Inspection on 13/02/07 for St Peters Home

This inspection was carried out on 13th February 2007.

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

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

Other inspections for this house

St Peters Home 19/06/07

St Peters Home 04/07/06

St Peters Home 02/02/06

St Peters Home 08/08/05

St Peters Home 30/01/05

St Peters Home 20/07/04

St Peters Home 16/02/04

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

CARE HOMES FOR OLDER PEOPLE St Peters Home Limited St Peters Home 26 St Peters Road Margate Kent CT9 1TH Lead Inspector Sandra Crosby and Marion Weller Key Unannounced Inspection 13 February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Peter`s Home Limited DS0000023548.V326959.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 Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peters Home Limited Address St Peters Home 26 St Peters Road Margate Kent CT9 1TH 01843 291363 01843 299789 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) St Peters Care Home Limited Post Vacant Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 Brief Description of the Service: St Peters Home occupies two semi-detached premises. There are 24 single bedrooms and 3 double bedrooms, of which 19 have en-suite facilities. Accommodation is available on three floors and there is a shaft lift. All rooms have call bells. The Home is close to local facilities and is located in a residential area close to Margate town centre with all its amenities. There is a large garden to the rear that is maintained for service users use. The home provides showers for Service Users use, but offers no baths. The aim of St Peters Home is to retain and promote independence for service users and there are specific objectives to underpin this aim. Information from the Registered Provider in July 2006 states that the fees range from £367.82 to £445.00 per week. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The second key inspection visit was unannounced and carried out by two Inspectors on Tuesday 13 February 2007 between 10.00 and 15.00, and on Wednesday 14 February 2007 between 10.30 and 16.15. During the inspection the Inspectors spoke mainly with the Manager, the Registered Provider, staff on duty, several Service Users and observed practice over one dinner time period. Records were seen and an accompanied tour of some areas of the premises was made. The focus of this second key inspection visit was to inspect the home in relation to the Key Standards and check on compliance with the requirements and recommendations made at the random inspection visit dated 16 October 2006. Feedback from the inspection was provided at the end of the second day of the inspection visit when discussion took place between the Inspectors, the Registered Provider, the Manager, and the home’s Consultant. The Pre-inspection Questionnaire documentation was not requested for this inspection as it had been completed for the first Key inspection visit, however information requested at the time of the visit was provided by the home. This information together with observational information and discussion with the Registered Provider, the Manager, the Consultant, Service Users and staff at the time of the inspection, has been used when compiling this report. Since the last key inspection visit dated 14/07/06 the then Deputy Manager has taken on the role of Manager, and the Inspectors appreciated the helpful attitude and approach to the inspection adopted by the Manager. It was evidenced that the management at the home have made improvements and are working hard to further improve the standard of care at the home. What the service does well: What has improved since the last inspection? Pre-assessment documentation was seen appropriately completed. The Service User Plans are in the process of being re-formatted. Medication practices have improved, however further improvement is needed. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 6 Individual Activity records are being recorded. The arrangements at mealtimes indicated that the majority of Service Users are now able to sit at a table for their meal, and that several areas of the home are used for this purpose. Meals provided by an external contractor indicates from the example seen that a varied and nutritious menu is used, and the introduction of finger foods has proved beneficial. Comprehensive food records are being maintained. Appropriate complaints records are being maintained. Re-decoration is ongoing at the home. Training is being undertaken, and further training is being accessed. The Manager is undertaking the Registered Managers Award. A Quality Assurance system is being developed. Formal supervision of staff is provided with written records being maintained. What they could do better: The Statement of Purpose and Service User Guide need to be amended in order to comply with the requirements of regulation. Contracts/Terms and Conditions of Residence to be provided for all Service Users admitted to the home. The main care plan needs to adequately detail how Service User needs will be met and by whom, when, how, why and more importantly, must give staff clear direction and a safe system of work to follow. Monthly reviews need to record changes that have taken place. All components of the service user plan need to be regularly updated. Improvement is needed in relation to meeting Service Users health care needs. Staff practices to be improved when assisting Service Users at mealtimes ensuring the promotion of Service Users dignity. A number of issues in relation to the environment require addressing. Moving and Handling practices to be improved thereby promoting health and safety of Service Users and staff. Maintain control of odours noticed in some areas of the home at the time of the inspection visit. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 7 Further training needs to be undertaken by staff to understanding of working with Service Users with Dementia. Staff to undertake training - Protection of Vulnerable Adults. broaden their 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 Peter`s Home Limited DS0000023548.V326959.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 Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 and 6 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose and Service User Guide require further amendments in order to provide Service Users and prospective Service Users/Relatives with the information they need to make a decision about moving into the home. Service Users move into the home knowing that their needs have been assessed, and the home endeavours to meet their needs. Standard 6 was judged as not applicable at this inspection visit. EVIDENCE: The Statement of Purpose and Service User Guide documents are in the process of being amended. It was evidenced that some statements about the services offered were not always consistent with evidence and practices observed. The Service User Guide states resident/relatives meetings take place twice a year, the Manager said that this is not so at the moment but indicated that this would be implemented in the future. It was seen that some revisions St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 10 in the Statement of Purpose shown to the Inspectors later on the second day of the inspection visit had been made. Another example that requires amendment was ‘an outside caterer provides the dinner and teatime meals’, whereas the Manager said that currently the teatime meal is provided at the home. The two documents require a number of amendments to be made in order for the documents to comply with the requirements of regulation. A blank copy of a Service Users contract was seen, the Manager said that five contracts had not been completed, but that the work was in hand. The home is aware of new guidance about fees and services to be illustrated in information documents. Pre-assessment documentation was seen appropriately completed and indicated that this had been undertaken prior to the admission of the Service User. St Peter`s Home Limited DS0000023548.V326959.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): Standards 7,8,9 and 10 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system contains all components as required by regulation but is not always clear and consistent when providing staff with the information they need to meet Service Users needs. Service Users health needs are not always met, although Service Users have full access to all professional health care services as required. Service users are mainly protected by the home’s policies and procedures for dealing with medicines but some minor errors were highlighted. Personal care is not always offered in a way to protect Service Users’ privacy and dignity. EVIDENCE: Five Service User Plans were examined, a new format is being implemented by the Manager and indicated that all the components as required by regulation is being provided and efforts to improve the documentation has been ongoing. It was discussed that the care plans seen identify needs, but the main plan does not adequately detail how the needs will be met and by whom, when, how, why and more importantly, does not give staff clear direction and a safe St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 12 system of work to follow. Monthly reviews are being carried out, however it was evidenced that these do not always reflect changes that have occurred between reviews. It was also observed that some of the components of the care plan were not always updated regularly. It was indicated that some Service Users health care issues identified as of concern are not followed through to a satisfactory conclusion, and there was no evidence on occasion of what actions the home has taken to secure the Service Users welfare. On previous inspections it was observed that a Service User required a more supportive chair to meet her needs. On this inspection, the provision of a more suitable chair was still not in evidence. The staff had however placed a pillow in the existing chair, to provide additional support. The Service User appeared to be sitting uncomfortably, and leaning to the right. The Manager stated that medication prescribed for the individual, also made her less supple and it was noted that her posture appeared to be stiff. The stiffness in her lower limbs added to her inability to find a comfortable, supportive position. Records show that in a period covering one week, staff recorded her, ‘slipping out of the chair, but not falling.’ The Manager has made enquires in relation to the provision of a more suitable chair and is actively seeking address to this longstanding issue. The current situation potentially places the individual at risk. The same Service User was seen to be incorrectly transferred to the dining room at lunchtime by staff. Contrary to good practice guidance, the Service User was not warned of the two staff members’ intention to move her from a sitting to a standing position. It should also be noted that she was observed by the inspectors to have been asleep prior to the staffs’ intervention. The Service User was clearly startled by the transfer move and was then almost dragged to the dining area. Her mobility was seen to be poor and she was given insufficient time to gain her senses to be of any assistance to staff. Her dignity was compromised during the transfer with her underwear clearly visible throughout the manoeuvre. The issue was discussed with the Manager and she stated that moving and handling training is booked and will be undertaken in small groups to ensure all individuals receive practical experience. Current poor practice is a hazard to staff and Service Users and the above observations made reflect on the home’s ability to promote and make proper provision for the health and safety of Service Users. The medication records were examined and overall indicated that they were appropriately recorded and up to date. Issues discussed were that for one Service User the known allergies were not recorded in the medication folder, there was no second signature in evidence to confirm accuracy of transcription on hand written MAR sheet entries. Discussion in relation to a prescribed medication for one Service User requires clarification as to dosage and a clear record to be kept as to whether one tablet or a half of a tablet is administered. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 13 The medication storage was not seen at this inspection visit. Staff at the home have undertaken medication administration training. Staff were observed using inappropriate terminology at times when dealing with Service Users for example ‘darling, dear, and sweetheart’ was heard and this approach lacks individuality and respect on occasions. The issue was discussed with the Manager. The home previously used multi purpose cloths for attending to Service Users personal care. The cloths were then laundered and reused. This is not best practice and had been previously discussed with the Manager and mentioned in inspection reports. It was noted that on this visit, the home continued to use the cloths on occasions. However, they are now considered for single use only and then disposed of. Comments from the Registered Provider in a letter to the Commission dated 28/03/07 states that ‘Staff have been reminded on several occasions that they are for single use and are to be thrown away. A memo was put up for all staff by the manager to follow this instruction’. St Peter`s Home Limited DS0000023548.V326959.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): Standards 12,13,14 and 15 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. As the home is registered for Dementia Category, it is difficult to judge if the lifestyle the Service Users experience in the home matches their expectations and preferences. The home endeavours to provide suitable services to meet Service Users needs. Service Users are able to maintain contact with family and friends. EVIDENCE: The routines for daily living at the home are such that it has previously been seen that all Service Users are up and dressed before breakfast, and Management have previously stated that this is due to the Service User category and that Service Users may be in bed by 6.00pm. Comments from the Registered Provider in a letter to the Commission dated 28/03/07 states that ‘several residents do choose to have a ‘lie in’ bed and have breakfast later. Some residents also choose to stay up later with the night staff’. Once Service Users are up and dressed before breakfast, it was observed that the majority of Service Users spend their day in the main Lounge/dining area of the home. Management said that efforts are being made to encourage Service Users to use the other communal areas of the home. Improvement was seen in St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 15 that the majority of Service Users are encouraged to take their meal in one of three dining areas rather than mainly remaining in the lounge, as was the previous practice. The home’s staff provides recreational and diversional activities for Service Users. Events are recorded and entries seen included manicures, games, music and movement and playing ping-pong. The home needs to investigate whether current provision is suitable for all levels of resident capacity and is in line with good practice guidance for this client group. Service Users due to their mental state of health are unable to exercise many choices and little control over their lives, and staff practices need to promote and encourage choices wherever possible. It was noted that all Service Users are assumed to be ‘at risk’. No individual assessment is currently made of an individual’s capacity and ability to lead as ‘normal’ a life as possible. For example, all Service Users were given only a spoon to eat with at the lunchtime meal. The dining tables were not laid up with cutlery, although it was clear that some individuals would have had the capacity to use them correctly and safely. A carer was observed taking around a tray of drinks with a choice of plain water, orange squash or cranberry juice. A drink was placed in front of each Service User, with no communication being entered into with the recipient at all. All Service Users were served their food on plastic plates and in bowls. It is this lack of any effort to maintain individual abilities for as long as possible, that is of concern and gives the service an appearance of providing institutionalised care, albeit, well meaning. These issues were discussed with the Manager. She stated that current practice is necessary for safety. The home’s current practice and resources do not promote client individuality or independence, but support increasing levels of dependency on staff. Service Users have become overly compliant with the home’s practices and this involves some loss of personal dignity and individual freedom. For example, the home offers only showers for the maintenance of Service Users personal hygiene. There are no baths installed in the home and thus Service Users are offered no choice of resource. A shower requires the carer to be present during most of the procedure; a bath would allow some Service Users moments of privacy. Once safely seated, the carer can absent themselves from the room to allow the Service User to enjoy a few moments of privacy and the ability to maintain their independence in dealing with personal areas of care. A member of the family as an external contractor is providing the main meal of the day. The meal observed on the first day of the inspection visit was salmon with a sauce, mash potato and vegetables, with some Services Users having finger food for example pizza. The sweet was jelly and blancmange. The main meal looked appetising and was well presented. The menus seen indicated that a varied diet was catered for with alternative choices provided. Comprehensive records of the food being provided are now being kept. St Peter`s Home Limited DS0000023548.V326959.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): Standards 16 and 18 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints record was seen and indicated that complaints are recorded together with action taken and the outcome, thereby Service Users/relatives and friends can be confident that their complaints are listened to, taken seriously and acted upon. Further staff training in relation to adult protection needs to be undertaken in order to ensure Service Users are protected from abuse. EVIDENCE: The complaints book was seen, and from discussion it was indicated that since the Manager took up post at the home complaints were being appropriately dealt with and records are being maintained. There is currently an Adult Protection investigation being undertaken, and the outcome is not as yet known. The staff training matrix provided by the Consultant showed that a large number of staff still need to undertake Adult Protection training. The Manager said that training is ongoing at the home and that this issue would be addressed. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 and 26 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home where the routine maintenance, decoration, and renewal of the fabric of the premises are maintained, however refurbishment is required in some areas. EVIDENCE: The Manager stated prior to accompanied tour of the home, that new carpet had been laid in dining room, lounge, conservatory, and stairs. The home now has a dishwasher installed and the Registered Provider said that the kitchen refurbishment is underway. The external grounds are well maintained and provide sheltered areas where Service Users may be encouraged to utilise, dependent upon the availability of staff to supervise. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 18 An issue that arose in relation to the position of a Service User seen sitting in one of the lounge chairs was again discussed (see information under Health and Personal Care heading above). It is considered that there are many adaptations available that would provide this Service User with a more comfortable seating arrangement. The Manager is still looking to address this issue. Issues that need to be addressed that were seen during the accompanied tour of the premises are: Lock codes detailed on cupboards in Service User Bathrooms – unsafe practice Topical medication seen in blue plastic open storage basket/ tray on floor in duty office couple of these creams with no named person on – unsafe practice Wooden dining table - unprotected as the surface is not sealed - Hazard to good infection control - small amounts of dried food seen on surface Armchairs are all of the same type – lack diversity and therefore Service Users who need different types/ style of chair are not given any choice but to be uncomfortable No table lamps seen in bedrooms – Service Users have to get out of bed to switch light on/off - Hazard – risk of falls Ensure headboards are appropriately attached to the beds Duvets on Service Users beds are plastic covered - thin, not cosy and may not provide sufficient heat for Service Users - Outer plastic covers seen to be grubby - Comments from the Registered Provider in a letter to the Commission dated 28/03/07 states that ‘ Duvets are plastic due to the high level of incontinence and are purchased from Clinicare. I can confirm that covers are washed regularly’. Lots of boxes of continence pads seen in Service Users bedrooms - no attempt made to store away and provide space for individuals in their rooms - evidence that individuals are not encouraged to utilise their own private space to best effect - Comments from the Registered Provider in a letter to the Commission dated 28/03/07 states that ‘it is my intention to provide room for storage in the plans to extend the home which would help alleviate the incontinence pad box problem’. Although atomising sprays are used, there were noticeable odours in three bedrooms St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 19 Machinery seen stored in Sluice room that needs to be stored appropriate elsewhere in the home One of the Fire escapes observed is in need of repainting Several of the waste pedal bins seen are not of a suitable size for purpose No Category ‘A’ clinical waste bags for the disposal of soiled dressings – Razor seen incorrectly disposed of in yellow clinical waste bag Category ‘E’ - Comments from the Registered Provider in a letter to the Commission dated 28/03/07 states that ‘I have been informed by the company who provided waste bags that we are using the correct category bags. I have written to them and have asked them to put this in writing, following your inspection’. The Inspectors were told that a new laundry facility is to be provided when the proposed further extension is completed. Baby alarms used at night to monitor residents’ movements. The Registered Provider/Manager stated that these are only in corridors and are not intrusive. The Consultant suggested that reference to these to be mentioned in the Statement of Purpose and Service User Guide. St Peter`s Home Limited DS0000023548.V326959.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): Standards 27,28,29 and 30 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users’ needs are met at all times by the numbers and skill range of the staff. Service Users are protected by the home’s thorough recruitment procedures, and staff training is ongoing. EVIDENCE: The home’s staff roster evidences four carers and a senior during the daytime hours. Three carers are on duty at night to meet the needs of up to 30 residents. The home is intending to appoint a further senior carer soon. Existing care staff responsibilities include also dealing with Service Users laundry. The Manager stated that this task would now be allocated to the home’s domestic staff. The home must evidence that staffing levels, even after the current changes are made, provide adequately for the holistic needs of Service Users. Personal care and daily support of Service Users must be balanced against the necessity to also provide them with meaningful activities and diversions both inside and outside the home. Staff files were viewed and indicated that the home is carrying out a thorough recruitment process. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 21 The staff training matrix indicates that over 50 of staff have completed NVQ 2/3. The attitude of some staff, and observations made in relation to staff practices does not always support their NVQ training and some issues need to be addressed by management. The home’s access to training events is improving. The staff training matrix shows for example that thirteen staff have undertaken First Aid training and fifteen staff have undertaken Fire Safety training, with further training booked in relation to Moving and Handling and Infection Control. Further training needs to be booked in relation to for example Dementia, and Health and Safety. The Manager stated that training would be ongoing. The home’s training matrix needs improvement to give a clear overview of staff training needs and should illustrate training completed, training planned and updates due over a set period. The Consultant agreed to address this issue. Discussed with the Manager the Skills for Care – induction and foundation training. The home could evidence information documents. The Manager states that her intention is to use and further develop the home’s induction procedures. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36 and 38 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users are now benefiting from the ethos, leadership and management approach of the home. The standard of care Service Users receive is improving due to members of staff being appropriately supervised. Service Users and staff cannot always be confident that their health, safety and welfare are promoted and protected. No judgement was made in relation to Standard 35 at this inspection visit as Management confirmed at the announced inspection visit that currently they do not handle personal allowance monies for any of the current Service Users. St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Manager is currently undertaking the Registered Managers Award and her formal application to register is pending. The home needs more supervisory staff that are empowered to ensure the home performs properly, and the Manager is hopeful that the extra senior person to start work at the home in March will assist her in continuing to raise the standards. Evidence was seen of a good quality assurance exercise that had been undertaken, currently results not collated and shared with stakeholders and CSCI. The Manager stated that this is to be done. Accident Records seen were good, collated monthly and give a clear overview. The home notifies CSCI as appropriate and Regulation 37 notices have been received. The Manager stated that a recent visit by the fire officer over a 3-day period took place at the home. The building was evacuated and fire drills discussed with staff, including night staff. The home has updated fire risk assessments in line with revised legislation. Staff receive formal Supervision with written records maintained in accordance with regulation. Systems are in place in relation to the safe storage of records. St Peter`s Home Limited DS0000023548.V326959.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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 1 2 2 2 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X 3 X 2 St Peter`s Home Limited DS0000023548.V326959.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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Sch 1 and 5 Timescale for action The Statement of Purpose and 31/03/07 Service User Guide to be reviewed and additions and amendments to be made in order to comply with the regulations – Provide amended copies of both documents to the Commission Office when completed Previous requirements have been made under this standard 05/07/06 31/03/06 31/12/05 30/01/04 31/10/04 2. OP7 15 A service user plan of care 30/06/07 generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered The main plan to provide detail as to how the needs will be met and by whom, when, how, why and more importantly, give staff clear direction and a safe system of work to follow - Monthly reviews to contain all relevant information – Risk Assessments St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 26 Requirement to be undertaken as appropriate Previous requirements have been made under this standard 31/12/06 05/07/06 02/02/06 11/08/05 03/07/05 30/01/05 21/07/04 3. OP8 12(1)(a) To promote and make proper 31/03/07 provision for the health and welfare of Service Users Provide catheter care information together with risk assessment Maintain client behaviour observation documentation as appropriate Previous requirements have been made under this standard 31/12/06 05/07/06 02/02/06 11/08/05 4. OP9 13 The registered person ensures 31/03/07 that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines Known allergies to be recorded – clarification to be obtained in respect of one prescribed medication – records to detail whether one tablet or a half of a tablet has been administered Previous requirements have been made under this standard 20/10/06 05/07/06 02/02/06 5. OP10 12(4)(a) The registered person shall make 31/03/07 suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users Form of address used – verbally St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 27 offering choices – providing those that are able with china plates/knives/forks – dignity when undertaking moving and handling practices Previous requirements have been made under this standard 05/07/06 02/02/06 6. OP12 16(1)(n) The routines of daily living and 31/03/07 activities made available are flexible and varied to suit service users’ expectations, preferences and capacities Sufficient meaningful activities to be provided suitable for Service Users with dementia Previous requirements have been made under this standard 31/12/06 05/07/06 7. OP14 12 The registered person conducts 31/03/07 the home so as to maximise service users’ capacity to exercise personal autonomy and choice Staff to promote individual independence and not to treat service users collectively 8. OP18 12 The registered person ensures 30/06/07 that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies All staff to undertake training in relation to Protection of St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 28 Vulnerable Adults 9. OP22 23(n) The Registered Person shall not 31/03/07 use premises for the purposes of a care home unless …suitable adaptations are made, and such support, equipment and facilities, including passenger lifts, as may be required are provided, for service users who are old, infirm or physically disabled Provision of appropriate and suitable armchairs Provision of specialist armchair as necessary Provision of hoist as necessary 10. OP24 23 The home provides private 31/03/07 accommodation for each service user that is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user Provision of bedside lighting as appropriate Audit bed-linen and replace as appropriate The premises are kept clean, 31/03/07 hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance Odour noted in three areas Provision of correct category clinical waste bags for disposal of clinical waste Previous requirements have been made under this standard 31/12/06 05/07/06 02/02/06 St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 29 11. OP26 16(2)(j) (k) 12. OP12 16(1)(n) The routines of daily living and 31/03/07 activities made available are flexible and varied to suit service users’ expectations, preferences and capacities Sufficient meaningful activities to be provided suitable for Service Users with dementia Previous requirements have been made under this standard 31/12/06 05/07/06 13. OP38 18(1) The registered manager ensures 31/12/07 so far as is reasonably practicable the health, safety and welfare of service users and staff Staff to update mandatory training as appropriate Previous requirements have been made under this standard 31/12/06 05/07/06 31/03/06 11/08/05 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. Refer to Standard OP2 Good Practice Recommendations Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately) A more appropriate wash basin for hair washing would be beneficial if installed in the newly decorated hairdressing room 2. OP19 St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 30 3. 4. 5. OP19 OP26 OP38 It is recommended that the fire escapes are checked as may be in need of repainting/refurbishing Upgrade the laundry facilities at the home Remove machinery seen in sluice appropriately elsewhere in the home room and store St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Peter`s Home Limited DS0000023548.V326959.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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