Inspection on 22/11/06 for St Michaels Nursing Home

This inspection was carried out on 22nd 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 Michaels Nursing Home 25/06/07

St Michaels Nursing Home 03/05/06

St Michaels Nursing Home 05/01/06

St Michaels Nursing Home 08/09/05

St Michaels Nursing Home 04/03/05

St Michaels Nursing Home 29/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE St Michaels Nursing Home 9 Chesterfield Road Brimington Chesterfield Derbyshire S43 1AB Lead Inspector Susan Richards Key Unannounced Inspection 22nd November 2006 02:05 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 Michaels Nursing Home DS0000059738.V320854.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 Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michaels Nursing Home Address 9 Chesterfield Road Brimington Chesterfield Derbyshire S43 1AB 01246 558828 01246 233768 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) Sun Care Homes Ltd Vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 39 service users to be accommodated, which includes x 3 service users aged under 65 years, category PD as named in the notice of proposal letter. The registration includes the accommodation of a named service user under the category DE, E - not transferable to any other service user, other than the person named. Completion of the programme of redecoration, upgrading and renewal of the fabric of the home in accordance with that detailed separately in writing - letter dated 220506, by 31 October 2006. 13th July 2006 2. 3. Date of last inspection Brief Description of the Service: St Michaels Care Home provides accommodation, nursing and personal care and support for up to 39 older persons. It is located approximately 2.5 miles north east of Chesterfield town centre on a direct bus route and within a residential area. The home provides a choice of lounge/dining space and individual accommodation comprises of 29 single bedrooms and 10 shared (two of which are currently used for single occupancy). Fifteen of the single bedrooms have an en suite. There is a pleasant enclosed rear patio and wellkept garden area providing a choice of seating, which is accessed via a conservatory. There is a choice of bathroom and toilet facilities to each floor. A passenger lift is provided and there is an emergency call system throughout the home. A variety of disability equipment is provided, both environmental and individual equipment. Individual’s care is assessed, planned and reviewed by Registered Nurses employed in the home, who are supported by a team of care and hotel services staff and led by an acting manager, who had only been in post for a few weeks at the time of the inspection. The range of fees charged by the home are as follows as at 18/04/06: Nursing – Derbyshire County Council assisted – from £389.90 to £482.90 Nursing – Self Funded - from £400.00 to £490.00 Personal care – DCC assisted - from £313.20 to £343.20 Personal care – Self Funded - from £315.00 to £350.00 Information is provided in writing and in the service user guide for the home. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second key inspection for this service for the inspection year April 2006-March 2007. The home has also received a shorter random inspection in July 2006. Case tracking was used as part of the methodology. This involved the random sampling of three service users whose care and service provision was examined more closely. Discussions were held with those service users (in accordance with their given capacities) and were possible their representatives and staff involved in their care. Individual’s care and related records were examined and their private and communal accommodation inspected. At the time of this site/inspection visit, there were twenty-two service users accommodated, including 14 receiving nursing care. What the service does well: What has improved since the last inspection? St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 6 The written programme for the upgrading, repair and renewal of the building has been fully completed in accordance with the home’s condition of registration. Residents were provided with pressure relieving cushions in accordance with the risk-assessed needs as recorded. Medicines records were properly kept. There were sufficient supplies of gloves, aprons and disposable continence wipes. Bars of soap were not being left out and used in communal areas and linen and incontinence pads were suitably stored. Newly recruited staff had commenced their employment in the home following confirmation of satisfactory POVA/CRB checks. The acting manager had begun a review of the management of clinical risk systems, although this was in its infancy. What they could do better: Ensure that staffing arrangements consistently promote service users dignity and choice in respect of their preferred daily living routines. Maintain consistent and accurate records in respect of individual’s health care needs in respect of clinical risk and care planning interventions. Ensure that all complaints made are taken seriously, properly investigated and acted upon in a prompt and responsive manner. Review and replace waste bins and commodes as necessary to reduce potential infection risk to staff and service users. Ensure that service users needs are consistently met by the numbers and skill mix of staff and ensure that there are suitable ongoing arrangements in place to enable staff to undertaken training appropriate for the work they are to perform. Develop and operate clear and efficient management monitoring systems, which aim to ensure that the home is operated and run in a competent manner in the best interests of service users and that the health, safety and welfare of service users and staff is best promoted. St Michaels Nursing Home DS0000059738.V320854.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 Michaels Nursing Home DS0000059738.V320854.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 Michaels Nursing Home DS0000059738.V320854.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): 3&6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are admitted to the home on the basis of a full assessment of their individual needs determined in consultation with them. EVIDENCE: At the time of the inspection there were 24 service users accommodated and case tracking was undertaken in respect of three of those. The Inspector was not able to engage in meaningful discussions with two of those due to their given capacity. Discussions were held with a number of service users about their care, including one for case tracking purposes. They said that their needs were discussed with them either prior to or on their admission to the home and St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 10 that they had received written information regarding the home and its service provision. The recorded needs assessment information for each of those service users case tracked was examined. These were comprehensive and written in accordance with a recognised care model and were signed and dated by the person completing them. Individual’s written plans detailed some aspects of their lifestyle preferences and routines. Copies of individual’s needs assessment and single care plan summaries were in place as provided by way of care management arrangements for the purposes of individual’s admission to the home. The home does not provide for intermediate care. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. At times staffing arrangements impacted on service users dignity and choice in respect of some of their preferred daily living routines. Omissions of recording in respect of the health care needs of service users may potentially undermine their safety, although the management review of clinical practise and audit by the new acting manager should reduce potential risks to service users when implemented. EVIDENCE: Since the previous key inspection for this service on 03 May 2006, a random inspection was carried out on 13 July 2006 prompted by an anonymous complaint, which the Commission received on 10 July 2006. During that inspection three requirements were made in respect of care planning, these were not wholly complied with at this inspection. The written care plans of St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 12 service users case tracked were examined and discussions were held with them about these in accordance with their given individual capacities and also with staff. Written care plans were not routinely signed by the service user or recorded as agreed with the individual service user (or where applicable, their representative). Service users spoken with said that they had not seen their care plans, although were involved in discussions about their care at care reviews held under social services care management arrangements. Care plans seen were generally in accordance with recorded risk assessment scoring tools, which had monthly review dates recorded and were signed by the reviewer. However, one service user’s care plans and risk assessments did not give a clear picture in respect of their skin integrity. Details of service users access to outside health care professionals were accounted reasonably well accounted for, including for the purposes of routines health care screening, with the exception of one service user who had a written record regarding the possible need for referral to an outside healthcare professional in respect of their dental care. Care records did not detail as to whether this had been arranged/or the outcome of this. The acting manager, who is new in post, (by a few weeks only – see also Management section of this report) advised that the care records required complete review and audit, and provided a management plan in respect of this, which included the introduction of formal systems of clinical audit, including pressure ulcer prevention, nutrition, continence and falls risk. A formal review of the continence needs of all residents was due to commence in conjunction with the continence specialist nurse advisor from the local PCT. Discussions were held with the manager regarding pressure ulcer prevention, management and recording – progress will be monitored at the next inspection of this service in respect of these. Specialist aids and equipment were seen as being provided for service users case tracked in accordance with individually assessed/recorded needs. At the last key inspection for this service on 03 May 2006 and also at a random inspection on 13 July the arrangements for the management and administration of medicines were examined. Requirements made during these inspections were assessed as complied with at this inspection and were satisfactory. Discussions were held with a number of service users and their representatives, who felt that staff were respectful to them and maintained their privacy. Written feedback received from five service users/representatives said that staff always listened and responded with a smile and usually were available when they needed them. However, during the afternoon of the inspection two service users, who had asked to rest on their beds after lunch were still waiting for staff assistance to do this at 14.50 hrs, St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 13 one of who was very tired. During discussions with them they said that this often occurred in an afternoon. Discussions were held with the manager and staff regarding staff provision, deployment and organisation and staff duty rotas examined - (see also staffing section of this report). The level of care planning information in respect of service users social care needs was minimal. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are suitable daily living arrangements in respect of activities and social contacts and to ensure adequate food provision. EVIDENCE: Discussions were held with some service users and their representatives regarding the arrangements for social contacts and activities. All said they were able to receive visitors when they chose and that visiting to the open is open. They said that seasonal celebrations were always arranged, including birthdays that visits from outside entertainers were periodically arranged, although the activities co-ordinator post had recently become vacant. Crafts and board games were provided, and there are regular arrangements for religious expression and worship within the home. The activities co-ordinator had recently left and the manager advised that this vacancy was being advertised. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 15 Arrangements had also been made by the manager to engage an outside group to provide gentle exercise/activities on a monthly basis commencing the following week, which some residents expressed interest in joining. Written feedback was also obtained from five service users/their representatives regarding activities in the home. The majority indicated that activities were usually organised and that service users engaged in these in accordance with their choices and/or individual capacities. However, the representatives of two newer service users said they did not know what activities were arranged/available in the home. The Inspector was advised that there were no service users accommodated at the time of the inspection who had chosen to handle their own finances, all having representative who did this on their behalf, either by way of relatives or social services. Comments received from resident consulted with were reflective of this. All residents spoken with said they were able to bring their own personal possessions into the home with them and the bedrooms, which were inspected of those residents case tracked reflected this. Written information was provided regarding access to advocacy in the entrance area of the home. Discussions were held with service users and their representatives about meals provided in the home and written comments were received from five service users/or their representatives. Satisfaction with food provided was variable from being always satisfied to usually satisfied, although one representative was unsure and held the perception that visiting at mealtimes was not encouraged. Two people surveyed in writing and two spoken with said that the food was very good and that they could have anything they requested at any time and that the cook was very accommodating. At the previous inspection of this service in July 2006 a requirement was made in respect of the provision of drinks for service users. Drinks were provided for service users at regular intervals throughout the inspection. Residents spoken with said they were offered plenty of drinks. There were no persons accommodated with diverse religious or cultural requirements in respect of their diet, although the manager advised that these would be provided in accordance with assessed or expressed needs. Copies of menus were provided and detailed a balanced nutritious diet. Lunches served during the inspection were well presented in an unhurried and calm manner and service users received the support they needed. The new manager advised of his proposals to hold regular meetings with residents and also relatives/representatives. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 16 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): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Anonymous complaints made during the summer were effectively acted upon in a prompt and responsive manner, thereby placing service users at potential risk. EVIDENCE: There is a clear written complaints procedure in the home, which is openly displayed and also details are provided within the home’s service user guide (or brochure). Service users and their representatives spoken with during the inspection said they knew how to complain. Written feedback was provided from a mixture of five service users/representatives. All said that they knew how to complain. One advised that they had recently made a complaint, which was dealt with to their satisfaction. Since the last key inspection of this service in May 2006 an anonymous written complaint was received by the Commission in respect of the home, which St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 17 included allegations regarding poor management by the previous acting manager and bullying and intimidation of staff, financial irregularities, a lack of care of residents and inadequate staffing arrangements. As a result of this complaint, an additional random inspection was undertaken at the home. The complaint was partially upheld and details were passed to the registered provider and a number of requirements were made in respect of these. Three further complaints were made to the Commission during the summer with continuing allegations in respect of the above. All of these were anonymous. These were each passed to the registered provider for investigation. The Commission also held a management review about the home and met with the registered provider to discuss concerns arising from that review, including the written responses provided by him with regard to the stated complaints. Five key areas of improvement were identified. These included the provision of food and drinks, staffing arrangements, including staff deployment/infection control and record keeping. The fifth area related to the environment and is detailed under the environment section of this report. See also management section of this report with regard to management arrangements. At this inspection the five key areas stated above were assessed. Some progress was identified. These are referred to under the relevant sections of this report. Records of complaints were not being properly made at the random inspection for this service in July 2006. Records were examined during this inspection. These were appropriate detailed. There is relevant key policy guidance in the with regard to safeguarding adults and staff were familiar with internal and local procedures. Since this inspection the registered provider has verbally advised of action taken in respect of alleged financial irregularities/thefts in the home, although written notification has not been forwarded to the Commission in respect of these. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 18 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): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, service users live in a safe and well-maintained environment, although a review of a small number of waste bins and commodes may reduce potential infection risk to staff and service users. EVIDENCE: It is a condition of the home’s registration that an agreed programme of upgrading, repair and renewal of the fabric of the home be completed by 31 October 2006. This was complied with by this inspection. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 19 A full tour of the building was undertaken. The private and communal accommodation of those service users case tracked were inspected. These were clean and comfortable and suitably furnished, decorated and equipped in accordance with individuals’ assessed needs. However, a number of commodes were old and worn, with varnish peeling and also waste bins in some toilet and bathroom areas were not fully occlusive and therefore unsuitable with regard to promoting good infection control. These were discussed with the acting manager. Service users and their representatives spoken with said they were satisfied with the environment and their own rooms, which they felt to be clean and comfortable and to suit their needs. The laundry has been totally refurbished over the last year. This is suitably equipped. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users needs were not always met by the numbers and skill mix of staff who were not all sufficiently trained, which may place them at risk. EVIDENCE: At the time of the inspection there were twenty-two service users accommodated and two in hospital. Fourteen received nursing care and eight, personal care only. Nursing and care staffing of the home was planned by way of a rolling rota. Rotas were examined and nursing and care staff provision is as follows: A.M. shift – 1 Registered Nurse and 5 care staff (occasions with four care staff) P.M. shift – 1 Registered Nurse and four care staff Night - 1 Registered Nurse and one care staff The new acting manager covers 8am – 4 pm over five days per week. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 21 Dependencies in the home were reported to be medium to high, although no formal assessment documentation existed in respect of individual’s dependency scoring. At the random inspection carried out in July a requirement was made in respect of staffing levels and skill mix/training. At that time there were twenty-nine service users accommodated and kitchen staff hours had been reduced since the key inspection in May, resulting in care staff preparing teas and serving teas and also carrying out laundry duties, evenings and weekends. A review of these arrangements had been undertaken and kitchen hours increased to provide cover for teas until 5pm, although care staff then served these and cleared away. The laundry cover remained for 37 hours per week, care staff said that they still continued to do the laundry during the evenings/night and weekends. All spoken with said additional staff hours were required to fully cover teas and also additional laundry duties as additional care hours were not provided to account for these. Details of domestic staff hours were provided, which were satisfactory – all areas of the home as seen had good standards of cleanliness. Service users spoken with gave accounts of having to wait for assistance often during afternoons particularly. (See also Health and Personal care section of this report). These were discussed with the acting manager and Registered Provider during this inspection. Since the inspection took place, minutes of a meeting held via social services safeguarding adults’ procedures, has been received by the Commission in respect of the home. Details recorded in respect of individual care reviews via care management arrangements indicate some significant omissions of record keeping in relation to the care needs of individual service users. It is understood that these issues have been raised with the home by social services. The registered provider and acting manager need to consider the possible impact of staffing arrangements, including training and deployment in respect of these. The personal records of four new staff starters were examined. These contained all required information for the purposes of their recruitment, although for one very recent staff member a reference remained outstanding. This was discussed with the acting manager and administrator, who advised this would be dealt with immediately. Details of staff training undertaken and planned were not completed on the pre-inspection questionnaire provided by the home prior to the site visit. However, details of the number of care staff with at least NVQ level 2 or above were stated as being approximately 30 . St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 22 Five care staff had left since the previous inspection and two named agency care staff were being used. The previous acting manager at the inspection in May 2006 had devised a staff training needs analysis and training plan. The analysis detailed significant gaps in staff training, with training planned, although progress was poor to date. The new acting manager advised that he had reviewed those arrangements and with revised arrangements agreed by the registered provider to ensure consistent and ongoing delivery, via an outside training organisation, whose details were provided. He had made suitable arrangement for the induction of the most recent staff starters. Discussions were held with staff with varying experience and training. Gaps in their training for some of those were evident, including areas of health and safety, such as first aid and food hygiene and handling and also access to NVQ training. St Michaels Nursing Home DS0000059738.V320854.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): 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not always effectively run in the best interests of service users and the health, safety and welfare of service users and staff is not always best promoted, which may place them at risk. The efficacy of the provider’s monthly reports regarding the conduct of the home, are significantly undermined by matters arising within this inspection process. EVIDENCE: St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 24 The home has been without a consistent registered manager for some two years. There have been acting management arrangements for the most part within this period, with the exception of a registered manager appointed during the summer of 2005, who left her employment in January 2006. Following her departure, an acting manager was appointed who applied for registration with the Commission. This application was processed and refused. That individual no longer works at the home. The registered provider has appointed a further acting manager who had only been in post a few weeks at the time of this inspection. A formal quality assurance system was in place, which included service user surveys, although this had not been operated since 2004. The strategies identified by the previous acting manager to promote service users health, safety and welfare, had not been effectively implemented - staff training and development. The registered provider is present in the home regularly each week and provides monthly written reports in relation to the conduct of the home. Action is not always progressed within agreed timescales to implement requirements identified within CSCI reports. The arrangements for the management and handling of service users monies for those service users case tracked were examined and were satisfactory. The previous acting manager had devised a system of individual staff supervision, which had only recently been introduced. This was discussed with the current acting manager. Comments made under the Staffing section of this report apply here in respect of core health and safety training for staff. Details of records of maintenance of equipment have been previously provided and are up to date. Records were being kept in respect of weekly fire alarm system testing and staff fire drills. The acting manager advised that he had located the last known fire risk assessment undertaken for the building, which he provided for inspection. He was aware that this required review. This was discussed with him. St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 2 2 2 St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Residents care plans must be reflective of their changing needs and always specify clear objectives and health/care interventions. (In this instance referring to tissue viability and access to outside health care professionals). The home must be conducted in such a manner, which respects the dignity of service users and as far as practicable takes into account their wishes and feelings with respect to their daily living routines. The registered person must always ensure that any complaint made is taken seriously and fully investigated. The registered person must give written notice of any theft in the care home (to include full details, including action taken). Suitable arrangements must be made to prevent infection in the home – in this instance a review of commodes and waste bins, with replacement as necessary. There must be at all times, DS0000059738.V320854.R01.S.doc Timescale for action 22/01/07 2. OP10 12 22/01/07 3. OP16 22 23/12/06 4. RQN 37 22/01/07 5. OP26 13 22/01/07 6. OP27 18 22/01/07 Page 27 St Michaels Nursing Home Version 5.2 7. OP33 24 8. OP38 23 suitably qualified, competent and experienced persons working at the care home in such numbers as are appropriate to the health and welfare of residents. (Staff must undertake training appropriate to the work they are to perform). The registered person must 22/02/07 maintain an efficient and competent system for reviewing at appropriate intervals and improving the quality of care and service provided by the home, including nursing care. The registered provider must 22/01/07 ensure that adequate precautions are take against the risk of fire – in this instance, the fire risk assessment is completed and reviewed at appropriate intervals. 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. 4. Refer to Standard OP7 OP7 OP8 Good Practice Recommendations Care plans should be agreed and signed by the resident whenever capable, or their representative (if any). Individual daily living plans should be developed in respect of each service user, which account for their known preferred routines and daily living preferences. The incidence of pressure ulcers, their treatment and outcome should be recorded in the residents care plan and reviewed on a continuous basis. Up to date written information about activities should circulated to all service users in formats suited to their capacities. Service users rights to access their records should be DS0000059738.V320854.R01.S.doc Version 5.2 Page 28 5. 6. OP12 OP14 St Michaels Nursing Home actively promoted and facilitated (in accordance with Data Protection Act 1998). St Michaels Nursing Home DS0000059738.V320854.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Michaels Nursing Home DS0000059738.V320854.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. 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