Inspection on 02/02/06 for St Peters Home

This inspection was carried out on 2nd February 2006.

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

The inspector 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 13/02/07

St Peters Home 04/07/06

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 Peter`s Home Limited St Peter`s Home 26 St Peter`s Road Margate Kent CT9 1TH Lead Inspector Sandra Crosby & Christine Grafton Unannounced Inspection 2nd February 2006 10:30 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 Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 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.V280638.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Peter`s Home Limited Address St Peter`s Home 26 St Peter`s Road Margate Kent CT9 1TH 01843 291363 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 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.V280638.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 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 aim of St Peters Home is to retain and promote independence for service users and there are specific objectives to underpin this aim. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and carried out by two Inspectors on Thursday between 10:30 and 2:30. During the inspection the Inspectors spoke with Service Users, observed practice over one dinner time period, and spoke with the Registered Person, the recently appointed Manager, and staff. Records were seen and an accompanied tour of some areas of the premises was made. The focus of the inspection was to check on compliance with the requirements and recommendations made at the announced inspection visit dated 08 August 2005, and to discuss issues with the Registered Person and new Manager of the home. The Inspectors returned to the home on the 09 February 2006 to provide the feedback summary sheets, and to discuss the requirements and recommendations made at the time of the unannounced inspection visit on the 02 February 2006 with the Registered Person and the Manager. The Registered Person and Manager agreed to address the issues raised. What the service does well: What has improved since the last inspection? The recently appointed manager has been in post for three months. The Manager reported that the large number of agency hours previously used has been reduced as the home she said was now fully staffed, with flexi-staff available as needed. Training is being undertaken, and further training is being accessed. Re-decoration is ongoing at the home. The Registered Person said that the issue in relation to the privacy curtains had been addressed following the announced inspection visit dated 08 August 2005. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 6 What they could do better: Small additions and amendments to be made to the Statement of Purpose and Service User Guide to clearly show that for example the home has shower facilities only and no baths, no ironing is carried out as part of the laundry service provided. This requirement was made at the announced inspection visit dated 08 August 2005. Although Service User Plans were seen to be comprehensive improvement needs to be made in relation to cross-referencing, together with ensuring that all appropriate entries are made for example a visit by a GP. Medication administration practice to be improved Staff practices to be improved when assisting Service Users at mealtimes ensuring the promotion of Service Users dignity. Moving and Handling practices to be improved thereby promoting health and safety of Service Users and staff. Provision of suitable dining room furniture Utilise all communal areas of the home, and provide a self-closure fitting to the door of the new lounge area to encourage Service Users to make use of this additional well presented communal area. The Registered Person agreed to provide this at the announced inspection visit dated 08 August 2005. It had not been fitted on the 02nd February 2006, however it was seen that the selfclosure had been fitted to the lounge door at the short visit made on the 09 February 2006. The conservatory area of the home was very hot on the days of the announced inspection visit, and very cold at the time of this visit. Management were advised to consider ways of addressing this situation in order to make better use of the space that is included in the registered day space. Maintain control of strong odours in the home especially noticed in the front dining room at the time of the visit. The upgrade of the kitchen was discussed, and the Registered Person said that this might be undertaken in 2007. In the meantime consideration should be given to providing some means of reducing the temperature in the kitchen in the summertime, and also to the provision of a dishwasher. All of the above issues were discussed with the Management of the home. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 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.V280638.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 The homes Statement of Purpose and Service User Guide following some additions and amendments agreed with the Registered Person and Manager will provide Service Users and prospective Service Users 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 application at this inspection visit. EVIDENCE: Standard 3 was judged as standard met, Standard 1 was nearly met and Standard 6 was judged as not applicable at the announced inspection visit dated 08 August 2005. These standards were not inspected at this inspection visit, and the information below refers to the judgement made at the announced inspection visit, except for Standard 1 that was again judged as nearly met at this inspection visit. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 10 Discussion took place in relation to the Statement of Purpose and Service User Guide provided by the Manager. It was again requested that the documents be reviewed to ensure accuracy and add any information as appropriate in relation to the practices undertaken at the home, for example the home provides shower facilities only and no baths, the laundry service provided does not include the ironing of clothes. These examples and other small amendments needed to these two documents have been discussed at previous inspections. At the visit on the 09 February 2006 the Manager said that she had made the changes discussed to the two documents. At the announced inspection visit it was seen that Care Management provide completed assessment paperwork for Social Services Service Users, and the home would carry out a pre-assessment for any privately funded Service Users prior to admission to the home. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The care planning system meets the requirements of the national minimum standards and regulations, however it was found that not all information recorded was then followed up, and that some information was not recorded and this could be detrimental to the well being of Service Users. The health needs of Service Users in the main are met, but again not always appropriately recorded. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure Service Users medication needs are met, however a practice seen in relation to administration of medication was questionable at this visit. Staff endeavour to treat Service Users with respect, and aim to promote privacy and dignity, although practices witnessed at a mealtime would question this. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 12 EVIDENCE: Standards 9 and 10 were judged as standard met, and Standards 7 and 8 was nearly met at the announced inspection visit dated 08 August 2005. Standards 7,8,9 and 10 were judged as nearly met at this inspection visit. A selection of Service User Plans were examined, and showed that all the components as required by the Standards and Regulation were in place, and efforts to improve the documentation has been ongoing. There was however evidence that one visit the Manager said a GP had made was not recorded in the Service User Plan, and there was also evidence to show that one Service User was recorded as having lost seven pounds in weight in a two month period, and the review of the Service User Plan did not reflect this or indicate that any action should be taken. At the visit on the 09 February 2006 the Manager said that action had been taken and that she was currently making changes to the Service User Plan format. It was seen that the home as previously advised now has individual weight records in a separate folder, however due to the fact that it was found that one Service User did not have a weight record form, it was suggested that these forms be incorporated into the Service User Plan folders. In relation to the promotion and making proper provision for the health and welfare of Service Users, it was discussed that the Manager had eventually managed to address and hopefully resolve an ongoing issue, however the Inspectors opinion is that from the records seen action should have been pursued within a shorter timescale, in order to alleviate unnecessary suffering. The Manager confirmed that the relatives were satisfied with the final outcome. Although the medication records and storage were not seen at this inspection visit, a poor practice was observed when the dinnertime medications were being administered. This issue was discussed with the Manager who said that she would address this issue, and that the carer had undertaken medication training. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 13 There were some good practices seen by a couple of members of staff over the mealtime time period, for example sitting with a Service User assisting them to eat their meal. However other issues seen and raised with Management included at one time there being no members of staff in the large lounge/dining room. Staff members terms of address for Service Users, staff assisting with feeding being stood over the Service Users and Service Users not being asked about choices of drink, or the sweet as the bowls were just put down in front of Service Users with very little communication at times. It was also seen that for some Service Users the seating arrangement at a mealtime were unsuitable. The tabards were not provided for Service Users in order to keep the clothes clean until after the Service Users had started to eat their meal. None of these practices work towards the promotion of Service User dignity and respect. At the visit on the 09 February 2006, the Manager said that the provision of appropriate dining room furniture was being looked into, together with a better utilisation of the communal space at the home St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 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. Service Users do not usually go outside of the home and grounds unless taken out by family. 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. Conversation and interaction, particularly during mealtimes, was minimal in the home. If more verbal contact was generally undertaken, this would encourage and promote choices even if this is through observation. The menus in the home have been changed again since the new Manager started at the home. It is the Inspectors opinion that the meals supplied indicate that low budget meals are often provided at the home. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 15 EVIDENCE: Standards 12 and 13 were judged as standard met, Standard 14 was nearly met and no judgement was made in relation to Standard 15 at the announced inspection visit dated 08 August 2005. Standards 12,13 and 14 were mainly not inspected at this inspection visit, and the information below refers to the judgement made at the announced inspection visit, together with information in relation to this visit. 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. 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. Both the conservatory area, and the recently appointed small lounge were not observed as being used by Service Users at this inspection visit. In relation to the use of Multi Purpose cloths used for personal care as seen in use at previous inspection visits the Manager at this visit reported that many of the Service Users now had flannels to use. The Inspectors were told at the announced inspection visit that the care staff that are on duty at the time undertake activities, and the activities record book was seen. It remains the same at this inspection visit and discussion took place in relation to ways that this could be improved upon. The Manager said that she is looking at ways of improving stimulatory activities, and it was discussed that she had been considering the possibility of some Service Users being able to visit the local pub across the road from the home. At the time of the inspection visit the Inspectors observed the mid-day meal. This was a sausage-meat pie, with mash potatoes, peas, leaks and gravy with semolina and jam or yogurt for sweet. The menus were discussed and it was said that again the main meal of the day was a low cost meal. From the figures provided by the Registered Person it was indicated that approximately £16.00 per week per Service User was spent, although of course if the home were full to maximum this would show that £14.00 a week per Service User if the budget remained the same. The Registered Person discussed that the Inspectors said that food was returned to the kitchen, and the Inspectors said that this might be because Service Users were not suitably assisted to eat their food. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The complaints record was seen and indicated that complaints are recorded together with the action taken and outcome. The training matrix does not indicate that staff have received training in relation to Adult Protection. It is however known that a recent Adult Protection issue was dealt with appropriately by the home. EVIDENCE: The complaints book was seen, and in discussion about the odour smelt by the Inspectors on arrival at the home, there was also reference in the complaints book about odorous smells in the home. There was evidence that appropriate action had been taken in relation to the complaint. A recent Adult protection issue was appropriately handled by the home. Suitable documentation was seen, and the Manager said that ‘in house’ training was to be arranged and undertaken by staff. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The standard of the environment within the home is good providing Service Users with on the whole an attractive and homely place to live. The garden area is well maintained. The home was mainly clean and pleasant at the time of the inspection visit. EVIDENCE: Standards 19,20,21,23 and 25 were judged as standard met, and Standards 22,24 and 26 were nearly met at the announced inspection visit dated 08 August 2005. These standards were mainly not inspected at this inspection visit, and the information below refers to the judgement made at the announced inspection visit, together with some information obtained at this visit. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 18 It was seen at the announced inspection visit that Service Users remain mainly in the large Lounge/dining area during the day. One Service User only was seen in the conservatory area on the second day of the inspection visit. It was a very hot day and it was suggested in order to utilise this area; window/roof dressing for example blinds could be installed to reduce the temperature in this area and thereby make better use of this communal space. The Registered Person said that he has taken no action as yet in relation to this issue. At this inspection visit the conservatory area was very cold and as such would not be a comfortable area for Service Users to make use of. This issue was discussed with the Registered Person, who seemed to think that as the service user number had until recently been 23 that there was sufficient day space in the main lounge/dining room and small lounge areas. The Inspector pointed out that the home was registered for 30 persons and as such the conservatory area was included in the communal space and as such should be maintained at an ambient temperature. It was also seen at the announced inspection visit that the new lounge area in the extension wing was being used mainly for activities. It was suggested at that visit that a self-closure fitment needed to be provided for the door of the lounge, as if this room door was open it would hopefully encourage more use by Service Users. Currently when the door is closed it looks just the same as all the bedroom doors on the new extension. At this visit it was discussed that this issue had not been addressed and the Registered Person immediately arranged for the handyman to go out to purchase a self-closure fitment. The bedrooms do not have a bedside light, as this has been risk assessed as a hazard for the whole of the Service User group. The Registered Person confirmed that action had been taken to address the issue of the privacy curtains in one of the double bedrooms needing adjusting in order to ensure privacy for both residents. The kitchen area seen on the second day of the announced inspection visit was extremely hot even with the fans that were seen in use. The Registered Person said that plans were underway to redesign this area of the home. The Inspectors requested that the fans in this area be kept clean. The Registered Person has since informed the Commission that the upgrade of the kitchen area was currently on hold. At the visit to provide a feedback summary of the inspection the Registered Person after some discussion said that plans to upgrade the kitchen might be implemented in 2007. A recommendation has been given in relation to this area, and includes maintaining a suitable temperature in the kitchen in the summertime, and the provision of a dishwasher. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 19 It was observed at the announced inspection visit that the laundry area again very hot and the possibility of a covering for the roof area extension was discussed with the Registered Person. At this inspection visit the Inspectors were told that no action had been taken to address this issue. The Manager reported that a new washing machine had been purchased. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 It is judged that consideration needs to be given to staffing levels especially during the meal time periods in relation to the number of Service Users who require assistance with eating their meals. Action is also to be taken in light of current changes at the home, and this standard will be further assessed at future inspections to ensure that the homes staffing levels meet the needs of the Service Users. The home has a thorough recruitment procedure in place to ensure that Service Users are supported and protected. Care needs to be taken to ensure that all documentation is completed. Staff training is ongoing at the home. EVIDENCE: Standards 27,29 and 30 were judged as standard met, at the announced inspection visit dated 08 August 2005. These standards were mainly not inspected at this inspection visit, and the information below refers to the judgement made at the announced inspection visit, together with some information obtained at this visit. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 21 The staff rota seen at the announced inspection visit showed that at that time with 21 Service Users, there was one senior carer and three carers on duty, together with the Cook and one domestic cleaner. The carers are also required to cover laundry duties and provided occupational therapy activities. In addition to this on the first day of the inspection visit, the Registered Person, the Registered Manager and the Deputy Manager were in the home, and on the second day of the inspection visit the Registered Person and Deputy Manager were in the home. It was discussed with Management at the announced inspection visit that during the observation of the main meal on the second day of the inspection visit, it was indicated that extra staff assistance at this time would have been beneficial. Management said that usually the Registered Manager and another family member was there and provided assistance. It was found at this inspection visit that currently with 26 Service Users, there is the Manager, one Senior Carer and three carers on shift during the day. The Manager reported that an extra domestic cleaner has been employed; however staff are still required to undertake some laundry duties and the recreational activities. It is indicated therefore that although the Service User number has increased by 5 high dependency persons, the staff level remains the same. The Manager did say that there had been discussion with the Registered Person in relation to the staffing levels being increased. More positively it was stated that the large number of agency hours used at the home has been greatly reduced, and it was said that the home is now fully staffed, with flexi staff members available to help out as required. It remains a concern that staff undertake laundry duties and any activities provided and makes it debatable as to whether the staffing levels at the home meet the required minimum standards, although Management confirms that the Residential Staffing Forum hours are met. When considering the assistance that is required during the day, the support needed to provide a good quality of life and the stimulation that Service Users obviously need to develop or maintain skills, it is questionable that staffing levels are always adequate. It is therefore suggested that Management review the staffing levels at the home. Staff files were viewed at the announced inspection visit and showed that all necessary documentation was in place indicating that a thorough recruitment process is completed. The Management were asked to ensure that all documentation was fully completed, and this they agreed to do. The Inspectors were told at the announced inspection visit that staff have attained NVQ Level 2 training or the equivalent in order to meet the required standard. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 22 It was seen at the announced inspection visit that the staff training records needed to be updated, and the Manager was able to provide a copy of the staff training matrix that she had completed for the home. The Inspectors advised that the full date of training be entered, and not just the year. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 No judgement was made in relation to Standard 31 as the Manager has only been at the home for approximately three months, however it is known that the Manager has many years of experience and has managed other homes prior to St. Peters. 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. Some practices seen at the home do not promote and safeguard the health, safety and welfare of the people using the service. The Manager talked about supervision of staff, and of regular meetings taking place. Systems are in place in relation to the safe storage of records. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 24 EVIDENCE: The Deputy Manager at the announced inspection visit confirmed that the home does not hold any personal allowance monies for the current group of Service Users. She did say that recently a new system had been set up whereby if Service Users relatives wished they could pay the monthly sum of £7.50 to cover all toiletries as needed. Currently some relatives bring in toiletries for their family member, and some relatives have signed and agreed to pay this monthly amount. Although Standard 38 was not fully inspected at the announced inspection visit, discussion took place in relation to the need to provide a self-closure fitment to the door of the new lounge area in the extension, and the Registered Person agreed to do this. Action has not been taken to address this issue, but on the day of this inspection visit the Registered Person sent the handyman out to purchase a suitable fitment, and this has since been fitted. The Fire Log Book was seen at this inspection visit and showed that up until four weeks ago all the regular monitoring tests were being undertaken and recorded. There is a need for a Fire Practice Drill to be undertaken as records show that one has not been undertaken for many months. The Manager said that a Fire Practice Drill had been arranged for the day of the visit. Fire training is also to be arranged, and the Manager said that two staff members are due to undertake First Aid Training in March this year. St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 3 2 3 2 2 2 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 2 St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 26 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 OP1 Regulation 4&5 Timescale for action The Statement of Purpose and 31/03/06 Service User Guide to be reviewed and additions and amendments to be made – Previous timescales 31/12/05 30/01/04 31/10/04 Comprehensive Service User 02/02/06 Plans to contain all appropriate information - Cross-referencing within the Service User plan to be improved – Previous timescales 11/08/05 03/07/05 30/01/05 21/07/04 To promote and make proper 02/02/06 provision for the health and welfare of Service Users – Previous timescale 11/08/05 The registered person ensures 02/02/06 that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines The Registered Person shall 02/02/06 make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users DS0000023548.V280638.R01.S.doc Version 5.1 Page 27 Requirement 2. OP7 15 3. OP8 12(1)(a) 4. OP9 13 5. OP10 12(4)(a) St Peter`s Home Limited 6 OP25 23(2)(p) 7 OP26 16(2)(k) 8 OP27 18(1) 9 10 OP38 OP38 18(1) 17(2) Schedule 4-14 The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users The premises are kept clean, 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 Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users Staff to update First Aid Training – Previous timescale 11/08/05 The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff – Maintain Fire Records and undertake regular Fire Practice Drills 02/02/06 02/02/06 02/02/06 31/03/06 02/02/06 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. 4. Refer to Standard OP19 OP20 OP26 OP38 Good Practice Recommendations To consider blinds or similar to reduce the temperature in the conservatory area, to enable full utilisation of communal space Review current dining chairs, it may be found more appropriate for dining chairs with arms for support to be provided Provide window/roof covering in the Laundry area to reduce temperature Self-closure fitment to be fitted to the door of the new lounge area in the extension DS0000023548.V280638.R01.S.doc Version 5.1 Page 28 St Peter`s Home Limited 5 OP19 Upgrade kitchen area together with provision of equipment to maintain a suitable temperature in the kitchen and surrounding area. Provision of a dishwasher St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. Extracts may not be used or reproduced without the express permission of CSCI St Peter`s Home Limited DS0000023548.V280638.R01.S.doc Version 5.1 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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