Inspection on 21/03/07 for St Teresa`s Nursing Home

This inspection was carried out on 21st March 2007.

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

The inspector 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 Teresa`s Nursing Home 16/03/09

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Teresa`s Nursing Home Corston Bath Bath & N E Somerset BA2 9AE Lead Inspector Wendy Kirby Key Unannounced Inspection 21st March 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Teresa`s Nursing Home DS0000068847.V331488.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 Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Teresa`s Nursing Home Address Corston Bath Bath & N E Somerset BA2 9AE 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) 01225 873614 01225 872157 Barkers Chemicals Ltd ****Post Vacant**** Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: St. Teresas is registered as a care home to provide nursing care for up to 44 older people. The home is a converted older property partially extended and set in well-maintained gardens with a pleasant location. The home offers accommodation over 2 floors, level access being provided by a main passenger lift. The Home is situated within 3 miles of the centre of Bath. The cost per week to reside at St Theresa’s Nursing Home will cost from £600.00 to £750.00. Fees are reviewed annually and if care needs increase. This weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by accessing the Service Users Guide, which will detail the services and facilities available at the home. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process. The inspection lasted one day. St Theresa’s has changed ownership since the last inspection was conducted in September 2006. The inspector has continued to liaise with the new registered provider, acting manager, residents, visitors and staff to monitor the effects of this change. It was evident at this inspection that efforts had been made to try and ensure that all people who use the service were unaffected by any changes that can be expected under new ownership and that many anxieties, concerns and frustrations that people have been experiencing are being resolved. Prior to the visit the inspector spent some time examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire, notified incidences in the home, (Regulation 37’s) and the unannounced reports conducted by the Registered Providers (Regulation 26’s). The inspector sent “Have your say” questionnaires to residents and relatives prior to the inspection and eleven were completed and returned. “Comment Cards” were also sent to visiting health and social care professionals and four of these were completed. Information from these has been collated and is detailed throughout the report. The inspector spent time throughout the inspection in discussions with the acting manager, and members of staff, a number of records and files relating to the day-to-day running and management of the home were examined. The inspector also attended a staff meeting. Four residents were case tracked. Their care plans, care files and medication records were examined. The inspector had discussions with the residents and observed them indirectly going about their daily routines. The inspector toured the premises accompanied by the acting manager. Feedback was given to the acting manager on the outcome of the inspection. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? As mentioned throughout the report the transitional takeover period has not been without problems; however, things have settled down and it was evident that the home is continuing to make every effort to relieve the anxieties that people who use the service may be experiencing. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Teresa`s Nursing Home DS0000068847.V331488.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 Teresa`s Nursing Home DS0000068847.V331488.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): 1,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents or their families have all relevant information to make a decision about the nature of the home. Prospective residents needs are assessed prior to admission to determine the suitability of placement to ensure that their needs can be met. Trial visits give prospective residents an opportunity to assess the nature of the home. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 10 EVIDENCE: When an initial enquiry is made a booking enquiry form is completed and prospective residents are invited to visit the home. During the visit staff use a viewing information checklist ensuring that valuable information is given in order to assist prospective residents when making a decision about the home. Information provided includes the homes statement of purpose, the preadmission process, how residents’ exercise choice and developing care plans. Needs are thoroughly assessed by the acting manager prior to admission to ensure that the home can meet those needs. The prospective resident, family and carers are involved in this process. Where relevant comprehensive assessments and care plans are obtained from other professionals involved for example, social workers and hospital staff. The inspector looked at the preadmission assessments completed for residents, which were very person centred and comprehensive including levels of dependency and past medical history. The prospective resident/family members are given forms to complete prior to admission detailing life history and personal preferences. Information obtained was very useful and included what residents preferred to eat and drink, where they would prefer to eat their meals, what time liked to go to bed and get up in the morning and whether they preferred baths or showers and how often per week. The pre-admission assessments and the information gathered prior to admission provides a sound benchmark of the resident’s ability and state of health prior to admission and gives the staff at the home an insight into how they can assist the resident to live the life they wish to live. The plans demonstrate that the homes philosophy centralises on empowering residents and encourages residents to maintain independence, autonomy and choice throughout the duration of their stay. Prospective residents are encouraged to visit the home either for the day or perhaps for lunch dependent on their wishes. A month’s trial period on both sides is usually undertaken to ensure that everyone is happy with the arrangements and to ensure that the placement is suitable. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Because they are consulted about their health and personal care needs residents can be sure their views and expectations will be considered. End of life plans ensure that residents last wishes will be acknowledged and respected There are safe systems of practice in receiving, storing, administering, and disposing of drugs. Residents can be confidant that staff have a good awareness of their needs and that they will be treated with dignity and respect. EVIDENCE: From the pre admission assessments the manager and the registered nurses are able to develop a set of care plans based on identified needs. During the first months trial period the residents’ plans are reviewed weekly and developed accordingly. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 12 The care planning system is new to the home following new ownership and it was evident that the acting manager and staff had worked extremely hard in developing and reviewing existing residents care files. Each resident and their families are told about “residents consultation and family reviews”. A delegated trained nurse and a carer are responsible for contacting the family and notifying the resident to review and evaluate the care received. The reviews allow opportunity to discuss and evaluate residents’ care plans and any issues or concerns they may have. Relatives were asked in their surveys “Are you kept up to date with important issues?” and “Does the home give the care/support that is agreed and expected?” Generally the feedback was positive and comments included, “The home caters to individual needs and handles residents with compassion”, “Staff are mindful of individual preferences” and “I have been pleased with the care received so far”. Some relatives through discussion and from comments received from the surveys expressed that, “I would like to be kept more informed on issues affecting my relatives care” and “I feel that I should be consulted more and explain things that are going on in the home”. The acting manager explained that the reviews were a new initiative and that these comments were possibly from relatives who had not been invited to a review as yet. Four residents files were examined during the inspection, which included care plans, risk assessments, daily record accounts and visits and outcomes from community professionals such as General Practitioners. Each resident had a comprehensive portfolio and person centred assessments, which means that staff put the views, wishes, likes and dislikes of each resident at the centre of all care provided. Health Care needs were well evidenced in the care files and included, wound care charts and photographs, nutritional, and pressure area risk assessments. All information had been regularly reviewed. The acting manager takes responsibility as the tissue viability nurse in the home and told the inspector that he is enrolled on further courses to enhance his practice and knowledge. Ten health/social care professional surveys were sent prior to the inspection and only four were returned. The acting manager explained that he was working hard to forge professional relationships within the local community. Comments received from two of the surveys included “There are some communication problems with staff whose first language is not English” and “The recent complete change of staff and management seems to have caused only a temporary upset and I have no complaints”. These comments are addressed later in the report under staffing. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 13 The information for each resident was very informative and useful enabling staff members to identify individuals and how to support their health and social needs including, psychological, emotional, and cultural needs which demonstrates that the home takes a holistic approach to the provision of care. Policies and procedures for receiving, storing, administering and disposing of medications were examined and discussed with the manager; all systems in place are effective and well managed. The home operates a monitored dosage system for the administration of medication, which is supplied at regular intervals by the local pharmacist. The GP’s conducts a medication review for all residents every six months. The home also keeps an accurate stock check of medicines given on an as required basis. Fridge temperatures are recorded daily. The administration charts were legible and continuity of administration was shown with a signature from the person dispensing. The home promotes privacy and dignity to all people who use the service. Staff receive training on “Promoting Privacy and Dignity” on induction, which covers issues like closing doors and pulling curtains when delivering personal care and knocking on residents doors and waiting for an invitation to enter before entering their rooms. Training records were looked at and included questions, “How can we promote residents rights, dignity and respect?” Staff answers stated, “We must honour residents decisions and help them remain in control of their lives” and “By talking to residents and reading their care files we can respect that people are different and help to support them to follow their beliefs”. The acting manager and staff make every effort to establish resident’s wishes concerning palliative care by developing end of life care plans. The acting manager explained that the plans are sensitively completed with residents and their families and significant others. Plans are personalised and signed by the residents and a member of staff. The information sought is well thought out and should help ensure that residents’ choices are respected. Trained nurses at the home access courses through Dorothy House, and act as link nurses in palliative care. The training they receive is cascaded down to all the staff in the home through in house training sessions, including “Symptom Control”, “Assessing Pain” and “Care of a Syringe Driver and administering medication”. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although support is given to residents with their social opportunities, residents would welcome additional outings to provide daily variation. Encouragement from staff enables residents to maintain good contact with family and friends. The home actively promotes residents to exercise choice and control over the lives they choose to live. Residents receive a varied and wholesome diet that they are able to influence. EVIDENCE: There does not appear to be any unnecessary rules in the home and it was evident that the homes philosophy centralises on empowering residents and encourages residents to maintain independence, autonomy and choice. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 15 Residents’ daily routines are flexible within the home, residents can get up and go to bed when they like, having their meals in their bedrooms, they can go out when they wish and participate in activities they have a particular interest in. This was confirmed through documentation in residents care files and in discussion and through observation during the inspection. The home has two “Lounge Assistants” who work six days a week supervising residents either in groups or on a one to one basis. At present the assistants organise such things as daily games, quizzes and reminiscence therapy, manicures and walks around the grounds. The home has also just appointed a full time activities coordinator who will be responsible for developing an activities and outing programme to work alongside the services already provided. The residents and relatives at the home who had made comments in their surveys requesting for more outings and short trips will welcome this news. All activities are recorded including who took part and feedback on how successful the session was and whether it was enjoyed. As mentioned previously in the report residents are asked to complete forms detailing personal preferences, likes and dislikes and preferred daily routines. Some of this information in then transferred onto a matrix and placed in staff working zones, so that staff can use the information as a quick reference guide. For example the matrix specifies when residents like to get up and whether they like to have breakfast in their rooms or in the dining room. The acting manager told the inspector that he likes to visit residents on a daily basis. Conversations include enquiring how residents are, what was their meal like and what are their plans for the day. Residents meetings at present are organised every three months. The residents are informed a week in advance and the acting manager asks them individually if there is anything they would like to add to the agenda. Minutes of the meeting were examined and evidenced that any concerns/issues that were raised were transferred into an action plan on how they would be resolved. The inspection surveys ask, “Does the home support people to live the life they choose? In general the answer was yes and comments included, “ As far as possible, yes, they do”, “My relative will not ask for things in fear of reprisals, although I know this would not be the case” and “Now I have come to terms with the need to rely on help, I feel more at home now.” St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 16 The menu rota displays traditional meals and choice is available at each sitting. The menus are reviewed to reflect seasonal trends and availability of produce. Extras are ordered on request for birthdays and special occasions. Fresh fruit and vegetables are delivered daily and bowls of fruit are on offer throughout the day. Surveys confirmed that residents were satisfied with the meals provided and residents’ comments included, “There is always an alternative choice if there is something I don’t like”, “Meals are well presented and tasty, fresh fruit is always available” and “There is an acceptable food menu and the food is cooked adequately”. At present the existing dining room is very small and does not allow for all residents to enjoy the social advantages of dining together. The acting manager explained that there is an opportunity to look into this later in the year, as there are various large rooms in the home currently used for other purposes, which could cater for this provision. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are policies in place to ensure that complaints by residents or their families are taken seriously and acted upon. There are good arrangements in place for staff training and awareness of protection of vulnerable adults so that residents are protected from abuse. EVIDENCE: A copy of the complaints procedure is on display in a well-frequented part of the home, which means people will know how to obtain the required information if they want to make a complaint. The complaints policy and procedure is detailed and contains all the required information. Any concerns raised by residents and visitors are dealt with immediately; information of the outcome is cascaded down to the staff through hand over time and recorded in the resident’s notes. Where necessary, written confirmation of the outcome and how issues will be resolved is also sent to the relative and families and evidence of this was seen prior to the inspection. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 18 It is evident that residents are encouraged to voice their concerns at all times. All residents and relatives stated in the surveys that they knew who to talk if they were not happy and how to make a complaint. Relatives also stated that the home responded appropriately when concerns were raised. There are procedures as well as a range of guidance information on the topic of protection of vulnerable adults from abuse’ including the Local Authority “No Secrets” document. The staff induction provides education on topics for whistle blowing, management of aggression and bullying. The availability of this information should increase staff awareness and understanding of their role in protecting vulnerable adults who live at the home. Records evidenced that staff had received protection of vulnerable adults training and future dates have been booked for this year. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the topic of the protection of vulnerable adults from abuse. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. With the exception of some bedrooms and bathrooms the home is comfortable, tastefully decorated and furnished. It provides a peaceful environment for the residents to live in. The safety of people who use the service may be compromised due to fire safety issues. The home is clean, pleasant and hygienic. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 20 EVIDENCE: Through previous inspections it has been identified that some areas of the home require redecoration and in some cases refurbishment. Particular areas include the bathrooms and some of the residents’ bedrooms. During the tour of the home the acting manager explained to the inspector that these areas had been identified and an improvement plan is being developed. The new owners also have plans to upgrade and change various parts of the home; however, it is understandable that the owners’ priority since registration in November 2006 has been to focus on ensuring a smooth transitional period for residents, families and staff. Although these areas need to be attended to the inspector did not consider that the current state of the home was having any adverse effects on the residents and no comments had been received through discussions or from the surveys with regards to any complaints about the environment. One area that was a particular concern, however, was the possible risks around the fire safety in the home. Whilst the inspector was looking at the fire drill records an entry had been logged following a ceiling light exploding. The log entry confirmed that procedures were followed correctly; however, the information detailed smoke escaping from the affected room around the doorframe. On inspection it was noted that several doors did not fit flush to the doorframe when closed and residents’ bedroom doors did not have intumescent strips. When examining records in the home it was evident that a Fire Safety audit had not been conducted by the Fire Authority since May 2002. This was fed back to the owner and acting manager and a requirement will be made to arrange for a full Fire Safety audit to be undertaken by a competent individual in order to ensure that safety is not compromised. The home was clean and free from unpleasant odours. The home employs domestic staff on a daily basis. Residents’ and relatives surveys confirmed that the home was always fresh and clean and one relative stated, “The general cleanliness of the premises in very good”. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels help to ensure that resident’s needs are met. Residents are supported and protected by the homes recruitment policy. Staff are trained and residents can be assured that they will have the skills and resources to meet their needs. EVIDENCE: Prior to new ownership levels of staff and volunteers who worked at the home were excellent. As expected with any change following a takeover staff decided to leave and routines within the home in some instances were different to those previously adopted. It is unfortunate in this case that very early on in the takeover the home experienced a vast change over in staff and the mass extent of staff leaving was bound to have an affect on all the people who use the service and to the new owners of the home. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 22 The inspector received several phone calls from relatives and staff in the early stages voicing their concerns about new routines and staffing levels; however, over the past six months things have steadily improved and following this inspection it was evident that things had settled down quite considerably. The acting manager told the inspector that the home ensures staffing levels are indicative of the needs and levels of care required by the residents. All residents’ and relatives surveys agreed that staff were generally available when they needed them and listened and acted upon what the residents say. One resident said, “No one is slow to give help when needed”. Several residents’ expressed very positive views about staff and the care they receive providing comments, “The new staff are very kind and helpful” and “Staff are always ready to help, happy to help and courteous”. Residents, relatives and visiting health/social care professionals had concerns that some staff members whose first language is not English had limited communication skills. Comments received included, “Communication can be difficult when trying to discuss certain points, although the standard of care is extremely good” and “Communication is difficult when staff do not speak very good English”. Evidence was seen to support that the home was doing much to support all people who use the service in various ways in order to alleviate any anxieties/frustrations. Where required staff attend English language classes; where necessary mandatory training is being provided in Polish, various documentation including policies and procedures are given to staff in their own language and dictionaries and phrase books are given to all staff on induction. Staff are receiving regular formal supervision with the acting manager and are shadowed on shifts by a senior member of staff until both parties feel confident in their competencies, skills and knowledge. The inspector spoke with several staff members who expressed that they were enjoying working at the home, the training opportunities and the support given to them by all the staff team. The induction training for all staff is very comprehensive. One relative stated, “When the care home changed ownership there was a question about whether the staff had the right skills and experience to do the job and whether training was sufficient, but this does seem to have been resolved”. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 23 The acting manager and staff are conscientious in attending training relevant to the care needs of the residents; this year courses will include, “Getting the Message Across (Achieving a better understanding of the needs of people with hearing and sight impairment), “COSSH and Infection Control” and “Caring for People Following a Stroke and How to Care for People with Epilepsy”. The home continues to support their staff with their NVQ training. Staff records and the homes training matrix confirmed that training was up to date and that future courses had been arranged. The recruitment process was examined and all staff records examined showed that the home follows a robust recruitment procedure. Records contained application forms, references, and a CRB (Criminal Records Bureau) disclosure. Registered Nurse PIN’s are validated annually. The inspector attended a staff meeting on the day of the inspection. The attendance of staff was good and staff off duty had made every effort to be there. The agenda was informative and useful ensuring that staff were kept up to date with new initiatives and issues within the home. Staff were given opportunity to express their ideas and any concerns they may have during the meeting and it was clear that relationships between the acting manager and staff were respectful and supportive. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and best interests are central to the management approach in the home. Good accounting methods are adopted and policies and procedures are followed correctly when handling residents’ personal money. The health and safety of people in the home may be compromised and potentially at risk due to fire safety in the home. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 25 EVIDENCE: Mr Joseph has made an application with the Commission to become the Registered Manager. He is a Registered General Nurse and previously managed a thirty-five bedded nursing home for four years. As the acting manager he has worked hard over the last six months with the support of the registered provider and staff group and continues to develop new initiatives demonstrating confidence within his role. It was evident from discussions and observation that the management team and staff are becoming a stable team that supports a commitment to providing quality care for the benefit of the residents. Comments received from relatives surveys included, “Since the home has been under new management large improvements to care and the contact with relatives has been seen” and “We are very satisfied with the care our relative receives”. The home is developing various initiatives towards quality assurance, including monthly audits of the premises and a monthly care audit. This will be looked at in more detail at the next inspection. The policy and procedure for holding residents personal money was examined and four individual accounts were looked at. It was evident that good accounting methods are adopted which account for all transactions documented and receipts for sundries were available to see. Some of the Health and safety records in the home were examined. Documentation showed that relevant checks were maintained correctly and at the required intervals including all fire alarms and equipment and emergency lighting. Some of the emergency lighting was faulty on the day of the inspection, the maintenance operative told the inspector that an electrician had been called and that the problem was being dealt with that day. The homes records showed all necessary service contracts were up to date including, gas and electrical services, and manual handling equipment. As mentioned previously in the report health and safety of people who use the service may be compromised around areas of fire safety. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 (4) Requirement Arrangements must be made to ensure that the building complies with the requirements of the local fire authority. CSCI must be notified of the outcomes. Timescale for action 27/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Residents must be given opportunities for stimulation through leisure and social activities, which suit individual needs and preferences. St Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Teresa`s Nursing Home DS0000068847.V331488.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!