wiring and the testing of portable electrical appliances were in order. The stair lift was serviced during August 2007. The hoisting devise within the bathroom had not been serviced as required under The Lifting Operations and Lifting Equipment Regulations 1998. This piece of equipment needs servicing with a degree of urgency and at six monthly intervals. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 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.V336758.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement A full and comprehensive care plan must be in place in relation to each person using the service. The care plan must be regularly reviewed and updated to reflect all aspects of an individuals care taking into account their views. This requirement replaces a previous similar requirement with a time scale for action of 31/07/06 and 30/06/07. Risk assessments must be carried out and reviewed on a regular basis in relation to all aspects of actual or potential care need. The information from the risk assessments must form part of a comprehensive care plan. A policy and procedure for the receipt, recording, storage, handling, safe administration and disposal of medication must be drawn up and implemented. Previous timescale not full met. A revised timescale is given for full compliance. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 28 Timescale for action 31/10/07 2 OP8 13 31/10/07 3 OP9 13 30/11/07 4 OP9 13 (2) Medication must be given as prescribed and recorded accurately. Medication removed from the home must be recorded. 21/08/07 5 OP9 13 All staff must undertake 30/11/07 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 not full met. A revised timescale is given for full compliance. 6 OP16 22 A record of all complaints made against the home must be maintained. Previous timescale not met. A revised timescale is given for full compliance. 30/10/07 7 OP18 12,13 30/11/07 The home’s policy and 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 timescales of 31/07/06 and 30/04/07 not met. A revised timescale is given for full compliance. 8 OP18 12,13 A policy to help staff understand and respond appropriately to physical and/or verbal DS0000065811.V336758.R01.S.doc 30/11/07 St Martins Care Home for the Elderly Version 5.2 Page 29 aggression by service users must be introduced in accordance with Standard 18.5. Previous timescales of 30/04/07 not met. A revised timescale is given for full compliance. 9 OP27 18 Suitably trained and sufficient 30/10/07 staff must be on duty throughout the day in all areas of the home to ensure that the care needs of people using the service are met taking into account health and safety matters. This requirement replaces a previous similar requirement with a time scale for action of 30/04/07. 10 OP29 19 Staff files must contain evidence of thorough recruitment procedures to safeguard people using the service from the potential of harm. This requirement replaces a previous similar requirement with a time scale for action of 31/03/07. 11 OP30 12,18 All staff must receive induction training to National Training Organisation specification within 6 weeks of appointment to their posts. This requirement was not assessed as part of this inspection. The previous timescale of 30/04/07 remains. 12 OP31 8,9 The acting manager must make an application to the CSCI for registration. DS0000065811.V336758.R01.S.doc 30/10/07 21/08/07 30/10/07 St Martins Care Home for the Elderly Version 5.2 Page 30 13 OP33 24 A quality assurance system must be introduced in accordance with the requirements Regulation 24 and Standard 33. Previous timescales of 31/07/06 and 30/06/07 not met. A revised timescale is given for full compliance. 30/11/07 14 OP38 12,13 Risk assessments must be carried out and recorded for all safe working practice topics covered in Standards 38.2 and 38.3. Previous timescales of 31/05/06 and 30/04/07 not fully met. A revised timescale is given for full compliance. 30/11/07 15 OP38 23 A The necessary actions listed within the fire risk assessment must be carried out and the records held must be accurate. Safe systems must be in place to protect the health, safety and welfare of people using the service including the necessary servicing of all hoisting equipment. 30/11/07 16 OP38 13 30/10/07 St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Services Users Guide should be revised. The home should have an up to date list of the signatures of all the staff who are involved in the administration of medication. 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 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. DS0000065811.V336758.R01.S.doc Version 5.2 Page 32 OP9 OP10 4 OP13 5 OP14 6 OP14 7 8 OP17 OP18 St Martins Care Home for the Elderly 9 10 11 OP19 OP29 OP36 A programme of routine maintenance and renewal of the fabric and decoration of the premises should be introduced and implemented with records kept. All of the staff should be issued with a copy of their terms and conditions of employment (contract). Care staff should receive supervision at least six times a year. St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 33 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. Extracts may not be used or reproduced without the express permission of CSCI St Martins Care Home for the Elderly DS0000065811.V336758.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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