Inspection on 30/11/06 for St Michael`s Rest Home

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Michael`s Rest Home 23/03/09

St Michael`s Rest Home 06/02/09

St Michael`s Rest Home 31/03/08

St Michael`s Rest Home 05/06/07

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

CARE HOMES FOR OLDER PEOPLE St Michael`s Rest Home 107 Cooden Drive Bexhill-on-sea East Sussex TN39 3AN Lead Inspector June Davies Unannounced Inspection 30 November 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 Michael`s Rest Home DS0000067223.V319038.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 Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Rest Home Address 107 Cooden Drive Bexhill-on-sea East Sussex TN39 3AN 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) 01424 210210 Balwinder Singh Khera Baljeet Kaur Khera Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the maximum number of service users to be accommodated is fifteen (15). Service users with a dementia-type illness only to be accommodated. Service users must be older people aged 65 years or over on admission. New registration 30/06/06 Date of last inspection Brief Description of the Service: St Michael’s Rest Home is situated in a residential area of Bexhill-on-Sea. The home is a detached house with 12 bedrooms comprising of 9 single bedrooms and 3 double bedrooms all bedrooms are fitted with a washbasin and two rooms have en suite toilet. There is a large lounge with integral dining room. A stair lift provides access to the first floor. The front garden has been adapted for car parking, and there is a large rear garden, which is secure for the residents. Fees charged are £375.00 to £450.00 St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over a period of seven hours, and included a thematic probe and a short observational framework for inspection. This was the first key inspection since a new provider was registered at the end of June 2006. The inspector was able to look at documentation relating to the key standards, discussion took place with the acting manager and care staff on duty, discussion with visitors including a social worker visiting the home, a tour of the home, and observation of care staff working with the residents in the lounge. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included in the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk What the service does well: What has improved since the last inspection? What they could do better: Policies and procedures and information documents need to be updated on a regular basis, this includes the service user guide, complaints policy and procedure, pre-admission assessment, residents risk assessments, the privacy St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 6 policy and procedure, protection of vulnerable adults policy and procedure, generally other policies and procedures kept in the home need to be reviewed and updated. The administration of medication needs to be carried out in accordance with the Royal Pharmaceutical Societies guidelines for administration of medication within care homes. The privacy of the residents’ needs to be upheld, and their own bedrooms respected as their personal space and not used by others, without the residents making an informed choice. The offensive odour when entering the building needs to be dealt with, and some health and safety issues have been referred to within the report, this also includes controlling the risk of infection within the home. At present there is a high turn over of staff in the home, not enough staff with qualification, or appropriate training relevant to the needs of the residents, and health and safety requirements in the home. The registered person needs to ensure there is a good robust quality assurance system in place to ensure the home is offering a high standard of care to its residents. All appliances used in the home should be regularly serviced to ensure the safety of the residents. Residents falls should be monitored with the aim of reducing the risk of falling and injury. 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 Michael`s Rest Home DS0000067223.V319038.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 Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards – 1, 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service user guide needs to be updated to give prospective service users accurate information before making a decision to move into the home. Clear information is not contained within the contract/statement of terms and conditions; to clarify what current fees the resident is paying. The homes pre-admission assessment document does not provide for detailed information on which a care plan can be based. EVIDENCE: (Thematic probe) The service user guide needs to be updated to include correct information regard to management, that nursing care is not provided by the home, the full St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 9 fire precautions, timescales for dealing with complaints, and that relatives/representatives can attend the review of their resident’s care plan. Service users in this dementia care home, were not aware of the service user guide, but visitors confirmed that residents were given a copy prior to coming into the home. (Thematic probe) All service users have a statement of terms and conditions/contract contained these are kept at the rear of the care plan. These documents were seen by the inspector to be signed by the service users relatives/representatives. None of these documents had been updated with fee increases since the resident moved into the home. The inspector was able to view the care plans of five residents living in the home; all but one care plan contained a care manager pre-admission assessment. In the case of resident they had moved from another home to St Michael’s rest home, the previous home had supplied detailed information. All care plans contained the homes own pre-admission assessments carried out by previous managers. These pre-admission assessments consisted of a tick list and did not give sufficient information on which to base a care plan, it is important that the pre-admission assessment is updated to include all the items outlined in National Minimum Standards for older people 3.3 especially where a resident is admitted to the home without care management involvement. Relatives spoken to stated that their residents had been visited by a representative from the home prior to moving in. The home does not offer intermediate care. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. The care planning system does not adequately give sufficient information to staff, to ensure potential risks can be kept to a minimum. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The systems for medication administration are poor and potentially place residents at risk. Privacy and dignity of the residents needs to be adhered to especially in regard to the residents own bedrooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector viewed five care plans. All contained sufficient information relating to the residents needs for health and social care, and were based on the care managers’ pre-admission assessment. Risk assessments need to be updated, at present the guidelines for staff to reduce risk states ‘encourage St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 11 and ensure.’ Clear steps should be given to staff as to how they can help prevent risk to the resident. Each care plan had evidence of a monthly review, but these had not been signed by the resident and/or their relative/representative. Care plans seen by the inspector were informative and showed details of visits from continence nurse, district nurse, community psychiatric nurse, general practitioners, chiropodist and opticians. The inspector did note when personal care is delivered it is not specific, and just described as full care given, general practitioner visits are recorded, and not followed through in daily reports. Part of the activities programme is music to movement, and this provides a form of weekly exercise for the residents. The inspector carried out an audit of medication that is supplied in MDS by Boots the Chemist. The home has up to date policies and procedures for the administration of medication. It was noted that there was no list of staff that have been trained to administer medication together with their signatures and initials. Medication training has been booked for the 15th December 2006. MAR sheets were correctly signed off after the administration of the medication to the resident. The inspector noted from the MAR sheets, that medication brought in, prescribed mid-month, carried over, and over the counter medication and medication for respite care residents’ is not recorded as received, this should include the date, quantity and initials of the person receiving the medication. Night medication which is not blister packed is placed into pots by the acting manager and left in the medication cupboard for the night staff to give out, this does not comply with The Royal Pharmaceutical Societies guidelines for the administration of medication in care homes. The home has recently had a resident who was on a controlled drug, while the home does have a controlled drug cabinet screwed to the wall in the Managers office, there was no controlled drug register and the MAR sheet had not been signed by two medication trained members of staff. The drugs trolley is kept on the ground floor in a locked cupboard but it is not secured to the wall when not in use. The home does keep a record of all medication returned to pharmacy. During the course of the visit the inspector observed that staff refer to the residents by their preferred name, which is also recorded on their Care Plans. Communication between staff and residents was respectful and caring. The inspector does have three areas of concern, one where the inspector was shown into a double room on the ground floor to discuss the format of the inspection. The two residents were not in the room at the time. The second concern is that when the hairdresser visits the home, one of the residents’ bedrooms is used for the majority of the residents in the home, bearing in mind this is a dementia care home where none of the residents are able to make informed choices, this is considered to be an infringement of a resident’s privacy. In double bedrooms there was no evidence of screening to provide residents occupying those rooms with privacy when carrying out personal St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 12 hygiene. The inspector noted that all residents were well dressed, one member of staff said that they make sure all residents clothes are labelled with their name to ensure clothes are returned to the right person. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good. The social care of the residents is good and does much to enrich their lives but information regarding activities and events could be better displayed within the home. Residents are able to make choices, but should also be given information regarding outside sources who will act in their interests. The meals in the home are good offering both choice and variety and catering for special diets. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager and care staff told the inspector that residents have a choice of when to get up in the morning and go to bed at night. Due to the dementia care needs of the residents none were able to discuss what choices they were given. Two residents did tell the inspector that they like being in the home. One resident said, ‘she supposed it was the best you can get.’ From evidence in the form of a poster situated in the staff room, activities consisted of – skittles, memory activity, arts and crafts, puzzles and games, flower arranging/plants and a Sunday matinee. The Church of England holds St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 14 a monthly communion in the home, the acting manager said that one resident is Roman Catholic but she attends Church of England communion, and that her family has no objections to this. The care plans viewed did state the interests of the residents. There was no evidence within the communal areas of the home to inform residents of what activities are on offer on any specific day. From daily records, the inspector noticed that some residents are taken out into the community by their relatives. Residents are able to have visitors when and as they wish; the acting manager stated that they try to discourage visitors at mealtimes as this distracts the resident/s from eating. Residents are able to have visitors in their own bedrooms if they wish to. The home does have a policy on visiting, but this document does not describe how the home wished to maintain the involvement from relatives and friends. None of the residents in the home are able to manage their own financial affairs, and relatives act as power of attorney. The manager does deal with some of the residents’ personal finances and this is dealt with in OP35 of this report. There was no information in the home regarding local advocacy groups. During a tour of the building the inspector did note that residents are encouraged to bring personal possessions into the home with them so they may personalise their own bedrooms. The acting manager stated that if residents wished to do so they would be able to have access to their own personal records. The inspector viewed the menus for the residents and these showed that the residents are offered a wholesome and nutritious diet. One member of staff stated that residents were not offered choices, but two other member of staff stated that residents were offered choice of menu. During the visit the inspector noted staff offering residents drinks and biscuit snacks. None of the residents have liquidised meals. The home does cater for diabetic diets. The menu is reviewed every six months. One visitor told the inspector that the staff help their relative with their meal, and this is done in a sensitive and caring manner. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy in the home is adequate, and is not updated frequently to give residents accurate information. Arrangements for protecting residents are not satisfactory placing them at possible risks of abuse. EVIDENCE: Thematic Probe. The complaints policy and procedure does not include the timescale in which complaints will be dealt with. The home has had one complaint dating back to July 2006, this had been appropriately recorded, investigated and outcomes were telephoned to the complainant. The complaints policy and procedure was not clearly displayed in the home, none of the residents could remember seeing the complaints policy and procedure, but three relatives said they were aware of this document, which was included in the service user guide. None of the residents could remember seeing the complaints policy and procedure, one resident said that they would talk to a member of staff, relatives spoken to said they would discuss any complaint they needed to make with the manager. The home does have a policy and procedure for recognising and dealing with abuse, and whistle blowing but these have not been reviewed since 2005. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 16 The home also has a dated copy of East Sussex County Council’s Protocols and guidelines for the Protection of Vulnerable Adults. The acting manager is aware of who she should report any instances of abuse to. The last complaint received by the home did result in adult protection being involved, but after being properly investigated and adjustments made, the adult protection has now been lifted. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is poor. Improvements to the environment will enhance the resident’s quality of life. Provision for the control of infection within the home are poor, placing the residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Michael’s Rest Home is a detached house that has been converted for residential care use. The home has recently been taken over by a new provider, who has a programme of maintenance and renewal, some of the bedrooms have been redecorated and new carpets have been laid in these rooms. Toilet 13 on the first floor needs redecorating and the emergency bell needs to be lengthened, if a resident should fall in this toilet they would not be able to call for assistance. The inspector also noted that the emergency bell St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 18 cord is white and does not differentiate between a light cord. The back garden is secure, and well tended, but the steps leading onto the lawned area need to be made more distinguishable to prevent residents from falling, it was noted that there is a build up of rubbish by the back gate, which needs to be disposed of for the safety of the residents. The inspector was shown a letter from the last fire officer visit, and noted that some requirements had been made. Most of these requirements have been met, but automatic fire door closures still need to be fitted. The home complies with the requirements of the environmental health officer. There are no CCTV cameras either externally or internally. On entering the home the inspector noted an offensive odour. Visitors spoken to during the course of the visit, and reports via the service user survey, also highlighted that there was an unpleasant odour in the home, although some said that the odour was not as bad since bedroom carpets had been replaced. The laundry facilities are sited in a garage area attached to the home. A staff cloakroom is situated just off the laundry area; the inspector noted that the seal around the washbasin was black with mould, and in need of attention to control the spread of infection. During a tour of the building the inspector did observe that communal toilets did not have provision of liquid soap or paper hand towels. Two toilets had bar soap, which was cracked and posed a risk to infection control. The home does not have a proper sluicing facility, and any foul laundry is rinsed off in an ordinary domestic sink. The washing machine does have a sluicing facility and a programme to meet with disinfection standards. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff morale is low with a high level of staff turnover that does not offer consistency of care to the people using the service. Recruitment practices could improve to ensure that residents are not placed at risk. Staff qualifications and training are poor and need to improve to ensure that the residents assessed needs are being met. EVIDENCE: While staff rotas confirmed that there were sufficient staff on duty to meet the needs of the residents in the home, staff, visitors and resident surveys, commented on the large turn over of staff in the home, with many staff working extra hours to cover the shifts. Relatives also stated that due to the high turnover of staff it was not easy to know who to speak to. Only 30 of care staff working in the home have an NVQ qualification, and this again is mainly due to the high turn over of staff. The acting manager at the present time is trying to recruit new members of staff who already have a NVQ qualification. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 20 The inspector viewed the personnel files of three members of staff. While all files had application forms, none gave a full employment history. All files had current CRB checks. Two files had written references, in the third file, one reference was addressed to ‘Whom it may concern’ and the second reference had been obtained via a telephone call with no referral as to what questions were asked, the date or the name of the person giving the reference. None of the staff had been given the GSCC code of conduct. Only two staff had received statements of terms and conditions of employment. While staff files contained evidence of training, they were not up to date. The inspector also noted that some staff training certificates were displayed in the main entrance hall, but some of these certificates were also out of date. The staff-training matrix in the office had not been kept up to date. From evidence available and talking to staff, not all staff have up to date – fire training, first aid, infection control, moving and handling. Very few of the staff have completed a dementia care training course, POVA training, dealing with challenging behaviour or health and safety training. Induction training only consisted of an introductory health and safety checklist and did not cover the competences required by the National Training Organisation, Skills for Care induction. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is poor. The management of the home is satisfactory overall but records are not well managed. This practice could place the residents at risk. The home has done very little to adopt an effective quality assurance system, to ensure that residents receive a good quality of care. Residents’ personal allowances are well administered and kept safely. The health, safety and welfare of residents and staff is adequate, with further improvements required to ensure safety and reduce risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the present time an acting manager is managing the home, but it is the intention of the registered provider to get the manager registered with CSCI. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 22 The acting manager told the inspector that she is hoping to complete her NVQ level 3 in February 2007, when she will then start her Registered Manager’s Award. The manager also stated that she has not recently completed any other job related training. The manager said that there were clear lines of accountability within the home, but this needs to be recorded and placed within the Statement of Purpose. The inspector was shown resident questionnaires that had been sent out and returned to the manager. Many of the residents would not have been able to complete these questionnaires, and there was evidence that families had completed them on the residents’ behalf. No questionnaires have been compiled for relatives/representatives, stakeholders or staff. The acting manager told the inspector that the registered provider does carry out regulation 26 visits to the home, but none of these reports were available at the time of the inspection. To develop the quality assurance system within the home the acting manager needs to ensure that recorded monitoring checks are carried out in the home to cover, administration of medication, cleanliness of the home, care plans, care plan reviews, staff files, staff training including the competency of recently trained staff, and building risk assessments. The acting manager looks after the personal allowance for three of the residents. The inspector was shown that each resident has a pocket money recording sheet, this records monies coming into the home for the resident, and any expenditure that the resident makes, with all receipts being kept. Separate money envelopes for each resident are kept in a locked cash box. The home has a policy and procedure for the health and safety of residents and staff, but this policy needs to be reviewed and updated accordingly. Not all care staff have been trained in moving and handling, fire safety, first aid, food hygiene, and none of the staff have received training in infection control. This has been referred to in standard 30. The inspector was shown that the home does have up to date maintenance certificates for the following appliances used in the home – gas, electrical circuit, portable appliance testing, fire extinguishers, fire alarm, emergency lights; the home does not have recent certificates for the stair lift or the in bath hoist. Hot water taps are fitted with thermostatic valves and hot water is checked monthly to ensure that it is delivered at 43ºC. All windows have been newly fitted and have opening restrictors. Fire risk assessments are carried out each month and recorded. All accidents and injuries are recorded in a HSE accident book, the manager needs to log residents who fall regularly, where, how, when, to see if a pattern occurs, and if possible some remedial action can be taken to prevent frequent falls and possible injury. St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 1 STAFFING Standard No Score 27 2 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4(1)(b)(c) Schedule 1 Requirement Timescale for action 22/01/07 2. 3. OP3 OP7 14(1)(a) 13(4)(a) (c) 4. OP9 13(2) The statement of purpose and service user guide must be updated to provide the correct information in regard to management, that the home does not offer nursing care, full fire precautions, timescales for dealing with complaints, review of care plans, and involvement of relatives and or representatives. Pre-admission assessment must 22/01/07 contain sufficient evidence as stipulated in OP3.3 The registered person must 05/02/07 ensure that risks are identified, recorded and show appropriate steps to be taken to ensure the risk is kept to a minimum. The registered person shall make 08/01/07 suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The medication trolley should be secured to the wall when not in use. There should be a list of staff trained to administer medication, together with their signatures and initials. DS0000067223.V319038.R01.S.doc Version 5.2 St Michael`s Rest Home Page 25 5. OP10 12(4)(a) (b) 6. OP16 22 (1-8) 7. OP19 23(2)(c) (o) 4(a) Any medication brought into the home (including mid-month) should be recorded onto the MAR sheet. Night medication that is not blister packed should not be taken out of its original packaging and placed in pots for the night staff to administer. The home should have a controlled drugs register, which must have controlled drugs appropriately recorded by the staff administering it, and should have two signatures of two trained members of staff after medication. The registered person shall make 08/01/07 suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users; with due regard to the sex, religious persuasion, racial origin, and cultural and linguistic background and any disability of the service users. Therefore other residents, visitors, must not use resident’s bedrooms for meetings or hairdressing use. Shared bedrooms should have screening to ensure privacy when personal care is being carried out. The registered person must 22/01/07 ensure that the complaints policy and procedure is reviewed to include the timescale in which the complaints will be dealt with. The complaints policy and procedure must be made clearly available to visitors and service users. The registered person shall 05/02/07 having regard to the number and needs of the service users ensure that all parts of the home are kept clean and reasonably decorated. That equipment DS0000067223.V319038.R01.S.doc Version 5.2 Page 26 St Michael`s Rest Home 8. OP26 16(2)(k) 9. OP26 13 (3) 10. OP26 23(2)(d) (k) 11. OP27 18(1)(a) 12. OP28 18(1) (a – c) Schedule 2(4) Schedule 13. OP29 provided at the care home for use by the service users is maintained in good working order. That the external grounds, are suitable for, and safe for use by service users, are provided and appropriately maintained. Take adequate precautions against the risk of fire, including the provision of suitable fire equipment (automatic fire door closure). The registered person shall having regard to the size of the care home and the number and needs of the service users, keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall having regard to the number and needs of the service users ensure that any necessary sluicing facilities are provided. The registered person shall, having regard to the size of the care home, the statement of purpose and number and needs of service users – ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. A minimum ration of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved this excludes the registered manager. Application forms should contain DS0000067223.V319038.R01.S.doc 15/01/07 15/01/07 05/03/07 26/03/07 02/07/07 15/01/07 Page 27 St Michael`s Rest Home Version 5.2 2 14. OP30 18(1)(a) (c)(i) 15. OP31 10(1)(2) 16. OP33 24(2)(b) (c)(3)(4) 17. OP38 13(4)(c) a full employment history, with any gaps in employment investigated. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that the persons employed by the registered person to work at the care home receive; training appropriate to the work they are to perform including structured induction training. The manager must continue to up date her training to ensure that she has the qualifications skills and experience necessary for carrying on the care home. At the request of the Commission, the registered person shall supply to it a report, which describes the extent to which, in the reasonable opinion of the registered person, the care home provides good quality care for service users, takes the views of service users and their representatives into account in deciding what services to offer them, and the manner in which such service are to be provided. The report shall also contain details of the measures that the registered person considers it necessary to take in order to improve the quality and delivery of the service provided in the care home. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The stair lift and in bath hoist must be serviced on a regular basis. 26/03/07 05/03/07 01/05/07 12/02/07 St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 28 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. 6. 7 8 Refer to Standard OP8 OP8 OP12 OP12 OP13 OP14 Good Practice Recommendations Staff record what personal care has been given for each resident, to ensure that all personal care tasks have been carried out. When a resident has a G.P. visit, the resident’s health condition should be monitored and recorded, until the condition has improved. Provision should be made in the home to meet the religious beliefs of the residents. A rota of activities for the residents should be clearly displayed, and openly shown and discussed with the residents by the care staff team. The visiting policy to be reviewed with the addition of how the home wishes to maintain the involvement of relatives and friends. The home ensures that advice on local advocacy groups is available to residents and or their relatives/representatives. References addressed to ‘Whom it may concern’, should be followed up by a telephone call, with date, name of person giving the reference, and all details recorded in writing. The manager to keep a falls matrix, to show regular falls to service users, with where, how and when they fell, to enable steps to be taken to reduce the risk of falls. OP29 OP38 St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Michael`s Rest Home DS0000067223.V319038.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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