Inspection on 08/01/07 for St Vincent`s Nursing Home

This inspection was carried out on 8th January 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 Vincent`s Nursing Home 29/09/08

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth 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 Nursing Home Wiltshire Lane Eastcote Pinner Middlesex HA5 2NB Lead Inspector Mrs Clare Henderson Roe Key Announced Inspection 8th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Vincent`s Nursing Home DS0000067739.V321266.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 Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Vincent`s Nursing Home Address Wiltshire Lane Eastcote Pinner Middlesex HA5 2NB 0208 872 4900/90 020 8868 5347 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 Vincent’s Hospital Shiria Halsey Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Registration Brief Description of the Service: St Vincent’s Nursing Home is a purpose built home and is registered to accommodate 60 service users with nursing care needs over the age of 65 years. The home has been built on the site of the old St Vincent’s Hospital and has a long Roman Catholic tradition, started in 1907. The home has a chapel where daily mass is celebrated. The home offers quality accommodation to members of religious orders, retired priests, laity workers and to people from any religious background that wish to live within this peaceful environment. The home has four units, each one with its own facilities. All the bedrooms have en suite facilities to include toilet, wash hand basin and shower. The communal rooms are spacious and there the gardens are well maintained. The home is situated in a quiet residential area of Eastcote and there are local public transport links with a bus stop near to the home. Car parking space is available. The current fees are £120 per day for respite care and £795 per week for permanent placements. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out as part of the regulatory process. A total of 15 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. The CSCI Pharmacist Inspector carried out a medications inspection on 08/01/07 and a separate report is available. The requirements and recommendations have been incorporated into this report. 6 service users, 6 staff and 2 visitors were spoken with as part of the inspection process. The pre-inspection questionnaire and comment cards from service users, representatives/visitors and health & social care professionals have also been used to inform this report. It is acknowledged that many of the people accommodated at the home are members of religious orders, and for the purpose of this report the term ‘service user’ is used to encompass all those living at the home. At the time of inspection two of the four units were occupied and the Registered Manager was in the process of staff recruitment for the first floor units, with a view to opening these units in the coming months. What the service does well: The home is being effectively managed. The home has been open for a few months and the process of assessment and admission is being well managed, to ensure the home can meet the needs of each service user. Service users and their representatives are provided with information about the home and encouraged to visit prior to admission, allowing them to make an informed choice. Prospective service users are assessed prior to admission to ensure the home is able to meet their needs. Specialist care needs to include cultural and religious needs are being met. Service user plans viewed plus CSCI comment cards completed by healthcare professionals indicated good care provision at the home. Staff care for service users in a courteous, gentle and professional manner, respecting their privacy and dignity. Service users spoken with plus those who completed CSCI comment cards praised the home for the high standard of care they receive. Systems are in place to provide palliative care, and to facilitate service users to remain at the home during their final days if they so wish. The activity provision at the home is good, with service users interests and needs being ascertained and respected. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said they are made welcome at the home. There is some advocacy provision for the home, with further information being gained to provide for all service users who may wish to access advocacy services. The food provision is of a good standard, offering variety and choice and catering for individual dietary needs. Robust procedures are in place for the management of complaints and POVA. The home has been purpose built to a high standard, providing service users with St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 6 an attractive, good quality, homely environment to live in. The home is clean and fresh and there are good systems in place for infection control. The home is appropriately staffed to meet the service users needs. Systems for staff recruitment are overall robust, with a recent photograph of each member of staff to be obtained to fully meet the recruitment requirements. There are systems in place for quality assurance and these will be expanded once the home is fully functional. Policies and procedures are in place for the management of service users monies. Overall health & safety is being well managed in the home, with good systems in place. 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 Nursing Home DS0000067739.V321266.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 Nursing Home DS0000067739.V321266.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, 3, 4 & 5. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information about the service, thus allowing them to make an informed choice about the home. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Service users and their representatives are encouraged to visit the home prior to admission, thus giving them the opportunity to make an informed choice. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, and these documents are up to date and provide a good picture of the services provided. The Registered Manager said that a copy of the documentation is provided to anyone making enquiries about the home. Copies of the Service User Guide are also available in each bedroom and in the reception area. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 9 The home has a pre-admission assessment document. This is comprehensive and provides a good picture of prospective service users and their needs. Those viewed had been completed appropriately. Where available copies of the Social Services or Primary Care Trust assessments are also obtained. The home is registered to accommodate service users over the age of 65 years. The home has a religious ethos and there is a Roman Catholic chapel where mass is celebrated daily. The CCTV provision includes a link to the chapel so that service users who are unwell or who so wish can follow the service from their room. The home is open to service users from all religious backgrounds who wish to live in this peaceful environment. Service users from other religious sectors have been admitted and those spoken with expressed their satisfaction with the home. Service users individual religious and cultural needs are respected. Service users and visitors spoken with plus comments received on the CSCI comment cards evidenced that service users and/or their representatives had been given the opportunity to visit the home prior to admission to make an informed decision about living there. One visitor spoken with said that they were shown around the home and staff were helpful and answered questions, plus arrangements for assessment and admission were made without delay. St Vincent`s Nursing Home DS0000067739.V321266.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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans are well completed and maintained up to date, thus giving a good picture of the service users needs and how these are to be met. Shortfalls should be easy to address. Medication management in the home is fair, however shortfalls identified could potentially pose a risk to service users. Staff care for service users in a gentle and professional manner, thus respecting their privacy and dignity. Systems are in place for end of life care, thus respecting service users wishes. EVIDENCE: Four service user plans were viewed. The ‘long term need assessment and care plan’ document covers all aspects of daily living and those viewed had been completed comprehensively, providing a good picture of each service users needs. For service users with higher dependencies individual care plans to address each need were not always in place, however this had been addressed by the second day of inspection. Risk assessments for falls had been completed for most service users, and the Registered Manager said these would be completed for all service users. A generic risk assessment for the use St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 11 of bedrails had been formulated and was available on each unit. By the second day of inspection individual assessments and signed consents were in place for those for whom bedrails are in use. Moving & handling assessments had been completed and in some cases the specific equipment to be used for each service user had been identified. This information is to be included for all service users with moving & handling needs. Apart from signed consents for photography, influenza vaccines and bedrail use there was no evidence of input from the service users and/or their representatives in the formulation and review of service user plans, and this was discussed with the Registered Manager. Daily records had been completed and were clear. In most cases monthly reviews of documentation were taking place, and gaps identified had been addressed by the second day of inspection. Wound care documentation was viewed. For one service user the documentation was comprehensive and included a wound assessment, dressing regime, record of dressing changes and photographs of the wounds. Wound documentation for another service user was in place and was being reviewed to update some information. Care plans had been formulated for a service user with superficial wounds, and these had been signed off once each wound had healed. Pressure sore risk assessments had been completed. Pressure relieving equipment was seen in use in the home and had been recorded in some service user plans. The Registered Manager said that this would be included for all service users with pressure relieving equipment in use. Nutritional assessments had been carried out. Service users are weighed on admission and some monthly weights had not been recorded in the service user plan. A separate record had been being maintained and by the second day of inspection the information had been incorporated into the service user plans viewed. The Registered Manager said that any service user experiencing weight loss is referred to the GP. A continence assessment document has been introduced and the Registered Manager said that this was being completed for all service users, from which individual care plans would be formulated for those identified with continence care needs. Evidence of this was seen in one of the service user plans viewed. Clear records are kept of any input from the GP and other healthcare professionals. The Registered Manager said that the GP service is supportive and provides good input for service users at the home. CSCI comment cards completed by health and social care professionals evidenced that staff are helpful and provide a very good standard of care to the service users, plus they communicate well with the visiting health and social care professionals. The CSCI Pharmacist Inspector carried out an inspection on 08/01/07 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. On the second day of inspection the Registered Manager provided an action plan to address the requirements. The abbreviation ‘MAR’ stands for medication administration record. The abbreviation ‘PGD’ stands for Patient Group Directions. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 12 Staff were seen caring for service users in a gentle, courteous and professional manner. Comments received from service users at the time of inspection and on the CSCI comment cards evidenced that service users feel they are being very well cared for at the home. Service users personal clothing is labelled and service users were well dressed to reflect their own individuality, and also respecting the religious sisters mode of dress. Service users can bring in personal belongings to the home in line with fire safety. Policies for the care of service users after death are in place, and the Registered Manager said that she would be formulating one for the care of service users in their final days. The home has access to the Macmillan Nursing Service and GP cover is provided up until 10pm, with a night on call system in place. Some staff had received training in palliative care and the Registered Manager is accessing this training for other nursing and care staff. The Registered Manager is aware of the different religious and cultural needs and the service user and their families are involved in discussions regarding end of life care, so that the service users care during their final days can be managed according to their wishes. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. The activity provision is varied and service users are consulted about their interests, thus ensuring individual wishes are catered for and respected. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the service users rights and opinions are heard and respected. The food provision in the home is of a good standard, offering variety and choice, with menus to meet the service users preferences. EVIDENCE: The home has an activities co-ordinator who is experienced in the provision of activities for older people. She keeps a diary of all activities and those who have participated in each. A good range of activities are provided at the home and it was clear that the activities co-ordinator understood the potential need for increased diversity as more service users with differing social and leisure interests are admitted to the home. There is an activities programme formulated for each week, with events planned. The ethos of the home is a Christian one and there is a daily service in the chapel, plus the religious sisters have a daily routine of worship, which is respected and facilitated. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 14 Some information is contained in the service user plan regarding service users social and leisure interests, and this is to be expanded as appropriate. Four of the religious sisters from the Community House attend the home each day and provide an advocacy service for the religious sisters accommodated at the home. From speaking to one of the visiting sisters it was clear that they are very pleased with the care provision, and also that staff are willing to listen and learn how to meet all the needs of the service users, to include religious and cultural needs. The Registered Manager had contacted Age Concern and the Royal National Institute for the Blind with a view to providing help and support, to include advocacy services. The home has an open visiting policy and visiting is encouraged. Visitors can stay overnight if a service user is unwell. Visitors spoken with said that they had been made very welcome at the home. The kitchen was clean and tidy. Records for fridge/freezer temperatures are recorded three times daily. Cleaning schedules are in place and were up to date, with some gaps noted, and this is to be discussed with the catering staff. The storage facilities are good, and there was a supply of fresh, frozen, tinned and dry goods available. The menus offer a main choice with alternatives if service users wish. The Registered Manager said that the menu is being reviewed to include a daily vegetarian option. Service users spoken with and information from CSCI comment cards indicate that the food provision at the home is good. The lunchtime meal was seen, and this was a social occasion with service users chatting and enjoying the mealtime. The Inspector sampled the lunchtime meal and this was well presented and tasty. A document to record service users menu choices has been formulated and is being introduced. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 robust procedures in place for the management of complaints and adult protection allegations, thus safeguarding service users. EVIDENCE: The home has a complaints procedure containing contact details for the home and for CSCI plus timescales for addressing any concerns raised. 14 complaints had been received, and it is acknowledged that all concerns, however minor, are recorded and responded to promptly. It was clear from the evidence available that complaints are taken seriously and responded to appropriately. The home has Adult Protection procedures in place. Staff spoken with said that they would report any concerns, and POVA training had been given by the Safeguarding Adults co-ordinator for Hillingdon Social Services. Further training and updates had been planned. There have been no adult protection issues since registration. St Vincent`s Nursing Home DS0000067739.V321266.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, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has been purpose built to a high standard, is very well appointed, thus providing a good quality clean, safe and homely environment for service users to live in. Communal rooms are available on each unit, providing the service users with a choice of venue. Equipment is available for assisting service users as required, thus providing for the service users needs. Individual accommodation is personalised, maintaining a very homely feel. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: The Inspector carried out a tour of the home. The home has been purpose built to a high standard. The reception area is welcoming and smart. The home employs a maintenance person and any repairs are carried out promptly. The home has been recently built and registered, with two of the four units open so far, therefore a refurbishment plan is not required at this stage. The décor is to St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 17 a good standard throughout and colour schemes have been well matched. As part of the registration process, the Fire Safety Officer and the Environmental Health Officer inspected the home to ensure it met the required standards. The home has CCTV in use for the external and reception areas of the home. There is also a camera to provide a television link from the Chapel to each service users bedroom, so that they can participate in the daily service if they are unable to attend in person. Each unit has two sitting rooms and a dining room, and the furnishings are of good quality. There is a Courtyard Garden, which is enclosed and well presented. The gardens have been landscaped and are being well maintained. There is a good amount of communal space available, with areas for social gatherings and entertainment, plus those for quiet reflection, to meet the needs of the service users. There is a kitchen area in each dining room. Each bedroom has an en suite facility with a toilet, wash hand basin and shower facility. There are two baths on each unit, one standard bath and one assisted bath. Toilets are available near the communal areas. The corridors are wide, with handrails provided on both sides. There is also a ‘Cloisters’ area, where consideration has been given to the potential of providing dementia care in the future, with a safe walkway and enclosed courtyard garden, so that service users could wander as they so wish within a safe environment. Moving & handling equipment and ‘sit on’ scales are available in the home. All the beds are adjustable, profiling beds. Assisted bath and toilet facilities are provided on each unit in addition to the en suite facilities for each room. Grab rails have been provided in the en suite and assisted facilities. Equipment such as special chairs was also seen to aid the service users use of their en suite facilities. There is a call bell system in place throughout the home and service users spoken with said that requests for assistance are responded to promptly. Storage facilities are provided on each unit. The bedrooms are spacious and bright, and thought has gone into the high quality décor, furnishings and fittings, being both smart and practical. Each room has a flat screen television, and some rooms viewed also had additional equipment as the service users so wish, for example, free view box and telephones. Bedrooms viewed had been personalised and were very homely. The home was clean and tidy and smelled fresh throughout. The laundry room has 3 industrial washing machines and 2 industrial tumble dryers. There is also a roller iron and a separate ironing board and standard iron. Clear washing protocols were on display in the laundry room. Service users personal clothing is collected in individual laundry bags for washing. There are good systems in place for the laundering and return of service users personal clothing to ensure it is maintained in good condition and returned to the right individual. All personal items viewed were labelled appropriately, and the home also carries St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 18 out any repairs necessary. An external laundry service is used for bed linen, towels and tablecloths, and there was a good supply of all these items in stock. Protective clothing to include gloves and aprons were available, and there are facilities available in all areas where service users, staff and visitors may require to wash their hands. Staff had received training in the use of the machinery, and there was safety data and COSHH information available for the products in use. The home has policies and procedures in place for infection control. St Vincent`s Nursing Home DS0000067739.V321266.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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the service users can be met. Systems for vetting and recruitment practices are in place and protect service users. The majority of staff had received training, and the programme is to be reviewed and updated to ensure all staff receive training, thus providing them with the knowledge to meet the needs of the service users. EVIDENCE: At the time of inspection the home was being appropriately staffed to meet the needs of the service users. The staffing rosters evidence that staffing levels maintained at a constant level. The Registered Manager said that should the dependencies of service users change, then the staffing would be reviewed to ensure service users needs continue to be met at all times. The Registered Manager was in the process of recruiting staff for the first floor units still to be opened. The home was clean and tidy throughout, and employs sufficient nursing, care, administration and ancillary staff to meet the needs of the service users and of the home. The Registered Manager reported that 47 of the care staff had attained NVQ in care level 2, with two more staff currently undertaking this qualification. The Registered Manager is aware of the need to achieve and maintain a minimum of 50 of care staff with NVQ level 2 in care or an equivalent qualification. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 20 The Inspector viewed three sets of staff employment records and with the exception of photographs for 2 staff, contained the information required under Schedule 2 of the Care Home Regulations 2001. The Registered Manager said that she would obtain photographs of all staff. Prior to commencing work at the home, all staff employed at the time the home opened received full induction training. The training pack provided for induction is thorough and the Registered Manager said that she would check that the contents meet the Skills for Care Common Induction Standards. Some new staff spoken with said that they had not yet undergone induction training, and the need to ensure any new staff have a full induction was discussed with the Registered Manager, who said she would address this. Several staff spoken with said that they had received training in health & safety topics and also other subjects related to the needs of the service users. The Registered Manager is also setting up a training matrix to plan for all staff to receive required training, plus training in topics relevant to the diagnoses and needs of the service users. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 21 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. The Registered Manager has the qualifications and experience to manage the home, and does so effectively. Audits for quality assurance are carried out, thus providing an ongoing process of system and practice review. Policies and procedures for the management of service user monies are in place, thus safeguarding service users. Overall systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with a Diploma in Management Studies. The Registered Manager has undertaken periodic training in topics relevant to her role, to include the care of the service users accommodated at the home. The Registered Manager has several years St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 22 experience of managing a unit for the elderly within her remit in a previous management role. The Registered Manager had an open management style and service users, staff and visitors spoken with said that she is supportive and approachable. The Registered Manager said that satisfaction surveys had been carried out for staffing, catering/domestic and maintenance provision and the results collated. A separate survey for catering was also carried out and with the results of this the home is currently looking at menus and to implement change to meet the service users needs. Staff meetings and service user meetings are held monthly, and minutes are taken and distributed. The Registered Manager completes a monthly progress report for the Board of Trustees meeting, and this is comprehensive and provides an audit of many areas of care, administration and management processes for the home. The Registered Manager is currently concentrating on staff recruitment, admitting new service users to the home and bringing the home up to full occupancy and function. The Registered Manager said that once this process has been satisfactorily completed, she will look to formulate and implement a development plan for quality assurance for the future of the home. The home does not hold any monies on behalf of service users. There are clear policies in place for the management of service users monies and the staff guide booklet has information in respect of hospitality and gifts. The servicing and maintenance records were sampled and those viewed were up to date. Policies and procedures for health & safety are in place. From discussion with the maintenance person it was clear that he is aware of the importance of maintaining good systems for health and safety management throughout the home. Staff had undergone health & safety training to include fire safety, moving & handling and infection control. Some staff had undertaken First Aid training. Some staff had not received moving & handling training updates, and following the inspection the Registered Manager has confirmed that all staff have now received moving & handling training, to include the use of equipment. Fire drills had been carried out for both day and night staff, and the Registered Manager said she would ensure these are carried out in accordance with the required timescales. A Fire Risk Assessment was carried out on 21/09/06 and some shortfalls were identified. There was evidence that work had been carried out to address some areas and an action plan to address all the shortfalls with timescales for completion has been forwarded to CSCI. Risk assessments had been carried out for all safe working practices, and the need to complete risk assessments for equipment in use in the home, to include the laundry and kitchen areas, was discussed. Hot water temperatures are checked regularly and the maintenance person said he also checks the hot water flow and return temperatures and would record this in future. Systems were in place for testing for Legionella, and the maintenance person said that water flushing was being carried out for all the water outlets in the empty units. Overall health & safety is being well managed in the home. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 4 4 X 4 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement There must be evidence of input from the service user or their representative in the formulation and review of the service user plan. Medicines must be recorded accurately when administered. If not administered the correct endorsement must be used. The home must store controlled drugs in a cupboard meeting the requirements of the Misuse of Drugs Act. Adhesive labels must not be used on the MAR and the allergy section must be completed. The medicines policy must be expanded to include the management of leave medicines and homely remedies. PGD must be removed. The section on drug errors could be expanded The disposal records must be signed and witnessed. Each staff employment record must include a recent photograph. All new staff must receive induction training to meet the DS0000067739.V321266.R01.S.doc Timescale for action 30/01/07 2. OP9 13(2) 14/01/07 3. OP9 13(2) 01/03/07 4. 5. OP9 OP9 13(2) 13(2) 01/03/07 01/03/07 6. 7. 8. OP9 OP29 OP30 13(2) 19 18 01/02/07 09/02/07 09/02/07 St Vincent`s Nursing Home Version 5.2 Page 25 9. OP38 13(4) Skills for Care Common Induction Standards. An action plan to address this must be in place. Risk assessments for equipment in use in the home must be formulated and action taken to minimise any risks identified. 16/02/07 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. 2. 3. 4. Refer to Standard OP8 OP9 OP9 OP9 Good Practice Recommendations The specific pressure relieving equipment in use for a service user should be recorded in their service user plan. That the written evidence of INR/Warfarin dose is kept with the MAR for reference. That the instructions on as required medicines are reviewed and also the availability of liquid preparations for residents who are unable to swallow That a separate seizure chart is kept. St Vincent`s Nursing Home DS0000067739.V321266.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. 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