Inspection on 31/03/08 for St Michael`s Rest Home

This inspection was carried out on 31st March 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Michael`s Rest Home 23/03/09

St Michael`s Rest Home 06/02/09

St Michael`s Rest Home 05/06/07

St Michael`s Rest Home 30/11/06

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

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 31st March 2008 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.V361582.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.V361582.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 F/P 01424 210210 Balwinder Singh Khera Baljeet Kaur Khera Post Vacant Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places St Michael`s Rest Home DS0000067223.V361582.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. 5th June 2007 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 £404.00 to £450.00 St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place on the 31st March 2008, over a period of 6.5 hours. The inspector viewed documentation relative to the standards inspected, talked to the Manager, Deputy Manager, some of the staff, as well as residents who had the capacity to hold a meaningful conversation. A tour of the premises was carried out, as well as a partial audit of medication. Five requirements have been made at this inspection and there are 3 requirements outstanding from previous inspections which must be met. What the service does well: What has improved since the last inspection? Pre-admission assessments now contain good information where the manager can assess if the staff have the skills and knowledge to meet a prospective residents needs, and sufficient information on which to base the initial care plan. Care plans are relevant to each individual resident and contain good information for care staff to meet the needs of the resident’s. The administration of medication has improved, but there is further work to be done to ensure that resident’s medication is effective. When the inspector entered the home it was pleasant to see so many residents involved in group or personal activities of their choice, and this was a great improvement on what was observed at previous inspections. During the course of the day several of the residents were taken for short walks by members of staff. One particular resident was full of praise for the home and the staff. St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 6 There have been some major improvements to the environment, in the provision of a refurbished specialist bathroom, and another bathroom that has recently been refurbished, and also the replacement of the old AGA for a new cooking range. The rear garden has been tidied and no longer poses a trip hazard to the residents. Staff levels have improved as have the numbers of staff who now have a National Vocational Qualification. Recruitment practices are good with appropriate checks being carried out prior to a new employee being deployed to work in the home. Health and safety issues have improved in the home and residents are now longer placed at risk. What they could do better: At the present time residents do not have a choice menu to select from, and due to their level of dementia, the menu is very difficult for them to understand, therefore the manager must devise ways in which a choice can be made, and residents can make informed indecisions as to what food they would prefer. Bedrooms must provide at all times readily accessible call bells, which the residents can use to call for assistance as and when required. There are some bedrooms, which have offensive odours and the manager must ensure that action is taken to prevent offensive odours in resident’s bedrooms. All new staff must completed a ‘Skills for Care’ induction within the first six weeks of their employment to ensure they have the basic skills to meet the aims and objective of the home as outlined in the Statement of Purpose and Service Users Guide. The appointed manager must ensure that she develops a good quality assurance system that involves residents who have the capacity, relatives, friends and visiting professionals to the home. She must also ensure that she monitors on a regular basis, all the systems used in the home, such as care plans, care plan reviews, daily report sheets, activities, medication, food cooking and presentation, cleaning and infection control, and laundry presentation. St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 7 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.V361582.R01.S.doc Version 5.2 Page 8 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.V361582.R01.S.doc Version 5.2 Page 9 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 3 and 6 People using this service experience good outcomes in this area. Residents move into the home knowing that their needs can be met and that their independence will be maximised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two pre-admission assessments were viewed, for the two most recent residents who have moved into the home. Both assessments contained sufficient information to enable the manager to judge if the home would be able to meet the residents’ care needs. Both residents had moved into St Michael’s Rest Home from other homes in the area, and the manager had obtained discharge notes from these homes, which outlined the particular care needs of each resident. The home does not offer intermediate care. St Michael`s Rest Home DS0000067223.V361582.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 People using this service experience good outcomes in this area. Resident’s personal goals are reflected in their individual plans and their potential risks are managed. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication in the home is well managed and promotes good health. Generally the staff respect the privacy and dignity of the residents, but residents should be allowed to make choices on a daily basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 11 Two care plans viewed for the most recent residents to the home show detailed information regarding the care needs of each resident. The information contained within each care plan covered physical well being, personal care required, weight and dietary preferences, mobility, continence, medication, mental state, social interests and hobbies, each care plan had a front sheet which gave details of family and other contacts. The daily records for residents have improved, but further work still needs to be done in ensuring that personal hygiene care is recorded in detail. While there was evidence on a daily report that one of the male residents have been shaved, there was no evidence to suggest that oral hygiene care and hair care are carried out on a regular basis. Bathing of residents is not always recorded onto the daily report sheet or into the care plan. Staff must ensure that they record on daily records where residents become agitated, as this information could be pertinent to future care needs. Each resident had individual risk assessments in place, but these need to be more informative regarding the amount of assistance required, what staff must do to reduce the risk and the number of staff that the resident would require to keep the level of risk at a minimum. Where staff have concerns regarding tissue viability, these are referred directly to a district nurse. The manager must ensure that staff record district nurse visits. Daily reports showed when a district nurse had been requested, but there is not always a follow through to show that the district nurse has visited the resident. The manager and deputy are able to request the services of the continence nurse as and when required, the continence nurse also carries out annual assessment of continence needs. Evidence on one care plan showed that a resident had regular access to a consultant psychiatrist and community psychiatric nurse. The activities programme in the home shows that residents are able to participate in movement to music exercises. Several residents are taken out walking on a daily basis, when the weather is nice. Each care plan had a weight chart in place and this shows that residents’ are weighed on a monthly basis. Visits sheets were also in each care plan and showed that residents have access as and when required to their General Practitioner, Chiropodist, Dentist and Optician. A partial audit was carried out of medication administered in the home. All medication received into the home showed that it is properly recorded onto the monthly administration record, with the quantity of medication and date of St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 12 receipt; the person checking the medication in initials this. All monthly administration records had been appropriately signed off when medication is administered. Discussion took place with the manager and deputy manager regarding General Practitioners who prescribe medication (as directed), the deputy manager agreed to write to these General Practitioners to ensure that prescriptions give clear guidelines as to the amount and time of day that this medication should be administered. All medication policies and procedures have been reviewed and are up to date, and give clear procedures for staff administering medication to follow. It is important that staff read the medication data sheets for medication to ensure that medication is being administered correctly, one particular medication for a resident needs to be administered half and hour before eating, but there were no directions on the monthly administration record to ensure that this happens. The manager must ensure that the medication trolley is kept in a clean and hygienic order. In general staff treat residents with respect and ensure residents’ privacy and dignity, by calling residents by their preferred name, ensuring that bathroom, bedroom and toilet doors are shut when carrying out personal hygiene tasks. The ethos of the home is to ensure that residents’ maintain social contacts with families and friends. None of the residents have telephones in their rooms, but they are able to use the office mobile phone to make personal call as and when they want. All three double rooms now have privacy curtains fitted around the beds and at washbasins. The inspector did note that staff do not always consult residents about some issues. During this inspection staff were giving out cups of tea in the lounge after lunch, none of the residents were consulted as to if they required sugar in their tea. The sugar was automatically put into the teacups. Two residents spoken to said, ‘This home is very nice, the staff are very kind’. One resident said, ‘It is very nice living here.’ One resident said ‘ I do not like this place.’ A requirement was made at the previous inspection on 05/06/07 for personal hygiene care tasks to be recorded in detail on each individual resident’s daily record, this has only partially been met. St Michael`s Rest Home DS0000067223.V361582.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 and 15 People using this service experience adequate outcomes in this area. The choice of activities in the home has improved, and resident’s individual needs are taken into consideration. Residents are able to have access to the local community with supervision of the staff, and this enriches the resident’s social opportunities. The home does not make provisions for varied menus and the residents using the service are not able to exercise choice and control over their diet and what they eat. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The programme of activities in the home has improved, and on the day of this key inspection it was noted that residents are kept individually occupied or occupied in groups according to their wishes. Activities on offer are magnetic darts, skittles, knitting, music, playing cards, musical exercises, ball games, connect 4 and quizzes. There is evidence that individually residents are able St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 14 to spend one to one time chatting with the staff. Several residents are taken for short walks by the carers. One resident was occupied with a building blocks game and was being supervised by a member of staff. Occasionally another resident is able to go swimming. An activity book is kept in the home and staff record what activities have been offered on each shift and what activities residents have been involved in. Outside entertainers are brought into the home on a monthly basis, and one entertainment very much enjoyed by the residents is when the ‘cuddly bunnies’ come to visit. A local church visits the home to carry out ‘Communion’ and to chat with the residents. One resident is taken by her family to a Roman Catholic service every Sunday. Families, friends and staff sometimes take the resident’s out for a trip into town for a meal or a cup of coffee. The home has an open visiting policy with the exception of mealtimes. From discussion with the manager she stated that when visitor arrive at mealtimes this often distracts the residents from eating their meals. The visiting policy is displayed and is clear in asking families and friends not to visit at these times. None of the residents have the capacity to manage their own financial affairs, and families or solicitors have power of attorney. The manager is in the process of contacting ‘Age Concern’ regarding advocacy services. A tour of the building showed that residents’ are encouraged when moving into the home to bring personal items and small items of furniture into the home with them so that they may personalise their bedrooms. A four-week menu is in operation in the home, and while this offers a balanced and nutritional diet to the residents, there is no evidence that residents are offered choices at mealtimes. Residents are able to make choices at breakfast times as to what cereal they would like, and whether they would like jam or marmalade on their toast. The manager said that it was difficult to offer choices at lunch and teatime due to the residents high levels of dementia, they often forget what they have ordered or do not realise what they are ordering. During discussion the manager said that she was considering producing daily picture menus for the residents. None of the residents have liquidised food. Due to the lack of choice at mealtimes a requirement is being made for alternatives to be offered at each mealtime. Two residents said ‘The food is very nice.’ ‘I always enjoy my food.’ St Michael`s Rest Home DS0000067223.V361582.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 People using this service experience good outcomes in this area. The home has a satisfactory complaints system with some evidence that residents would know how to complain. Staff have a good knowledge and understanding of adult protection issues, which helps to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure is up to date and displayed in the front entrance of the home. There have been no complaints since the last inspection. One resident said, ‘I would know how to complain if they need arose.’ The home has a Protecting Vulnerable Adults policy and procedure and this is in the process of being reviewed. 72 of staff have now received POVA training. The manager still needs to obtain – ‘Sussex Multi-Agency Policy and Procedures for Safeguarding Vulnerable Adults.’ There has been one Adult Protection issue, investigated by East Sussex Social Service since the last inspection and this was closed in September 2007. Two residents are restrained by cot sides on their beds, but from investigation the inspector notes that both permissions and risk assessments have been completed. St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 16 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, 22 and 26 People using this service experience adequate outcomes in this area. Improvements to the environment will enhance the resident’s quality of life. Further attention needs to be paid to infection control issues in the home to ensure residents are not placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building and external grounds took place on the day of this key inspection. While there have been some improvements in the home, with the provision of privacy curtains in double bedrooms, two bathrooms have been refurbished (one not completed), and décor in the home has been attended to. A new cooking range has been purchased, and the chef said how much better it was to use. It was noted however that the majority of bedrooms did not St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 17 have accessible call bells, one of the refurbished bathrooms had a toilet frame around the toilet that was not safe or suitable to be used, and none of the resident’s bedroom doors have been fitted with appropriate locks. Communal areas in the home provide a comfortable and homely place for residents to sit and relax or be involved in activities. The manager informed the inspector that planning permission had been granted to extend the home to provide for a further five bedrooms and some ancillary rooms and that building work was due to start in the very near future. The manager spoke with the inspector regarding the requirement for a handrail on the external ramp, which leads from the communal lounge to the garden area. With the layout of the garden at the present time it would not be suitable to provide a handrail on this ramp as it would restrict procedures in the event of a fire in the home. The manager will carry out a proper risk assessment of this area and ensure that if residents do need to be evacuated from the building that a member of staff is present by the ramp to ensure that residents are not placed at risk. During the tour of the building it was noted that some bedrooms had offensive odours and these need to be addressed. Generally the home was in a clean condition. The laundry room is situated in the garage adjoined to the home, and is provided with an industrial washing machine, which provides a sluicing facility and an industrial tumble drier, there is a sink, which is provided with liquid soap and paper hand towels. Red alginate bags are used for foul laundry. It was noted that the clinical waste bin was not appropriate and the manager is going to approach the contracted clinical waste company regarding the provision of the proper waster container that can be used with the yellow clinical waste sacks. Other waste bins throughout the building must be of the foot pedal or swing bin lid type, to prevent the risk of cross infection. In some bedrooms attention needs to be paid to the splash backs behind wash hand basins, where the grouting has become dislodged and there is a build up of grime. Staff are provided with disposable gloves and plastic aprons (blue for mealtimes and white for personal hygiene tasks). 63 of staff have completed infection control training. All communal hand-washing facilities in the home are provided with liquid soap and paper hand towels. St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 18 There is an outstanding requirement from the previous inspection on the 05/06/07 that residents must be able to lock their bedroom doors if they wish to. Locks should be provided that are suitable to the residents capabilities and accessible to staff in emergencies. St Michael`s Rest Home DS0000067223.V361582.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 People using this service experience adequate outcomes in this area. Staff are presently employed in sufficient numbers to ensure the needs of the residents are met. The number of staff with NVQ qualifications has improved, and ensures that residents receive care from staff with the skills and knowledge to meet the residents assessed needs. Since the last inspection the standard of vetting and recruitment practices has improved and appropriate checks are carried out so that residents are not placed at risk. There has been some improvement in mandatory training, but further training needs to take place to ensure that all staff have appropriate in health and safety issues, so that residents are not placed at risk. All new staff must receive ‘Skills for Care’ induction to ensure that they have the basic needs and skills to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 20 Since the appointment of the new manager, staffing levels have improved with three care staff on each morning and afternoon shift. There are two waking night staff on duty Monday to Sunday. There has been little turnover of care staff since the last inspection. The manager stated that she will keep staffing levels under review. At the present time 63 of staff have NVQ level two or above, and further staff are about to embark on achieving NVQ. Two personnel files were viewed for newly recruited care staff, and this showed that the manager now runs a stringent recruitment process, with all the relevant documentation and checks completed prior to the new member of staff taking up employment in the home. The following documentation was in each file:- application form with full employment history, interview form, POVA first check, CRB, two written references, two forms of identification, job description, health questionnaire, contract and conditions of employment, code of conduct, and initial basic induction. From training documentation there is evidence that the following staff have completed mandatory training:- Moving and Handling 63 with a further course booked in May 2008, First Aid 18 , Food Hygiene 55 , Fire Safety booked for 1st April 2008, Infection Control 63 , Protection of Vulnerable Adults 72 , Dementia 55 . The last medication training took place in 2006 and needs to be updated, 18 of staff have completed advanced medication training. Some staff have also completed continence training, challenging behaviour and understanding of the Mental Capacity Act. Further training booked is Health and Safety in June 20078 and COSHH training in July 2008. At the present time none of the staff employed in the home since the last inspection have completed a ‘Skills for Care Induction.’ A requirement was made at the last key inspection on 05/06/07 regarding all staff completing mandatory training, and this has only been partially met. St Michael`s Rest Home DS0000067223.V361582.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 People using this service experience adequate outcomes in this area. The appointed manager has made many improvements in the home but there is still work to be done to ensure that residents receive a good quality of care. The manager needs to ensure that a good quality assurance system is in place that can measure the standards of care that the residents receive. Health and Safety issues in the home have improved, and both residents and staff live and work and in a safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 22 A new appointed manager has been in place since the end of June 2008. At the present time she is in the process of completing her NVQ\ level 4 and will then be doing her Registered Managers Award. She has several years experience of management in residential care homes. At the present time she is awaiting the return of her CRB so that she may send her registration documentation through to CSCI. The appointed manager and her deputy manager have worked hard at improvements within the home since the last inspection, and a good team of care staff supports them in this. The manager has an open door policy and is always available to staff and residents during the time when she is on duty. There has been no relevant quality assurance system in place for 2007, this was discussed with the manager, who will now ensure this is put into place for 2008; this will include surveys for those residents who are able to complete a survey, for families and external stakeholders. The manager will also monitor on a monthly basis all the systems used in the home. The inspector was able to view a Health and Safety and Fire Risk Assessment for all the rooms in the home. The home no longer looks after personal allowances for any of the residents in the home. As reported earlier all staff must completed mandatory training to cover health and safety issues. Current maintenance certificates were seen for all appliances used in the home. There was weekly recording of fire points in the home. The manager stated that the registered provider carries out regular checks of the hot water outlets in the home but there was no recorded evidence to show that this is done. All windows have opening restrictors fitted. The premises are secure with a number lock fitted to the front door and all other external doors are linked to the nurse call system. There was evidence that a health and safety and fire risk assessment had been completed for all rooms in the home. The Health and Safety Executive accident book is appropriately completed and a monthly monitor is kept of all accidents in the home. The health and safety policies and procedures are in the process of being reviewed. St Michael`s Rest Home DS0000067223.V361582.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 3 St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 24 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 OP15 Regulation 12(2)(3) Requirement The registered person shall enable residents to make decisions with respect to the care they are to receive and their health and welfare, and therefore must ensure residents are offered a choice of meals in written or other formats to suit their capacity. The registered person must ensure that all bedrooms have an easily accessible nurse call system to enable residents to call for assistance if required. The registered person must ensure that the whole home is kept free of offensive odours. The registered person must ensure that all new staff complete a ‘Skills for Care’ induction within the first six weeks of their employment. The registered person must ensure that an effective quality assurance system is put in place to measure the success in meeting the aims, objectives and statement of purpose of the home. DS0000067223.V361582.R01.S.doc Timescale for action 02/06/08 2. OP22 23(2)(n) 02/06/08 3. 4. OP26 OP30 12(1)(a) 16(1)(2) (j)(k) 12(1)(a) (b) 18(1)(a) (c) 24(1)(a) (b)(2)(3) 19/05/08 02/06/08 5. OP33 02/06/08 St Michael`s Rest Home Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP9 Good Practice Recommendations Risk assessments for individual residents must give staff clear guidelines as to how the level of risk can be kept to a minimum Staff must read data medication sheets to ensure medication is being administered correctly. The medication trolley should be kept in a clean and hygienic condition at all times. St Michael`s Rest Home DS0000067223.V361582.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V361582.R01.S.doc Version 5.2 Page 27 - 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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