Inspection on 07/11/06 for St Vincent`s Care Home

This inspection was carried out on 7th November 2006.

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

The inspector 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 Vincent`s Care Home 14/06/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Vincent`s Care Home Down Road Bexhill-on-sea East Sussex TN39 4HD Lead Inspector Judy Gossedge Key Unannounced Inspection 7th November 2006 10:45 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 Vincent`s Care Home DS0000066775.V315535.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 Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Vincent`s Care Home Address Down Road Bexhill-on-sea East Sussex TN39 4HD 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) 01424 211244 `F/P` 01424 211244 St Vincent`s Care Ltd. Ms Gillian Gilkes Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That service users are aged sixty five years (65) and over on admission The maximum number of service users to be accommodated is twenty five (25) Date of last inspection Brief Description of the Service: St Vincent’s is a large, detached Edwardian property, standing in its own grounds next to the parish church of St Stephen’s. The home is registered to provide residential care for twenty-five older people. The home is situated in a quiet residential area of Little Common, within ten to fifteen minutes walking distance from the shops in Bexhill town centre. Accomodation comproses of nineteen single bedrooms and three double bedrooms if service users request to share; these may be used also to provide single accommodation if required. All but three of the service users bedrooms have en-suite toilet and wash-hand basin facilities. Assisted communal bathing facilities are provided in the home. There is a separate lounge and a lounge and dining area for service users to use and an attractive garden at the rear of the home. A passenger lift to all floors provides level access in the home. A chair lift is fitted to the short flight of stairs, leading to some of the service users bedrooms on the ground floor. A copy of the Statement of Purpose and Service Users Guide is available to view in the home. At the time of the inspection fees were documented to be between £340.00 and £450.00 per week. Additional charges are made for hairdressing, chiropody, toiletries and magazines and newspapers. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over nine hours on 7 and 8 November 2006. This is the first inspection undertaken since a new proprietor purchased the home and all standards were inspected. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. This was returned and information detailed within is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms, rotas and care records were inspected. Thirteen service users were resident and four service users were spoken with in their bedrooms. The care that these four service users received was reviewed as part of the inspection process. Three service users were also spoken with in one of the lounges. The opportunity was also taken to observe the interaction between staff and service users in the communal areas. Ten service user surveys were sent out and all came back completed. The head of care, two care staff, the cook (who also works as a care worker), a member of the housekeeping team, the maintenance person and the Manager were all spoken with. The proprietor was also present and spoken with on the second day. Seven staff questionnaires were sent out prior to the inspection and four completed questionnaires were returned. Two relatives of one service user were spoken with on the day and one further relative was spoken with on the telephone after the inspection. Three General Practitioners comment cards were sent out and no completed comment cards were returned. What the service does well: The staff team were observed to deliver care in a way that ensured service users dignity and privacy was maintained. The feedback from all the service users and visitors was that they were happy with the overall care provided in the home. Comments included ’the staff are very kind’, ‘I have been very happy to live here. I find St Vincent’s very comfortable, very clean and they care’, ‘the home has a lovely atmosphere’, ‘I have been very happy to live here. I find St Vincent’s very comfortable, very clean and they care’, ‘a good standard of care is provided and all are so friendly it feels like a home’ and ‘I would not want to go anywhere else’. The admissions process is good with staff being provided with adequate information in advance of admission to ensure each service users care needs can be met in the home. Service users benefit from having their assessed care needs incorporated into commendable plans of care, with supporting risk assessments, that are regularly reviewed. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is detailed information available for prospective service users, but it should be ensured that this is fully accessible. Service users are protected by the completion of terms and conditions/contract. The admissions process is good with staff being provided with adequate information in advance of admission to ensure each service users care needs can be met in the home. Service users or their family/representatives can visit the home prior to any admission. Intermediate care is not provided in the home. EVIDENCE: There is a detailed Statement of Purpose, Service Users Guide and a copy of the last inspection report are available to read in the home. Service users and their representatives are notified of the availability of this information by notices in the home. Not all the service users stated they had received enough information about the home before moving in. This was discussed with the St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 9 proprietor and manager and the need to make this information more accessible in the home. There is a detailed contract/terms and conditions in place to be used between the home and the service user. The service users surveys did not in all cases confirm that a contract was in place. But during the inspection for the four service users whose care was reviewed all had a completed contract. New service users are visited prior to any admission. This is to ensure individual service users care needs can be met in the home and to provide staff with information on the care to be provided. There were two new service users resident and their pre-admission information had been fully completed and was detailed. Service users can and do access specialist services either at the home, or by accessing local facilities in the community. The care workers have been able to attend training opportunities to develop their skills and experience to deliver the care required, such as basic food hygiene, first aid, medication and moving and handling. The carer workers spoken with demonstrated knowledge about the support needs of the service user group. Two of the visitors who had been involved in the placement of their relative confirmed that they had had the opportunity to look around the home prior to their relative moving in. The two new service users spoken with stated they had been unable to visit the home prior to their admission, but their relatives had looked around the home on their behalf. The manager stated that potential service users are welcome to look around the home and stay for a meal if they wish. Intermediate care is not provided in the home. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by an individual detailed plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care which needs to be provided. Supporting risk assessments are completed and all these documents are regularly reviewed. Medication policies and procedures are in place. Service users are treated with respect. EVIDENCE: Five of the service users individual care plans were viewed. These were detailed and gave clear guidance to staff of the care to be provided, service users health care requirements, dietary needs, social and leisure interests, how any identified risks are to be managed and these had been reviewed. The service users surveys stated they always or usually received the medical support that they needed. One commented, ‘the District Nurse calls regularly’. Where General Practitioners and District Nurses are consulted with a record is maintained of these contacts and any agreed action necessary. All service St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 11 users spoken with confirmed access to their own General Practitioner, dentist, optician or chiropodist as required. The staff team were observed during the inspection to ensure that the privacy and dignity of service users is respected at all times. The care and support provided was observed to enable service users where possible to exercise choice whilst at St Vincent’s. The service users surveys stated they always or usually received the care and support they needed. The five service user files viewed and the four service users spoken with whose care was reviewed confirmed this. The feedback from all the service users and visitors was that they were happy with the overall care provided in the home. Comments included ’the staff are very kind’, ‘I have been very happy to live here. I find St Vincent’s very comfortable, very clean and they care’, ‘the home has a lovely atmosphere’, ‘I have been very happy to live here. I find St Vincent’s very comfortable, very clean and they care’, ‘a good standard of care is provided and all are so friendly it feels like a home’ and ‘I would not want to go anywhere else’. Medication policies and procedures are in place and the proprietor stated these are in the process of being reviewed. Care workers have received medication training. Staff confirmed that a pharmacist regularly visits the home, but the records of these visits were not available to read during the inspection. The storage and a sample of the recording of the administration of medication were viewed. Where new/repeat medication is ordered it is recommended that a record of the order should be kept in the home to reference and when the medication is received in the home. It is also recommended that a controlled drugs record book be kept in the home to ensure appropriate recording of controlled medication if prescribed. The four service users whose care was reviewed confirmed that they were happy with the arrangements for the administration of their medication and always received this at the agreed time. There are policies and procedures in place in the event of a death of a service user in the home. All three care workers spoken with demonstrated an awareness of these and following a recent death in the home were able describe what had been put in place in the home to support the service user and family during this period. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whist resident in the home, there are some opportunities to participate in social and recreational activities provided, service users maintain contact with family and friends as they wish and a varied diet is provide. EVIDENCE: St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 13 A programme of activities is displayed on the notice board in the home. External entertainment/activities groups are also arranged to provide entertainment in to the home once a month. But service users and staff confirmed that this is not always followed. The service user surveys completed varied with service users stating activities were always, usually or sometimes organised in the home. Further comments received were, ‘the activities are not on a regular basis. There is a list up in the hall, but it is never kept to on the right days. Some weeks we do not have anything at all’ and ‘we get some entertainment from outsiders, which is great and all service users can enjoy’. The three visitors had observed activities taking place in the home. No activities were organised on either of the days of the inspection. Service users religious denomination is recorded in their care plan. It was noted that service users are supported to participate in their beliefs either at the home or by attending a nearby church. Feedback from service users and the visitors identified that there is flexible visiting, that staff are always very welcoming and it is possible to go to a service user’s bedroom if a private meeting is required. The cook working on the day stated she held a basic food hygiene certificate and confirmed attendance on a range of training opportunities. There is a four-week rotating menu is in place, which the cook stated was in the process of being seasonally varied. The cook always meets new service users to discuss their dietary needs and talks generally with service users about the menu and seeking ideas for new dishes to be included. Special diets are catered for and one service user who is a diabetic confirmed that their dietary needs were catered for. Lunch on the day was cauliflower cheese, potatoes, peas and carrots, tinned fruit and cream. This was a change from the menu, due to staff being involved in staff training that morning. An omelette or a salad is offered as an alternative to the main meal provided. Staff stated and records viewed that the majority of service users always choose the main meal of the day. Individual service users dietary requirements are discussed during their reviews of the care provided, where further alternatives could be discussed as required. There was homemade cake served with afternoon tea and both the visitors spoken with on the day also confirmed they had observed and been offered afternoon drinks and cakes. Bacon and eggs or sandwiches was provided for tea, which service users either ate in their bedroom or downstairs in the dining room. Records are kept of food consumed individually by each service user, but should be further developed to include breakfast so that it can be monitored that service users are receiving an adequate diet. The service user surveys completed indicated a varied response of always or usually enjoying the meals provided. All the service users whose care was reviewed were happy with the meals provided and confirmed fresh fruit is available in the home. Comments received were ‘the meals are very good and we get a different menu each day. Also the suppers you get a choice’ and ‘lovely small meals, not like if I go out, when I waste half of the meal. It is just the right size here and nice’. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: There is complaints policy and procedure in place, but this does not include details of who will deal with the complaint, the timescales and process that a complaint will be taken through and further options which a complainant can access if they are not satisfied with the outcome of the investigation. This was discussed with the proprietor and manager who stated this would be incorporated in the revision of the policy and procedure currently taking place. Nine complaints have been received at the home since the last inspection, which had been dealt with satisfactorily. The service users surveys stated they always or usually know who to speak and how to if they are unhappy. The service users spoken with and the visitors felt it was an environment where they would feel comfortable to raise any issues and that they would be listened to. Comments received were ‘there is always someone at hand who will understand and listen’ and ‘the carers always listen. The manager is very good and listens to what you have to say’. The majority of the service users who reside in the home are able to manage their own affairs, or seek help from relatives, or their legal advisor. Some of St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 15 the service users go out, so are able to cast their electoral vote, for those who do not assistance can be offered. There are policies and procedures in place in relation to the protection of vulnerable adults. The majority staff surveys stated and all the care staff spoken with all confirmed they had an awareness of adult protection procedures. The pre-inspection questionnaire detailed staff attendance at this training, but it should be ensured that all staff have received training/guidance on these policies and procedures. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is decorated and furnished in a homely style. A maintenance plan should be in place to ensure that the standard of the environment continues to be maintained and improved and that service users are provided with a safe environment in which to live. EVIDENCE: A tour of the building was made. The home is decorated and furnished in a homely style. There was some evidence of wear and tear and a number of the vacant bedrooms were being redecorated and re-carpeted. The proprietor confirmed there is an ongoing maintenance-taking place in the home, but this has not been formalised in to a maintenance plan. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 17 The external décor of the home is good. There is a garden at the rear of the home, which service users can use and service users spoke of sitting out for coffee in the warmer weather. There is a passenger lift between the ground, first and second floor. A chair lift is fitted to the short flight of stairs, leading to some of the service users’ bedrooms on the ground floor. Currently the mobile hoist used in the home has broken and is not available to be used in the home. The proprietor stated that a new hoist is in the process of being purchased. There are nineteen single bedrooms of which one does not meet the minimum space requirements and three double bedrooms situated on all the floors in the home. All bedrooms have an emergency call system fitted. A number of bedrooms viewed displayed service users individual styles and interests. Some service users at the time of redecoration have been able to further personalise their bedroom by being able to choose the colour. Bedroom doors are now fitted with a lock and one service user stated how much they had valued being able to lock their door. All but three of the bedrooms have en-suite facilities of a toilet and washhand-basin. Seven bedrooms also have the facility of a bath, but these have been disabled as currently all service users resident access the communal bathing facilities in the home. A sample of eleven hot water outlets used by service users was tested. Seven were satisfactory and providing hot water close to the recommended safe temperature of 43°C, but for the remaining the temperature recorded in the vacant rooms were between 32º C and 37º C and in one bedroom the water tap was not working. This was discussed with the proprietor and manager who stated that the lower temperatures in the vacant rooms were where the heating had been turned down and the broken water tap would be mended. Where asked service users confirmed that there was adequate heating and access to hot water. Regular, recorded checks of the hot water temperatures have not been carried out in the home. A risk assessment to minimise the risk of legionela in the home is not yet in place. The proprietor stated she would now implement a risk assessment and regular checks of the water in the home and has sought a detailed format on which to record the outcome of the checks. There is one lounge and adjoining dining area on the ground floor and a further separate lounge area. A number of the service users had congregated in the separate lounge during the day for coffee and a ‘chat’ with each other and later to watch television. The laundry for the home is situated in the basement. The flooring is damaged and staff stated this is due to be replaced so that it is readily cleanable. There St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 18 is not a dedicated member of staff to handle the laundry in the home but is dealt with by the care workers. The home was clean and odour free and feedback from the majority of service users and visitors was that the home is always ‘fresh and clean’. There have been a number of changes of domestic staff in the home and currently two domestic staff is working in the home, with one working on each day of the week. On of the domestic staff was spoken with and it should be ensured that domestic staff receive training/guidance in infection control, control of substances hazardous to health regulations (COSHH) and the use of protective clothing. Recording of routine fire checks carried out in the home were viewed. The regular checks had not been carried out for the previous two weeks. This was discussed with the proprietor and the manager to ensure that these regular checks are maintained. The manager stated that she would undertake and record a check of the fire systems. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be kept under review to ensure that all service users care needs continues to be met. A robust recruitment procedure needs to be in place to ensure service users are in safe hands at all times. Care workers are provided with regular supervision and training. EVIDENCE: St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 20 The majority of the staff team was attending training during the morning of the inspection, which was being facilitated in the dining room. The care staff team attending the training were also monitoring service users care needs in the home and it must be ensured that adequate staffing levels to meet service users care needs are maintained during training. Two care workers and the manager were on duty during the afternoon and who were also responsible for the preparation of tea for service users. Past staffing rotas were viewed, but there was not a rota in place for the week of the inspection. These need to be kept up-to-date and detail the designation of the staff on duty, the times of each shift and the hours to be worked. Staffing levels will need to be reviewed when additional service users are accommodated up to the maximum registered number of twenty-five. At night the home deploys one ‘waking night’ member of care staff who is supported by another ‘sleep in’ member of care staff. Feedback from the majority of service users and visitors was that they felt there were adequate numbers of staff on duty during their visits. There was a varied response from the service users surveys who stated staff were always, usually or sometimes available when needed. The majority stated that staff listened and acted upon what was said to them. The four service users whose care was reviewed also confirmed that the emergency call bells were answered promptly. Additional comments received were, ‘nothing is too much trouble for the staff’ and ‘staff are always there to give me support and listen to me, especially if I am feeling in a low mood’. Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care. The manager stated that staff was working towards meeting this requirement. One care worker holds NVQ level 2 in care and also with two other members of staff holds NVQ Level 3. One member of the homes care staff is currently working towards NVQ level 2 in care and four care workers have applied to a local college and hope to be able start working towards this qualification shortly. The recruitment process followed was viewed for the five new members of staff who were working in the home. For four members of staff a POVA First check had not been received and for two of these members of staff a Criminal Records Bureau (CRB) check had not been applied for. For one member of staff two written references had not been received and for a further two the references had been supplied by the members of staff and these had not been verified to ensure that the authenticity of the references. This was discussed with the proprietor and the manager during the inspection and an Immediate Requirement Form was left requiring that with immediate effect any further new members of staff recruited to work in the home have been through a thorough recruitment process and for existing new staff the required recruitment checks have been carried out. The CSCI has received a satisfactory response from the manager to these issues raised. Where staff is awaiting a CRB check, it was not evident during the inspection that staff were being supervised as required whilst this check was being completed. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 21 All four of the staff surveys stated that they had received an induction. The manager stated that a new induction-training course has just been introduced to meet the requirements of General Skills for Care induction standards. One new member of care staff had not commenced this induction and it is recommended that new care staff commence this induction to meet the required timescales. St Vincent`s Care Home DS0000066775.V315535.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): 31,32,33,34,35,36,37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home benefits from an experienced manager who has managed the home for many years and who ensures an open, supportive, homely and caring environment. But systems need to be in place and maintained to ensure a safe environment for staff and service users. Quality assurance systems are being set up and should continue to be developed to enable ongoing feedback about the care provided in the home. EVIDENCE: The manager of St Vincent’s has managed the home for over seventeen years, and holds NVQ level 4 in Care Management. Confirmation will need to be provided as to how the remaining training requirements for a registered manager will be met. The management structure and senior responsibilities St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 23 within the home are clearly defined and the management team work together in running of the home. A quality assurance system is being developed. The proprietor stated and evidenced that feedback about the service provided is being sought from service users. Service users forums had started to be introduced in the home, but these need to be regularly maintained. The quality assurance process should be developed to also enable relatives/representatives and other professionals who attend the home to give their views on the care provided. The existing policies and procedures are still in place in the home and the proprietor stated these are all in the process of being reviewed and updated. A regular recorded visit by the proprietor of the home to meet Regulation 26 has not been maintained. Where a small ‘float’ of money is held for some service users the financial records to support this activity were adequate. All the records held were viewed. None of the service users spoken with had used this facility. The three staff questionnaires, staff spoken with and records viewed confirmed that staff supervision and team meetings occur on a regular and ongoing basis. Staff spoken with confirmed good access to training and of attendance on health and safety training. Training records were not up-to-date, but the manager was able to confirm all staff had received or are due to receive training in moving and handling, basic food hygiene, and fire training within the required timescales. The pre-inspection questionnaire detailed staff have received basic first aid training had been and staff spoken with on the day had attended this training. There is one fully qualified first aider working in the home, who at the time of the inspection was on extended leave. The Health and Safety Department should be consulted with and their guidance followed as to the number of fully qualified first aiders required to be working in the home. The first aid notices around the home need to be updated as currently these reflect the names of past staff members. The proprietor has recently commissioned an external agency to complete a fire risk assessment for the home and stated that recommendations made will now be addressed. Whilst walking around the home on the first day it was observed that there was extensive use of door wedges in the home. This was rectified on the first day and doors were not wedged open on the second day of the visit. This was discussed with the proprietor and the manager who stated that appropriate devices are due to be purchased to stop this practice and during the interim period wedges will not be used. Environmental risk assessments in the home have not been regularly reviewed. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 24 The pre-inspection questionnaire detailed that the maintenance of equipment and services has been carried out. Recording was viewed of incidents and accidents, which had occurred in the home. The collation of this information has improved to facilitate easy access and to identify any patterns in incidents and accidents, which have occurred in the home. St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 2 17 3 18 3 2 3 3 2 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 3 3 2 St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 Requirement Timescale for action 31/12/06 2. 3. 4. 5. 6. 7. OP9 OP12 OP19 OP26 OP31 OP33 8. OP38 9. OP38 4 (2) 5 That the Statement of Purpose, (1) (d) (2) Service Users Guide and previous inspection reports should be fully accessible in the home. 13 (2) That there is a record of medication received in the home. 16 (1) That the frequency and range of (m) leisure activities continues to be developed. 23 (2) (b) That there is a maintenance plan for the home. 13 (3) That domestic staff receive training/guidance on infection control and COSHH. 18 (1) (a) That the Manager confirms how the training requirements as Registered Manager will be met. 26 (3) (4) That the Responsible Individual (a-c) (5) will undertake a monthly visit to (a) the home, which will be recorded. 13 (4) (a- That it is evidenced that risk c) assessments completed of the homes environment are regularly reviewed. 13 (4) That the Health and Safety Department are consulted with to ensure there are an adequate DS0000066775.V315535.R01.S.doc 31/12/06 31/01/07 31/01/07 31/01/07 31/01/07 31/12/06 31/12/06 31/01/07 St Vincent`s Care Home Version 5.2 Page 27 number of qualified first aiders working in the home and this is acted upon. First aid notices in the home are updated. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Vincent`s Care Home DS0000066775.V315535.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Vincent`s Care Home DS0000066775.V315535.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. 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