Latest Inspection
This is the latest available inspection report for this service, carried out on 14th October 2008. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
For extracts, read the latest CQC inspection for St Judes.
What the care home does well N/A What has improved since the last inspection? N/A What the care home could do better: N/A CARE HOMES FOR OLDER PEOPLE
St Judes 89 Cardigan Road Bridlington East Yorkshire YO15 3JU Lead Inspector
Diane Wilkinson Key Unannounced Inspection 14th October 2008 9:30 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 Judes DS0000019726.V372768.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 Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Judes Address 89 Cardigan Road Bridlington East Yorkshire YO15 3JU 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) 01262 674129 Mrs Patricia Elizabeth Lewis Mrs Patricia Elizabeth Lewis Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14) of places St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th April 2008 Brief Description of the Service: St Judes is a privately owned care home that is registered to provide care and accommodation for fourteen service users (male and female) who are over 65 years of age, including those with dementia related conditions. Accommodation at the home is provided in single and shared rooms, with ensuite facilities in three of the nine bedrooms. In addition to private accommodation, there are two lounges (both with a dining area) and a small lounge that is used by staff and residents. There is a small garden at the rear of the property. Most areas of the home are accessible via the provision of a passenger lift and ramps, but the second floor is only accessible via the use of stairs. St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. We would normally undertake a site visit to the premises as part of a key inspection. In this instance, no site visit has taken place as there have been no residents living in the home since the 21st April 2008. It is the Commission for Social Care Inspection’s policy to give services that are not in use (dormant services) a 1 star/adequate quality rating. However, this service has consistently had a quality rating of 0 star/poor and we have received no information that would lead us to change our opinion. A report will be produced at least every six months to keep the public as informed as possible. The last site visit took place on 17th April 2008 and a report was subsequently produced. The report resulted in fifteen requirements being made in respect of breaches of regulation as well as fifteen good practice recommendations. We have received no information from the registered person in response to this inspection report. At the last key inspection of the home the registered person told us that she intended to close the home. As a result of this, the local authority found alternative accommodation for the three remaining residents. The home is now up for sale. Because the service is still registered with us, the registered person was sent an Annual Quality Assurance Assessment (AQAA) form to complete; it has not been returned. An AQAA gives the registered person the opportunity to tell us about what is happening in the service prior to their key inspection. On two occasions voluntary cancellation documentation has been sent to the registered person for completion and return, but to date this has not been received by the Commission for Social Care Inspection (CSCI). Enforcement action is currently being considered in respect of various breaches of regulation by the registered person. What the service does well: St Judes DS0000019726.V372768.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 Judes DS0000019726.V372768.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 Judes DS0000019726.V372768.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): Adequate EVIDENCE: St Judes DS0000019726.V372768.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): Adequate EVIDENCE: St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 10 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): Adequate EVIDENCE: St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 11 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): Poor EVIDENCE: St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 12 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): Poor EVIDENCE: St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 13 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): Poor EVIDENCE: St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 14 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): Poor EVIDENCE: St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 15 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 “ ” 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 16 Are there any outstanding requirements from the last inspection? Yes – all of the following 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 OP3 Regulation 17, Schedule 3 13 Requirement Any admissions to or discharges from the home should be recorded. Previous timescale of 23/10/07 not met. Any incidences of bruising or other signs of injury must be explored, and appropriate people must be informed. An immediate requirement notice was sent to the home on 26/10/07 in respect of this breach of regulation. Previous timescale of 23/10/07 not met. The registered person must complete accredited medications training or cease administering medication. Previous timescales of 31/3/07, 30/06/07 and 30/11/07 not met. A hand washbasin must be provided in the ground floor bedroom. Previous timescales not met. There is an unpleasant odour in one bedroom and the carpet is
DS0000019726.V372768.R01.S.doc Timescale for action 14/10/08 2. OP8 14/10/08 3. OP9 13 and 18 14/10/08 4. OP24 16 14/10/08 5. OP26 16 14/10/08 St Judes Version 5.2 Page 17 stained. The carpet must be replaced. Previous timescale of 31/5/08 not met. 6. OP27 17, Schedule 4 19 The staff rota must be a true reflection and a full record of the actual staff on duty. Previous timescale of 23/10/07 not met. Staff must not commence work at the home until two written references and a satisfactory CRB check (or POVA first check in exceptional circumstances) have been received. A person’s employment history as recorded on an application form should also be checked. The registered person agreed that this information would be forwarded to the CSCI but at the time of writing this report it has not been received. An immediate requirement notice was sent to the registered person on 26/10/07 in respect of this breach of regulation. Previous timescale of 23/10/07 not met. There must be a training and development plan in place, as well as an individual record of the training achievements and needs of all staff. This must be available for inspection at all times. Previous timescale of 30/11/07 not met. Improvement plans must be returned to the CSCI within given timescales. Previous timescale of 3/12/07 not met. The Annual Quality Assurance Assessment (AQAA) must be completed by the registered person as requested, and returned to the CSCI within
DS0000019726.V372768.R01.S.doc 14/10/08 7. OP29 14/10/08 8. OP30 18 & 19 14/10/08 9. OP31 24A 14/10/08 10. OP33 24 14/10/08 St Judes Version 5.2 Page 18 given timescales. Previous timescale of 23/10/07 not met. 11. OP34 25 The registered provider is required to provide the CSCI with details of the bank used by the home to enable information about financial viability to be obtained. Previous timescales not met. 14/10/08 12. OP35 20 Alternative means must be found 14/10/08 for the holding of service user monies; monies must not be held in the business account of the registered person. Previous timescales of 31/10/07 and 31/12/07 not met. Records for monies held on behalf of service users must be kept and these records must be kept up to date. Previous timescale of 23/10/07 not met. 14/10/08 13. OP35 20 14. OP37 17Schedul Records required by regulation es 3 & 4 must be kept at the home, including admission/discharge records, recruitment records, resident’s financial records and a duty rota. These must be available for inspection at all times. Previous timescale of 23/10/07 not met. 23 There must be evidence that the fire alarm system has been serviced by a qualified contractor. An immediate requirement notice was left at the home in respect of this breach of regulation. Previous timescale of 24/4/08 not met. 14/10/08 15. OP38 14/10/08 St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 19 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Refer to Standard OP2 OP7 OP7 OP9 OP9 OP12 OP15 OP19 OP26 OP27 OP31 OP33 Good Practice Recommendations All service users should have a contract or statement of terms and conditions in place with the home that has been signed by the service user or their representative. Monthly reviews of care plans and risk assessments should take place consistently. Service users should be involved in the care planning process. There should be a sample signature held for each person that is trained to administer medication to enable records to be checked. Medication administration records should be signed when residents refuse ‘as required’ medication to evidence that this has been offered to them. Staff should spend more one to one time with service users in an attempt to maintain their social skills and levels of memory impairment. A menu should be displayed to encourage service users to become involved in daily meal provision and to encourage conversation. There should be a maintenance programme in place. The registered person should pay particular attention to the risk of infection control due to staff undertaking both care and catering duties. The role of each member of staff should be recorded on the rota. There must be plans in place for a registered manager to be in post who has achieved NVQ Level 4 in Care & Management. There should be a quality monitoring system in place that gives service users and others the opportunity to affect the way in which the home is operated. The system should include an annual development plan and the updating of policies and procedures. Staff should receive formal supervision so that they have
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St Judes OP36 14. 15. OP38 OP38 the opportunity to discuss their concerns and training opportunities with a manager. Testing of the electrical installation is overdue and the registered person should arrange for this work to take place. Staff should receive health and safety training at the time of their Induction, and then on an on-going basis. St Judes DS0000019726.V372768.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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
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