Inspection on 11/01/07 for St Winifreds

This inspection was carried out on 11th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Winifreds 21/01/10

St Winifreds 30/01/09

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Winifreds 236 London Road Deal Kent CT14 9PP Lead Inspector Jenny McGookin Key Unannounced Inspection 11th January 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 Winifreds DS0000068203.V319062.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 Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Winifreds Address 236 London Road Deal Kent CT14 9PP 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) 01304 375758 01304 370911 st.winifreds@nellsar.com Nellsar Limited Mrs Janet Spree Care Home 59 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (35) of places St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: St. Winifred’s is a large care home situated on the London Road in Deal. The property has been extended over a number of years to its current size, which provides accommodation for 59 service users. There are 35 elderly residents in the main part of the home and 24 residents with dementia in a secure wing of the home. The home is located half mile from the town centre of Deal and is on a local bus route. There is off street parking to the front and the side of the home. Accommodation comprises 51 single and 4 double rooms mainly situated on ground and first floors with 2 rooms at second floor level. All areas are accessible via the two shaft lifts, one at either end of the home. All bedrooms have a wash hand-basin and a large proportion of the single bedrooms have en-suite facilities. All rooms are provided with a telephone. The home has five lounge/dining areas and also a porch, which serves as an additional small sitting area. There is a smoking lounge for service users situated in the older part of the building. Kitchen facilities are provided for service users able to make themselves drinks and snacks. Service users also have the benefit of well-maintained and accessible gardens to enjoy the sunshine and fresh air. The current fees for the service at the time of the visit range from £303.25 £475 per week. Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service User Guide. The e-mail address for this home is: St.winifreds@nellsar.com St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on two site visits, one unannounced and a follow up visit, which was prearranged with the manager, and is being used to inform this year’s key inspection process and to check on any developments since the home’s registration under its new ownership. The inspection process took fifteen and a quarter hours in total. It involved meetings with four residents (including one group of three over lunch), a relative, the manager and her service manager, two shift leaders, the home’s bookkeeper and the cook. Interactions between staff and residents in the EMI Unit were observed throughout the day. And account was taken of feedback from an extensive feedback survey carried out in October 2006. The inspection also involved the examination of records and the selection of five residents’ case files (representing all three Units), to track their care. Eight bedrooms were inspected for compliance with the National Minimum Standards on this occasion, along with communal areas / facilities. What the service does well: The location of this home is judged suitable for its existing registered purpose, convenient for visitors and a generally satisfactory level of compliance with the National Minimum Standards is being maintained throughout the property and site, accepting some areas are scheduled for refurbishment. All areas of the building inspected were odour free. Records indicate that the health and personal care needs of the residents are generally adequately provided for. There is input from a range of healthcare professionals and some evidence of equipment and adaptations throughout the home. There appear to be sufficient management and staffing resources in place to keep people safe. The meals tend to be traditional English. There is a choice of meals and some special dietary needs can be catered for. The standard of catering was judged satisfactory. This home is generally viewed very positively by those using its services. Residents are being consulted and are afforded choices on a day to day basis. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some matters have been raised for attention in respect of the home’s Service User Guide, and to a much lesser extent it’s Statement of Purpose, and contract, to obtain full compliance with the national minimum standards or current legislation. Some areas of the property require refurbishment, and bedroom provision needs to comply with all the elements of the National Minimum Standard. Some facilities (such as WCs, bathrooms) require better accessibility for residents with wheelchairs of mobility impairment requires better provision. And the home would benefit from shower facilities, so that residents have a choice. CRB checks carried out as part of the home’s recruitment processes, need to be periodically updated, to ensure residents stay safe. Notwithstanding overall numbers of staff on site on any given day, there needs to be an assured minimum staffing level on each Unit, so that residents can have confidence in their ready availability. The home’s investments in staff training in dementia and care of the elderly, could usefully be extended to include catering, to ensure this aspect of its operations keeps pace with best practice standards. The current food storage arrangements should be risk assessed, as the carriage of deliveries down stairs is judged potentially hazardous. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 7 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 Winifreds DS0000068203.V319062.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 Winifreds DS0000068203.V319062.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1, 2, 3, 4, 5, 6 Prospective residents and their representatives have most of the information needed to choose a home, which they can be confident will meet their needs They have their needs assessed; and there is a contract, which tells them about the service they will receive. This home does not provide intermediate care. EVIDENCE: The home’s Statement of Purpose and Service User Guide usefully provide a range of information on the home, its principles of care and its facilities and services, particularly when underpinned by the contracts Nellsar Ltd. are introducing. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and contract already show a close level of compliance with all the elements of the National Minimum Standards. The Service User Guide, however, will require more attention, to take account of emerging elements in the standards. All three documents are currently in the process of being updated to ensure residents or their representatives have all the information they need to make an informed choice, and the manager said they will also be available in larger print. Other languages are not currently warranted. Understandably, the residents spoken to on this occasion had variable recall about the preadmission process, but one relative was better able to provide the detail. And the home maintains an admissions checklist to evidence that information is provided and that an assessment of needs is carried out before each admission. There are opportunities for residents or their representatives to visit the home before admission to assess its suitability for themselves, and there is a trial stay. This home does not provide intermediate care. See sections on “Environment” and “Health and Personal Care” for findings in respect of the home’s capacity to meet the needs of its residents. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 7, 8, 9, 10, 11 The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Each resident has a plan of care which sets out the action, which needs to be taken by care staff to ensure that all aspects of the health and personal care needs of the residents are met. And care plans are properly underpinned by daily reports and a range of risk assessments - covering the individuals, their behaviour, activities and their environments. Less clear, however, was compliance with the National Minimum Standard in respect of formal multi disciplinary reviews (except those led by mental healthcare professionals), to reflect changing needs. Records need to better evidence the home taking a lead in this. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 12 It was not clear, moreover, to what extent residents or their relatives / representatives are actively engaged in the care planning process, except in respect of reviews carried out by care managers or mental healthcare professionals. None of the residents (and only one relative) spoken to on this occasion showed any recognition of the process, though they did recall being asked questions about their care on a day-to-day basis and the feedback exercise in October 2006 confirms they are generally very appreciative of the level of care given. With one or two exceptions, the home’s staff were also reported to be very good at notifying relatives of any changes. The residents’ health is monitored regularly. This home is served by seven GP practices, so that residents have some choice. And records confirm they have access to a range of medical services, according to need. Residents would need to pay for chiropody, physiotherapy or any special or private treatment of medication themselves. The home uses the Boots Monitored Dosage System of medication, over a 4week cycle. The home has its own policy on medication, but also has ready access to a copy of the latest CSCI Guidance on medication and directories on drugs, for reference. There were no gaps of anomalies in the medication administration records seen on this occasion. Staff are trained to administer medication. The home’s Medication trolleys are kept properly secured when not in use. A few recommendations were made to further to further improve this aspect of the home’s operations. The feedback exercise in October indicated that one resident’s ability to self medicate could be usefully explored. With four exceptions, all the bedrooms in this home are single occupancy, which means health and personal care can be given in privacy. Feedback from residents and relatives confirmed that the daily routines are generally as flexible as healthcare needs and staffing levels will allow, although it also indicated that in one or two instances residents need to be reminded and reassured about their choices. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 exercise choices over their daily life style, and social activities - and can keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: Residents were not able to give many examples of any particular interests or hobbies being actively promoted by the home, but a feedback questionnaire in October 2006 obtained a number of ideas for the future (e.g. darts; more outings and Bingo, chair exercises, knitting, sewing, and flower arranging) which the home was trying to address through it’s “Helping Hands” arts and crafts sessions, and some organised outings. The EMI Unit has a more structured programme, which the other residents of the home are welcome to join in. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 14 One or two residents clearly missed opportunities for the more meaningful conversation they had been used to when living at home, but others said they were generally very content; and staff said a number of them had been disinclined to join in any activities offered. A hairdresser comes in regularly, and there is a visiting chiropodist. The home has regular visits from Church of England and Catholic priests. Residents are able to have visitors at any reasonable time. The home is reasonably well placed for links with the local community (see also section on “Environment”). All the bedrooms have telephone points. The cost of calls would be borne by the residents or their representatives. And the home is likely to benefit by the recent installation of computers / e-mail links. Unless other arrangements have been made, residents receive their mail unopened. Catering needs are properly identified as part of the preadmission process and updated or amended thereon. There is a four-week cycle of menus, which is generally the same for each unit. This is traditionally drawn up by the cook in consultation with staff giving direct care, and alternatives are always available, although the feedback exercise in October 2006 came up with other suggestions, and indicated that one or two residents might need reminding and reassuring over the choices available to them. Records are maintained of the options chosen by individuals, as required, and special provision is made for vegetarians, individual preferences, and residents with swallowing problems. Some special equipment is available (e.g. large handled and angled cutlery, plate guards, slip mats, lidded cups) and therapeutic diets are provided; and staff are ready to offer assistance in eating where necessary. When asked, the cook said she hadn’t had specialist training for the elderly or dementia (this is strongly recommended), but had been able to experiment with different dishes and, in one case, by pureeing food, to diversify the residents’ palate, all to good effect. The inspector joined residents for lunch on both visits and judged the meals well prepared and well presented. The residents confirmed this was representative, and that alternatives were readily available. The pace was unhurried and congenial. The dining areas provides pleasant settings, and families and guests are always welcome to stay for lunch. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure. Residents are protected from abuse and have their legal rights protected. EVIDENCE: This home has a clear complaints procedure, which is detailed in its Service User Guide and is on open display. There have been no complaints registered since the home was registered under its new ownership, but previous inspections have found that the home’s culture has been to take concerns and complaints seriously, and to properly evidence the action it takes. The feedback exercise carried out in October 2006 indicated that one or two residents did not know who to talk to if they had concerns, but the records showed that the process was immediately explained to them. The home has procedures to ensure that service users are safeguarded from abuse in all its forms, and staff confirmed their commitment to challenge and report any incidences of abuse, should they occur. St Winifreds DS0000068203.V319062.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 19, 20, 21, 23, 24, 25, 26 The physical design and layout of the home enable residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: This home is on the busy London Road linking it to Deal, Sandwich, Ramsgate and Margate, with all the community and transport links that implies. The home is also about a mile from the nearest train station, and there is a bus route, which stops just yards from the home. On-site car parking facilities are good, and measures are in place to keep the premises secure against unauthorised access, without infringing on the residents’ freedom of movement – accepting that the residents in the EMI Unit require more secured provision. There are two local pubs, a post office, general store and bakers. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 17 The layout of this home is judged generally suitable for its stated purpose; it is accessible, safe and, for the most part, well-maintained. Comfortable temperatures and lighting levels were being maintained throughout. The residents have a good choice of communal areas (which includes a dedicated smokers’ lounge), and they are each spacious. The furniture tends to be domestic in style and of good quality, and there were homely touches everywhere including the residents’ art and craft work. One Unit’s communal areas were, however, judged shabby but the manager said that this area was scheduled for refurbishment All corridors have handrails on each side (though an OT assessment has recommended a different model, for better grip) and there are shaft lifts and staircases to access all floors, so that residents can move about as independently as possible – with the exception or residents from the EMI Unit who require more secured arrangements. All areas are linked with a call bell system. Specialist equipment is not overly conspicuous and includes raised toilet seats, push and lever operated taps, grab rails and lifting equipment, including hoists, pressure relieving cushions and “Ski” base chairs. An Occupational Therapist was contracted in to carry out an extensive assessment of the premises and site in December 2006, and commented favourably on many of its features. She made some recommendations, which should be used to inform future planning to ensure the home maintains it capacity to meet the emerging needs of its residents and best practice standards. This home is registered to provide care for up to fifty nine residents, and with the exception of four double bedrooms, all the bedrooms are single occupancy, so that residents can for the most part be assured of privacy. Eight bedrooms were inspected on this occasion, and judged reasonably well maintained and personalised. In terms of their furniture and fittings, however, they were not all fully compliant with all the provisions of the National Minimum Standards. Most of them did not have a lockable facility, a table to sit at or bed tray, or a second comfortable chair. Their non-provision needs to be supported by fully documented consultation and/or risk assessment. All the bedrooms have telephone points, and television points - and all are linked to a call system facility. There are also additional call points in the en-suite facilities. Thirty six bedrooms have their own en-suite facilities. And there are eight communal bathrooms and five communal WCs i.e. reasonably close to bedrooms and communal areas. However, provision in A Block has proved problematic for some residents with mobility impairment, and although two St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 18 baths have shower attachments, there is no discrete shower room, to give residents a choice. It is accepted that this is planned. All the maintenance records seen were up to date and systematically arranged. Some matters were raised for consideration or attention, to improve the facilities. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 27, 28, 29, 30 Staff in the home are well recruited and trained, to fill the aims of the home and meet the changing needs of residents. But the home’s ability to maintain minimum staffing levels throughout shifts or within units requires further attention. EVIDENCE: This home’s staffing arrangements were designed to provide each Unit with sufficient staffing to meet the assessed needs of the residents. The working / waking day is interpreted as 7am till 8pm A and B Blocks: 3 staff (mornings and afternoons) EMI Unit: 5 staff In each Unit this is achieved by individual staff working a range of shifts (7am till 12pm; 7am till 3pm; 12-8pm; 3-8pm; 3-10pm. And in each case this staffing level should include a designated shift leader. An examination of staffing rotas for a three-week period (2-23 December) indicated that, although on an hour-by-hour basis the total number of staff on St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 20 site invariably exceeded this arrangement during the mornings, there were 10/21 days when there were shortfalls of one or two staff for periods of between 1-7 hours at a time in the afternoons. Although this period coincided with a sudden outbreak of sickness, this arrangement does not take into account the extra staffing required to meet the needs of day care service users. And staffing levels / availability had been raised as an issue warranting further attention in the feedback exercise of October and in two instance since these current site visits. It is accepted that the manager had completed another recruitment drive in the meantime. Notwithstanding overall numbers of staff on site on any given day, there needs to be an assured minimum staffing level on each Unit, so that residents can have confidence in their ready availability. Overnight, A and B Block should each have one waking staff plus a second member of staff to “float” between the units. The EMI Unit should have 2 waking staff. The examination of staffing rotas did show that these night-time staffing arrangements were maintained throughout i.e. 5 waking staff on site. In the absence of the manager there is always someone in charge, with an oncall system as a back up. An examination of five personnel records, selected at random, confirmed feedback from staff, that this home has a systematic recruitment process to comply with the key elements of the standard, induction and training - to keep the residents safe. Some CRB checks were in need of updating, to ensure residents remain safe. Staff confirmed that their supervision sessions properly covered all those elements prescribed by the standard, and that the frequency of these sessions was on course to meet the National Minimum Standard, given the home has yet to run its first year of registration under its new ownership. See also section on “Management and Administration” in respect of the manager’s qualifications and ethos. Staff and records confirmed that there is a generally adequate level of investment in mandatory training (e.g. moving and handling, medication, food hygiene, First Aid and Health and Safety, COSHH and infection control) to keep the service users safe, as well as some specialist training such as dementia care, challenging behaviour and mental health. The manager has reported having obtained something like 80 of staff accredited to NVQ Level 2 or above. This is judged exemplary. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 31, 32, 33, 34, 35, 36, 38 The management and administration of the home is based on openness and respect, and a good start has been made with quality assurance systems. EVIDENCE: Mrs Janet Spree has been the registered manager since October 2006 and the Commission’s registration process has established that she has a range of relevant qualifications and experience. She has completed all the elements of her NVQ Level 4 accreditation, Registered Managers Award. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 22 There are clear lines of accountability within the organisation and staff and residents have reported that in-house line management is accessible and supportive. Since the home’s registration under new ownership, the proprietor has complied with the regulatory duty to carry out formal documented inspection visits once a month (Regulation 26). All the residents are white British. There are approximately two female residents for every male. All the staff are white and with two exceptions, British. Two are male and the rest are female. The male staff work in the EMI Unit where the residents have not expressed a gender preference. But the home has responded to residents in the other Units who have expressed a preference for female staff giving personal care. A good start has been made with quality assurance initiatives to evaluate the home’s performance against its stated aims and objectives. The views of service users and feedback from other stakeholders will be crucial to the success of any development planning processes hereon. The home’s management does not act as appointee for handling any resident’s financial affairs, but makes proper provision for the proper storage and accounting of personal effects and small sums of pocket money. Insurance cover is up to date and at a suitable level. The home’s property maintenance certificates seen were up to date. St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 3 2 3 3 2 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5,6,16 Requirement Work will need to be done to the Service User Guide, to obtain full compliance with the National Minimum Standard A Block General Lounge requires refurbishment and re-carpeting. Action plan to be submitted Bathroom / WCs • A Block G/F o Floor discoloured in places o Requires refurbishment • Work will need to be done to improve the accessibility of WCs and bathroom facilities • The home needs to have a shower facility so that residents have a choice Action plan to be submitted OT Assessment of Premises 08 12 06. The OT’s recommendations should be used to inform planning processes. Action plan to be submitted Timescale for action 31/03/07 2 OP20 23(2)(d) 31/03/07 3 OP21 23(2)(d) 31/03/07 4 OP22 23(2)(n) 31/03/07 St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 25 5 OP24 16(2)(c) Bedroom furniture and fittings. All bedrooms require assessing against the National Minimum Standards, and non-provision requires documented risk assessment or consultation. Action plan to be submitted Initial CRB checks must be systematically updated, to ensure residents remain safe 31/03/07 6 OP29 12 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The home’s Service User Guide document will require particular attention to ensure fully compliant with all the latest elements of this standard. Care Plans should better evidence: • How the home plans to promote the social care needs of residents, • The active participation of residents and their relatives / representatives in formal reviews • The home taking the lead on formal multi-disciplinary reviews Medication. The following recommendations are made: • That dividers are introduced in the MAR charts file to separate out each resident’s records, and • Each section would benefit by a front sheet for each resident with their photo, and key information on each medication (e.g. purpose, side effects, contraindications etc) as per BNF. Medication Rooms. • All surfaces (flooring, walls and work or storage surfaces) should be impervious, easily cleanable • Flooring should be coved at edges DS0000068203.V319062.R01.S.doc Version 5.2 Page 26 2 OP7 3 OP9 4 OP9 St Winifreds • • 5 OP19 These rooms would benefit by the installation of handwash basins with wrist or elbow operated taps; liquid soap / disinfectant gel, paper towels and lined/lidded bin; These rooms should be provided with readily available disposable aprons and gloves. Kitchen. • Would benefit from a larger oven. • Food storage arrangements should be risk assessed as the carriage of large deliveries down stairs is judged potentially hazardous. Should consider the conversion of a bedroom with external door. Tea urn and dishwasher require repair Bathroom / WCs • A Block G/F o Very dated suite / decor • “B Block UP” - 1st Floor o Sling hoist not popular so should be replaced • “B Block UP” - 1st Floor o Should have a chair for assisted dressing o Should have blind or curtain on external window to ensure privacy and as homely touch • EMI Unit – G/F o Should have a chair for assisted dressing o Should have a blind or curtain on external window to ensure privacy and as homely touch • WC – A Block 2nd Floor. Toilet roll requires holder • Laundry area requires refurbishment Notwithstanding overall numbers of staff on site on any given day, there needs to be an assured minimum staffing level on each Unit, so that residents can have confidence in their ready availability. 6 OP21 7 8 OP26 OP27 St Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Winifreds DS0000068203.V319062.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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