CARE HOMES FOR OLDER PEOPLE
St Marys Haven Respite Unit St Marys Street Penzance Cornwall TR18 2DH Lead Inspector
Paul Freeman Unannounced Inspection 30th July 2007 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.V340472.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.V340472.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 post 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.V340472.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection Brief Description of the Service: St Marys Haven respite care centre is located near the town centre of Penzance, and has access to local amenities with good transport links. The facility provides accommodation and care for up to nine older people. Of the current residency, seven are permanent residents and two rooms are used to provide care on a short-term basis. St Marys Haven is an inter-denominational home working within Christian principals, and opportunities are provided for regular Christian services. Other denominations are also welcome at the home. Accommodation is provided on three floors, all of which are accessible by stairs and a lift. All the rooms are for single occupancy. The two bedrooms on the ground floor are dedicated to short term care residents who have access to bathing and toileting facilities close by. The respite care service users, share access to the dining and lounge facilities that are also located on the ground floor. Permanent residents bedrooms are located on the first and second floors of the home; all have access to nearby bathing and toileting facilities. All the rooms face the front of the building and there are some nice views of Penzance town. 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 located near the town centre of Penzance. Currently the registered managers post is vacant but the providers have a responsible individual in place to act on their behalf in regard to the operation of the care home. St Marys Haven Respite Unit DS0000008906.V340472.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 30 July 2007. The purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the last inspection on 27 July 2006, and to inspect other core standards. Therefore some of the key standards considered included assessment of resident’s needs, care planning, staffing arrangements and safe working practices. The manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. Written information from the providers about the services and facilities provided was also taken into account. There has been no registered manager at the home for over fourteen months. The Commission are very concerned about the situation and the registered providers failure to recruit to this key management post. The vacancy also results in the providers failing to comply with the Care Home Regulations. The Commission are pursuing this area of non-compliance with the providers as a matter of urgency. What the service does well:
Each prospective resident is assessed in order that the providers have a clear picture of the individuals’ needs, preferences and choices. Residents are invited to participate in the assessment. The views of relatives, representatives and professionals involved with the person are also taken into account. Each resident also has a care plan that describes their needs and summarises the care and support required. The providers have recently introduced a new format for recording the plans that is designed to provide staff with better information and guidance. Residents are positive about the care and support they receive and said they were always treated with dignity and respect. Good arrangements are in place to meet residents’ health needs and medical services are promptly accessed when required. Trained staff administers medicines and residents are able to administer their own medication when it is safe to do so. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 6 Residents said they experience a flexible lifestyle and it is clear that positive, meaningful and trusting relationships 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. Residents said that staff always positively welcome visitors. Residents are also able to participate in a range of social and recreational opportunities at the home or in the local community. A balanced and nutritional menu is in place that reflects the residents’ preference and choice. The residents were positive about the quality of the food provided and described the meals as “excellent”, “wholesome” and “lovely”. Positive arrangements are in place to deal with any concerns or complaints residents may have and to protect residents from abuse. Residents said there are no barriers to raising any issues or concerns. Within the campus there are two registered care homes and a day centre for older people. The respite unit operates as a separate registered care home and provides accommodation over three floors. Stairs and a passenger lift provide access to all floors. The ground floor comprises of a reception area, sitting room and dinning room. Two bedrooms are used for people who stay at the home for short periods. The other two levels are principally for bedrooms but also includes 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. A range of aids and disability equipment are also 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 high standard and reliable arrangements are in place to deal with any repairs that are required. The furniture and fittings are mostly of a domestic nature, and consequently result in a homely place for residents to live. 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. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 7 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. What has improved since the last inspection? What they could do better:
There continues to be occasions where more detailed information is required in the resident’s assessments and care plans. This would improve the quality of care, and better inform staff about care and support needs. The arrangements to administer prescribed medicines also needs to be reviewed, to make sure that good records are maintained Residents should also be able to make a choice about the meals they wish to have each day. This important aspect of daily living should be reviewed to ensure that resident’ preferences and choices inform menu planning. The providers must make sure that living areas, particularly bathrooms, are not cluttered. This could become hazardous for residents, and detracts from the homely environment. The providers need to comprehensively review staffing arrangements to make sure that sufficient staff are on duty. This review is required so that sufficient staff are on duty at all times to provide the care and support required. The failure of the providers to regularise the management arrangements is of concern and results in regulatory breeches. This is a matter of concern the Commission are actively pursuing with the providers to achieve a resolution at the earliest opportunity. The providers also need to improve and develop their quality assurance measures to make sure a reliable system is in place to evaluate the services and facilities provided. The risk assessment and risk management arrangements and the fire safety and fire precaution measures require improvement in order that residents can be safeguarded. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 3 and 6. Quality in this outcome area is adequate. Prospective residents are assessed so the providers can be satisfied the facilities and services are suitable to meet the prospective residents needs, preferences and choices. On certain occasions the assessments need to be more detailed to make sure the providers have a comprehensive picture of the care and support required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers undertake 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 the providers are able to meet the care and support needs of the prospective residents.
St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 11 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. Residents who 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. The assessments summarise the individual’s needs, and detail individual choices or preferences. In some records the information was not sufficiently detailed to make sure a comprehensive picture of care and support needs was in place. This also impacts upon the providers’ ability to be satisfied the services and facilities are suitable to meet the needs, preferences and choices of the person concerned. The care home does not provide a dedicated rehabilitation service. Staff at the home are committed to promoting residents independence and providing the support required to achieve this goal. Residents and their families view the short stay facilities positively, as the service aims to assist people to remain in there home setting. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 7, 8, 9 and 10 Quality in this outcome area is adequate. The care plans need to provide more information and guidance to make sure there are clear statements about the care and support required and that residents are safeguarded. Good arrangements are in place to promote residents health and medical services are promptly accessed when required. The providers need to review the arrangements about the administration of medicines to make sure they are consistent with the recently improved policy and procedures and reflect the British Pharmaceutical Society guidelines. This judgement has been made using available evidence including a visit to this service. EVIDENCE:
St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 13 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. 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 positive terms about the way they are 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 evidence indicates that care plans are regularly reviewed to make sure the most appropriate care and support arrangements are in place. There is also evidence the 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 regarding 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. Staff also assist residents when required, and each staff member administering medication has been suitably trained. The providers have also reviewed and improved the policy and procedure for administration of medicines. The records about administration were found to be incomplete and require improvement. A formal record is also required when of any directions are given by a General Practitioner or other health professional to change the prescribed medication. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 14 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.V340472.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is good. Residents experience a varied and stimulating life style and are able to determine their patterns of daily living. The providers continue to improve and develop the recreational and social opportunities available to maximise residents’ stimulation. Flexible visiting arrangements are in place and a varied menu is provided that promotes the residents health. The providers can improve and develop the residents’ opportunities to choose the food they have at each mealtime. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said they were very satisfied with the manner in which their life style expectations and preferences are met. Residents are able to choose how they spend their leisure time and a range of activities is provided at the home if they wish to participate. Then providers are also actively consulting with
St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 16 residents to try and improve and develop the opportunities provided. There are also no barriers to residents accessing opportunities in the local community when it is safe to do so. There are regular opportunities for residents to participate in Church services and prayer meetings. Representatives of religious denominations also 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 the residents are able to decide where they meet with visitors. It is also evident that a trusting and relaxed relationship exists between residents and staff. Residents said that every reasonable step was taken in order so they can 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. A varied and nutritional menu is in place that reflects the residents’ needs, preferences and choices. However there is only one main meal provided each day. The kitchen staff will provide an alternative meal if this is required. The alternative meals are therefore provided on the basis of the kitchen staff knowledge of an individual’s preference and choice. However this prevents the residents from making an informed choice about the meals they want each day. The providers should work towards residents making a choice about the food they have at each mealtime. The kitchen is suitably equipped and the equipment and services are regularly serviced and maintained. The kitchen staff is appropriately trained and satisfactory health and safety practises are in place. Residents said they were very satisfied with the food provided. The kitchen staff are in the process of reviewing menus with residents, and consulting with them about preferences and choices. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 16 and 18. Quality in this outcome area is good. Positive arrangements are in place to protect residents from abuse and respond to any complaints or concerns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A satisfactory policy and procedure for dealing with complaints is in place. The providers or the Commission has received no complaints since the last inspection on 27 July 2006. Residents said there are no barriers to raising any issues, concerns or complaints and were confidant that any issues will be dealt with efficiently and in a satisfactory manner. Satisfactory arrangements have also been established to protect residents from abuse and a suitable policy and procedure is in place to guide and direct staff if any concerns arise. Any allegations are reported to the appropriate authorities and where appropriate a formal investigation takes place. Suitable whistle blowing arrangements are in place for staff and this makes sure that staff can report any concerns to a third party if they feel unable to
St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 18 raise the matter with the providers. This provides further protection for the residents. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 19 and 26. Quality in this outcome area is good. A good standard of accommodation is provided that is homely and comfortable for residents. High standards of cleanliness and hygiene are in place at all times which promote residents’ health and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the campus there are two registered care homes and a day centre for older people. The respite unit operates and is registered as a separate care home and provides accommodation on three floors. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 20 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. 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 addition 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. It was disappointing to establish the providers had not been able to change the colour scheme in one bedroom at the request of a new resident. Consideration needs to be given to making sure that sufficient resources are in place to meet reasonable requests of this nature. 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. The providers need to make sure the environment does not become cluttered and therefore a potential hazard to residents. In certain bathrooms there were a number of pieces of equipment that restricted access and made the room look untidy. 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.V340472.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is adequate. The providers need to take steps to make sure sufficient numbers of staff are on duty to safeguard residents and provide the care and support required. The recruitment, selection and vetting arrangements have improved and good arrangements are in place that protects residents. Staff are provided with regular opportunities to participate in training to make sure their skills and knowledge are up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers have established staffing arrangements on the basis of providing additional staff at peak times during waking hours. Outside of peak times one staff member is on duty. The indications are the arrangements require review and improvement to make sure that residents’ needs are met and they are safeguarded. The key times appear to be around the periods when only one staff member is on duty (late mornings and late afternoons). On the day of the inspection it was clearly evident that one staff member during the late
St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 22 afternoons was not sufficient. This staff member is also responsible for collecting the teas from the kitchen and in effect this means there are periods when no care staff are on the premises. This needs to be urgently addressed. In addition waking night staff are employed to make sure that residents needs are met each night. 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 recruitment, selection and vetting arrangements have improved and meet the required regulatory standards and therefore make sure that residents are protected. Each new staff member also undertakes an induction programme that reflects the standards set by Skills for Care. Recently appointed staff were positive about the induction arrangements. The staff said that good arrangements were in place for them to regularly undertake training and each staff member has an individual training plan. This means that staff are able to regularly update their knowledge and skills. A good percentage of the staff are also trained to NVQ 2 standard. The staff group said they worked well as a team and felt appropriately supported by the senior staff. Suitable arrangements are also in place for staff to receive advice, guidance and assistance where this is required. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 31, 33, 35 and 38. Quality in this outcome area is poor. The Registered Manager post is vacant and an interim manager is currently in post. The current arrangements are not satisfactory and it is of concern the position has not been regularised by the providers. This matter is being actively pursued with the provider to make sure a resolution is reached expediently. The quality assurance measures also require improvement so that the providers have reliable feedback about the quality of the services and facilities provided. The arrangements to promote safe working practices and good fire safety and precaution arrangements also require improvement in order that residents are safeguarded. Satisfactory arrangements are in place to provide a safe environment for residents and staff. The arrangements require more regular review to make
St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 24 sure every reasonable step is taken to safeguard service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered mangers post is currently vacant but a manager has been appointed in the interim while the providers recruit to the vacant post. It of concern that the post has been vacant for over a year and progress to appoint a registered manager and therefore comply with the regulations appears to have been painfully slow. This is not an acceptable situation and the Commission are actively addressing the areas of non-compliance with the providers directly. The provider has appointed a responsible individual who is responsible for supervising the management of the care home. An external person has also been appointed by the providers to undertake the duties prescribed in regulation 26 of the Care Homes Regulations 2001. The post holder makes unannounced visits to the home on a monthly basis and provides a detailed written report of their findings and any action that is required to promote good practise and comply with the regulations. The providers make efforts to consult with residents, staff, relatives or representatives and professionals about the services and facilities provided on an annual basis. The absence of a manager has resulted in delays to the annual quality review cycle. This has therefore placed limitations on the providers obtaining a clear picture of the quality of the service 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 suitable record is maintained of each transaction that occurs which is also signed by the staff or the resident concerned. A range of policies and procedures are in place to promote safe working practices. Where any situations arises that could compromise the health or safety of residents or staff it is the policy that a risk assessment takes place. However there are occasion when the risk assessment or risk management plans do not provide adequate detail and information. This could result in compromising the health safety and wellbeing of residents, staff and visitors. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 25 At the Fire Officer last inspection in November 2006 they found areas of noncompliance regarding the fire safety and precaution. It is of concern the providers have not yet fully complied with the fire officer’s requirements. This also could compromise the health, safety and wellbeing of residents, staff and visitors. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 05/11/07 2. OP7 15(1) 3. OP9 13(2) The registered person must assess the needs of service users by suitably qualified or trained persons. Good assessments must be in place that detail the service users needs, choices and preferences. The registered person must have 05/11/07 a care plan in place for all service users that detail how their health and welfare needs are to be met. The registered person must have 05/11/07 a comprehensive policy and procedure about the storage, administration and disposal of medication in place. 05/11/07 4 OP19 23(2)(d) 5 OP19 The registered person must ensure that service users bedrooms are decorated to a standard that reflects the occupant’s gender, preference and choice. 13(4)(a)(c The registered person must ) ensure the environment must be free from hazards and unnecessary risks are eliminated as far as possible.
DS0000008906.V340472.R01.S.doc 05/11/07 St Marys Haven Respite Unit Version 5.2 Page 28 6 OP27 10(1)(a) 7. OP31 8 OP33 The registered person must employ staff in sufficient numbers to be on duty at all times to meet the health and welfare and needs of service users. 8(1)(a)(2) The registered person must appoint an individual to manage the care home and be the registered manager expediently. 24(1-3) Effective quality assurance arrangements must be in place and a report must be sent to the Commission of the findings. 05/11/07 05/11/07 05/11/07 9. OP38 10 OP38 13(4)(a-c) The registered person must ensure that the risk assessment and risk management arrangements be improved and developed to make sure all reasonable steps are taken to safeguard service users. 23(4) The registerd person must have good fire safety and fire precautions arrangements in place to safeguard service users. 05/11/07 05/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12 OP15 OP38 Good Practice Recommendations The registered person should continue to improve and develop the recreational and social opportunities available to service users. The registered person should ensure that all service users have a choice of food at each mealtime. The registered person should ensure that environmental risk assessments are reviewed on a regular basis. St Marys Haven Respite Unit DS0000008906.V340472.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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