Inspection on 28/02/07 for St Werburghs House

This inspection was carried out on 28th February 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 Werburghs House 22/10/08

St Werburghs House 27/11/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE St Werburghs House Church Street Spondon Derby DE21 7LL Lead Inspector Helen Macukiewicz Key Unannounced Inspection 28th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Werburghs House DS0000069393.V328169.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 Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Werburghs House Address Church Street Spondon Derby DE21 7LL 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) 01332 851800 01332 200644 European Care (Derby) Limited Karen Margaret Walker Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. European Care (Derby) Limited is registered to provide nursing and personal care to service users whose primary needs fall within the categories of: Old Age, not falling within any category, (OP) - 35 The maximum number of service users to be accommodated at St Werburghs House is 35 27 February 2006. 2. Date of last inspection Brief Description of the Service: St Werburghs is a two-story detached house, which has been adapted and extended as a care home. It is a listed building and sits in its own grounds behind the local church. It is situated in Spondon close to local shops and a bus route. The home opened in 1989. The Registered Proprietors have recently changed to European Care Derby. The home provides nursing and personal care for persons aged 65 years and over with physical health needs. The home has 3 lounges areas and a dining area on the ground floor. The large garden is accessible to service users. The current fee range per week is between £385 to £545. This information was taken from the pre-inspection questionnaire completed by the Manager. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 7.15 hours over 1 day. During this time both the Manager and Operational Manager for the Home were present and provided information as needed. Time was spent undertaking a brief tour of the Home, looking at records and speaking to resident’s and staff about their experience of the Home. Lunch was spent with the residents and medication was also examined. Five resident’s care files were seen. Prior to this Inspection, comments were received via pre-Inspection questionnaires from 12 residents/relatives representing views for over a third of all residents accommodated in the Home. Their comments have been incorporated into this report. Since the last Inspection, a new Company has purchased the home. This was the first Inspection visit by the Commission for Social Care Inspection since this new ownership. What the service does well: What has improved since the last inspection? What they could do better: Systems for the recruitment of staff need to be more stringent to ensure that resident’s are safeguarded. Management of medications needs more careful oversight to ensure errors do not occur and care planning needs to be more detailed and updated as residents needs change. Staffing during the early part of the day needs to be reviewed in light of resident’s comments and more one to one activities planned. There are some health and safety matters within the environment to be dealt with to ensure residents live in a safe environment. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 6 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 Werburghs House DS0000069393.V328169.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 Werburghs House DS0000069393.V328169.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): Standards 1, 2 and 3. Standard 6 does not apply; the home does not offer intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given sufficient information and assessment to ensure they have a choice of home, which will meet their needs. EVIDENCE: There is a service user guide and statement of purpose for the Home; European Care has updated both. The manager confirmed that the new version would be issued to residents when available. The previous Inspection report was available in the home and residents/relatives were notified of its availability through a notice in the foyer. When asked, residents couldn’t remember if they had seen the service user guide or previous report and care files did not contain evidence that these had been issued, although the St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 9 manager confirmed a Service User Guide was put in each bedroom. However, residents said that they felt that they had enough information about the home. A copy of individual contracts stating terms and conditions of stay were seen in resident’s care files. All care files seen contained a pre-admission assessment of need. These were completed in full. Some files also contained an assessment of need undertaken by Care Management. St Werburghs House DS0000069393.V328169.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have their health needs met in a respectful and dignified way although gaps in care planning and management of medicines means their well being is not fully safeguarded. EVIDENCE: Three care files were seen in detail and a further two examined to follow up specific issues. Forms used to assess resident’s needs on admission were generally filled in although the Nurse who completed one had not signed it. Usual routines and preferences were not always recorded and there was little evidence of resident’s involvement. One form had not been completed in the areas of ‘dying’ or ‘sexuality’. On separate sheets there was good assessment of the residents risk of pressure sores, continence, nutrition and general risks. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 11 Care needs were generally identified, and some resident’s had a ‘family tree’ as a one-off fact finding exercise about their life. However there was a focus on medical/nursing needs and little inclusion of social and spiritual needs in the care plans. One resident said they required emotional support to come to terms with the recent loss of their home and move into care, but the help they needed was not recorded in their plan of care. One resident had recently required antibiotics for an infection but there was no care plan for the care they might need for both the infection or for monitoring the potential side effects of the antibiotics. Despite the need for more detail in care plans, residents felt they were receiving the care that they required in most areas. A low staff turnover contributes towards ensuring that resident’s needs are well known by staff. Staff also confirmed that they are encouraged to record changes in resident’s condition into the daily care records. Residents confirmed that they could see their G.P, optician and chiropodist when they want to. One resident said ‘I’m OK here, I’m looked after well’. The Manager confirmed that residents who need specialist equipment have an Occupational Therapist assessment. There was also plenty of Nursing equipment in use and the Manager has ordered some more specialist mattresses. One resident was self-medicating but there was no risk assessment or care plan for this in their care file. This person had also been given a prescribed medication to take at a later date. The timing of this medication should be altered or it should be formally acknowledged that it is being self-administered. Storage and management of medicines was generally good with the exception of the following: 1 medication had passed its expiry and required disposal; allergies were not recorded on the MAR sheet (Medication Administration Record); the amount of tablets received into the home had not been recorded on one MAR sheet. There are no ‘homely’ remedies such as paracetamol or cough syrup stored in the Home. Should anyone require pain/symptom relief during the night, this may cause unnecessary delay. Two residents confirmed that staff always knock on their bedroom door to request permission to enter. Another said ‘some staff are better than others but generally they knock on the door’. One resident said that they needed help to bathe but got enough privacy whilst being assisted. Another resident said that she had a key to her bedroom door and had enough privacy. One resident said they would like a key to their door, or a drawer in their bedroom, but hadn’t got one. The Matron said that the Home had a programme for gradually providing door locks to all rooms. Residents also confirmed that staff treat them with respect and that they are able to exercise choice in the home such as what they wear and how they occupy their time. St Werburghs House DS0000069393.V328169.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose their lifestyle, social activity and keep in contact with friends. Social, cultural and recreational activities meet resident’s expectations although more one to one time with staff would enhance their lifestyle. EVIDENCE: 8 of residents/relatives completing pre-inspection questionnaires answered that there are sometimes activities arranged that they can participate in. 2 answered that this was usually the case and 1 did not reply to the question. One comment received asked for more 1 to 1 activity, particularly for people with mental health problems who might not be able to participate as well in group activity. Findings during the Inspection were equally mixed. One resident said that they didn’t know what activities were planned in the Home but wouldn’t choose to join in if asked, although they had enjoyed a recent valentines party and quiz organised by the staff. This person said that they would prefer more one to one time with staff. Another resident confirmed that someone had been in St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 13 recently to play an instrument and went on to say that they had played cards with a staff member but would like more one to one time with staff. A further resident said they ‘would like more to do’. One resident said that they wouldn’t join in activities but they get bored at times. Another said they would like to go shopping with staff. Staff confirmed that they work extra hours to accommodate individual shopping trips with residents. The Operational Manager confirmed that the motivational staff member who had been employed had just handed their notice in so this post would be re-advertised. Talking books and library books are available within the Home. The local paper is delivered free of charge each day and resident’s can opt to pay for their own choice of newspaper, which would also be delivered daily. Residents either have their own telephones or can use the office phone, which is portable for privacy. Resident’s confirmed that they receive visits from their respective churches. There were plenty of visitors on the day of the Inspection and resident’s said that their visitors can come anytime. One said they regularly went out at the weekends with their relatives. Findings from the pre-inspection questionnaires received were that 5 of people who responded always liked the food provided in the Home, 3 said this was usually the case and 3 offered alternative comments. Comments included “mum says the meals are substantial” and “meals are generally excellent”. 1 person said that they never enjoy the food in the Home. Time was spent with residents over the lunch time period. Lunch was unhurried and residents were offered drinks throughout. Residents who were unable to eat without help were given assistance. Those with reduced appetites were encouraged to eat. Observations of staff showed that they were very attentive to resident’s needs throughout. Residents said that they have a choice of meal, although the system for offering choice the previous day meant that they often forgot their menu choice. However, residents on the day said that they were satisfied with the meal that they had been given and that the portions were sufficient. The cook said that she always cooks extra of each choice of meal so that residents can opt to change their menu choice on the day. The cook was aware of the different dietary requirements of residents. There was evidence to support that staff involved in catering duties are suitably qualified. St Werburghs House DS0000069393.V328169.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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s rights to complain are upheld and they are protected from abuse, although gaps and outdated information in documentation means there is potential for error in the management of both. EVIDENCE: All of the 12 respondents in the pre-inspection questionnaires said that they knew how to make a complaint and that there is someone they can talk to in the Home. A copy of the complaint procedure was on display in the foyer and included all required information, although the details for contacting the Commission for Social care Inspection needed updating. Resident’s said that they had not seen this although they had not specifically looked for it. The displayed procedure is written in normal size print. For people with visual impairment, this would benefit from being in larger print. The Homes’ records showed that there had been 2 complaints received since the last Inspection. There were incomplete records held for one complaint so it was difficult to say how well the complaint had been managed by the Home. The more recent complaint had yet to be resolved but there was evidence it had been well managed to that point. The Operational Manager confirmed that the new Company had stricter criteria for maintaining records about complaints St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 15 and felt confident that this area would improve. There have been no complaints received by the Commission for Social Care inspection since the last Inspection. Staff had access to the Home’s adult protection procedures but not the Local Authority’s multi-disciplinary procedures. All five staff members who were asked confirmed that they had received adult protection training within the last three years. The Home’s procedures have a former member of staff as point of contact for suspected abuse issues, so need updating. Staff will also need to be updated with changes. St Werburghs House DS0000069393.V328169.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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical layout of the Home enables residents to live in a comfortable environment, which is clean and generally well maintained. EVIDENCE: In pre-inspection questionnaires residents/relatives were generally happy with their surroundings. One comment stated, “the bedrooms are always spotless”. A couple of comments suggested areas for improvement, one being that “the carpets are a bit sticky at times”. Another person said “the general rooms do look a bit tired but there is ongoing redecoration”. On the day of the Inspection, residents said that they were happy with their environment. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 17 The Home and gardens were generally well presented although some of the fixtures and fittings such as armchairs, sheets, pillows and commodes were looking worn and needed replacement. The Manager said that she had ordered some new sheets and dining chairs and intended to gradually replace fixtures and fittings although this was not recorded. Resident’s bedrooms that were seen appeared to be a good size and personalised and resident’s confirmed that they could bring in their own possessions from home. Residents have a choice of seating areas during the daytime and some bedrooms are en-suite. The Home is located near to village shops and facilities. There is a smoking room on the ground floor, which is also used as a hairdressing room. When asked, non-smoking residents did not appear to have been affected by the smoke and those who smoked did not mind vacating this room when hairdressing took place. The manager said that an alternative room is not available for smoking due to the physical layout of the home. There is a separate laundry with sufficient equipment for the safe handling of resident’s laundry including soiled items. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Competent staff care for residents although gaps in staffing and in the recruitment of staff mean that resident’s welfare is not fully safeguarded. EVIDENCE: Pre-inspection questionnaires received raised no concerns about the attitude of staff in the Home. Positive comments were received such as ‘very attentive to both our needs and the resident’ and ‘we (relatives) have a very good relationship with the Matron and staff’. On the day of Inspection, positive comments were also received from residents including ‘staff are very good – excellent’, ‘there isn’t one you could fault’ and ‘they try as hard as they can to please’. Similar comments were also seen on ‘Thank you’ cards displayed about the Home. 3 of responses in the pre-inspection questionnaire stated that there are always staff available when you need them, 8 said this is usually the case and 1 said this is sometimes the case. One comment received stated ‘not enough staff on for how many residents are in, more so at weekends’. Another commented that ‘the staff are always available but they have to work hard given the St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 19 amount of residents – on balance we think there are enough staff’. A further comment said that staff are busy due to work loads/emergencies. The actual number of staff on duty on the day of Inspection was consistent with numbers identified on the staffing rota. There was also additional support from cooks, cleaning staff and laundry staff. One resident said that staff are quick to respond to the call bell but another resident said that they had been waiting 13 minutes to have their call bell answered at 6am. Residents reported that this is a busy time of the day as some residents are assisted to rise by night staff. The timing of shifts has been amended to allow for extra staff in the mornings but not as early as 6am. There were no preferred rising/retiring times stated on the assessments in the care files so resident’s choice/needs to rise this early, and therefore requirements for staffing at this time, could not be assessed during the Inspection. Staff recruitment files were viewed. Where the new owners have been alerted to the fact that some staff have not had Criminal Records Bureau (CRB) checks undertaken by St Werburghs, they have sent these requests off and undertaken interim police checks. Controls on recruitment of staff are not currently strict enough. Of the 3 files seen, 1 did not contain 2 references; reasons why the person left former employment in a position where they were looking after vulnerable children or adults were not explored or recorded; also, there was no record of any interviews prior to appointment. The Manager said she had recently devised an interview form and intended to keep this in each file. About a third of residents living in the home have dementia or mental health needs, qualified staff were due to attend a specific training day on dementia the week after this Inspection. A notice was on display in the office, requesting volunteers to attend a training day for care staff on this subject. The operational manager said that all staff will receive training on this subject through European Care. Staff said that they had received training in many areas, such as Basic First Aid, Continence and Nutrition. This was consistent with training records. Training is funded by the Home and staff receive both mandatory training and other training relevant to the type of care provided by the Home. Staff induction programmes are available and appropriate to the care setting. There was written evidence to support that staff receive an induction and staff also said that they had received one when they first started working in the home. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed effectively although health and safety hazards create unnecessary risks to the welfare of residents. EVIDENCE: There is an experienced registered manager in post. The manager and two other qualified staff have undertaken the Registered Manager’s Award. The staff benefit from regular visits by the operational manager, an administrator, and a regional manager. These staff members are well qualified and provide support to the management and also undertake quality monitoring of the service. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 21 The Home has a comprehensive list of policies and procedures. These are being updated and brought into line with European Care policies. The new policies will not be available to staff until a new Computer is delivered as these are communicated electronically. However, the Operational Manager had copies of the new policies and where sampled, these looked satisfactory. There is a new self-audit document to complete for staff to complete which European Care produces. This includes consultation with residents and relatives. Some internal quality assurance surveys have been done in the past although visiting professional such as Care Managers were not included. The new documentation is much more robust. The Manager largely deals with resident’s personal finances. A check of the systems for managing money proved satisfactory. Residents said that they have money when they need it. Generally the Home provided a safe environment for residents, although this inspection identified some health and safety matters that required attention. In a couple of bedrooms, window restrictors were missing from upper floor windows. At one point during the Inspection, some cleaning materials had been left in an unlocked area and one bedroom fire door had been wedged open and the area left unsupervised. The Operational Manager said that European Care required a full health and safety audit and it is their intention to complete this audit during 2007. Documentation to support this had previously been seen by the Inspector. Documentation supported that gas, electrical and fire safety equipment is regularly checked for safety and there are systems in place to ensure nursing equipment is maintained. The Legionella maintenance program did not cover all areas of maintenance that are required. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2)( b) Requirement Residents care plans must contain a full assessment of need, which supports consultation with the resident/relatives to ensure residents lead a lifestyle similar to that which they would in their own home. Resident’s care plans must record all care needs including emotional, social and spiritual needs to ensure that all care needs are identified. Any changes in care must be updated into the plan of care to ensure residents are safeguarded. Resident’s who are selfmedicating must have a risk assessment for this completed and a plan of care in place to ensure safeguards are in place. Allergies must be recorded in the appropriate section of the Medication Administration record to ensure no medication is given in error. St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 24 Timescale for action 30/04/07 2 OP9 13(2) 30/04/07 3 OP18 13(6) Medications that have expired must be removed from stock to safeguard residents. Copies of Local Authority Adult Protection Procedures must be accessible to staff to ensure residents are safeguarded against abuse. 30/04/07 4 OP27 18(1)(a) 5 OP29 19 (1) (5) and Schedule 2 The Homes adult protection procedures must be updated to ensure a current member of staff is the point of contact for issues arising, so that suspected abuse is quickly responded to. Staffing levels during the early 30/04/07 morning must be reviewed in light of residents’ comments to ensure their needs can be met at this time of the day. CRB checks on staff must be 30/04/07 carried out prior to appointment to ensure residents are safeguarded. Recruitment checks on staff must be consistent with the requirements of Regulation 19 and schedule 2. Windows must be risk assessed 30/04/07 and necessary safety measures put in place for the first floor bedroom windows, to prevent falls from a height; All chemical cleaning products must be correctly stored and Legionella maintenance must be up to date, to ensure residents live in a safe environment. 6 OP38 13(4)(a) St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 25 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 OP1 Good Practice Recommendations The revised Service User guide and Statement of Purpose should be issued and resident’s supported to understand their contents. The availability of the Inspection reports should be publicised further and resident’s supported to read this. Qualified staff should sign the care assessment. A small stock of homely remedies should be provided. When appointing a new motivator, consideration should be given to resident’s needs for more one to one activity. The complaints procedure should be amended to update the Commission for Social Care contact point. The complaint procedure should be improved to make it easier for people with visual impairment to read. The program for replacement of fixtures and fittings should be formalised to demonstrate the actions that are being taken to provide a pleasant environment for residents. The ways in which alternative smoking provision has been investigated should be recorded to demonstrate that action has been taken to provide a separate area. Residents preferred rising times should be sought and recorded in their plan of care, in order to assess staffing levels required during the early morning. 2 3 4 5 OP7 OP9 OP12 OP16 6 OP19 7 OP27 St Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Werburghs House DS0000069393.V328169.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!