Care Home: St John`s Nursing Home Limited

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What the care home does well The atmosphere at the home was calm, relaxed and congenial despite having carpets laid and the decorators in. During our visit we noted that the staff interacted with people living in the home in a positive and supportive manner. We saw a staff member squat so they were at eyelevel with someone who was obviously distressed and offer support by holding their hand and talking in a quiet, calming way. This is an example of good practice. The home has recently been awarded four stars for its food hygiene after an environmental health inspection. The manager told us that she meets with the trained nurses every day and the carers three times a week, we sat in on the meetings and there was a relaxed but purposeful atmosphere, some good humour and it was evident that people were trying to support each other. What has improved since the last inspection? Proper in depth assessments are now carried out prior to people moving into the home and include life histories. There is evidence that the person being assessed and their families contribute information for the assessment. Care plans have improved and are reviewed monthly. A lot of decoration and refurbishment is being undertaken in the communal areas and bedrooms are being decorated as they become vacant. A room to the front of the house has been made into a dinning room so that people are able to sit at a dinning table to eat; the room was well used. People are still able to eat in the lounges if they choose. What the care home could do better: It is expected that the home checks that the nurses it employed have a current registration with the Nursing and Midwifery Council (NMC) We noticed the manager was only taking copies of registration cards without using the NMC`s checking service. It will be required that she does this in future. Care should be taken that sluice rooms are kept clear of obstruction so that they can be used for their intended purpose, it was noticed that one was used to store wheelchairs and that footrest were left in the sink. The home should make sure that they keep us informed of any issues that may have a detrimental effect on people`s lives. We found that on two occasions people had needed emergency medical treatment due to falls but we had not been informed as required in Regulation 37. CARE HOMES FOR OLDER PEOPLE St John`s Nursing Home Limited St John`s Nursing Home 129 Haling Park Road South Croydon Surrey CR2 6NN Lead Inspector Ann Wiseman Unannounced Inspection 11th July 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St John`s Nursing Home Limited DS0000019041.V367117.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 John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St John`s Nursing Home Limited Address St John`s Nursing Home 129 Haling Park Road South Croydon Surrey CR2 6NN 020 8688 3053 020 8649 9611 susanstjohns@hotmail.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) St John`s Nursing Home Limited Susan Nyakudya Care Home 45 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (22) of places St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2008 Brief Description of the Service: St Johns is a 45-bed nursing home set in South Croydon. It lies within easy reach of the centre of Croydon, and a selection of public transport links. It is registered to cater for elderly people who require general nursing care, (22 beds) and also people with dementia who require nursing care (23 beds). The stated aim of the home is to provide a safe and comfortable environment with a happy atmosphere. The manager has recently been registered with us. The home provides information about its services in a User Guide, which is made available to people who live in the home and those people thinking of moving in. Additional information can be found in the home’s Statement of Purpose. The current weekly fees range from £525 - £650. St John`s Nursing Home Limited DS0000019041.V367117.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection and involved two inspectors; we arrived at the house at 10am. The manager facilitated the inspection and was open and friendly throughout the visit. We were on site for six hours. Work has been ongoing throughout the house to bring the decoration and furnishing up to standard. A party is planned very soon, the Mayor is invited, the process of finishing the decoration in the main reception area and laying new carpets is going on. During the day we were shown around the building and we met and chatted to several people and visiting relatives. The house was clean and tidy apart from the areas where workmen were located. The manager has sent us the Annual Quality Assurance Assessment (AQAA) she had completed. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living in the home. It also gave us some numerical information about the service. As well as talking to people and their visitors we looked at five of their care plans. We inspected five staff personnel files and sampled health and safety records, which were up to date and in order. Overall the home was found to be comfortable and able to meet the needs of those living there. What the service does well: The atmosphere at the home was calm, relaxed and congenial despite having carpets laid and the decorators in. During our visit we noted that the staff interacted with people living in the home in a positive and supportive manner. We saw a staff member squat so they were at eyelevel with someone who was obviously distressed and offer support by holding their hand and talking in a quiet, calming way. This is an example of good practice. The home has recently been awarded four stars for its food hygiene after an environmental health inspection. The manager told us that she meets with the trained nurses every day and the carers three times a week, we sat in on the meetings and there was a relaxed but purposeful atmosphere, some good humour and it was evident that people were trying to support each other. St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St John`s Nursing Home Limited DS0000019041.V367117.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 John`s Nursing Home Limited DS0000019041.V367117.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): Key standards 3 and 6 were examined on this occasion. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are properly assessed before anyone moves into St John’s. This service does not offer Intermediate care. EVIDENCE: During this inspection we examined five peoples files and found that they contained assessments that had been done before people moved into the home, they were detailed and contained personal histories. In the Annual Quality Assurance Assessment (AQAA) the manager said that, “Most people are assessed within 48 hours of referral. The assessments are carried out by staff that are trained to do so.” Those we saw had been done prior to admission. St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards 7, 8, 9 and 10 were inspected during this visit. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People living in this home benefit from having care plans in place and having their health needs fully met. Medication is managed appropriately, people are treated with respect and their privacy is upheld. EVIDENCE: We examined five peoples care documentation in detail. Care plans had been drawn up based on assessment of the individuals needs, including information supplied by relatives and incorporated into life histories. There was other evidence of family involvement for one persons, with the next of kin signing to confirm preferences about care delivery. Ethnic monitoring forms had been completed for each person. Overall, the plans offered enough guidance to staff to meet people’s needs. There were specific night care plans and end of life wishes had been recorded. St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 10 The plans had been reviewed monthly, with the reviews being generally brief but adequate. The behaviour plan for one person had been reviewed with the outcome ‘no change’ but this did not take account of a recent event recorded in the daily notes. It is important that evidence is carefully checked while reviewing care plans so that recent changes can be reflected in the plan. We asked the manager to remind staff to always sign and date their entries on care records, as there were examples where this had not happened. On some record formats there was no space to allow people to sign, for example the monthly weights and nutrition assessments, and the home needs to revise these. There were records of care given to a person for pressure ulcers. There were relevant risk assessments, and records of progress including body maps and photographs. There was evidence of input from the tissue viability nurse, including assessment and treatment advice to staff, and consultation with the GP. Aids included a pressure relieving mattress and a cushion for their chair. The manager informed us that the deputy manager is the home’s tissue viability link nurse. She attends meetings with nurses from other local homes to discuss practice issues and can undertake nursing treatment within protocols that involve calling the tissue viability nurses for advice at certain trigger points. Another person was being nursed in bed and was on a turn chart. This stated They should be turned 2-3 hourly but it was not evident from the chart that this plan had been adhered to. For example, on one day (9 July) there were no entries at all. The manager must remind staff to complete these records as they are proof that proper care is given and blank spaces lead people to assume that people are being neglected. Our records show that the home has sent us some information about events that have a detrimental effect on peoples lives, but records we examined showed that someone had fallen in their room in March 2008 and been seen by a doctor, and in July 2008 had been taken to hospital by ambulance. There were no regulation 37 notifications for either of these in the home’s file. When this was raised with the manager she said she had not realised notifications were needed for such events. We advised her about the requirement in this respect and suggested that she visit our website to download our guidelines on what sort of event we expected to be notified about. There was a cot side risk assessment in place, that had been signed by the next of kin in April 2005. It was not evident the risk assessment had been reviewed since that date, neither was it evident that the advantages and disadvantages of cot side use had been explained to the next of kin to enable an informed decision. Files showed evidence that people received the health care they need. There were records of doctor’s visits and hospital appointment letters on file. People St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 11 also have access to dentists, opticians and chiropodist as well as specialist care such as psychiatry and speech and language. All appointments and their outcomes are recorded on the care plan. We carried out a check on the medication and records, no errors were found. The Nurse who assisted us with the check displayed a good knowledge of the homes medication policy and the procedure. The medication was stored as required. The manager assures us in the AQAA that all the staff at the home treat people with respect and uphold their privicy. Staff personnel files held evidence that staff receive training in this area and observation of interactions between people and staff members was seen to be respectful, discreate and supportive. St John`s Nursing Home Limited DS0000019041.V367117.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): Key standards 12, 13, 14 and 15 were assessed during this inspection. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. This home offers a daily routine that is varied and flexible, people’s interests are recorded and they are given opportunities for stimulation through leisure and recreation. Visitors are made welcome at the home and people can receive visitors in private and are supported to exercise choice and control over their lives. Menus are varied and food portions are ample. EVIDENCE: When assessments are being done people and their relatives are asked to talk about what they like to do and how they can be helped to continue with their favourite activities. They are also asked what food they like and other lifestyle preferences. Visitors have told us that they are made welcome at the home and will be offered a drink when they arrive. Religious services are held in the home monthly. We watched the administrator leading an activity, skittles, music and singing, in the afternoon. The manager said the administrator does 30 hours admin St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 13 work each week and about 10 hours as the activities coordinator. She keeps a record of what activities are offered and who participates in them. She assured us that she visits people who prefer to stay in their room and will tailor activities to suit individual needs. The dinning room is an attractive room with high ceilings, large front facing windows and has been well decorated making it a pleasant area to eat. We observed lunch being served in ground floor dining room and lounge. Two people told us that they could choose what they want and that the food is good. The dining room tables were prepared with tablecloths, drinks, placemats, and flowers on each table. People were not stigmatised by the use of bibs but were given clean linen napkins to protect their clothes. Staff wore blue aprons while serving food the food and assisting people to eat. The food was well presented, including pureed meals, which were separated into their different ingredients. The portions were tailored to each person and seconds were offered. People who needed help to eat was given it from staff who sat with them at the table and interacted in a positive way. The whole meal was a leisurely and relaxed affaire. The manager said that some people chose to eat in the lounge because they find it more comfortable. St John`s Nursing Home Limited DS0000019041.V367117.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): Key standards 16, 17 and 18 were judged during this visit. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Relatives are confident that their complaints will be listened to and acted upon. Legal rights are protected and those without capacity are facilitated to access available advocacy services. The homes policy, procedures and practice are aimed at protecting the Residents from abuse. EVIDENCE: People and their visitors we spoke to felt that they would be listened to if they made a complaint and that it would be dealt with in a way that was appropriate. Complaints and their outcomes are recorded in the homes complaints book and there is a policy in place. We examined the complaints book and records kept were as required. There haven’t been any complaints regarding this home raised directly with us. Approximately 50 of the people living in this home have one or other of the different forms of dementia so it is important that they work within the new Mental Capacity Act 2005 and that the manager and staff have a good understanding of it. Some training in this area has already been provided, it is essential that all the staff receive it. Staff have already undertaken safeguarding training. St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards 19, 20, 24 and 26 were assessed during this inspection. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People living in the home have access to comfortable indoor and outdoor communal facilities. The house is clean and has its own maintenance person. EVIDENCE: The providers are in the process of refurbishing this home and there was a lot going on while we were there; the entrance hall and corridors were being decorated and a new carpet was being laid in the hallway. Bedrooms are being decorated as they become vacant and soft furnishings and bedding is being replaced. Those rooms that have been done are attractive and different to each other. During our tour of the building we noticed that there were some areas where work was in progress that had been left unsafe, for example tools were left out and unattended or handrails had not been replaced or left loose. While it is understood that it is disruptive to have workmen around every effort must be St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 16 made that they understand that they must keep the people living in the home safe at all times. Risk assessments should be carried out at the start of every maintenance job to ensure that it is done in a way that is safe for everyone. Several windows were noticed not to have window restrictors fitted; We discussed both issues with the manager as we walked around the building and she has undertaken to take action to amend the both situations. The home employs a maintenance person who is responsible for keeping it in good condition and keeping maintenance up to standard. The bedrooms were individual to each other and there were personal possessions, pictures and ornaments in the rooms. Sluice rooms with disinfectors were seen on the first and second floors. The one on the first floor had two wheelchairs in it, which blocked access to the disinfector and had wheelchair footplates in the wash hand basin. This will make access to the room difficult and will discourage staff maintaining hygiene standards. Wheelchairs must be stored safely where they will not cause an obstruction. The house was clean and hygienic and there were no offensive odour. St John`s Nursing Home Limited DS0000019041.V367117.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): Key standards 27, 28, 29 and 30 were inspected on this occasion. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People living in the home have their needs met by sufficient numbers of staff on duty that are well trained and qualified. The homes recruitment policy meets requirement and staff receive training. EVIDENCE: We looked at five personnel files and spoke to six staff members; three nurses, two carers and the housekeeper. The files contents and the people we spoke with confirmed that the required recruitment procedure is carried out and that safeguarding checks are completed before people start work in the home with one exception. The manager had failed to obtain appropriate evidence that the nurse’s registrations with the Nursing and Midwifery Council (NMC) were current. She had believed that by taking copies of their membership cards she had fulfilled this obligation. However she should make use of the NMC’s checking service for employers on their website and retain evidence this has been done. This was raised with the manager at feedback so she could take appropriate action; she has undertaken to do so. While we were at the house there were sufficient staff on duty to meet the needs of the people. We were able to see that the staff are capable and those we spoke to displayed a good knowledge of how to care for older people. The St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 18 Manager has said that she is investigating opportunities for the staff to take training is specialist areas such as dementia care. During the last twelve months training in the following areas have been offered: manual handling, health and safety, fire safety, and dementia, POVA training, manual handling, first aid and infection control. One nurse’s file we checked showed that they attended basic life support training and another nurse had attended training in supervision, tissue viability, care planning, Mental Capacity Act, and phlebotomy. Also NVQ 2 and 3 in care is offered, at the moment the home have nine carers who are studying for an NVQ in care. St John`s Nursing Home Limited DS0000019041.V367117.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): Key standards 31, 33, 35, 36 and 38 have been examined on this occasion. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People living in this home benefit from a home that is well managed by a person who is qualified, experienced and fit to be in charge. She puts peoples need to the fore and runs the home in their best interests. EVIDENCE: The manager has recently undergone our registration process when we check that she is a fit person to manage a care home by examination of her character, background, experience and knowledge. She has achieved a lot of improvement in the home since she became its manager and is organised and committed. During our discussions she has shown herself to have a good understanding of people with dementia and of St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 20 safeguarding issues. She has realistic and practical plans to improve the standard of care for the people living in this home. The home does not manage any of the peoples monies, they encourage relatives to take control if people can’t manage it themselves and will arrange independent support if they do not have anyone to support them. We spoke with a representative of two of the people living in the home; he has power of attorney jointly with their next of kin. They said they are always made welcome in the home and has observed that staff are kind and caring. If they had any concerns they would have no hesitation in raising them directly with the manager. It was confirmed they have a contract from the home with terms and conditions, “we’re happy with all that.” and said they had no concerns to raise at present, and also said he thinks “they couldn’t be anywhere better”. The home keeps a small amount of spending money for day-to-day expenses and will keep records of money spent and receipts. If someone needs something and does not have any money it will be provided and the relatives will be invoiced. Visitors we spoke to all said they were happy with the care their relatives received; they said the staff were friendly and helpful and that the manager was easy to approach and talk to. If they had any problems she was reassuring and normally sorted things out quickly. Staff personnel files contained copies of supervision notes and the staff we spoke to confirmed they received 1-1 supervision and felt able to approach the manager between times if they had any issues to raise. The CSCI registration certificate was seen on display in the home. It was issued on 29th January 2008 and shows Susan Nyakudya as the registered manager. A liability insurance certificate was also on display and is valid till 13th August 2008. Health and safety is properly addressed. We checked a small sample of the health and safety records and found that they were up to date and properly recorded. There has been an environmental health inspection on 22nd April 08, at which 4 stars had been awarded for food hygiene. This award was displayed on the front door to the home. The manager told us that the environmental health inspector had suggested our recommendation made in our previous inspection report that they provide heated food trolleys was not necessary. Regulation 26 in the Care Homes Regulations calls for someone that is not involved in the day to day running of the home to make an un announced visit once a month to speak to the people living in the home and inspect it to be able to judge its conduct. They must produce a written report of the visit and set out any needed actions. The manager told us there had only been one regulation 26 visit carried out since she had been in post and she did not get a report from it. St John`s Nursing Home Limited DS0000019041.V367117.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 3 8 2 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 3 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 12 Requirement Timescale for action 08/10/08 2. OP38 23 The manager must ensure that staff complete all records as they are proof that proper care is given and blank spaces lead people to assume that people are being neglected. Window restrictors must be fitted 08/10/08 to all windows above ground level and kept maintained. The premises must be kept clear of any hazards that may cause harm or injury to the people living in the home. In this instance workmen must keep the work area free from dangerous items when not attended. 08/10/08 3. OP38 23 4. OP29 19(5b) Proper checks through the right channels must be made to ensure that qualifications are valid and current, specifically nursing qualifications. 08/10/08 5. OP33 26 Provider visits as set out in 08/10/08 Regulation 26 must be implemented and a report generated with necessary actions highlighted. St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 23 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 OP7 Good Practice Recommendations It is important that any assessments, care plans and reports etc are dated and signed by the person who produces them. This way origin and timescales are identified. It must be assumed that any document that is not dated is out of date and is due to be reviewed. It is recommended that templates are redesigned to allow a designated space for people to date and sign it and that they are strongly encouraged to do so. 2. OP7 It is recommended that all risk assessments are reviewed regularly, it is particularly important if the outcome involves any form of restraint such as the use of cot sides. Records must be kept of any meetings that show what information was considered, who was consulted and who gave consent for the action to be used. St John`s Nursing Home Limited DS0000019041.V367117.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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