Inspection on 16/07/07 for St Vincents House

This inspection was carried out on 16th July 2007.

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

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

Other inspections for this house

St Vincents House 16/03/09

St Vincents House 22/09/08

St Vincents House 30/06/08

St Vincents House 21/01/08

St Vincents House 05/02/07

St Vincents House 25/07/06

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 Vincents House Queen Caroline Street Hammersmith London W6 9QH Lead Inspector Ffion Simmons & Wynne Price-Rees Key Unannounced Inspection 13:00 16 , 17th & 18th July 2007 th 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 Vincents House DS0000066934.V341457.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 Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Vincents House Address Queen Caroline Street Hammersmith London W6 9QH 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) 0208 600 0510 0208 748 5912 manager.st.vincent@careuk.com Care UK Community Partnerships Ltd Mrs Karen Madeleine Ottaway Care Home 92 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (44) of places St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. On the Ground Floor Unit up to 10 people may be aged between 50 and 65. 5th February 2007 Date of last inspection Brief Description of the Service: St Vincent’s House is a purpose built registered care home providing nursing care for elderly frail people and people with dementia. There is also a separate unit on the ground floor for people aged 50-65. The home opened on 3rd April 2006 and is situated in Hammersmith, West London. It is well located, close to public transport links, shops and services. The weekly fees for the service ranges from £795-£908. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over three days between the 16th and 18th July 2007. This was the home’s first key inspection for the inspection year 2007/2008. During this visit the Inspectors spoke with the residents, nursing and care staff and the home’s Manager. Residents’ personal records were checked in order to track the care they were receiving. Two hours of the inspection were spent observing the care being given to a small group of people using the Short Observational Framework for Inspection (SOFI) methodology. Questionnaires were also used to gain feedback from residents, relatives and professionals. The return rate was low, only three questionnaires were completed and returned to the Commission. Some of their comments have been included into the report. What the service does well: Residents are encouraged to be involved in meaningful daytime activities of their own choice and according to their interests. Staff were observed to be engaging well with residents and were welcoming and helpful throughout the inspection. St Vincent’s provides accommodation. very good standards of private and communal When we asked what the home does well we received the following comments: “kindness, sense of humour, communication and patience” “Residents are clean and tidy” “My relative is always clean, hair washed, room is clean and tidy.” “Social activities are good and varied.” What has improved since the last inspection? The assessment and recording of service users’ social care needs has improved. Nursing, care and activities staff now work together as a team to include social care needs in the provision of daily care. The home holds the relevant papers from the Home Office in the staff personnel files. Improvements were noted in the staffing rotas to ensure that staff must not work for a number of consecutive days without a break. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 6 Staff now receive formal supervision and a matrix has been created to identify due dates for supervision. 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 Vincents House DS0000066934.V341457.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 Vincents House DS0000066934.V341457.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): 3, Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full needs assessment is undertaken prior to admission by a competent person. EVIDENCE: The records of residents whose care was tracked during the inspection indicated that their needs had been assessed prior to admission by a registered nurse. It was also evident during the inspection that residents’ needs are reassessed following a period of hospitalisation to ensure that the home can still meet their needs. The assessments are discussed with the home manager and then a decision is made whether to admit the resident or not. The inspectors also noted that hospital discharge summary or care needs assessment completed by medical staff or a social worker were available file. Since the last key inspection in February 2007, the home has ensured that assessments such as falls, continence and manual handling assessment are undertaken prior to where possible or promptly following admission. St Vincents House does not provide intermediate care. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Medication records are not up-to-date and gaps were evident in the recording of mediation. The poor recording does not provide enough evidence that the residents are receiving their medication as prescribed and could be putting residents at risk. There is a need to improve the monitoring of residents’ health and respond by referring concerns to the appropriate health care professionals. EVIDENCE: Each resident whose care was tracked during the inspection, had an up-to-date care plan which included their health, personal and social care needs. The home uses a computerised system for recording the needs of the residents. The care plans are reviewed on a monthly basis or more frequently should their needs change. Each resident has an allocated key worker and support worker for promoting continuation of care to the residents. The needs of residents were well assessed. The assessments included manual handling, continence, sensory, risk of falls and waterlow (for assessing risk of developing pressure sores). Night care assessments are also completed outlining preferred times for going to bed and getting up. It was noted however that some of these assessments such as Waterlow and falls risk assessment had not been regularly reviewed and updated, and for one resident St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 10 in particular, not for a period of approximately six months. taken to ensure that risk assessments are regularly reviewed. Steps must be The inspectors noted that the risk of malnutrition was assessed for each resident. The tool had identified a resident of being at high risk of malnutrition. The residents’ care plan indicated that the resident’s weight needed to be monitored weekly. Weekly monitoring was not taking place and the latest recording of the resident’s weight was six weeks prior to the date of the inspection. There was no evidence either that the input of the dietician had been sought. A comment received in a questionnaire included “Nursing staff don’t tend to notice when resident looks unwell or don’t follow up when visitors mention that resident looks unwell.” Another resident had a care plan in place for eating and drinking which outlined that weight should be monitored monthly. The care plan was not being followed as the resident’s weight had not been recorded for two months. Fluid and nutrition charts were checked during the inspection. There is an urgent need to improve the recording of residents’ fluid and nutritional intake. Some of the records had gaps in them, for example no intake had been recorded for a resident for the whole of the afternoon shift. Another resident had returned from hospital at 12 noon, but there were no record of fluid intake until 21:00. The inspectors noted that residents’ fluid intake was not being totalled at the end of the 24 hour period either and some records were difficult to read. The inspectors were concerned to see the fluid intake for a resident to be as low as 430 ml in a 24 hour period. It was unclear from the records, what steps had been taken by staff to highlight this low fluid intake as a concern and what action was taken. The medication management was checked on two of the four units during the inspection. Medication is received into the home mainly in blister packs. On both units, medication was securely stored. The room temperatures were monitored daily in both units and these recorded correctly. Fridges were available on both units and the minimum and maximum temperatures within the fridge were being recorded and were within correct temperatures. Controlled drugs were in use on the ground floor. The balances of the controlled drugs were correct but there is a need to ensure that there are two staff signatures recorded in the controlled drugs register when destroying controlled medication. It remains a requirement that the index within the controlled drugs register is kept up to date. This unit provides palliative care to its residents. Pain charts were seen on file and were completed. An up-todate policy for the safe handling of medication was in place and available for staff reference. The inspector noted that the date of opening was not being recorded on liquid medication such as eye drops and this must be rectified. The inspector noted in response to the requirement set at the pharmacy inspection on the 15th February 2007, that written evidence of the current INR St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 11 and warfarin dosage was available in the home and kept with the residents’ medication administration records. The medication administration records for a number of residents contained some gaps in them. Paracetamol had not been signed for on eight occasions despite this being a regular prescription not as required medication. The inspector noted that one of the staff’s signature consisted of one initial. It remains a requirement, to avoid confusion and so that it is not mistaken for an endorsement, that both initials are used when signing for medication given. There is also a need to ensure that when the letter F is used in the medication administration records for when medication is not administered, this must be defined. St Vincents House DS0000066934.V341457.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, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to be involved in meaningful daytime activities of their own choice and according to their interests. Mealtimes are unhurried and relaxed. EVIDENCE: “Social activities are good and varied. Residents’ committee is a good idea”. “Food is dreadful. Brussel sprouts in July? All vegetables cooked to death” “Food can sometimes be an issue and meals can be inappropriate. Staff do respond though when this is pointed out.” (comments received in surveys) There is a good level of information obtained about the residents including their family life, significant life events and an outline of occupational history, hobbies and interests and likes and dislikes. The information captured within the assessment provides a very good basis for meeting the residents’ social, cultural and religious needs. The residents case tracked had an activities programme in place outlining that the plans were based on their hobbies and interests and were varied. Designated activities staff are employed in the home to arrange group and 1:1 activities. The inspectors found the activities staff to be very professional in their approach to residents, and aware of their needs and preferences. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 13 The activities that took place were agreed with residents, demonstrating that residents’ choice was respected. Residents appeared comfortable voicing their opinions within what felt, a very comfortable atmosphere. The staff were very friendly and many jokes were exchanged between staff and residents as part of the engagement. Residents’ also occupied themselves with a number of tasks that they seemed to be enjoying either singularly or as a group and it was refreshing to see the residents looking after and encouraging each other as a group. There were very few moments that any of the residents were not occupied either in conversation or other activities. A relative who completed comment cards commented that often residents are not aware of social events going on in the home and that staff seem unaware of them and that the residents do not get taken to the right place at the right time. It was noted that a programme of outings and group sessions are advertised in the passenger lift. Checking the visitor’s book and observation during the inspection provided the evidence that many visitors visit the home and are welcomed. Mealtimes in the home were observed on two of the four units. The tables were nicely laid out and there was music playing in the background. The atmosphere was a pleasant and relaxed. If residents required prompting, it was carried out in a quiet, encouraging and patient way. The Manager has agreed to look into the comments received about the quality of the food. The home has an action plan in place for improving the quality of the food, and the Manager has offered to share the action plan with the Commission. St Vincents House DS0000066934.V341457.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 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are recorded and investigated. Policies and procedures are in place for protecting the residents from abuse and training is provided for staff. EVIDENCE: Information on how to make a complaint is included in the home’s welcome pack, which is given to all residents on admission. Information taken from the homes’ Annual Quality Assurance Assessment indicates that the home has received 15 complaints within the last twelve months. Complaints records were checked during the inspection. Information relating to each of the complaints was recorded and details of actions taken in response to the complaint were available. It was difficult to ascertain from some of the records what the outcome of the investigation was and if the complainant was satisfied with the outcome. The Manager explained that a new computerised system is being introduced to record all complaints. This will provide a clear system for recording each stage of the complaint and the outcome. The home has a policy in place for the protection of vulnerable adults from abuse. Staff receive training in this area. There were adult protection investigations ongoing at the home at the time of the inspection. The inspector noted a delay in reporting two incidents to the CSCI and communication in this area must improve. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the residents. There is a choice of communal space for residents to spend time in with visitors. There was a very strong odour on the third floor, other units were fresh. EVIDENCE: St Vincent’s is a purpose built home that provides accommodation on the ground, first, second and third floors. The building is new and was opened in April 2006 and completed to a high specification. There is an alarm call system fitted throughout the home. During the inspection, problems were noted with the alarm call system on the second floor, which was being investigated. Security cameras are located at the reception area. Each unit has a number of communal lounges where residents can spend time, alone or in small groups. There is a small library on the ground floor and there is a designated activities and sensory room where residents can spend time. The home has a large garden, which is attractive and accessible to residents and their visitors. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 16 The home is suitable for stated purpose clean, tidy and hygienic. There was a very strong odour on the third floor, the home needs to investigate the cause and rectify this issue. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedure meets the required standards. There is an acceptable use of agency/temporary staff in the home. The home recognises the importance of training. The Manager is aware of some gaps in the training programme, and is taking steps to address this. EVIDENCE: “The staff are very nice here, very accommodating” (Comments from a resident) The staffing rotas were checked during the inspection. Improvements were noted in the shift patterns of nurses and carers. Staff were receiving sufficient time off and not working long stretches of shifts without a break as identified at the last inspection. There is a large team of managers, nursing, care, catering, domestic and administrative staff employed at the home. The staffing levels on the dementia units have been reviewed since the last inspection, and must be kept under review to ensure staffing levels meet the changing needs of residents whose dependency levels are increasing. A cross section of staff files were checked during the inspection to assess the home’s recruitment practices. The recruitment practices are sound and the necessary pre-employment checks including two professional references and Criminal Records Bureau checks including checks against the protection of vulnerable adults list had been undertaken. The inspectors noted that the home has met previous requirements relating to recruitment practices, which included the need to ensure that copies of applicants’ documents are signed to demonstrate that the original document was seen. Where staff require a work St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 18 permit to enable them to work in the UK, the Home Office documentation was on file. The staff whose files were checked, had received a contract of terms and conditions of employment and a job description. Staff spoken with during the inspection said that the organisation provided a thorough induction in March and December 2006 and there is a rolling training programme in place. The home has a computerised system that tracks training attended and identifies and flags up any that is required. Training needs are discussed as part of formal supervision sessions. The system also provides staff with on-line training through the El box system with the onus being on them to access this. All staff have two weeks supernumary training at the start of their employment. There are three lifting and handling trainers on site and Protection of Vulnerable Adults training is provided. Some staff have attended palliative care workshops and two nurses attended the GSF and Liverpool pathway course. Over 50 of staff are qualified at NVQ level 2 or above. As the home is now in its second year of operation, annual appraisals for staff should be taking place. Adult protection investigations have identified areas for further training and the home must ensure that this takes place. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience and is competent to run the home. The Manager has highlighted areas where they need to make improvements and has an action plan for undertaking this work. The internal auditing systems need to be improved to ensure records are regularly updated and the quality improved. EVIDENCE: The home’s manager has registered with the Commission and is an experienced and qualified person. During the inspection process, the Manager was very open and responsive to the inspectors’ feedback. The inspectors received the following comments about the Manager from a relative “the Manager is always available when I visit and always finds time to listen to any concerns and act upon them. An excellent leader.” The first day of the inspection was the new Deputy Manager/Clinical Nurse Manager’s first day in post. There are now two Deputy Managers/Clinical Nurse Managers supporting the Registered Manager. The Deputy Managers have been assigned two units St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 20 to oversee with the aim of providing closer supervision and support to unit staff. The home is financially viable, has a business plan and set annual budget. Monthly external profit and loss audit takes place. The required insurance cover is in place. The home has a quality assurance process in place, which is based on seeking the views of residents and their representatives. Customer satisfaction surveys are used to gain their views and a report was produced based on these findings. The report was shared with the Commission and is available for interested parties. A new residents committee was set up in May. Monthly visits on behalf of the registered provider are conducted and the findings forwarded to the Commission. The home’s auditing of residents’ records should improve so that risk assessments, medication records and fluid and nutrition intake in particular are up-to-date and the quality improved. The home has a policy of not taking part in making wills. It is currently holding one will for a resident. There is a written policy and procedure regarding resident’s money and financial affairs that also details access and storage. The Care Manager is not an appointee for any resident and their finances are dealt with either by the placing authority, family or legal representative. The home holds a maximum of £100 cash for residents and a sample of fifteen residents monies demonstrated that all transactions are recorded, with receipts and the money held matched the records. These records are audited as part of the monthly unannounced proprietor visits. Each resident has a lockable facility in their bedroom. Any valuables kept on behalf of a resident are stored in the safe with accompanying possessions list. Policies are in place for maintaining the health and safety of residents. Accidents or injuries are recorded. The required tests, drills and equipment checks were taking place within timescale. Any work required is reported to maintenance. There are three lifting and handling trainers on site to ensure that staff receive regular updates in manual handling. The information within the Annual Quality Assurance Assessment, confirmed that written assessments on hazardous substances are in place. Steps must be taken to ensure that the risk to service users including the risk of falls, the risk of developing pressure sores and malnutrition are regularly reviewed. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 & OP8 Regulation 13 Timescale for action Steps must be taken to ensure 20/08/07 that all risk assessments are regularly reviewed. Steps must be taken to ensure that residents receive the input of a community dietician and the GP when they have been identified of being at high risk of malnutrition and where concerns about their nutritional and fluid intake have been identified. Residents’ weights must be monitored frequently and as outlined in their care plans. Food and fluid charts must be completed accurately, with sufficient detail. This requirement is repeated for the second time. Original timescale of 30/09/06 not met. The index of the controlled drugs register must be kept up to date. Original timescale of 01/03/07 not met this is a repeat requirement. All medicines must be recorded accurately with the full initials DS0000066934.V341457.R01.S.doc Requirement 2 OP8 13 20/08/07 3 4 OP8 13 13, 16 20/08/07 20/08/07 OP8 5 OP9 13 (2) 20/08/07 6 OP9 13(2) 20/08/07 St Vincents House Version 5.2 Page 23 7 OP9 13 (2) when administered. If not administered the correct endorsements must be used. This includes variable doses. Original timescale of 24/02/07 not met this is a repeat requirement. When the letter F is used in the 20/08/07 medication administration records for when medication is not administered, this must be defined. Medicines must be given as prescribed. If given as required they must be prescribed as such. Original timescales of 01/03/07 not met, this is a repeat requirement. The date of opening of all liquid medication must be recorded. The Manager must ensure that two staff signatures are recorded in the controlled drugs register when destroying controlled medication. The Registered person shall give notice to the Commission without delay of any allegation or event in the home, which adversely affects the well-being or safety of any resident. The home must investigate the cause of the very strong odour in the third floor and rectify this issue. 20/08/07 8 OP9 13(2) 9 10 OP9 OP9 13 (2) 13 (2) 20/08/07 20/08/07 11 OP18 37 20/08/07 12 OP26 16 (2) 20/08/07 13 OP27 18 Staffing levels in the dementia 30/09/07 care unit must be kept under review to make sure that service users’ care needs are met. The home’s internal audit systems must be improved to ensure that residents’ records are up-to-date and the quality improved. DS0000066934.V341457.R01.S.doc 14 OP33 24 01/09/07 St Vincents House Version 5.2 Page 24 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 OP30 Good Practice Recommendations Staff should receive an annual appraisal of their work. St Vincents House DS0000066934.V341457.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local 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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