Inspection on 22/05/06 for St Martins Care Home for the Elderly

This inspection was carried out on 22nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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... 15/02/07

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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 N Andrews Unannounced Inspection 22 and 23 May and 8 June 2006 09:30 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.V298493.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.V298493.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 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 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.V298493.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 8 November 2005 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 service users to gain access to the first floor. The communal space consists of a dining room, a front lounge and a smaller rear lounge and a conservatory. The fees ranged from £1380.00 to £1420.00 per month. The acting manager stated that prospective service users would be given their own copy of the statement of purpose and service users’ guide that contained information about the services and facilities provided by the home. The home’s stated purpose is to provide an environment that seeks to support people for the remainder of their lives. St Martins Care Home for the Elderly DS0000065811.V298493.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 inspection that took place over two days. In addition, a visit was also made by the Pharmacist Inspector to inspect the home’s policy and procedures on medication. The inspection included time spent with the acting manager and the proprietor assessing the progress made by the home in implementing the requirements and recommendations arising from previous inspections. Various records that the home is required to maintain were inspected and individual discussions were held with three service users, a relative of one of the service users and three members of staff. A brief tour of parts of the premises was also carried out. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose and service users’ guide must be amended in order to enable prospective service users to make a fully informed choice about the home. The form used for assessing prospective service users must be improved in order to ensure that all of the service users’ needs are fully assessed prior to admission. The care plans must be fully and accurately maintained and risk assessments must be carried out in order to ensure that all of the service users’ needs are appropriately met. The range of social and St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 6 recreational activities should be extended so that the service users are able to pursue their individual interests. A comprehensive written medicine policy must be provided in order to ensure that the service users’ medicine and healthcare needs are met. The systems for checking that medicine has been given to service users as prescribed by the GP should be implemented. The policy and procedure for the protection of vulnerable adults from abuse must be improved and correct staff recruitment procedures must be adhered to at all times 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. Further staff training must be provided and greater diligence must be given to the provision of clear, accurate and well-maintained records, policies and procedures in order to support good practice and to ensure appropriate standards of care. The acting manager said ‘I can’t think of anything that needs improving. Everything is running smoothly’. 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. St Martins Care Home for the Elderly DS0000065811.V298493.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.V298493.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. Further work was needed to ensure that prospective service users are provided with clear and sufficient information to enable them to make a fully informed choice about the home. The form that is used to assess the care needs of prospective service users must be amended so that a full and accurate care plan can be prepared in order to ensure that all of their needs are met. EVIDENCE: Two requirements were made in regard to Standard 1 as a result of the previous inspection. The first requirement was that the statement of purpose must be amended so that it includes all of the information detailed in Regulation 4 and Schedule 1 and the guidance given in the previous report. The requirement had not been fully implemented and still stands. The second requirement was that the service users’ guide must be amended to include all of the information detailed in Regulation 5 and Standard 1 and the guidance given in this (i.e. the previous) report and copies given to all current, and any prospective, service users. This requirement had not been fully implemented and still stands. The acting manager stated that all of the current service users had been given a folder containing a copy of the statement of purpose St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 9 and a copy of the service users’ guide. The folders were evident in some of the service users’ bedrooms. Standard 2 was not fully assessed during this inspection. However, it was noted that the statement of terms and conditions of residence (contract) in respect of three service users had not been dated or signed. One of the contracts did not include details of the monthly fee payable to the home. A requirement was made in regard to Standard 3 as a result of the previous inspection 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. A copy of the form used by the home for assessing the needs of prospective service users was made available for inspection. It was noted that the form did not include a reference to mental state and cognition or to personal safety and risk. The form was also headed ‘Care Plan’. The form should state clearly that it is an assessment form. The requirement had not been fully implemented and still stands. The acting manager stated that all of the service users had been assessed using the above form. A recommendation was also made as a result of the previous inspection that the layout of the form that is used by the home for assessing the care needs of the service users should be revised in order to provide a single, consistent format with adequate space to record all of the relevant information. The recommendation had been implemented. A requirement was made in regard to Standard 4 as a result of the previous inspection that arrangements must be made for the service user who is refusing the help of the district nurse to be reassessed in order to ensure that all of her care needs are being appropriately met. The requirement had been met and appropriate arrangements had been made for her care. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality outcome in this area was poor. This judgement has been made using available evidence including a visit to this service. The service users felt that they were treated with respect and that their right to privacy was upheld. However, the contents of the care plans must be improved and risk assessments must be carried out in order to ensure that all of the service users’ needs are fully met. The service users’ medicines were stored safely and medicine records were being maintained. However, there were insufficient systems in place to enable a medication audit to be carried out. The control and handling of medication must be developed supported by a detailed, comprehensive medicine policy in order to maintain the safety and welfare of the service users. EVIDENCE: A requirement was made in regard to Standard 7 as a result of the previous inspection that the service users’ 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 staff to ensure the safe delivery of care. A copy of the form used by the home as a care plan was made available for inspection. The form was called ‘Monthly Residents Plan’ and was similar in layout to the form used for assessing prospective service users. It was noted that the form did not include a reference to mental state and cognition, social St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 11 interests, hobbies, religious and cultural needs or to carer and family involvement and other social contacts/relationships. Several of the care plans did not include details of the action to be taken by the staff to ensure that all of the care needs of the service users were met. The requirement had not been fully implemented and still stands. It was also noted that the care plans did not contain a signature of the service user and/or their relative or a signature of the acting manager or member of staff i.e. key worker. The care plan of one of the service users had not been reviewed since 3 April 2006. Two of the care staff with whom discussions were held both confirmed that they were key workers and involved in care planning. Two requirements were made in regard to Standard 8 as a result of the previous inspection. The first requirement was that a multi-disciplinary review must be carried out regarding the care of the service user who is currently refusing the help of the district nurse and recorded evidence of the decisions made about her care clearly recorded. The acting manager stated that the staff had held their own review on 23 January 2006 and, as a result, had contacted the service users’ relative. In turn, the relative had referred the service user to a Consultant. A multi-disciplinary review had not been held. However, a satisfactory outcome for the service user had been achieved. The requirement has, therefore, been deleted. The second requirement was that a tissue viability risk assessment in respect of the service user who is refusing the help of the district nurse must be carried out and recorded in order to prevent skin breakdown. The requirement had not been implemented and still stands. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to this matter. The care plan for the service user stated ‘No treatment needed at the moment only cream applied to legs due to skin condition’. The care plan did not specify the name of the cream or how often the cream should be applied. The acting manager stated that none of the service users had a pressure sore. However, the acting manager confirmed that the district nurse would be asked to assess any service user at risk of developing a pressure sore. The district nurse would also arrange for any pressure relieving mattresses and/or cushions to be supplied. Five service users are benefiting from the support of the continence adviser who visited the home approximately every three months. The acting manager stated that the continence adviser would be visiting the home to talk to the staff about continence, catheter bags and stomas on 31 May 2006. None of the service users were provided with any ‘formal’ physical exercise programme. However, light exercises to music were arranged for the service users by the staff at least once a week. It was also stated that the service users had the opportunity to visit the local shops and to walk around the vicinity of the home. These activities should be recorded in the activities book. The home did not carry out any nutritional screening. However, a record of the service users’ weight was maintained. It was confirmed that all of the service users were registered with a local GP and that a dentist and an optician visited the home every three months to carry out checks on the service users as St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 12 necessary. It was also confirmed that a chiropodist visited the home every month and offered treatment to all of the service users. Three requirements and one recommendation were made in regard to Standard 9 as a result of the previous inspection. The first requirement was that risk assessments must be carried out and recorded in respect of all service users regarding the risk of falling. The care plan in respect of one service user stated that the service user ‘had a fall in her bedroom when she was getting dressed but has been better since then. She hurt her shoulder. She doesn’t show any risks of falling over when she walks around the home’. It was noted with concern that, despite having had a fall, the service user had not been the subject of a risk assessment. It was also noted that the risk assessments on falls in respect of other service users had only been partly completed. Therefore, the requirement had not been implemented and still stands. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. The second requirement was that a risk assessment must be carried out and recorded in respect of the use of a stoma bag used by one service user. It was noted that this matter had been referred to in the service user’s care plan but not in a separate risk assessment. The requirement had not been implemented and still stands. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. The Pharmacist Inspector inspected the home against Standard 9-Medication and also assessed the home’s response to the third requirement that a policy and procedure for the receipt, recording, storage, handling, safe administration and disposal of medication must be drawn up and implemented. A copy of the home’s ‘Policies and Procedure on Medication’ was made available for inspection. The medicine policy did not reflect the control and handling of medication within the home. There were insufficient or no details for the receipt, recording, storage, handling, safe administration and disposal of medicine. The requirement had not been implemented and still stands. The administration and disposal of medicine was recorded. However, the receipt of medicine was not always recorded accurately. There was no date of receipt for the majority of medicines and in some instances there was no record of the quantity received and no staff signature. The date of opening of the majority of medicine containers was not recorded and the total balance of medicine was not always accurately transferred on to new medicine charts. Some service users were prescribed Warfarin that was recorded on the medicine charts. However, the records did not state exactly which strength of tablet was actually given to the service users. This meant that a full medicine audit could not be done to ensure that medicine had been given to service users as prescribed by the GP. Some medicine charts were hand written or changed by staff. However, there was no double check system to ensure the accuracy of the records. This meant that there was an increased risk of recording incorrect instructions for the service users’ medicine. The care plan for one service user was inspected. The care plan included up to date information regarding current medication details and professional visits were recorded. The recommendation was that a policy and procedure on the St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 13 administration of medication should be developed that includes a statement that any errors in the administration of medication must be reported to the CSCI in accordance with Regulation 37 and that when a service user dies medicines should be retained for a period of seven days in case there is a coroner’s inquest. The second part of the recommendation had been implemented. However, the first part of the recommendation had not been implemented and still stands. The staff had received training in the use of the Boots monitored dosage system. However, they had not undertaken any accredited training in the administration of medication. The service users with whom discussions were held confirmed that their privacy was respected and that the staff followed appropriate practices to maintain their dignity. The service users expressed their satisfaction with the standard of care that they received. The two care staff with whom discussions were held outlined good care practices when dealing with the service users’ personal care e.g. knocking the bedroom doors before entering, ensuring that care was provided in private, making use of screens when necessary. They both stated that they would maintain confidentiality. The comments made by the staff regarding the care of two service users that had recently died in the home showed sensitivity and respect and a supportive approach towards the service users’ relatives. The home had a mobile handset to enable the service users to make and receive telephone calls in private. The service users wore their own clothes and were referred to by the staff using their preferred term of address. A recommendation was made in regard to Standard 10 as a result of the previous inspection that 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. The supervision records that were inspected in respect of two staff members did not include any reference to the service users’ privacy and dignity. The recommendation had not been implemented and still stands. Screens were provided in the two double rooms. The home’s response to the three recommendations that were made in regard to Standard 11 as a result of the previous inspection was assessed. The first recommendation was that the service users should be asked to confirm their agreement to the proposed funeral arrangements following death as outlined by their relatives in accordance with the records held by the home. The acting manager stated that she had approached all of the service users’ relatives and they had confirmed that they would take responsibility for the funeral arrangements. All the service users except one had also confirmed that they were satisfied with the proposed arrangements. Appropriate alternative arrangements had been made in respect of one service user. Therefore, the recommendation had been implemented. The second recommendation was that the policy and procedure for handling dying and death should be developed in order to include details of the home’s practice and procedures. A copy of the home’s policy and procedure was made available for inspection. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 14 The recommendation had been implemented. The third recommendation was that the service users’ care plans should include clear, written guidance regarding the need for the staff to check the service users regularly for any signs of pressure sores developing. The care plans did not include any clear written guidance from the acting manager to the staff regarding pressure sores. However, the care plans did include a section on pressure sores. If this section of the care plans is completed regularly i.e. at least once a month when the care plans are reviewed, the staff should be helped to remain alert to the possibility of pressure sores developing. Therefore, the recommendation was regarded as having been implemented. St Martins Care Home for the Elderly DS0000065811.V298493.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 at least once during a 12 month period. 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 helped to exercise choice over their own lives and they were able to maintain contact with their relatives and friends. The service users received a balanced and wholesome diet. However, further work could be done to extend the range of social and recreational activities provided. EVIDENCE: A book was maintained which contained a record of the activities that were provided by the home. The activities that were recorded in the ‘Activities Book’ were mainly group activities. Since the beginning of the year the activities had included Bingo, I-spy, manicures, sing a longs, skittles, exercise to music and television. The service users had also helped to make cards at Easter and flash cards had been used to promote reminiscence and discussion. During the inspection the birthday of one of the service users was celebrated. A record should also be maintained of the individual social and recreational activities enjoyed by the service users. Members of St Luke’s, the local church, visited the home every month and held a Communion service. Although the range of activities provided was limited, the service users with whom discussions were held expressed their satisfaction with them. One of the service users said that she sometimes went to the local shops with a member of staff. The service users were informed of activities verbally and by information being displayed on a notice board in the dining room. The service St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 16 users with whom discussions were held confirmed that they were able to get up and to go to bed when they wished. The care plans that were inspected did not include specific details of the way in which the service users social/personal interests would be met. A notice was prominently displayed on the front door to the home asking visitors to avoid coming to the home at meal times. The service users confirmed that they were able to receive their visitors in private either by using the small rear lounge or their bedrooms. During the inspection, one of the service users received her relative in the conservatory at the main entrance to the home. The service users also confirmed that their visitors were made welcome. A recommendation was made in regard to Standard 13 as a result of the previous inspection that the 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. The statement ‘we welcome all relatives’ had been included in the statement of purpose under the heading ‘Contact between family and friends’. The paragraph should be amended so that it can be more easily understood. The service users enjoyed the visits to the home by members of the local church. This was the only involvement in the home by any local community group at the present time. The acting manager stated that the home encouraged the service users to handle their own financial affairs. However, the home was responsible for handling the personal allowances on behalf of nine service users. A requirement and a recommendation were made in regard to Standard 14 as a result of the previous inspection. The requirement was that the home’s policy and procedure for dealing with service users’ personal allowances that are held by the home must be amended in accordance with the guidance given in this (i.e. the previous) report. A copy of the home’s ‘Policy on Personal Money’ was made available for inspection. It was pleasing to note that the requirement had been implemented. However, the policy had not been dated or signed and contained a number of typographical errors. The 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 statement of purpose contained some relevant information about the service users’ right to see personal data, however, there was no reference to an advocacy service. The service users’ bedrooms contained personal possessions. The service users’ guide should make it clear to prospective service users that they are entitled to bring personal possessions with them, the extent of which will be agreed prior to admission. The cook prepared a weekly menu and maintained a record of the food provided. The record of the food was inspected and showed that a varied and St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 17 balanced diet was provided. None of the current service users required special diets or liquidised meals for medical, cultural or religious reasons. Meals for service users that had diabetes had been provided in the past. Information about the food provided was placed on a notice board in the main corridor so that the service users knew what the meals were. The service users usually ate their meals seated at three tables in the dining room. If the service users were poorly their meals would be served to them in their bedrooms. The dining room was furnished in a homely way. The meal that was observed during the inspection was nutritious and wholesome. One service user that required her food to be cut into smaller pieces was given appropriate assistance. The cook stated that she asked the service users about their food preferences at the time of their admission to the home. She said that she had worked in the home for a little over 4 years and, therefore, knew what the service users liked to eat. A choice of mid-day meal was not provided. However, if any service user did not like what was on offer an alternative meal was provided. The cook confirmed that the service users were asked each day what they would like for their teatime meal. The cook also said that she consulted the service users once a month about changes to the menu. The service users with whom discussions were held confirmed that they enjoyed the food and that they were consulted. They said that there was always enough to eat and drink. The cook stated that she had all of the necessary kitchen equipment and that it was all in good working order. It was confirmed that a record of the fridge and freezer temperatures was maintained and it was observed that a small sample of food was kept and labelled. There was a cleaning schedule in the kitchen. The cook kept her own personal record of the service users’ food preferences. It was recommended that a similar list is kept in the kitchen for other staff to refer to if necessary. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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 service users felt confident about making complaints and that any complaints would be dealt with appropriately. However, the policy and procedure on the protection of vulnerable adults from abuse needed to be improved in order to ensure the safety and protection of the service users. EVIDENCE: The home had a satisfactory complaints procedure. The complaints procedure was referred to in the statement of purpose. A copy of the statement of purpose had been included in a folder and copies of the folders had been placed in all of the service users’ bedrooms. A copy of the complaints procedure had also been placed in the conservatory near to the main entrance. The home had a complaints book that was used for recording any complaints made against the home. The complaints book was made available for inspection. The complaints book contained one entry dated 7 April 2006. This related to a concern that had been expressed anonymously to the CSCI. The concern had been referred to the registered provider for investigation. The service users with whom discussions were held during the inspection said that they felt confident about making a complaint, if necessary. A recommendation was made in regard to Standard 17 as a result of the previous inspection 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. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 19 A requirement and a recommendation were made in regard to Standard 18 as a result of the previous inspection. The requirement was that procedures for responding to suspicion or evidence of abuse or neglect (including whistleblowing) must be drawn up in accordance with the Public Interest Disclosure Act 1998 and the Department of Health guidance ‘No Secrets’. A copy of the home’s ‘Policy on adult abuse’ was made available for inspection. The policy was deficient in several respects. The requirement had not been fully implemented and still stands. The recommendation was that a policy should be developed and implemented regarding service users’ money and financial affairs, ensuring safe storage of money and 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 copy of the home’s ‘Policy on Personal Money’ was made available for inspection. The recommendation had not been fully implemented and still stands. The acting manager confirmed that no alleged or suspected incidents of abuse had been reported to her or otherwise come to her attention since the previous inspection. The acting manager also confirmed that she had had no reason to discipline any member of staff or refer any member of staff who may be unsuitable to work with vulnerable adults for inclusion on the Protection of Vulnerable Adults register. It was also confirmed that all of the staff had undergone Abuse Awareness training. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. 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 users lived in safe, comfortable and well-maintained surroundings. However, action must be taken to ensure that appropriate hygiene standards are maintained for the benefit of the service users. EVIDENCE: The home was located in a mainly residential area near to shops and other local amenities. Ramped access had been provided at the front of the home for people who use wheelchairs or who have severe mobility problems. Inside, the home was comfortable, well maintained and homely. The home did not have a passenger lift. However, a stair lift was provided to enable service users to have easier access to the accommodation on the first floor. A record was kept of routine maintenance and renewal of the fabric and decoration of the premises. A new, single storey extension was being built to provide a further three single bedrooms in order to increase the number of service users from twelve to fifteen. Consequently, the rear garden was not being maintained to a satisfactory standard because of the building work. The registered provider gave an assurance that the garden would be returned to a St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 21 satisfactory standard following the completion of the extension. The Environmental Health Officer had visited the home on 20 March 2006. In response to the subsequent recommendations, the extractor fan in the kitchen had been cleaned and work had commenced to produce a written food safety management system. The acting manager stated that she was waiting for the Environmental Health Officer to return before completing it. A letter from the Fire Safety Officer dated 17 October 2005 stated that the premises and the fire risk assessment were found to be satisfactory. The proprietor was advised that he would be required to obtain written confirmation that the premises complied with all of the appropriate fire safety precautions before the CSCI could approve the use of the new extension. The premises were clean and free from unpleasant odours. It was stated that there was a low level of incontinence within the home and, therefore, the laundry facilities were considered to be adequate for the needs of the service users at the present time. However, the laundry did not have a sluicing facility. The acting manager stated that soiled linen was rinsed out in the sink in the laundry. The recently purchased washing machine did not have a sluicing facility. The location of the laundry meant that soiled linen from one of the bedrooms on the ground floor had to be taken through the dining room. It was confirmed that soiled linen was always placed in a red nylon bag when being transported from the bedroom to the laundry. This issue must be recorded in the home’s risk assessment. Two requirements were made in regard to Standard 26 as a result of the previous inspection. The first requirement was that a risk assessment must be carried out and recorded on the handling of soiled linen within the home. A copy of the risk assessment dated 21 January 2006 was made available for inspection. The acting manager was advised that the control measures referred to in the risk assessment needed to be more specific e.g. there was no reference to staff training, the ‘red bag’ system used by the home or the use of separate aprons etc. and there was no specific reference to the transporting of soiled linen through the dining room. The requirement had not been fully implemented and still stands. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. 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. A copy of the home’s ‘Policy and Procedures on Infection Control’ was made available for inspection. The policy and procedures needed to be more specific and more detailed and 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 requirement had not been fully implemented and still stands. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. 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 home was well on the way to meeting the 50 requirement in regard to NVQ 2 training. However, further staff training was needed as well as improvements in the level of management cover. Greater diligence was also needed in adhering to correct staff recruitment procedures. EVIDENCE: Two requirements and one recommendation were made in regard to Standard 27 as a result of the previous inspection. The first requirement was that the duty roster must show which staff are on duty at any time of the day and night and in what capacity. A copy of the home’s duty roster was made available for inspection and it was pleasing to note that the requirement had been implemented. The second requirement was that staff recruitment procedures must be developed in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. No new staff had been appointed since the previous inspection. Therefore, it was not possible to fully assess whether the requirement had been implemented. However, it was noted that a new recruitment form had been introduced in each of the staff files. The purpose of the recruitment form was to help ensure that all of the necessary checks had been carried out and all of the necessary information obtained in respect of newly appointed staff. Therefore, the requirement was regarded as having been implemented. The 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 copy of the duty roster that was made available for inspection showed that the acting manager and the deputy St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 23 manager were on duty at the same time. The acting manager stated that during some of the duty periods she was involved in ‘office-based work’ i.e. carrying out administrative tasks, and not directly available to the staff or service users. Nevertheless, the duty roster showed that there were still long periods in the evenings i.e. from 4:00 pm to 9:00 pm, and at weekends when neither the acting manager or deputy manager were on duty. The recommendation had not been implemented and still stands. The duty roster also showed that for most of the waking day throughout the week and at weekends there were only two members of care staff, including the acting manager and/or deputy manager, on duty. This was the absolute minimum level of staffing acceptable. The proprietor was advised that the level of daytime staffing would have to be increased in order to meet the needs of the proposed increase in the number of service users. There was one member of staff on waking duty and one member of staff on sleeping-in duty at night. The home had a part-time vacancy i.e. 12 hours per week, for a cleaner. It was stated that, at the present time, one of the night staff did the domestic work. The service users with whom discussions were held confirmed that the staff were kind and that they were well looked after. A recommendation was made in regard to Standard 28 as a result of the previous inspection that arrangements should 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 by 31 December 2005. It was noted that the home employed a total of 11 care staff. It was also pleasing to note that 5 members of staff had successfully completed the NVQ level 2 training and that the home was, therefore, well on the way to meeting the 50 target. However, the recommendation had not been fully implemented. The recommendation now becomes a requirement. Three requirements were made in regard to Standard 29 as a result of the previous inspection. The first requirement was that two written references must be obtained before appointing any member of staff and any gaps in employment records must be explored. It was noted that no new staff had been appointed to work at the home since the previous inspection. Therefore, the requirement has been deleted. However, the home will be inspected against this Standard during the next inspection. The second requirement was that an application for an enhanced Disclosure check from the Criminal Records Bureau (CRB) must be made in respect of all new staff prior to their appointment. As with the previous requirement, it was noted that no new staff had been appointed since the previous inspection. Therefore, the requirement has been deleted. The home will be inspected against this Standard during the next inspection. The acting manager confirmed that a CRB check had been carried out in respect of all of the current staff. The acting manager stated that she intended to carry out a CRB check on all of the staff every three years. However, it was noted with serious concern that information regarding the outcome of a disclosure application in respect of one member of staff had not been followed up. A Statutory Requirement Notice was issued in regard to St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 24 this matter following the inspection. It was also noted with concern that the same member of staff had commenced working at the home prior to the CRB check being carried out. The third requirement was that copies of the code of conduct and practice set by the General Social Care Council must be issued to all the staff as part of their employment at the home. The requirement had been implemented. The two members of care staff with whom discussions were held confirmed that they had been issued with a job description and a copy of their terms and conditions of employment (contract). Copies of the contracts were on the staff files. The acting manager stated that all of the staff had been issued with a copy of the ‘Employee Handbook’. A copy of the handbook was made available for inspection and it was noted that it contained a brief reference to the home’s equal opportunities policy. A member of staff that had recently returned to work after maternity leave had commenced the Skills for Care induction training. It was intended that she would commence the NVQ level 2 training in September 2006. One member of staff had not undertaken training in first aid. Another member of staff had not undertaken training in any of the core areas. The staff had not undertaken any training in key working or person centred planning. A recommendation was made in regard to Standard 30 as a result of the previous inspection that the details of the training undertaken by the staff as recorded in their individual training and development assessments and profiles should be completed in full. The recommendation had been implemented. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The quality outcome in this area was poor. This judgement has been made using available evidence including a visit to this service. The home did not have a registered manager. The systems for monitoring the quality of the service needed to be developed. The home’s standard of record keeping, policies and procedures did not fully protect the service users. EVIDENCE: The home did not have a registered manager. The acting manager’s application for registration is now the subject of an appeal to the Care Standards Tribunal. The acting manager stated that she was nearing the end of her NVQ level 4 training and had two units to complete. The acting manager hoped to receive confirmation of the successful completion of the NVQ 4 and Registered Managers’ Award training in the near future. One requirement and one recommendation were made in regard to Standard 31 as a result of the previous inspection. The requirement was that the acting manager must undertake appropriate training in risk assessment, the protection of vulnerable adults from abuse and dementia care to ensure that St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 26 she has the experience and skills necessary for managing the care home. The acting manager stated that she had undertaken risk assessment training on 8 January 2006 and training in abuse awareness and dementia awareness organised by Care Association Training on 8 February 2006. The requirement was regarded as having been implemented. The recommendation was that 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 this (i.e. the previous) report. A copy of the revised job description was made available for inspection. The recommendation had not been implemented and still stands. The deputy manager had undertaken all of the core training and was undertaking NVQ level 4 training. The two senior care assistants had undertaken NVQ level 2 training. Two recommendations were made in regard to Standard 32 as a result of the previous inspection. The first recommendation was that evidence should be provided to show that management planning and practice encourage innovation, creativity and development. The recommendation had not been implemented and still stands. The second recommendation was that an equal opportunities policy should be developed and an appropriate reference to it included in the staff application forms and in the service users’ guide. A copy of the home’s ‘Equal opportunities policy’ was made available for inspection. There was a brief reference to the policy in the home’s ‘Employee Handbook’ and a copy of the policy was included in the statement of purpose. The recommendation was regarded as having been implemented. One requirement and two recommendations were made in regard to Standard 33 as a result of the previous inspection. The requirement was that a quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. The acting manager provided a statement on ‘Quality Assurance’ and a statement on an ‘Annual Audit (January 2006)’ for inspection. It was pleasing to note that the home had made an attempt to address the requirement. However, the results of the audit were limited. In addition, apart from the use of questionnaires, no evidence was provided to show that the statement on quality assurance had been developed in any tangible way. The requirement had not been fully implemented and still stands. The first recommendation was that 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 recommendation had not been implemented and still stands. The second recommendation was that the views of family, friends and stakeholders in the community should be sought on how the home is achieving goals for service users. The acting manager stated that questionnaires were sent to the relatives of all the service users in January 2006. Questionnaires had not been sent to other stakeholders. Only four questionnaires were returned. The service users and their relatives had not yet been made aware of the results on the outcome of the questionnaires. The acting manager stated that she intended to issue a St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 27 new set of questionnaires in June 2006 in the hope that the home would receive a better response. The recommendation had not been fully implemented and still stands. It was pleasing to note that the home had introduced a ‘Development Plan’, a copy of which was made available for inspection. 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. Although the minutes of the meetings were limited in content it was pleasing to note that, since the previous inspection, two meetings had been held with the service users on 12 January and 11 March 2006. Action to implement a number of requirements identified in CSCI inspection reports had not been progressed within the agreed timescales. The acting manager stated that no one connected with the running of the home acted as the agent or appointee on behalf of any of the service users. However, the home handled the personal finances that were handed over for safekeeping on behalf of nine service users. The money belonging to each service user was kept in individual packets and accounted for separately. The money and the related records of account were kept in a safe, lockable facility. The records and corresponding amounts of money in respect of two service users were checked at random. It was noted with concern that there was a discrepancy in the amount of money held in respect of one service user, i.e. there was £5.00 less in the service user’s individual packet than there should have been. The acting manager stated that the home did not hold any of the service users’ personal possessions for safekeeping. A requirement was made in regard to Standard 36 as a result of the previous inspection that care staff must receive formal supervision at least six times a year that includes all of the issues referred to in Standard 36.3. The staff files that were inspected contained evidence to show that individual supervision meetings were being held with the staff. The staff with whom discussions were held also confirmed that they received individual supervision. However, one member of staff had only attended one supervision meeting and three other members of staff had only attended two supervision meetings since the previous inspection i.e. a period of approximately six months. The frequency of supervision meetings must be increased. The requirement had not been fully implemented and still stands. 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 registered provider must prepare a written report at least once a month on the conduct of the home and supply copies to the Commission as well as the manager in accordance with the requirements of Regulation 26. The requirement had been implemented. The second requirement was that the Commission must be notified without delay of any serious injury, illness, event, incident or allegation of misconduct in accordance with Regulation 37. The record of accidents was checked and it was noted that seven accidents had been recorded since 16 January 2006. It was noted that one accident form St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 28 dated 29 January 2006 had not been fully completed. It was also noted that one of the service users had had a fall on 15 May 2006 that had resulted in severe bruising. The service user was taken to the accident and emergency department for an x-ray. The accident, that was potentially serious, had not been reported to the Commission. Therefore, the requirement still stands. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. The recommendation was that a statement should be included in the service users’ guide informing service users of their right of access to their records and the information held about them by the home and of the opportunities to help maintain their personal records. The statement of purpose included a policy on ‘Data Protection’ that contained a reference to the service users’ entitlement to see the information held about them by the home. However, the second part of the recommendation had not been implemented and still stands. Two requirements 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 in Standards 38.2 and 38.3 including kitchen equipment, laundry machinery, the outside of the premises and the security of the premises. Copies of the risk assessments that had been carried out and recorded were made available for inspection. It was noted that there was no risk assessment on food hygiene or on any of the issues listed in Standard 38.3 apart from security of the premises. It was also noted that the action plans in a number of the risk assessments that had been carried out and recorded had not been completed. The requirement had not been fully implemented and still stands. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. The second requirement was that training in the protection of vulnerable adults from abuse and in the care of people with a dementia illness must be provided for all the staff. It was confirmed that all of the staff had undertaken abuse awareness training and dementia awareness training on 8 February 2006. The requirement had been implemented. The fire safety records were checked and these indicated that the weekly fire alarm tests had not been carried out for two weeks i.e. since 05/05/06. The most recent fire drill had been held on 30 March 2006 i.e. a fire drill had not been held for April or May. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. An outside contractor had serviced the fire alarms, smoke detectors and stair lift on 15 February 2006. It was confirmed that the battery operated bath hoist had been checked and that PAT tests had been carried out during the previous twelve months. The staff had undertaken moving and handling training on 22 July 2005. However, the training records indicated that moving and handling training was due to be provided every three years. Moving and handling training must be provided every year. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. Hazardous substances were kept in a lockable cupboard in the laundry. The home had two first aid boxes, one in the laundry and one in the office. Evidence was provided to show that the boiler and central heating St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 29 system had been serviced on 24 February 2005. The system must be serviced annually. A Notice of Immediate Requirement was issued in regard to this matter at the conclusion of the inspection. The proprietor was advised that an electrical safety certificate provided by a qualified electrician and written confirmation to show that Legionella tests had been carried out on the water supply would be required following the completion of the extension. The home had information regarding COSHH and RIDDOR. It was noted that all of the records, policies and procedures that the home is required to keep that were examined during the course of the inspection contained numerous typographical and grammatical errors. In addition, a number of the documents were not signed or dated. All of the records maintained by the home must be checked for errors and omissions and amended where necessary. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 30 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 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 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X X 1 St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 31 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 provided in previous reports. (Previous timescale 31/12/05 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 previous reports and copies given to all current, and any prospective, service users. (Previous timescale 31/12/05 not met). 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. (Previous timescale 31/12/05 not met). The service users’ care plans DS0000065811.V298493.R01.S.doc Version 5.2 Timescale for action 31/07/06 2 OP1 5 31/07/06 3 OP3 14 31/07/06 4 OP7 15 31/07/06 Page 32 St Martins Care Home for the Elderly 5 OP7 15 6 OP8 13 7 OP8 13 8 OP8 13 9 OP8 13 10 OP9 13 11 OP9 13 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. (Previous timescale 31/12/05 not met). 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). A tissue viability risk assessment must be carried out and recorded in respect of the service user who is refusing the help of the district nurse in order to prevent skin breakdown. (Previous timescale 09/12/05 not met). Nutritional screening must be undertaken on admission and for all current service users and subsequently on a periodic basis and a record maintained and appropriate action taken. Risk assessments must be carried out and recorded in respect of all service users regarding the risk of falling. (Previous timescale 09/12/05). A risk assessment must be carried out and recorded in respect of the service user who uses a stoma bag. (Previous timescale 09/12/05 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 09/12/05 not met). Appropriate action must be taken to ensure that a medicine audit can be completed. The date of opening of all medicine DS0000065811.V298493.R01.S.doc Version 5.2 31/07/06 26/05/06 31/07/06 31/05/06 31/05/06 01/07/06 01/07/06 St Martins Care Home for the Elderly Page 33 12 13 OP9 OP9 13 13 14 OP9 13 15 OP18 12,13 16 OP26 13 17 OP26 13 18 OP28 18 19 OP29 19 containers must be recorded and any balances carried over to new medicine charts. The receipt of all medication must be accurately recorded. The strength of any Warfarin tablet administered to service users must be clearly recorded on the medicine charts. 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. Procedures for responding to suspicion or evidence of abuse or neglect (including whistleblowing) must be drawn up in accordance with the Public Interest Disclosure Act 1998 and the Department of Health guidance ‘No Secrets’. (Previous timescale 31/12/05 not met). The risk assessment for the handling of soiled linen within the home must be fully completed. (Previous timescale 31/12/05 not met). A policy and procedure for the control of infection that includes the issues referred to in Standard 26.5 must be provided. (Previous timescale 31/12/05 not met). 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. The positive disclosure result from the CRB in respect of a member of staff must be fully investigated and recorded. DS0000065811.V298493.R01.S.doc Version 5.2 01/07/06 01/07/06 30/09/06 31/07/06 31/05/06 31/07/06 31/12/06 24/05/06 St Martins Care Home for the Elderly Page 34 20 21 OP30 OP30 18 18 22 OP33 24 23 OP35 13,17 24 OP36 18 25 OP37 13,17 26 OP37 37 27 OP38 12,13 28 OP38 13,23 29 OP38 13,18 Action must be taken to ensure that all of the staff undergo all of the relevant core training. All of the care staff must undertake appropriate training in key working and person centred planning. A quality assurance system must be introduced in accordance with the requirements Regulation 24 and Standard 33. (Previous timescale 31/01/06 not met). 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. 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 31/01/06 not met). The accident forms must be completed in full and checked by a senior member of staff at the time of the accident. The Commission must be notified without delay of any serious injury, illness, accident or event that affects the wellbeing of any service user in accordance with Regulation 37. (Previous timescale 09/11/05 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 31/12/05 not met). 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. Moving and handling training must be undertaken by all the DS0000065811.V298493.R01.S.doc Version 5.2 30/09/06 30/09/06 31/07/06 01/07/06 30/09/06 01/07/06 23/05/06 31/05/06 24/05/06 20/07/06 Page 35 St Martins Care Home for the Elderly 30 OP38 13,23 31 OP38 17 staff by 20/07/06 and, thereafter, at least every twelve months. 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. 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 in order to ensure that the contents of these is interpreted, understood and implemented correctly. 07/06/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP9 Good Practice Recommendations 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 policy and procedure for the administration of medication should include a statement that any errors in the administration of medication must be reported to the CSCI in accordance with Regulation 37. 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. 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. Relatives, friends and representatives of service users DS0000065811.V298493.R01.S.doc Version 5.2 Page 36 3 OP10 4 5 OP12 OP13 St Martins Care Home for the Elderly 6 OP14 7 OP14 8 9 10 OP15 OP17 OP18 11 12 OP26 OP26 13 14 15 OP27 OP27 OP31 16 17 OP32 OP33 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. Details of the service users’ food preferences should be kept in the kitchen. 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. Consideration should be given to the provision of a washing machine that has a built-in sluicing facility. 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 acting manager and deputy manager should work some separate shifts in order to spread the management cover for the home. The registered provider should give consideration to increasing the level of staffing in anticipation of the proposed increase in the number of service users. 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 previous 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. DS0000065811.V298493.R01.S.doc Version 5.2 Page 37 St Martins Care Home for the Elderly 18 19 20 OP33 OP33 OP37 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. A statement should be included in the service users’ guide informing service users of the opportunities to help maintain their personal records. St Martins Care Home for the Elderly DS0000065811.V298493.R01.S.doc Version 5.2 Page 38 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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