Inspection on 05/09/05 for St Peter`s House

This inspection was carried out on 5th September 2005.

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 Peter`s House 18/12/08

St Peter`s House 06/02/07

St Peter`s House 01/03/06

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE St Peters Cottage Nursing Home 29 Out Risbygate Bury St Edmunds Suffolk IP33 3RJ Lead Inspector Kevin Dally Announced 5 September 2005 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 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 Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Peters Cottage Nursing Home Address 29 Out Risbygate, Bury St Edmunds, Suffolk, IP33 3RJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01284 706603 01284 706811 gnm@countycarehomes.co.uk County Care Homes Ltd Post Vacant Care Home 15 Category(ies) of Old Age (OP) 15 registration, with number of places St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13/07/04 Brief Description of the Service: St Peter’s Cottage is a privately owned care home with nursing, and is registered to accommodate up to 15 Older People. The home is situated on a main road out of Bury St Edmunds, opposite the West Suffolk College. It is within a residential area close to facilities, such as shops and churches. The building, which is set in its own grounds with ample car parking, has an enclosed garden and patio area at the rear. The accommodation is partly in a converted domestic dwelling and partly in a purpose built extension. All rooms are on the ground floor and are single, five with en-suite facilities. St Peters recently changed ownership, and the new owners, County Care Homes Ltd, plan to extend the premises. There are two lounges and a dining room. There is access to the garden from all bedrooms and communal rooms St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report followed a routine announced inspection of St Peters Cottage Nursing Home, and was carried out over a 8.5 hour period on a weekday between 9.30am and 6pm. This was the first inspection since the new owners, County Care Homes Ltd, had taken possession of the home in June 2005. Mr Nixon-Moss, a part owner and the responsible individual, and Mrs Pam NoblePartridge, the proposed manager, were present throughout the day and were available to answer any questions. Residents, and support workers were spoken with about the service, and comment cards were received from 3 residents and relatives. Residents, staff and administration records were checked and a brief tour of the premises was completed. This inspection revealed that of the 30 standards inspected, 21 were assessed as fully met, and 9 standards as almost met. Whilst the new owners had made a number of changes, the home continued with the positive provision of a nursing care service to residents with medical problems. What the service does well: What has improved since the last inspection? In May 2005, the home was purchased by County Care Homes Ltd, and their application to register with the CSCI, was successful. This inspection demonstrated that the new owners were beginning to implement a number of positive changes, including the appointment of a permanent manager, the reorganisation of the home policies and procedures, and the reorganisation of the staff group. The new owners also propose to extend the building shortly to accommodate additional beds, storage space, and a new lounge. Dialogue had also been undertaken with residents, relatives and the staff group, to inform of the changes ahead. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 6 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. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 People can expect that they will receive helpful and informative information about the service provided. People can expect to have their care needs assessed prior to admission and will know whether or not the home is able to meet their needs. EVIDENCE: The home had an informative Statement of Purpose and Service User Guide, which described for each prospective or current service user the key points about the home. The new owners had recently updated this document. During the inspection, three resident’s records were examined and each contained a “Health and Social Assessment”, which incorporated 19 areas of basic assessed need. On completion of this assessment, various additional risk assessments would be undertaken, and finally a more detailed care plan developed from the information provided. Two service users spoken with, one service users comment card and one relatives comment cards confirmed that they were satisfied with the care provided. One relative stated that they thought that the overall care “could be better”. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 People can expect to receive adequate nursing care, although some care plans would not provide sufficient details or outcomes of some identified care needs. Based on service users comments, people can expect to be treated with respect and be encouraged to maintain their independence. EVIDENCE: St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 10 The home had recently introduced a new care plan format, which positively provided a logical sequence of assessment of a residents care needs. This included various risk assessments and outcomes, from which a detailed care plan would then be developed. Three residents new care plans were checked, and each included a “Health and Social Assessment” form, which incorporated 19 areas of basic assessed need. Further, all three plans included a manual handing assessment, a waterlow pressure care risk assessment and a nutritional screening assessment. Two care plans included a falls assessment. Each contained a record of that resident’s monthly weight. In discussion with the proposed manager, it was confirmed that from these assessments, a detailed care plan would then be developed around the significant care needs identified, and the action to be followed by staff. One of the three care plans checked contained a detailed description of the outcomes of the assessments undertaken. For example they identified the outcome from the waterlow and nutritional assessments, and described the action that must be followed by staff, to ensure that the residents care needs would be adequately met. However, two care plans did not include the details around the care to be followed. The proposed manager confirmed that some of the details required for these new care plans, and risk assessments were still in the process of being transferred by staff, and that the missing information from these plans, were available within the resident’s older plans. It was agreed that the details of outcomes of the new care plans must be completed without delay for all residents, where this information had yet to be provided. From discussion with residents and comment cards received from a resident and relatives, it was confirmed that the home met the healthcare needs of most people. One resident confirmed that they were “happy” with their care, whilst another stated that whilst they were satisfied with their care, they thought that, “they don’t get as much continuity as they used to”. One relative’s comments informed that they were satisfied with the overall care provided while a second relative stated that they [the home] “could be better”, but did not go on to say how. Residents confirmed that they had access to their own Doctor, the Dentist, the Chiropodist and the Optician, when required. The new care plans included a separate record of any Doctors, Dentists or Chiropody visits. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 11 The two residents spoken with were observed to both have one minor bruise, on one of their arms. One resident confirmed that this had been as the result of a recent fall at night, but was now recovering. Records checked, including the accident book, provided details of this event. The second resident stated that their small bruise was the result of a member of staff assisting them to mobilise. This had been recorded in their daily records, a few days earlier, but no reason was given as to the possible cause. No further action had been taken to investigate this situation. This was discussed with the proposed manager, and the owner, and it was agreed that this matter must be investigated immediately to confirm how this had occurred and address any issues around inadequate moving and handling procedures. Further, it was agreed that an appropriate system of monitoring and recording injuries must be in place, and consideration must be given to any identified need for staff training, and the redevelopment of care plans and moving and handling risk assessments to record any trends or risks. The proposed manager confirmed that since June 2005 (the period the new owners had taken over) that there had been 5 reported falls within the home, and that these were minor in nature. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 12 The homes medication system was checked and this revealed that medication was normally stored in the locked medication cupboard. The home used the Medication Dispensing System (MDS) with prepared blister packs, and Medication Administration Record (MAR) sheets. Registered nurses would check each resident’s records, and administer medication to residents via labelled pots. One nurse maintained overall responsibility for the ordering of medication each 28 days and had a system in place to ensure that ordering and sufficient stock was maintained. Medication records for three residents were examined and were found well maintained with no gaps in administration records. Further, a nurse was observed administering medication to residents. The practice of dispensing medication into labelled containers, and administering to residents should be discouraged, due to the possibility of medication errors. At the inspection it was noted that the medication cabinet was made of wood, not metal as specified by the Misuse of Drugs Regulations 1973, and which applied to Nursing Homes. This was checked with the CSCI pharmacist inspector, who confirmed that this must be replaced with an appropriate cabinet that met these standards. The home’s medication policy was checked and this included information around the storage, prescriptions, administration, errors, non-prescription medications, and disposal. This provided basic guidance for staff but should be further developed to include who is responsible for the medication ordering procedures, and the systems currently used including the system for record keeping. The Controlled Drugs policy was not very detailed and must be further developed to be clear about the process required for the storage, administration and disposal of Controlled Medication. Medication policy should also include whether there are any special requirements around the administration of specialised medication, for example insulin. Residents spoken with, and comment cards received, confirmed that staff respected residents privacy, and provided care in a supportive and dignified manner. The 3 returned comment cards received confirmed that residents were cared for, although one relative stated that “[care] could be better” but did not state why. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 People can expect a lifestyle that enabled them to participate in personal, social and leisure activities within the home, should they choose to do so. Relatives and friends can expect to be made welcome when visiting the home. Residents can expect to receive meals that are nutritious, balanced and which met their needs. EVIDENCE: Discussion with a group of residents and a group of the staff confirmed that residents are able to follow their own routines, and a variety of leisure and personal pursuits. Residents confirmed that they were able to choose when they rise in the morning and that staff would respect their requests to remain in bed should they so choose. Residents and staff spoken with confirmed that the home had a varied recreational programme which included various board games, music, gentle exercises, and local visiting groups. A Social Activities organiser now provided organised events every Friday and this included trips outside the home, visits to the local community or one to one with residents. The local Vicar called regularly at the home, and there was a prayer meeting for those who wished to join in. Further, there were social opportunities at meal times to gather with other residents and discuss the days events. Residents are able to choose where they eat their meals, including within their own room. Residents records examined evidenced that individual interests, likes, dislikes and preferences are recorded under “Leisure Activities”. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 14 Residents spoken with stated that the activities organised by the activities organiser were “very good and included outings”. Families, friends and representatives are welcomed at the home, and relatives and friends were seen visiting on the day of the inspection. Residents confirmed that friends and family were able to visit the home, and that there were no restrictions placed on visiting times. The home had developed a four week rolling menu, which offered residents a well-balanced, varied and nutritious diet. The evening meal was a lighter menu, but also offered a light hot option. The meal on the day of the inspection looked and smelt appetising and was appropriately presented. This was pork casserole, mashed potatoes, carrots, and cabbage. Dessert was lemon sponge with custard. The home also offered a variety of alternative hot meal options, if the main menu did not suit. Blended meals were offered to those requiring soft diets and components were liquidised and served separately on the plate to maintain a variety of textures, flavours and colours. Some residents chose to eat in the dining room, although meals could be taken in their rooms if they so wish. Drinks were available throughout the day and the lunchtime meal was unhurried with sufficient time given to residents to eat in comfort. Residents stated that they thought that the meals had been “up and down” but that they were waiting to see how the new chief worked out. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 People can expect to have their complaints taken seriously and acted upon. Resident’s safety, including by appropriate training and recruitment checking, can be expected. EVIDENCE: The home had a complaints policy, which included appropriate details about how a complaint can be made to the home or the CSCI. The home had a complaints book in operation, and had two recorded complaints since June 2005. These complaints had been investigated and responded to by the home. Resident and relative questionnaires indicated that people know about the complaints procedure and who to complain to if they are not happy. The complaints book did not easily identify relevant complaint information, and the home should consider reorganising this for ease of reference. On the day of inspection residents spoken with said that they felt safe at the home and felt confident that they could talk to someone, if they had any concerns. Care staff training records included abuse awareness, and staff spoken with confirmed that they had training, and had an awareness of protection of vulnerable adults procedures. Two staff records were examined, and while one included a Criminal Bureau Record check (CRB), one new staff member who was working within the home, had not had confirmation of their POVA or CRB check. The home was required to address this matter immediately. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 People can expect a safe well maintained environment, which would be clean, hygienic, and odour free. They can also expect to have the aids and equipment to meet their individual needs. EVIDENCE: St Peter’s Cottage is a privately owned care home with nursing, and is currently registered to accommodate up to 15 Older People. The building, which is set in its own grounds has an enclosed garden and patio area at the rear. The accommodation is partly in a converted domestic dwelling and partly in a purpose built extension. All rooms are on the ground floor and are single, five with en-suite facilities. St Peters recently changed ownership, and the new owners, County Care Homes Ltd, plan to extend the premises, and upgrade the existing building. There are two lounges and a dining room. There is access to the rear garden from all bedrooms and one of the communal rooms. A brief environmental tour of the premises concluded that resident’s personal rooms were adequately decorated, comfortable, and maintained. The main St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 17 corridor area was observed to have two tables, which partially obstructed the escape route. These were required to be removed. The hallway carpet to the rear of the home was found marked and required cleaning. The owner confirmed that this was due to be replaced after completion of the building programme but that this would be cleaned shortly. The home had a variety of aids, adaptations and a call bell system. On the day of the inspection the home was found to be clean, hygienic and odour free. The bathrooms, toilets and bedrooms seen were provided with liquid hand wash and paper hand towels. Residents and staff confirmed that the home was maintained in a clean and hygienic state, even though they were one cleaner short. A sample of hot water tap temperatures revealed that these were maintained around the recommended guideline of 43 degrees Celsius. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 People can expect that the home will be appropriately staffed, but some staff will be relatively new to the home. People can expect effective staff recruitment, training and supervision procedures. EVIDENCE: The home endeavours to ensure that there was one nurse on duty each shift, and in addition to the nurse, 3 care staff on an early, 2 on a late, and 1 at night. Relative’s comments received and residents spoken with stated that they did not think that there was always enough staff on duty. In discussion with the owner and proposed manager it was evident that there had been a significant turnover of staff, which had proved unsettling for residents, staff and management. However new staff had been employed, and rotas examined found that staffing levels had been maintained. In some instances, staff numbers had actually been increased. The staff group confirmed that there had been staff changes recently but also confirmed that staff numbers had improved, since the new owners had come. Two staff members records were examined, and while one included a Criminal Record Bureau check (CRB), one new staff member who was working within the home, had not received confirmation of their POVA or CRB check. The home was required to address this matter immediately. Both employees records included two written references, their personal details, and an application form. One staff member’s records did not include a proof of identity, which was required. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 19 Staff members confirmed that they had received various training relevant to their job. One nurse confirmed that they had been on separate relevant diabetic, wound care and first aid courses. Care staff confirmed that they had received relevant moving and handling training, first aid, fire training a continence course, and medication training. One staff member confirmed that they had completed their National Vocational Qualification level 3 in care. Records confirmed that staff had received various courses. One new employee had yet to receive moving and handling training, which was required to be provided. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 People can expect the home to be properly managed and which has an open atmosphere. They can also expect a safe environment. EVIDENCE: In May 2005 the home was sold to and purchased by County Care Homes Ltd, and their application to register with the CSCI, was successful. This inspection demonstrated the positive changes that the new owners were bringing to the home, which was in part gained from their experience of the operation of their first home. The new owners plan to extend the home and upgrade the existing premises, which are beginning to show some signs of wear. The owners had established dialogue with residents, relatives and the staff group, and had kept them informed of the expected changes ahead. Further, the owners have recruited a new manager who has now been in place around three months, and who must now make an application to the CSCI for registration. The owners will take responsibility for some of the more burdensome administrative tasks, which will ensure that the manager can focus on the nursing related issues. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 21 Administration and recruitment practices are under review and record keeping practices were being updated. Residents, relatives, and staff spoken with confirmed that the new management were approachable, and were keeping them in touch with developments. Staff confirmed the positive changes that they had seen over the past two months, and stated that they felt supported by the new management. Some staff and residents have found the loss of some of the staff group unsettling but are positive about the current direction of the home, particularly additional staff and the prospect of extended premises. Staff spoken with and records checked revealed that supervision had been sporadic over the last 6 months, but felt able to approach the new owners or the proposed manager. Staff had received relevant health and safety training appropriate to their job roles. The home was being properly maintained and relevant maintenance checks were now undertaken. Fire records checked revealed that these were regularly undertaken and a record was being maintained. The owner asked if the inspector could request a visit from the fire officer to clarify a number of matters around the home, and this was arranged. St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x x 2 x 2 St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 23 No 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. 2. Standard 7 7 Regulation 15(2)(b) 15(1) Requirement All new care plans must be completed without delay. Care plans must include the full details of the care to be provided, based on the assessed needs of each resident. The home must investigate the cause of one residents small bruise, and ensure that strategies are put in place to prevent any recurrence. The home must ensure that there is a system in place to monitor residents injuries and accidents. The home must ensure that an appropriate medication storage cabinet is installed Timescale for action 16/10/05 16/10/05 3. 8 12(1)(a) 13(4)(b) (c) 13(4)(c) immediate 4. 8 immediate 5. 9 6. 9 13(2) & Misuse of drugs act 1973 13(2) 16/12/05 7. 8. 19 19 13(4)(a) 23(2)(d) The Controlled Drugs policy must 16/10/05 be further developed to be clear about the process required for the storage, administration and disposal of Controlled Medication. Two small tables within the main Immediate corridor area must be removed to ensure a clear fire escape. The hall way carpet to the rear 16/10/05 of the home must be cleaned or relaced Version 1.40 Page 24 St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc 9. 30 10. 30 11. 12. 13. 30 31 36 19(7)(8)( 9)(10 and schedule 2(7) of the Misc Amend regs 2004 Schedule 2(1) of the Misc Amend regs 2004 13(6) 8(1)(a) 18(2) The results of a POVA check must be obtained for any new employee before they commence employment. Immediate Proof of identity must be obtained for the one staff member for whom this had not been obtained. Moving and handling training must be provided for new staff members. The proposed manager must make application for registration to the CSCI Supervision must be undertaken on a regular basis, and recorded. 16/10/05 16/10/05 16/10/05 16/12/05 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 7 9 Good Practice Recommendations The home should ensure that each residents records include a falls assessment, to evidence that there was no risk of falls for those people. Medication policy should be further developed to include who is responsible for the medication ordering procedures, and the systems currently used including the system for record keeping. Medication policy should include whether there are any special requirements around the administration of specialised medication, for example insulin. The complaints book did not easily identify relevant information, and the home should consider reorganising this for ease of reference. 3. 4. 9 16 St Peters Cottage Nursing Home I54-I04 S64425 St Peters Cottage V640832 050905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 5th Floor, St Vincent House Cutler Street Ipswich IP1 1UQ National Enquiry Line: 0845 015 0120 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. 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