Inspection on 21/01/08 for St Vincents House

This inspection was carried out on 21st January 2008.

CSCI found this care home to be providing an Adequate service.

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 16/07/07

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 & Sheila Lycholit Key Unannounced Inspection 11:30 21 & 22nd January 2008 st 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 Vincents House DS0000066934.V355811.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.V355811.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 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.V355811.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. 16th, 17th & 18th July 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.V355811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place over two days on the 21st and 22nd of January 2008. The inspection lasted a total of 13 1/2 hours, and was carried out by two inspectors. This was the home’s second key inspection for the inspection year 2007/2008. During this visit we 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. The care was observed on all four units. Questionnaires were sent to gain feedback from residents, relatives and professionals. The return rate was low, only 10 were returned to the Commission. Some of their comments have been included into the report. What the service does well: What has improved since the last inspection? The newly appointed Manager and the Area Manager have introduced a number of changes to improve the service, including an increase in staffing levels and the appointment of an additional experienced Activities CoSt Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 6 ordinator. The Manager regularly checks a sample of care plans and monitors, via the electronic system, that reviews are up to date. The Manager had arranged a meeting with relatives and carers, who had all been sent a letter about the changes being implemented. A number of examples of good interaction between staff and residents were observed, with staff providing reassurance to residents expressing anxiety and demonstrating patience and encouragement to eat and drink. The home has worked to ensure that the controlled drugs register is kept update and that two staff signatures are recorded in the controlled drugs register when destroying controlled drugs. A system has been introduced for checking the medication administration records at the end of every shift so that any gaps and or omissions are identified quickly. This has significantly improved the recording of medication. Dependency of residents has been reviewed and remedial action taken by Care UK to increase staffing levels by 1 Registered Nurse on duty between 08:00 and 14:00. Review of training has been undertaken to provide staff with activities and dementia training as a priority. Formal induction programme has been introduced for new staff. What they could do better: Although ideas are being put forward regarding how to improve the activities programme, this needs to be introduced. While the monitoring of fluid intake of residents’ identified at risk has improved, staff must ensure that frequent drinks and food are offered to residents whose intake is low. Families and carers must be informed when a resident’s weight loss is causing concern so they are involved in any decision to admit to hospital or to involve the palliative care team. All concerns raised by families and carers or others, for example concerning lost possessions or clothing, must be recorded, with action taken noted. Any allegation or event in the home, which adversely affects the well-being or safety of any resident must be reported to the Commission and the multiagency policy must be followed. Staff need further training in dementia care and especially in managing challenging behaviour. Senior staff should ensure that care staff develop strategies for managing challenging behaviour, with the support of the multiprofessional team. St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 7 Where it is decided that staff can commence employment prior to CRB check, a POVA 1st check result must be available. Unit Managers should not have to cover the home’s phones while on duty, which creates frequent interruptions to their work on the units. The recording of daily notes is variable, with some staff noting insufficient detail. Daily notes should cover all aspects of the core care plan. 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.V355811.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Referrals are discussed prior to admission to ensure that the home can meet the residents’ needs. EVIDENCE: Following the initial referral and receipt of care management assessment, residents’ needs are further assessed by a Registered Nurse prior to admission. The home Manager confirmed that all admissions are discussed with him and that he will makes the decision whether the home can meet their needs. St Vincent’s House does not provide intermediate care. St Vincents House DS0000066934.V355811.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of care planning has improved as a result of regular monitoring by senior staff, an audit by Care UK’s clinical governance team and documentation training for staff, though further work needs to take place to ensure that care planning is of a consistent standard. The home has a medication policy which is accessible to staff. The recording of medication has improved following the introduction of a regular audit system. Further steps need to be taken to promote residents’ dignity, by ensuring that they are appropriately dressed, by protecting their possessions and addressing them in the way that they prefer. EVIDENCE: Care plans and assessments for eight residents were looked at on the home’s computerised system (Saturn). It is clear that improvements have taken place since the last inspection as a result of staff training and monitoring and auditing by senior staff at the home and by Care UK’s clinical governance team. Dependency assessments have recently been reviewed for all residents. Care plans seen were generally up to date, though some included information, for example regarding continence, that was out of date. The involvement of the resident and of relatives in individual care plans was unclear. Risk assessments were up to date, though variable in detail. Some very good prevention plans were seen, which had involved other members of the multi St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 11 professional team. The moving and handling assessment for a resident receiving short-term care needed more information, including the type of hoist to be used and type and size of sling. Her eating and drinking plan was also unclear, stating that she needed a pureed diet and food cut up into small pieces. The Registered Nurse on duty confirmed that the resident was on a ‘soft’ diet. There was no risk assessment in place for a resident who was at risk of dehydration due to their low oral intake of fluid. The home’s management of medication was assessed on two of the four units. The home uses a monitored dosage system and medication is mainly received into the home in blister packs. Checks are undertaken daily to ensure that both room and fridge temperatures where the medication is stored are at the correct temperatures. Controlled drugs were in use on both units, the balances were checked and were correct. The home has worked to ensure that the controlled drugs register is kept up-date and that two staff signatures are recorded in the controlled drugs register when destroying controlled drugs. Staff now record the date of opening on liquid medication to ensure that medication is not used past their expiry date. The medication administration records (MAR) were checked for the last two cycles (2 months). Gaps appeared in the recording of medication on the Ground floor unit for the cycle ending on the 23rd December 2007. The Manager had identified these issues and introduced a tool for auditing the MAR charts each shift to identify any gaps in the recording. The introduction of this tool has resulted in much improved recording with no gaps appearing in the records of the cycle commencing 24/12/07 to 20/01/08. While some residents were well dressed, others were wearing clothes that were out of shape and appeared to have been over-washed or dried at too high a temperature. One regular visitor commented that her relative was frequently in his pyjamas at lunchtime, as was the case on the day of the inspection. Another regular visitor also commented to the Inspector about seeing a resident inappropriately dressed. A number of staff were observed to address residents as ‘darling’ rather than by their name. While the use of endearments may reflect the warmth and concern that staff have for residents, it is essential that staff reinforce residents sense of identity by using their preferred term of address. One of the dementia care unit was experiencing problems with a resident who was frequently going into other residents’ rooms, causing them distress and moving their possessions. The majority of bedrooms doors are kept open on this unit when residents are not in their rooms. Ways of securing residents’ rooms when they are elsewhere in the unit need to be considered. St Vincents House DS0000066934.V355811.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 adequate. This judgement has been made using available evidence including a visit to this service. Limited activities are currently provided to residents in the dementia care units, though the appointment of an additional Activities Co-ordinator and the involvement of Care UK’s advisor should result in improvements. The involvement of families and friends is high, with some families visiting daily. High levels of support needed in the dementia care units, particularly at mealtimes, make it difficult for staff to ensure that all residents receive sufficient assistance. EVIDENCE: The lack of sufficient activities and stimulation for residents has been acknowledged by the Area Manager and Manager, who have appointed an additional Activities Co-ordinator and arranged for Care UK’s advisor to provide training to staff. Records show that the number of families and friends who regularly visit is high. The Manager had written to all relatives informing them of changes at St Vincent’s and inviting them to a meeting, which was to take place in the week of the inspection. Two relatives who are very regular visitors were spoken with during the inspection. Both had a number of concerns about the care of their relatives, which are discussed elsewhere in this report. It is recommended that Unit Managers provide relatives with a regular up date, including changes to the care plan and that options regarding care are discussed. St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 13 Menus are varied, with the choice of a vegetarian dish each day. Records show that one resident is provided with Halal food. Most of the food is pre-prepared cook chill dishes. The quality of food has been discussed recently at a residents committee meeting where members complained about the standard of meals. Feedback received with the questionnaires included “The residents committee does meet to discuss issues, however meals have been on the agenda for a few months according to the minutes” and “the only issue that sometimes arises is with regard to the lunchtime hot meal and the meat which is usually very overcooked and difficult to chew.” Lunchtimes were observed on both of the dementia care units. The workload for staff, particularly on the third floor, is high with the majority of residents needing support to eat and drink. Staff were observed to try to make the mealtime as enjoyable as possible and were supporting residents to eat while at the same time managing the behaviour of another resident who was becoming very agitated. As well as supporting residents in the dining room, there were others in the two sitting areas and in their rooms who also needed assistance. The food and fluid intake of one resident was causing serious concern and she being seen by the GP on the day of the inspection. Records, which were up to date, showed that on some days her fluid intake was extremely low. Records showed that staff were offering her food and drink including food supplements but these were not being offered with sufficient frequency, given the concerns about her condition. There was no indication that her condition had been discussed with family members who visit regularly. St Vincents House DS0000066934.V355811.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): 17, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has an accessible complaints procedure but complaints from individuals are not always fully recorded and the outcomes and actions not always properly logged. There are policies and procedures for safeguarding people who use the service but referrals are not always made due to inconsistencies in knowledge and practice within the service. EVIDENCE: Information on how to make a complaint is included in the home’s welcome pack, which is given to all residents on admission. Feedback from residents and relatives indicate that they are aware of how to make a complaint. There is also a suggestions box available at main reception where residents and visitors may suggest ways for improving the service. A new computerised system has been introduced to record complaints. These records were checked during the inspection. It was not always clear from checking the records what the outcomes of the complaints were. One of the Inspectors spoke with two family members who were visiting their relatives. Both raised concerns about items going missing, including slippers, shoes and books. The Unit Manager confirmed that the loss of these items had been reported and that a search had taken place but the concerns and action taken had not been recorded. Although there has been an increase in the number of complaints being recorded since the last inspection, further work is needed in this area to improve the recording of complaints and action taken. St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 15 The home has a policy in place for the protection of vulnerable adults from abuse. Staff receive training in this area during their induction and further training has taken place since the last inspection. When checking the complaints records we saw two incidents that fell under the safeguarding procedures. We could not see evidence that these incidents had been reported immediately to the local authority’s adult protection team and the CSCI had not been notified as per the requirements of regulation 37. These incidents were discussed with the Manager. Further work is required in this area to ensure that staff are clear on the procedures for referring concerns and incidents to the relevant authorities and to make sure residents are protected from abuse. St Vincents House DS0000066934.V355811.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, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Vincent’s House is a well-designed building providing single rooms with en suite facilities. Residents in each unit have the use of a range of sitting areas, and a pleasant dining room. There is a safe, attractive garden with tables and chairs to the rear and side of the building. Although steps have been taken to improve the standard of cleaning, some odours remain in some parts of the building. EVIDENCE: Communal areas and bedrooms are suitably furnished and equipped. Residents have a choice of sitting areas and space to walk around on the units. The dining areas are attractively furnished, with tables laid with cloths and tablemats. Curtains are of good quality, although some needed re-hanging. The building is well provided with bathrooms and lavatories, which have a range of aids and equipment. A new cleaning regime has been implemented with some success, although there were strong odours on the second floor on the day of the inspection. One relative also commented to the Inspector on the strong odour on this unit. St Vincents House DS0000066934.V355811.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. Staffing levels on the dementia care units do not allow sufficient time, particularly at busy periods, for residents, many of whom have high needs, to receive sufficient one to one care. Staff on the dementia care units need training and support from the multi professional team to develop strategies for managing challenging behaviour. EVIDENCE: The majority of residents at St Vincent’s have high care needs and a number exhibit challenging behaviour as a result of dementia or other medical condition. The high dependency levels have been confirmed by a recent reassessment using Barthel. As an interim measure an additional RGN is to be employed on each unit from 8am to 2pm. The additional staffing was not in place during the inspection when staff were observed to be under considerable pressure, particularly at lunch time. A comment received within the feedback included “it is often difficult to locate any staff in the afternoon” Staffing levels were observed to be further eroded by staff having to deal with frequent phone calls to the home unrelated to their unit while the reception was unattended. Concerns were also raised about the staffing levels within the questionnaires and other contact with the Commission. Some comments included “there are constraints on time due to staff shortages and highly dependent patients” and “there is a high turnover of some staff which affects the continuity of care and communication.” St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 18 It was commented also that “the high use of agency staff puts pressure on the regular staff who have to supervise them.” Significant progress has been made however in reducing the number of agency staff used, which is expected to reduce further with the recent appointment of 12 new care staff. Care plans and observation indicate that staff do not have sufficient training in managing challenging behaviour. The Manager had arranged for members of the Community Mental Health Team to advise regarding one resident whose behaviour was causing great concern. Staff need to be provided with the training and support to develop strategies for managing a range of behaviour, especially in relation to dementia. The Manager confirmed that approximately 90 of staff have the relevant National Vocational Qualification in care. This figure is commendable. The newly introduced formal induction programme was shared with us. It was noted that new employees receive training in safe working practiced during the induction, which includes moving and handling, training in the protection of vulnerable adults and fire safety training. The files of four new employees were checked during the inspection to assess the home’s recruitment procedures. There was evidence available within these files that professional references had been obtained and that staff were required to attend a face-to-face interview. Checks against the Protection of Vulnerable Adults (POVA) list of people unsuitable to work with vulnerable adults had been undertaken for three of the four employees whose files were checked. Steps were immediately taken by the senior administrator to request a POVA 1st check for the employee who did not have the results available. Where staff had started work before the results of the Criminal Records Bureau check (and in the case of the one employee without the POVA 1st check), steps were in place to make sure that they were supervised at all times. Steps must be taken to make sure that a POVA 1st check is undertaken prior to employment. St Vincents House DS0000066934.V355811.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, 37, 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 but has not yet registered with the Commission as the home’s Manager. Residents’ financial interests are safeguarded. Daily notes have improved but some records seen contained insufficient detail EVIDENCE: The home has a new Manager in post, who commenced employment on the 3rd December 2007. He is a very experienced Manager with extensive experience of working in elderly care. He has a qualification in Mental Health Nursing and has completed the Registered Manager’s Award. An application to register with the Commission as the Registered Manager is currently being prepared and we were told will be submitted shortly. The home has a system in place for checking the quality of the care in the home, which includes seeking the views of the residents. Residents are given the opportunity to comment on aspects of the service through completing a St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 20 satisfaction questionnaire. The home also has a residents’ committee, who met on the 09/01/08 and was chaired by one of the home’s residents. Monthly visits on behalf of the registered provider are conducted and the findings are forwarded to the Commission. A review of the care records on the Saturn system has been undertaken and by the Clinical Governance Team. This has been beneficial to highlight areas needing attention. Regular medication audits have also been introduced, which has resulted in better recording of the medication administered to residents. There have been no changes to the home’s procedures for handling residents’ finances. Evidence at the last key inspection in July 2007 demonstrated that the systems in place are robust and makes sure that residents’ financial interests are protected Daily notes have improved, with 3 entries made each day. Some records seen contained insufficient detail, for example the name of the person giving care was not noted and there was not always confirmation that pads had been changed. St Vincents House DS0000066934.V355811.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 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 2 3 St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 22 Yes Are there any outstanding requirements from the last inspection? 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. 2. Standard OP7 OP8 Regulation 15 13 Timescale for action Action taken to improve care 01/04/08 planning needs to be continued to ensure a consistent standard. All areas of risk to residents 01/04/08 must be assessed and a risk management plan must be put in place to minimise these identified risks. Original timescales of 01/01/08 not met this is a repeat requirement. All medicines must be recorded 01/03/08 accurately with the full initials when administered. If not administered the correct endorsements must be used. Original timescale of 24/02/07 not met this requirement is repeated for the second time. Steps must be taken to make 01/04/08 sure that residents are supported to take part in activities, which meet their needs, preferences and capacities. Eating and drinking plans must 01/03/08 include offering frequent drinks and food when a resident’s intake is causing serious DS0000066934.V355811.R01.S.doc Version 5.2 Page 23 Requirement 3. OP9 13 (2) 4. OP12 16 (2) 5. OP15 15 St Vincents House 6. 7. 8. OP15 OP16 OP18 16 (2) (i) 22 37 9. OP18 13 [6] 37 10. 11. OP26 OP27 16 18 concern. The quality of the meals on offer in the home must be reviewed in view of residents’ comments. Staff should record all concerns raised, noting action taken and outcome of investigations. 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. Original timescale of 20/08/07 not met this is a repeat requirement. The Manager must ensure that all incidents and allegations of abuse are reported as per the multi-agency policy and procedures for the protection of vulnerable adults. The Manager must ensure that staff are aware of the procedure for reporting such incidents. Further action to eliminate odours in parts of the building needs to be taken. Staffing levels must be reviewed to ensure that there are sufficient staff at busy periods. Staff should not be distracted by having to take frequent phone calls for the whole building while the reception is unattended. Where it is decided that staff can commence employment prior to CRB check, a POVA 1st check result must be available. Staff must receive training in managing challenging behaviour. The designated Manager must submit an application to register with the Commission as the Registered Manager of the home. Daily notes must contain DS0000066934.V355811.R01.S.doc 01/04/08 01/04/08 22/02/08 01/03/08 01/03/08 01/03/08 12. OP27 18 01/03/08 13. OP29 18, 19 22/01/08 14. 15. OP30 OP31 18 Registration Regulations 01/04/08 01/03/08 16. OP37 17 01/04/08 Page 24 St Vincents House Version 5.2 sufficient detail to identify the staff member giving care and note the extent of care given. 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 OP13 Good Practice Recommendations Unit Managers should provide relatives with a regular up date, including changes to the care plan and that options regarding care are discussed. St Vincents House DS0000066934.V355811.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. Extracts may not be used or reproduced without the express permission of CSCI St Vincents House DS0000066934.V355811.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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