Inspection on 11/12/06 for St Nicholas House

This inspection was carried out on 11th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Nicholas House 08/12/05

St Nicholas House 21/07/05

St Nicholas House 01/03/05

St Nicholas House 15/07/04

St Nicholas House 23/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Nicholas House St Nicholas House Littlefields Dereham Norfolk NR19 1BG Lead Inspector Mrs Jacky Vugler Key Unannounced 11th December 2006 09:30 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 Nicholas House DS0000034973.V323959.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 Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Nicholas House Address St Nicholas House Littlefields Dereham Norfolk NR19 1BG 01362 692581 01362 699418 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) www.norfolk.gov.uk Norfolk County Council-Community Care Mrs Joanne Marie Bolton Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. It is recommended that the home is registered to accommodate 32 Service Users who are Older People, not falling within any other category. The accommodation is not suitable to accommodate people who need a wheelchair to assisit with independent mobility at the point of admission. No service user who relies on a wheelchair to assist with mobility should be accommodated on the first floor due to the size of the lift. 8th December 2005 Date of last inspection Brief Description of the Service: St Nicholas House is a two storey, residential care home providing accommodation and care for thirty-two older people. It is owned and run by the Local Authority, is situated within a short walk of all facilities and the town centre of Dereham and stands in its own, well kept grounds. All bedrooms are single, contain a washbasin, are arranged on both floors and are a mix of above or just at the minimum standard in size. On each floor there is a communal bathroom containing adapted bath and toilet and separate toilet facilities. The home has a passenger lift to the first floor that is not able to accommodate service users who use a wheelchair. There are four large communal lounges and several small sitting areas around the home and service users have the choice of eating in a large, downstairs dining room or in one of the lounges or their bedroom. A hairdressing facility is available and an independent chiropodist also visits the home. The gardens offer service users pleasant areas to sit and there is parking to the front and side of the building. The current fees are £368.72 a week as stated in November 2006. Additional costs include chiropody at £12, hairdressing at approximately £7.50, plus newspapers, magazines, toiletries, confectionary, optician and the payphone at varying costs. St Nicholas House DS0000034973.V323959.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 and it took place over nine hours. Not all the standards were assessed on this occasion, and of those standards assessed, not all the elements may have been covered. The manager, Mrs Joanne Bolton, was present throughout the day. There was a pre-inspection questionnaire completed by the manager before the inspection and preparation for this inspection had taken place in the CSCI office. Comment cards have been received from five residents, five relatives and two GP practices. All indicated an overall satisfaction with the service provided and some of their comments have been incorporated into this report. Six residents and three members of staff were spoken to privately on the day. Records were viewed and a tour of the premises was undertaken. What the service does well: What has improved since the last inspection? The Manager has now gained the Registered Managers Award and is more than halfway through the NVQ level 4 in Care. All hot water supplies are now thermostatically controlled at the point of delivery ensuring safe hot water temperatures for the residents. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 6 Since the last inspection the dining room has been refurbished to a high standard as previously stated, and the home now operates restaurant style mealtimes, which allows the residents a lot more choice of what, when and where they eat. Food is out for them to help themselves, for example, a large bowl of fruit and snacks. The Manager has now been guaranteed an extra fifty hours a week for care staff to be used as she feels necessary. The number of staff qualifying to NVQ level 2 standard is increasing although it still falls short of the 50 needed. What they could do better: 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 Nicholas House DS0000034973.V323959.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 Nicholas House DS0000034973.V323959.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): 2, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where to live. Each resident has a written contract stating the terms and conditions within the home. Each resident has his or her needs assessed before being offered a place at St Nicholas House. Prospective residents and their relatives and friends are encouraged to visit the home prior to admission so they can assess the suitability of the home. The home does not currently admit residents for intermediate care. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 9 EVIDENCE: All the appropriate information is gained from other healthcare professionals prior to a resident being admitted. Prospective residents and their families are encouraged to visit the home before admission and the Manager then undertakes an assessment of their needs. If this is not possible the Manager will visit the prospective resident wherever they are. A recently admitted resident said that it was not possible for him to visit the home prior to admission, but that the Manager visited him in hospital. Another recently admitted resident said that he had visited the home to look round and that some relatives had lived there before him so he knew the home anyway. A review is held after a four week assessment period and then the resident receives a contract. Each resident had signed a terms and conditions of residence. This home does not provide intermediate care. St Nicholas House DS0000034973.V323959.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents health, personal and social care needs are written in an individual plan of care. The residents health care needs are fully met. The residents are protected by the homes policies and procedures for dealing with medicines and those able can administer their own. Staff treat the residents with respect and uphold their right to privacy. EVIDENCE: Three care plans were viewed and those residents were spoken with. They all felt that their care needs were being met and the care plans appeared to reflect their needs. The care plans contained good detail and had been signed by the residents, although one had not been dated. The care plans were reviewed regularly and this was indicated by circling the month in which the review took place, comments were only made where necessary. A summary St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 11 sheet of the care plan is kept discreetly in each bedroom for a quick reference for the carers. Many risk assessments were in place and a record of medical visits was kept, and other healthcare professionals are involved when necessary. The dietician visits via a referral and a care coordinator is a link person working with the Malnutrition Universal Screening Tool (MUST). The link person for the blind association visits three residents annually and is contacted if any equipment is needed. The medication administration records are well recorded and display a photograph of the resident. A staff specimen signature chart is available. At the front of the records there is a chart stating the time each resident received their medication, and this is because the home now has restaurant style meal times and the medications are administered when convenient for the resident. This chart therefore ensures that there is always a four hour gap between medications and this is good practice. Part of a medication round was observed and the correct procedures were followed. Risk assessments are in place for medicines to be taken when necessary, and also for those residents wishing to administer their own medications. This risk assessment is reviewed monthly with an outcome and action recorded and is signed by the resident and a member of staff. One copy is kept with the medication records and the other in the care plan. The resident who wishes to self medicate is given her months supply of medicines and she signs for them and these records were seen. The medications kept in the trolleys are audited daily and this is good practice. The controlled drugs were all checked and found to be correct. All of the residents spoken with said that the staff treated them with respect, that they knocked on the door before entering and always closed the door before conducting any personal care. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are offered a variety of activities in a conducive setting. Visitors are encouraged and made welcome at the home. Residents have excellent opportunities to exercise choice and control over their lives. A varied and nutritious menu is provided, which is served in a very pleasant Bistro. EVIDENCE: Although there is not a structured, regular plan of activities, 80 of the questionnaires received from residents said that there were always or usually enough activities provided. A retired member of staff visits to run Bingo every week, which the residents said they enjoyed. Last week an afternoon was spent with a pampering party for the ladies. A raffle has been held. Last week all of the residents, except eight, went out for lunch and the afternoon at a local pub. They had lunch and played games, which the residents enjoyed. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 13 The Manager said that they sometimes have problems organising outings as they have to rely on transport with a tailgate. The Manager said that staff do not really have time to do the in-house activities, therefore more of the activities are provided by outside agencies. A monthly activities folder was seen, which contained photographs of a retirement party for a member of staff and a Grand National sweep. BBQs were held in the summer and the residents were able to invite guests, a May Day King and Queen were voted in and a Halloween party was held. During the day of inspection a singer was entertaining the residents and then they were going to have a fish and chip supper. Those spoken to were really looking forward to this. If residents take part in these activities it is recorded in their care plan. The home operates an open visiting policy and this was seen to be effective on the day of inspection. A weekly religious service is held in the home and this is non denominational. A Red Cross lady visits regularly to paint the ladies nails. There is a visitors room on the ground floor, which is used a lot, it is near the dining room so residents and their visitors are able to get a coffee and they are also able to have lunch and tea from the Bistro. The residents spoke of plenty of choices being available to them, for example they said they can get up when they like as breakfast is available from 8.30 am until 10 am. Two staff get the residents up and two stay in the dining room with those having breakfast. They can also choose where they eat, for example, the lounge, bedroom or the Bistro. The home has bought two recliner chairs for those who wish to stay up in the evening and the Manager said that two ladies sometimes like to get up particularly early. She also said that if there is to be a change over of a key worker, the residents involved are consulted and able to say who they would like. This is good practice. Monthly residents meetings are held and at the last one residents chose their Christmas menu and entertainment requests. The home now has a new restaurant style system for meals. There is a new Bistro dining room which is very attractive and decorated to a high standard, called Nics Bistro. The Manager said that the residents chose the decorations and pictures for this room. An individual menu is displayed on each table. A fruit bowl is always available and a coffee and water dispenser for those who are able to help themselves. A display fridge containing sweet and savoury snacks is always available. The menus are varied and nutritious and the residents spoken to all said they liked the food and the new restaurant. One resident said I like the restaurant style better, we can come and go as we like. Another resident likes a glass of wine every evening. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to, taken seriously and acted upon. The residents are protected from abuse by the homes recruitment procedures and training. EVIDENCE: Since last inspection there have been two complaints. These were appropriately dealt with and recorded. The complaints procedure is displayed and residents have a copy. All the residents spoken with said that they would complain if necessary, but currently had no complaints. All staff have received training on abuse awareness except for six and an email was seen confirming the booking of this training. All staff have a criminal records disclosure in place before starting and this includes the hairdressers. The chiropodists certificate from the Health Professional Council was also seen. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 15 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, 21, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well maintained environment. There are insufficient bathrooms in this home and an improvement to this facility has been required for the last three inspections. The home is clean, pleasant and hygienic. EVIDENCE: The home looked very welcoming and homely with the Christmas decorations and was generally well maintained. This is a non smoking home. There are many areas around the home for residents to sit and these include three large lounges, five alcoves, a coffee lounge and a visitors room, situated next to the Bistro where it was possible to buy cards. Also, there is a seating St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 16 area where residents can access a computer and the internet, although the Manager said that this is not well used at the moment. Residents were seen to walk around and freely use all areas. In the corridors all the pictures had matching frames and there were photographs of a resident boxing, which used to be his hobby, and a newspaper article about the new restaurant. A hairdressing room is available and the District Nurses have the use of a room in which they keep their notes. There are some wheelchair scuffs around doorways and a piece of plaster is off the wall outside one bathroom. Requirement. The residents bedroom doors all had an individual nameplate on, and the Manager said that the administrator spoke to all the residents to ask them what pictures they would like on their name plate and this was then made for them. This is good practice. This home has long corridors with only two assisted bathrooms, which makes the offer of a bath difficult for some residents who may have a bedroom at the far end of the building. The home has a room that used to be a bathroom and the Manager has discussed the possibility of converting this to another bathroom or a walk in shower room. There is another bathroom which is unused as it is not assisted and does not have access for a wheelchair. There is a repeated requirement, highlighted in the last three inspections, for a further bathroom or shower room to be provided as two assisted bathrooms for thirty-two residents is insufficient. The ground floor assisted bathroom has been decorated to a high standard with blinds, curtains and pictures on the wall. However, the other bathroom and toilets need redecorating and making homely. Requirement. Two toilets situated next to each other on the first floor are very small and if a resident uses a walking frame, this would have to be left outside the door, the Manager also said that if resident fell in the toilet, staff would have difficulty getting to them. Requirement. Although the home has the old metal framed windows, the Manager said that these are not draughty and they could be opened and closed by residents if they wanted to. A passenger lift is provided, which is very small therefore residents using a wheelchair are not admitted to the home, and this is written in the statement of purpose. All bedroom doors are fitted with a lock and residents are able to hold the key if they wish. The home has four EVAC chairs on the first floor in case of emergency. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 17 All windows to the first floor have restrictors fitted and since the last inspection thermostatic control valves have been fitted to all hand wash basins so the temperature of the hot water is regulated. The laundry is situated away from the main part of the building and has two industrial washing machines and one industrial and one domestic tumble drier. All surfaces are washable. During the inspection, work was in progress to fit twenty new fire doors with automatic magnetic closures to residents bedrooms. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are met by the numbers and skill mix of staff and they are in safe hands at all times. A robust recruitment procedure is in place, which protects the residents. However, some records, although obtained, need to be kept at the home. The home offers good training opportunities ensuring the staff are competent to do their jobs. EVIDENCE: The home currently accommodates thirty-two residents. Four care coordinators are employed and one works from 7 am until 10 pm with an overlap at lunchtime. Their duties mainly consist of administering medications, dealing with other healthcare professionals and record keeping and therefore they are only able to help with caring when needed. A senior care assistant and two carers cover all shifts with a third until 10 am for extra support over the breakfast period. Excluding the care co-ordinators hours, the care hours provided allow for 9.7 hours per resident a week and this is very much below what is expected. If the care co-ordinators hours are included in this calculation, then the hours provided would be 13 per resident a week, St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 19 however, as previously stated the care co-ordinators are only able to help with caring when they are needed and therefore cannot be included in the overall total. There are two waking night staff. In addition the manager has staff to provide an extra fifty relief hours. She said that with these extra hours she is able to cover 99.9 of the vacancies. One bed is currently being used for respite care. The manager said that many residents are highly dependent, although not all physically, some have other needs. Three questionnaires, from the five returned from relatives indicated that staffing levels are not sufficient, one comment was, staff work very hard at their jobs but there are not enough to take longer if need be, other comments included, staff are excellent and very caring. Residents spoken with said staff are great, carers are very, very good, not enough staff, they seem to be over-loaded with work, when I ring my bell, theyre up like a shot, mornings are hectic, they have to hurry and rush about and theyll do anything for you. It is required that residents dependency levels are monitored and extra staff provided when necessary. In addition to the above staff an administrator works for eighteen and a half hours a week. A domestic is employed for seven days a week, with two working for three of those days, and a dedicated laundry assistant works five days a week. The home currently employs twenty-four care staff and ten have achieved an NVQ level 3 or above. One member of staff has the NVQ level 3 and another has the Registered Managers Award and the City and Guilds in Family and Caring. This equates to 41 of the care staff having achieved this qualification, which is an improvement since the last inspection. However, the National Minimum Standards state that a ratio of a minimum of 50 members of staff are trained to NVQ level 2 or equivalent by the end of 2005, therefore a recommendation has been made. The home operates robust recruitment procedures using the Norfolk County Council policies. Three staff recruitment files were seen and these contained evidence of identification and all of the necessary checks except one where the references were missing. The manager said that these have been obtained, it is therefore required that copies of all the relevant documents are obtained from County Hall. Evidence of several Criminal Records Bureau disclosures were seen. The Manager said that staff interviews are usually conducted with herself and the Manager of another home. Each member of staff has an Evidence of Learning file and in this records are kept of all their training undertaken including induction. Training undertaken includes fire, moving and handling, food hygiene, emergency aid, protection of vulnerable adults, medication and the Malnutrition Universal Screening Tool (MUST). In addition senior staff keep a very clear record of all statutory training undertaken including the dates for updating. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 20 Staff spoken to said, training is brilliant, a leaflet on training courses is displayed in the staff room, we ask and Jo (manager) will put us forward for it, training is very good and we are kept up to date on everything, there is a wide variety of courses, but getting on training is more difficult. St Nicholas House DS0000034973.V323959.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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home which is run and managed by a person who is fit to be in charge. The home is run in the best interests of the residents. Residents finances are safeguarded, but recommendation has been made. Although the Managers door is always open, staff are not appropriately supervised. The health, safety and welfare of residents and staff is promoted and protected. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 22 EVIDENCE: Since the last inspection the Manager has completed the Registered Managers Award and is more than half way through NVQ 4 in care. She is also due to undertake the Mental capacity training in January 2007 and risk management. She said that she would like to undertake the supervision and appraisal training as well as recruitment and selection, and will then train the care coordinators in-house. In order to monitor the quality of the service, the Manager sent questionnaires to residents, relatives and friends, staff and two other agencies. The results have been forwarded to the Commission with an action plan. Feedback from all indicated that the home needs more staff. The outcome from residents indicated good quality care, relatives indicated that high standards were being achieved and staff indicated that further improvements could be made. Monthly health and safety audits are carried out and medication audits are conducted by the Manager of another home. The Manager has just received the paperwork for general audits, for example, cleanliness, day to day running, tidy rooms, and anything highlighted is written in a comments box with the action to be taken, dated and signed. One entry seen was the toilets on the first floor posing a hazard as residents are unable to access them with their frame (mentioned earlier in this report). Residents meetings are held monthly and the minutes were seen, the last one was on 8.11.06, when the Christmas menu was chosen and entertainment requests were made. An update on staffing situation is given to the residents and feedback was received about the new meals provision. Individual staff meetings are held six weekly for the care coordinators, senior carers, night staff, domestic as well as the six weekly general staff meetings. The financial records for the residents are audited weekly by the administrator and this sheet is kept in the front of the folder. The financial records are well recorded and include income and expenditure, and all receipts are kept and numbered. Signatures from staff and residents are in place where necessary. The individual monies were not checked on this occasion as it is not kept individually, but as a total making the auditing of it too time consuming. The administrator draws the personal allowance for two residents and it is recorded on front sheet what the resident likes to happen to it, for example, some in cash and some saved. It is recommended that, as good practice, the residents monies are kept individually. Since the last inspection some staff supervision has been carried out but not regularly or frequently enough. The Manager said that a planner was set up but it didnt work and now the date for the next supervision is planned during the current one, but this still not working as she does not have the capacity to take staff off the floor. Work based supervision is fitted in where possible. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 23 She said that the office door is always open and that staff come in if they have any issues, but this is not recorded. Requirement. The fire records were viewed and the weekly alarm tests were recorded and the manager regularly sets off fire alarm and records staff action. A full fire drill has been conducted with fire brigade and another is in the process of being booked. Fire risk assessments were seen as were the certificates for the testing of the emergency lighting test and the fire alarms. The fire officers inspection took place in June and the recommendations have been completed. Service certificates were seen for the hoists, gas installation, EVAC chairs, nurse call system and a certificate of cleaning and disinfection. The accident records were detailed with action taken and person responsible. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 24 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 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 1 x x x 3 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 1 x 3 St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23 (2) (b) (d) Requirement The Registered Person must submit a plan of improvement to the Commission to repair and redecorate any wheelchair damage to doorways and to redecorate bathrooms and toilets making them more homely. The Registered Person must put into place a plan to ensure there are enough bathrooms available for the number of residents accommodated. Previous timescales of 30/11/05 and 31/03/06 not met. The Registered Person must submit a plan of improvement to the Commission to make all toilets accessible to residents, including those using a walking frame. The Registered Manager must monitor the residents dependency levels to ensure that adequate staff is provided. The Registered Manager must ensure that a copy of all recruitment information is obtained from County Hall. DS0000034973.V323959.R01.S.doc Timescale for action 31/03/07 2 OP21 23 (2) (j) 31/03/07 3 OP21 23 (2) (a) (j) 31/03/07 4 OP27 18 (a) 31/01/07 5 OP29 19 (5) (d) 31/01/07 St Nicholas House Version 5.2 Page 26 6 OP36 18 (2) The Registered Manager must implement a system of formal supervision for care staff, which is recorded. The National Minimum Standards suggest at least six times a year. 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP35 OP36 Good Practice Recommendations It is recommended that care is taken to enter the date on records. It is recommended that, as good practice, residents monies held are kept individually. It is recommended that the management and senior staff team encourage the care staff to gain the NVQ level 2 qualification. St Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Nicholas House DS0000034973.V323959.R01.S.doc Version 5.2 Page 28 - 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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