CARE HOMES FOR OLDER PEOPLE
St Marys Haven Respite Unit St Marys Street Penzance Cornwall TR18 2DH Lead Inspector
Paul Freeman Unannounced Inspection 27th July 2006 10:00 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 Marys Haven Respite Unit DS0000008906.V306468.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 Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Marys Haven Respite Unit Address St Marys Street Penzance Cornwall TR18 2DH 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) 01736 331982 F/P 01736 331982 The Presentation Sisters Vacant Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 9 adults of old age (OP) for respite care Date of last inspection 21st November 2005 Brief Description of the Service: St Marys Haven respite care centre provides accommodation and care for up to nine older people. Of the current residency, seven are permanent residents and two rooms provide care on a short-term basis. There is a designated area for respite care, the bedrooms are on the ground floor, with access to bathing and toileting facilities close by. However the respite care service users share the dining and lounge facilities and can access the multi faith chapel and day care facilities located on the same site. The respite care beds are booked a long way in advance due to the popularity and demand of this service. Accommodation is provided on three floors, all of which are accessible by stairs and a lift. All the rooms are for single occupancy. Permanent residents occupy the first and second floor of the home; all have access to nearby bathing and toileting facilities. All the rooms face the front of the building and therefore there are some nice views of Penzance town. The home has a garden, which service users can access. The Presentation Sisters of Penzance are responsible for the management of the home. Within the grounds is a registered Residential care home caring for twenty-six residents. A day centre, which caters for fifty people and a group of terraced flats. St Marys Haven is an interdenominational home working in a Christian atmosphere. Opportunities are provided for regular Christian services, Catholic, Anglican and Methodist Ministers may also attend to the spiritual needs of the service users. St Marys Haven is located near the town centre of Penzance. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced key inspection took place on 27 July 2006. The purpose of the inspection was to consider the work that had been completed on the requirements and recommendation set at the last inspection on 21 November 2005. In addition the core key standards were also considered. Therefore some of the key standards that were examined include assessment and care planning, health and safety and staff recruitment. Residents, staff and a trustee were also consulted about the services and facilities provided. The environment, records and documents were also considered. Within the last year the responsible individual and the registered manager have both unexpectedly died. The trustees, staff and residents of the home recognise the valuable service and contribution both post holders made to providing the quality of life and the services and facilities they now experience. In the interim the trustees have appointed a new responsible individual and a temporary manager until a substantive post holder can be appointed. Two trustees have also played a key role in supporting the staff and taking steps to make sure the standards of the services and facilities are not compromised. The temporary manager was on annual leave at the time of the inspection but following the inspection provided written information and documents about the services provided. The Inspector found the recommendations set at the last inspection had been worked upon. What the service does well:
The provider assesses each prospective resident. The assessment identifies the person’s needs, choices and preferences and provides a clear picture of the care and support required. The assessment also makes sure that the facilities and services available at the home can meet the needs of the prospective resident. Each prospective resident is invited to participate in the assessment process and their relatives or representatives are also consulted. The views of any relevant professionals involved with the person are also taken into account. Residents that had recently moved to the home said they had been fully consulted and had felt in control of the assessment process. The residents also
St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 6 said they had been positively welcomed and helped to settle when they first arrived at the home. Each resident has a care plan that details their needs, preferences and choices and provides guidance to staff about the care and support required. Some of the care plans are also reviewed regularly to make sure they are up to date and provide a comprehensive picture. Residents’ health needs are well met and medical services are promptly accessed when required. Residents said they had confidence in the manner the staff met their needs and provided care and support when they experienced poor health. Residents are able to administer their own medication when it is safe to do so but where assistance is required the staff have been suitably trained. Medication is held in secure facilities and satisfactory arrangements are in place to dispose of unwanted medicines. Residents are also positive about the standard of care provide at the home and said this occurred in a dignified and respectful manner. Residents also stated they are able to direct their own care and feel in control of their daily lives. Residents said they also experience a flexible lifestyle and it is clear that positive, meaningful and trusting relationship have been established between the residents and staff. There are no barriers to residents maintaining links with family or friends at the care home or in the community and residents said the staff always positively welcome visitors. Residents are also able to participate in social and recreational opportunities at the home or in the local community. Activities are also provided at the home if residents wish to participate. A balanced and nutritional menu is in place that reflects the residents’ preference and choice. Residents are also provided with a choice at each mealtime. The residents were positive about the quality of the food provided and described the meals as “excellent”, “wholesome” and “lovely”. Arrangements have been established to deal with any concerns or complaints in a positive and efficient manner and residents said there are no barriers to raising issues with staff or managers. The residents were also confidant that issues would be dealt with efficiently and in a satisfactory manner. The providers are also committed to protecting residents form abuse and any allegations or concerns are reported to the statutory authorities for investigation. Within the campus there are two registered care homes and a day centre for older people. The respite unit operates as a separate care home and provides St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 7 accommodation over three floors. Stairs or a passenger lift provides access to all floors. The ground floor comprises of a reception area, sitting room and dinning room and two bedrooms that are used for people who stay at the home for short periods. The other two levels are principally for bedrooms but also include a small kitchen for snacks and refreshments and a small seating area on the second floor landing. Toilets and bathrooms are distributed throughout the care home and are within a reasonable distance from communal areas and residents bedrooms. There is also a range of aids and disability equipment provided throughout the home to assist residents to maintain their independence. This includes a parker bath, hoists and handrails. Residents said that a high standard of cleanliness and hygiene was maintained at all times and there were no offensive odours throughout the home. The environment is maintained to a very high standard and reliable arrangements are in place to deal with any repairs that are required. The furniture fitting and furnishing are of a domestic nature wherever possible and consequently results in a homely place for residents to live. Residents said they are very satisfied with every aspect of the facilities that are provided. Suitable numbers of staff are on duty during waking hours and at night and additional staff is employed at peak hours to make sure that residents needs and choices are met. New members of staff complete a satisfactory induction programme to make sure they have the knowledge and skills required to meet the needs of residents. Residents were very positive about the manner in which the staff undertake their duties and the standard of care provided. Residents also said that staff were flexible and treated them with dignity and respect. The providers have appointed a temporary manager until a substantive post holder can be recruited. Residents and staff said there had been no changes in the quality or reliability of the service and facilities following the change of managers. Reliable quality assurance arrangements are in place, which provide an opportunity for consultation with residents, staff, visitors to the home and other interested parties about the services and facilities provided. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 8 The providers will assist resident to manage their personal allowances where no third party help is available. Where assistance is provided the money is held in secure facilities and robust records are maintained. Suitable arrangements are in place to promote safe working practices and a range of policies and procedures are in place to guide direct and inform the staff. Equipment and services at the home are regularly serviced and maintained and good standards of hygiene are evident throughout. The providers have also established suitable fire precaution arrangements and staff at the care home is regularly trained. There are no concerns about the financial viability of the care home and a suitable insurance policy is in place. What has improved since the last inspection? What they could do better:
In certain instances the information and directions to staff in care plans need to be more detailed to make sure staff have a comprehensive picture of the care and support required. Regular reviews also need to take place for each residents and a suitable record of the review should be in place. This will also provide staff with an up to date picture of the care required. The policy and procedure and records for the administration of medicines require development in order that robust arrangements are in place to protect residents. The policies and procedure regarding complaints and protection from abuse also require improvement to make sure that comprehensive arrangements are in place to safeguard residents. The water temperature from certain taps appeared to exceed to recommended level. This requires further consideration to make sure residents are safeguarded. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 9 The recruitment selection and vetting arrangements are poor and require improvement to make sure that residents are protected. The arrangements have deteriorated following the unexpected death of the registered manager and are viewed as a temporary shortfall. The providers are aware of the situation and have taken steps to remedy the current deficiencies. The staff is well trained but the programme for the year ahead appears to has been interrupted as a further consequence of the absence of a registered manager. There is some evidence that training is continuing but there does not appear to be an annual programme of events or individual training programmes for staff. The providers are required to send to the Commission documentary evidence of the fitness of the manager. This is to make sure they have the skills and competencies to undertake the role and responsibilities of the post. The providers must also make arrangements for regulation 26 visits to be completed each month and a report of the visit sent to the Commission. This will ensure that the services and facilities are regularly monitored and any issues or difficulties are promptly addressed. The unexpected death of the registered manager has resulted in the suspension of the quality assurance arrangements. The providers are aware of this shortfall and are taking steps to implement the programme. This review will offer the providers valuable information about the current arrangements in place and identify any areas that require improvement. It is recommended te providers improve and develop the guidance and [procedures that in place regarding the actions the staff are required to take in the event of a fire. This will make sure that staff has a clear understanding of their roles and responsibilities. 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 Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 10 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 Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 11 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): 3 and 6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Suitable assessments of residents are undertaken in order that the providers have a clear picture of the care and support required. The assessments also make sure that prospective residents needs can be met by the services and facilities available. EVIDENCE: The assessments of needs for residents that have recently received a service were considered. The providers complete an assessment for each prospective resident in order that they have a clear picture of the person’s needs preferences and choices. The assessment also makes sure that the providers are able to meet the needs of the individual. The prospective resident is invited to take part in the assessment and their relatives or representatives are also consulted. In addition the views of any professionals that are involved with the person are taken into account. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 12 Residents that have recently moved to the home said they had felt in control of the assessment process and had been positively welcomed and helped to settle when they arrived at the home. The care home does not provide a dedicated rehabilitation service. The staff at the home is committed to promoting residents independence and providing the support required to achieve this goal. The residents and their families view the short stay facilities positively and this service assists the person concerned to remain in their home setting. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents care plans are sufficiently detailed to provide a clear picture of each resident needs, preferences and choices. The plans also provide staff with guidance about the care and support required. The arrangements to regularly review care plans require improvement to make sure the plans are up to date and comprehensive. Good arrangements are in place to meet residents’ health needs and medical services are promptly accessed when required. The arrangements to administer medicines require improvements to make sure that residents’ health needs are met. EVIDENCE: Each resident has a care plan that details their needs, and the care and support they require. Residents play a lead role in deciding the contents of the care plan and this makes sure their needs, preferences and choices are accommodated. The care plans also provide staff with information, direction and guidance about the care and support each person requires.
St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 14 In certain instances the information provided for staff needs to be more detailed to make sure that a comprehensive picture is provided and residents are safeguarded. The staff also verbally handover to each other in order that good communication occurs and a good understanding of the current situation is provided. Residents speak in glowing terms about the way they are positively treated by the staff. It is evident that residents are treated with dignity and respect and that every reasonable step is taken to make sure each individual has control over their lives and the care and support provided. The providers have also established a policy and procedure about dignity and respect to guide and direct the staff. The evidence indicates the care plans of long term residents are reviewed but the records of the review are not always clear or record the conclusions that have been reached and any action required. It is also recommended that reviews are signed and dated by the appropriate staff member. There is clear evidence that needs of short term care residents are reviewed before each stay. This is good practise and results in the provider having a clear picture of any changes that have occurred and the care and support required. Residents’ health needs are met to a good standard and medical services are promptly accessed when required. Residents said they had confidence in the arrangements and found the staff to be responsive, efficient and sympathetic during periods of poor health. Residents are also able to administer their own prescribed medicines when it is safe to do so. The staff also assist residents where required and each staff member administering medication has been suitably trained. The providers have established a suitable policy and procedure to guide direct and direct the staff and suitable records are maintained of the medicines administered. The policy and procedure needs to be developed to take account of any errors that may occur and to detail the action that will taken if a resident wishes to administer their own medication. The records also require improvement so that a formal record is made of any directions given by General Practitioners or other health professionals to change the prescribed medication. It is also recommended the policy includes procedures about homely remedies. Medicines at the home are held in secure facilities and suitable arrangements are in place to dispose of unwanted medication.
St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 15 St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The lifestyle at the home is flexible and residents said they felt in control of their patterns of their daily lives. Residents are also able to decide how they spend their leisure time and a range of activities is provided at the home. There are no barriers to residents maintaining links and relationships with family or friends at the care home or in the local community. A nutritional and balanced menu is provided that reflects residents’ preferences and choices ands promotes good health. EVIDENCE: Residents said they were very satisfied with the manner in which their life style expectations and preferences are met. Each residents care plan details the individual’s interests, hobbies and leisure pursuits. Residents are able to choose how they spend their time and a range of activities is provided at the home if they wish to participate. There are also no barriers to residents accessing opportunities in the local community. There are regular opportunities for residents to regularly participate in Church services and prayer meetings. Representatives of religious denominations also
St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 17 regularly have contact with the care home and this reflects each individual residents choice. Residents are able to maintain links with family and friends at the care home and in the local community. Residents said their visitors receive a positive welcome at the home and residents are able to decide where they meet with visitors. It is also evident that a trusting and relaxed relationship exists between each resident and member of staff. Residents said that every reasonable step was taken to provide the opportunity to exercise choice and control over their lives. Consequently positive and meaningful relationships are established and residents clearly feel that nothing is too much trouble for the staff. Residents are also satisfied with the food provided and a nutritional menu is in place that reflects residents’ preferences and choices. Two of the residents described the meals as “lovely” and “wholesome”. Residents are also able to decide where they eat their meals. St Marys Haven Respite Unit DS0000008906.V306468.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. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There are no barriers to residents raising any concerns or complaints with the managers and staff at the home. The providers are committed to dealing with issues in a positive and efficient manner so that issues can be resolved promptly. Reliable arrangements are also in place to protect residents from abuse and all allegations or concerns are reported to the statutory authorities. The policies and procedures for both standards require improvement to make sure that robust and transparent arrangements are in place. EVIDENCE: The providers have an open approach to concerns and complaints and any issues are dealt with promptly and efficiently. No formal complaints have been received following the last inspection. Residents said there were no barriers to raising any issues or concerns and had confidence that any issue would be dealt with in a positive manner. A policy and procedure is in place to guide direct and inform the staff but this needs to be reviewed given it does not reflect the statutory powers of Adult Social Care to investigate complaints. The document also states that any unresolved issues would be passed to the Commission for resolution. This does
St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 19 not accurately reflect the situation given the Commission do not have any statutory powers to investigate complaints. The providers have also established policies and procedures to protect residents from abuse. Any allegations or concerns are reported to the statutory authorities for investigation. However the policy states the providers should investigate any concerns. This does no reflect the Department of Health guidance “No Secrets” which directs that Adult Social Care is responsible for the coordination of any investigation. Therefore the providers’ responsibility is to report the concerns to the statutory authorities before any investigation takes place. A suitable whistle blowing policy and procedure is also in place. This enables staff members to report any concerns regarding abuse to a third party. St Marys Haven Respite Unit DS0000008906.V306468.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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The standard of the environment is high and provides residents with a homely and comfortable place to live. The water temperatures do require monitoring to make sure residents are safeguarded. EVIDENCE: Within the campus there are two registered care homes and a day centre for older people. The respite unit operates as a separate care home and provides accommodation on three floor. The ground floor comprises of the reception area, sitting room and dinning room. There are also two bedrooms that accommodate residents who visit the care home on a short term basis. The other two floors provide bedrooms and a small kitchen area for snacks and refreshments. A small seating area is also provided on the landing of the upper floor. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 21 A passenger lift is in place to assist access to and from the upper levels. There are also a wide range of aids and disability equipment provided to assist residents to maintain their independence. In additions residents have their own disability equipment that has been provided following a specialist assessment. Toilets and bathrooms are distributed throughout the home and are within a reasonable distance from communal areas and residents’ bedrooms. The facilities include a shower room and a parker bath. The environment is maintained to a high standard and there is an ongoing programme of maintenance, replacement and decoration. Residents said they were very satisfied with all aspects of the environment and were confidant that repairs are undertaken promptly and efficiently. Many of the residents have personalised their bedrooms and residents who visit for a short stay are able to bring personal items with them. The residents said they were very happy with their bedrooms and the quality of the furnishings and furniture provided. Residents are also able to bring certain items of their own furniture if they wish. Appropriate heating is provided and the temperature can be thermostatically adjusted in each room. In addition each radiator at the home has a suitable cover to minimise any potential accidents that could occur. Rooms are also suitably lit and the water temperature from each tap is controlled to make sure of compliance with the appropriate regulations. In one bathroom the temperature of the water appeared to exceed the minimum recommended and this require monitoring. The home is clean and there was no evidence of unpleasant odours. Residents said that a high standard of cleanliness and hygiene was maintained at all times. St Marys Haven Respite Unit DS0000008906.V306468.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. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Sufficient numbers of staff are on duty each day and night to provide the care and support required to meet residents’ needs. The staff group are mutually supportive and relatively stable. Therefore staff offer a wide range of knowledge, skills and experience to residents who have confidence in the manner they undertake their duties. The recruitment, section and vetting arrangements are poor and could place residents at risk. The records regarding the Induction arrangements for new staff are also poor and do not show the programme that has taken place or indicate that staff have the relevant skills and competencies to meet the needs of residents. This could also potentially place residents at risk. EVIDENCE: Sufficient numbers of staff are on duty each day and night to meet the needs of residents. Additional staff is employed throughout the day at peak hours to make sure that care is provided at the time residents require. Extra staff will also be on duty if this is required to meet the needs of residents. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 23 Residents commented they found the staff to be helpful, flexible, efficient and reliable. Therefore requests for assistance are dealt with promptly and residents are able to direct the care and support they receive. The home has a relatively stable staff group who are experienced and provide a positive mix of skills. The recruitment selection and vetting arrangements are not satisfactory and require urgent attention to make sure that residents are safeguarded. The records required by regulation are incomplete and staff have commenced duties before a satisfactory CRB and POVA check has been completed. The deterioration in the arrangements appears to have occurred as a consequence of the unexpected death of the registered manger. Steps need to been taken by the providers to address the shortfalls. The staff records indicate that some training has taken place in recent weeks regarding core care skills. In addition other staff said they were considering undertaking the NVQ 2 qualification. A number of the care staff are already trained to NVQ 2 standard. However it was unclear if a training programme has been established for the year ahead and there was no evidence to indicate that staff have an individual training programme. Newly appointed staff complete an induction programme that includes working alongside experienced staff members. Satisfactory records are also in place that confirm the competencies that have been successfully completed. Staff at the home consider the induction arrangements to be comprehensive. The staff group said they worked well as a team and felt appropriately supported. Suitable arrangements are also in place for staff to receive advice, guidance and assistance where this is required. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The temporary management arrangements are adequate but the responsible individual and registered manager need to provide the Commission with evidence of fitness. The established quality assurance measures have been interrupted as a consequence of the management issues. The programme needs to be put in place in order the providers have a clear assessment of the quality of the services and facilities. This will also assist the providers to maintain and improve the standards provided to residents. Where residents are assisted by the providers to manage their personal allowances robust arrangements are in place to manage the monies in a safe and responsible manner. A range of measures is in place to promote safe working practices and to safeguard residents and staff.
St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 25 EVIDENCE: Within the last year the responsible individual and the registered manager have both unexpectedly died. The trustee, staff and residents of the home recognised the valuable service and contribution both post holders made to provide the quality of life and the services and facilities they now experience. In the interim the trustees have appointed a new responsible individual and a temporary manager until a substantive post holder can be appointed. Two trustees have also played a key role in supporting the staff and taking steps to make sure the standard of services and facilities are not compromised. The responsible individual and manager have not yet provided the Commission with evidence of fitness but have made a commitment to provide this information and documentation in the near future. The trustees have also said they are at the point of advertising for a registered manager. The current circumstances have also resulted in the providers not being able to regularly complete the visits and reports required by regulation 26. The staff at the home said that the temporary management arrangements had not resulted in any changes to the standards of care or the support, guidance and assistance available. Residents although sad at the loss of the two key managers were also unable to identify any significant changes in the care and support they receive. Residents were also confidant that the home has continued to be run and managed in their best interests. The quality assurance arrangements have also been interrupted given the management position and the programme of events to consult with staff, residents, professionals and visitors has not taken place. The providers are aware of this situation and have taken appropriate action to make sure that measures are in place to complete the programme by the end of the year. In the interim regular staff meetings take place and residents are consulted on a day to day basis about the services and facilities provided. The providers will also assist residents to manage their personal allowances where third party help is not available. The monies are held securely and a record is maintained of each transaction that occurs which is also signed by the staff concerned or the resident. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 26 Some of the records at the home require improvement in order to comply with the regulations and standards. It is positive the providers have continued to make efforts to improve some of the recording practises and this can be illustrated by the daily record that are maintained in each resident and residents care plans. Other records and documents require improvement and these have been detailed earlier in this report. It is also recommended that the folders holding the policies and procedure for the home be changed to provide easy access for staff. A range of measures is in place to promote safe working practises and a number of policies and procedures have been established to safeguard residents and staff. Equipment and services to the home are also regularly maintained and serviced and suitable risk assessment and risk management arrangements are in place. The recent improvements in the management of risks have been sustained and risk assessments are now regularly completed where any situation potentially compromises a resident’s safety or well being. The providers have established suitable measures regarding fire precautions and an inspection by the Fire Officer in May 2005 found the arrangements to be satisfactory. Staff at the home is provided with regular fire training and the fire equipment is also regularly services and maintained. The fire arrangements are also included in the induction programme for new staff. It is recommended that a more detailed procedure be established to guide, direct and inform the staff about the actions they are required to take in the event of a fire. A trustee stated there are no concerns about the financial viability of the service and a suitable insurance policy is in place. St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X 2 3 St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? no 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(2)(b) Requirement A monthly review of each care plan must take place and suitable records of the conclusions and decisions recorded. A comprehensive policy and procedure about the storage and administration of medication must be in place. A suitable policy and procedure about the arrangements to manage complaints must be in place. A policy and procedure must be established to protect service users from abuse and reflect the Department of Health guidance “No Secrets”. Robust recruitment, selection and vetting arrangements that include CRB and POVA checks must be in place for each new member of staff. Comprehensive induction arrangements and records must be in place. An annual training programme must be in place for all staff. The responsible individual and
DS0000008906.V306468.R01.S.doc Timescale for action 30/12/06 2. OP9 13(2) 30/11/06 3. OP16 17(2) Sch4 (11) 22(1) 13(4)(c) (6) 30/11/06 4. OP18 30/10/06 5. OP29 18(1)(a) 19(1) (a-b) Sch 2 18(1)(a) (c)(i) (2)(b) 18(1)(a) (c)(1) 7(2)(c) 30/09/06 6. 7. 8. OP30 OP30 OP31 30/10/06 30/12/06 14/08/06
Page 29 St Marys Haven Respite Unit Version 5.2 9. OP31 (i-ii) 9(1) (2)(a-c) 26(1-5) 10. OP33 24(1-3) 11. OP37 17(1-3) Sch 3 Sch 4 manager must provide the Commission with evidence of fitness. Monthly regulation 26 visits must 30/09/06 take place and a report of each visit must be sent to the Commission. Effective quality assurance 30/12/06 arrangements must be in place and a report must be sent to the Commission of the findings. Records required by regulation 30/12/06 must be in place and completed to the required standard. 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. 4. 5. Refer to Standard OP7 OP7 OP9 OP25 Good Practice Recommendations Care plans should provide sufficient detail to guide and direct the staff and safeguard residents. The staff member conducting the review and the services users where possible should sign care Plan reviews. The medicines policy and procedure should include homely remedies. The water temperatures should be monitored to make sure they provide water at the level recommended in the national minimum standards. A detailed procedure should be in place that directs, guides and informs the staff of the action they are required to take in the event of a fire. OP38 St Marys Haven Respite Unit DS0000008906.V306468.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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