Care Home: St Phillip & St James Residential Home

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What the care home does well The home provides a small “family” homely environment where staff have a commitment too provide a quality service to individuals who live in the home. This is helped by a long standing group of staff and ability of the home to retain staff which provides a continuity of care. The home encourages as far as possible independence and this was noted on this visit with a number of individuals telling us that they felt able to “do as I wish” and also able to “go out when I like”. One person told us “I feel able to make my own decisions about what I do and when”. Another individual told us “Residents are treated as individuals and given the chance to follow their own interests, express their personalities and contribute to the life of the home”. What has improved since the last inspection? The last inspection identified a number of areas which required improvement and these were looked at as part of this inspection. We found that the home has addressed the concerns resulting in improved practice around care planning and recruitment of staff. What the care home could do better: St Phillip & St James Residential HomeDS0000008161.V378284.R01.S.doc Version 5.2 We have noted from this inspection that the homes practice around the use of assessment tools needs to be improved. This specifically relates to the use of nutritional and skin integrity however the home also needs to have in place a dependency tool to assist them in making a judgement about care needs of individuals in the home. It is also required from this inspection that the home advises ourselves of matters relating to the health and welfare of individuals in the home. Under Regulation we have to be informed specifically of deaths in the home, hospital admissions and where there are incidents which relate to the health and welfare such as possible abuse. We have also identified that staff training must be improved in respect of all staff having undertaken Safeguarding and Infection Control. At the time of our inspection we noted the shortfall in staff having completed this training however we have been advised by the home that staff are booked to complete this training in early 2010. There is a sense that the level of needs has changed since our last inspection with individuals having increased physical care needs as well as those associated with mental health. The home has no way of measuring that the staffing is at the correct level to meet those needs. Further when considering individuals for admission to the home if they are appropriate taking into account existing needs of those living in the home. It is our view and this was discussed with the manager that there must be a more robust admissions procedure in place to ensure as far as possible that care can continue to be provided at the necessary level and associated staffing is in place. We have also raised with the manager the need to review the use of communal areas of the home and toileting facilities and we have been advised of possible changes to the home which will if put in place address these areas of concern. Key inspection report CARE HOMES FOR OLDER PEOPLE St Phillip & St James Residential Home 9-10 Priory Road Keynsham Bath & N E Somerset BS31 2BX Lead Inspector John Clarke Key Unannounced Inspection 16th October 2009 09:00 DS0000008161.V378284.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Phillip & St James Residential Home Address 9-10 Priory Road Keynsham Bath & N E Somerset BS31 2BX 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) 0117 9863505 pipnjay@btconnect.com Mrs Patricia Elizabeth Clarke Mrs Patricia Elizabeth Clarke Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 19 persons aged 65 years and over requiring personal care only. 14th November 2007 Date of last inspection Brief Description of the Service: St.Phillip & St.James provide accommodation for up to 19 older people in single rooms all with en-suite facilities. All of the rooms except two are over 10 square metres; all are fitted with a call bell system. The home is two houses, which have been converted to provide a pleasant and spacious environment with attractive and accessible rear gardens with decking and seating area. There is one communal lounge, a dining room and conservatory. The home is situated a short distance from the amenities of Keysham. The homes philosophy of care: “To provide a warm and welcoming home environment for residents and their visitors. To allow residents the chance to express their individuality and respect privacy, residents are encouraged to bring personal possessions and rooms are fitted with a lockable door or lockable cupboard. To allow residents the chance to continue to live as a life as they wish within a support the supportive environment of the home. Care plans are agreed with each resident and regularly reviewed. To provide good quality food and well-balanced meals and allow for individual preferences. To encourage social participation and maintain skills and interests regular activities are provided.” St Phillip & St James Residential Home DS0000008161.V378284.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 stars. This means the people who use this service experience good, quality outcomes This was an unannounced visit to the home as part of our inspection of the service. We looked at a number of areas and records relating to the care provided at St.Phillip St James. These included pre-admission assessments, care plans, medication records, staff recruitment and training and health and safety. There was also an opportunity to talk with individuals who live in the home about their views of the service they receive and members of staff. We requested an Annual Quality Assurance Assessment (AQAA) however we did not receive this at the due date and it was therefore not available before the visit to the home. We have subsequently received the AQAA and have used this to help us in making a judgement about the quality of the service. We also sent a number of Have Your Say questionnaires and received responses from 5 individuals living in the home, 6 members of staff, 2 health professionals and 1 relative. What the service does well: The home provides a small “family” homely environment where staff have a commitment too provide a quality service to individuals who live in the home. This is helped by a long standing group of staff and ability of the home to retain staff which provides a continuity of care. The home encourages as far as possible independence and this was noted on this visit with a number of individuals telling us that they felt able to “do as I wish” and also able to “go out when I like”. One person told us “I feel able to make my own decisions about what I do and when”. Another individual told us “Residents are treated as individuals and given the chance to follow their own interests, express their personalities and contribute to the life of the home”. What has improved since the last inspection? What they could do better: St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.2 Page 6 We have noted from this inspection that the homes practice around the use of assessment tools needs to be improved. This specifically relates to the use of nutritional and skin integrity however the home also needs to have in place a dependency tool to assist them in making a judgement about care needs of individuals in the home. It is also required from this inspection that the home advises ourselves of matters relating to the health and welfare of individuals in the home. Under Regulation we have to be informed specifically of deaths in the home, hospital admissions and where there are incidents which relate to the health and welfare such as possible abuse. We have also identified that staff training must be improved in respect of all staff having undertaken Safeguarding and Infection Control. At the time of our inspection we noted the shortfall in staff having completed this training however we have been advised by the home that staff are booked to complete this training in early 2010. There is a sense that the level of needs has changed since our last inspection with individuals having increased physical care needs as well as those associated with mental health. The home has no way of measuring that the staffing is at the correct level to meet those needs. Further when considering individuals for admission to the home if they are appropriate taking into account existing needs of those living in the home. It is our view and this was discussed with the manager that there must be a more robust admissions procedure in place to ensure as far as possible that care can continue to be provided at the necessary level and associated staffing is in place. We have also raised with the manager the need to review the use of communal areas of the home and toileting facilities and we have been advised of possible changes to the home which will if put in place address these areas of concern. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Phillip & St James Residential Home DS0000008161.V378284.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 Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes full and comprehensive assessment of prospective residents so that they are able to make an informed decision about the capacity of the home to meet health and social care needs. EVIDENCE: We looked at a number of pre-admission information which included assessments completed by the home and copy of local authority assessment. There was good information about the health and social care needs of the individual including daily routines, likes and dislikes. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 9 There was no evidence of how the home measures that individuals moving into the home have needs which can be met taking into account the existing care needs of people living in the home. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care Planning and arrangements for meeting health care are generally good providing staff with the necessary information so that the health and social care needs of residents are met. Arrangements for managing resident’s medication make sure that resident’s health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld. EVIDENCE: We looked at a number of care plans which provided information about the care tasks including mobility, socialisation, self-care. Moving and handling assessments had been completed however for one individual this did not St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 11 reflect their current level of mobility and associated care needs. One individual had required bed rails on discharge from hospital there was no evidence of an assessment or risk assessment being untaken by the home as to their continued need in the home. It is noted that at the time of our visit the individual no longer required rails. Risk assessments had been completed for one individual about the use of kettle in their room. Care plans had been regularly reviewed. There were no assessments regarding nutrition or skin integrity. Individuals living in the home have access to community health services such as chiropody, optician and dental treatment. Where individuals need “nursing” support community nurses visit the home to provide this service. Individuals who live in the home and responded to our Have Your Say questionnaire said they “Always” receive the medical care they need. We looked at medication administering records and they had been completed as required. Storage of medication was secure and there is controlled drug storage. Staff have undertaken medication training. Individuals we spoke with all said how they felt staff treated them with respect and respected their privacy. One individual told us that staff “always knocks before coming into my room”. We observed staff during our visit and they were sensitive in their approach to individuals especially where this was giving care support. During our visit an individual was unwell and staff dealt with the situation in a calm and caring manner. We received a complaint regarding an individual being seen by the chiropodist and being treated in a communal area of the home rather then in private. We have confirmed with the manager that this practice is no longer taking place. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: We asked individuals living in the home about the activities and they told us “there is enough for me” “staff are good they spend time chatting with us”. One individual told us about a poetry group and on day of our visit individuals were doing craft. A music therapist visits the home fortnightly. Individuals who responded to our Have Your Say questionnaire said there are “always” 3 “usually” 2 activities we can take part in? St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 13 An individual told us that their visitors are always “made to feel welcome it’s a very friendly home” and another said “my relative visit me often and is made welcome and can have meal with me”. Individuals told us that they felt the home had “few routines” and “it’s up to us how we spend our time”. We asked one individual about getting up and going to bed and they told us “I can do as I wish” “staff are very flexible”. We asked about the meals provided in the home and was told that “they are always good” “there is always a choice” “food very good staff go out of their way to give something we like”. Menu were seen and showed a variety of meals being provided. On the day of our visit we had a meal and it was presented well and looked appetising. There was a relaxed and unhurried atmosphere and staff were available to give assistance where this was needed. Respondents to our questionnaire said that they “Always” 3 “Usually” like the meals in the home. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has clear procedures in place and this enables individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing training to staff in this area. EVIDENCE: The home has not received any complaints since our last inspection. However we received a complaint about a number of issues associate with the care provided in the home. Part of the complaint was about the alleged behaviour of the manager towards an individual. This was investigated by a local authority safeguarding social worker and the allegation was not proven. However there was concern about the practice when the chiropodist visits the home in that individuals were being given treatment in a communal area of the home. This has now changed to respect the privacy and dignity of individuals when receiving treatment and now takes place in a seperate room. It is noted that with regard to a specific incident regarding chiropody treatment the home St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 15 had taken all the necessary steps to act in a professional manner when providing this element of care to an individual. We spoke to a number of individuals about the laundry service because this was part of the complaint we found no evidence or matters of concerns regarding this matter. We also discussed the homes arrangements regarding admission to hospital (and examined records for one individual regarding their admission to hospital) and discussed this with staff. We found no evidence for cause for concern and believe the actions of staff in this respect are in the best interests of individuals. We spoke with individuals about what they would do if they were unhappy about the service they were receiving. They told us “I would talk with staff and they would do something” “tell the manager”. All of the respondents to our questionnaire said they knew how to make a complaint. The home has policies and procedures in place regarding Safeguarding and staff have completed the required training. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe and hygienic environment for people who live in the home and staff. People who live and work in the home benefit from a warm, welcoming and well-maintained environment. However the communal, toilet facilities and dining areas of the home would benefit from reviewing too make sure that they are adequate for the needs of people living in the home. EVIDENCE: In looking around the home it was evident that there is a good standard of maintenance and decoration is in good order. Since our last inspection a new kitchen has been installed and new dining area has been created. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 17 In talking with individuals living in the home there were comments made to us about the “lack of communal space”. The layout of the home is now such that the lounges and dining area are open plan and at mealtimes the lounge area is used as a dining area. During the mealtime there is limited space and creates a quite crowed and cramped environment and individuals commented on this to us. One individual told us “we lack a decent lounge, we need a proper dining room (not part dining and part lounge)” and another said “there is a great need for a separate quiet lounge, with its own door, to give some privacy.” Currently there is only one toilet near to the lounge and this has limited space and is not wheelchair accessible. One individual said that the home “needs another toilet downstairs”. It is noted that there is a toilet located next to the conservatory which at present is not accessible for individuals living in the home and only used by staff. We asked individuals about the cleanliness of the home and they told us “I have a nice room, it’s kept clean with a good cleaner, never any smells, excellent.” And “always clean”. Respondents to our questionnaire said that the home is “Always” fresh and clean. There are infection control procedures in place and we spoke to staff about their practice in this area of care. They were able to tell us of the correct procedures to follow with regard to use of protective clothing, use of gloves and disposal of soiled and used items. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements in the home are generally satisfactory so that the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. However the training of staff needs to improve so that all staff have the required level of knowledge. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of resident is protected. EVIDENCE: We looked at the worked staffing rota for a period of four weeks. Generally there are 2 care staff on duty at all times with one waking night and on call. On the day of our visit there were 3 care staff on duty am and two pm with cook and kitchen assistant. The deputy manager is on duty 4 days a week 10-3 or 11-4 as well as Management Assistant Monday to Friday (8-3pm) a week. The manager is usually available every day or on call each day and at night. We spoke with individuals about the availability of staff and one individual told us “more then 50 of people here need a lot of looking after, at times need extra staff, at times feel staff under pressure”, “staff all very good” “need more staff”. Respondents to our questionnaire said that there are “Always” 2 St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 19 “usually” 3 staff available when you need them. An individual also raised with us their view that the number of individuals who need “extra care” and support either because of frailty or mental health difficulties has increased over the past year. We had responses from staff members to our have Your Say questionnaire and they said that there are “Always” 3 “Usually” 2 “Sometimes” 1 enough staff to meet the individual needs of people in the home. One staff member commented that the home “needs more staff and more facilities for residents”. We looked at the recruitment records for three members of staff and found that all the required checks had taken place: POVA1st, Criminal Record Bureau. Two references had been obtained for the members of staff and full application form had been completed. Training records for 4 members of staff showed they had completed the moving and handling, health and safety training. Only one of the four had completed Safeguarding training and records showed that 6 staff have not undertaken this training, 10 of 23 (?) staff have undertaken infection control training. In our questionnaire all staff said they received training that was relevant to their role and helps to understand and meet the individual needs of people. One staff member said they were not being given training to provide enough knowledge about health care and medication. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good opportunities for individuals who live in the home and others to express their views about the service they receive. The practices of the home help to make sure that the health, safety and welfare of residents and staff is protected. EVIDENCE: The manager has extensive experience of managing a care home and has completed the required training. We spoke with individuals and staff about the management of the home and they told us “she is someone we can talk too” St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 21 “approachable”. Staff were positive about the support they received from the management of the home. Staff responses to our questionnaire said that they “Regularly” 2 “Often” 2 “Sometimes” 2 to the question Does your manager give you enough support and meet you to discuss how you are working? The home has sought the views of individuals through questionnaires and we looked at the responses they had received. They were very positive and comments included: “I appreciate all the kindness and care I have received” and “I think it could not be bettered, such friendliness by all concerned”. There were also comments from visitors; “keep up the tender care you give”, “care is there when needed while encouraging independence” “I am extremely happy with the care and support”. We looked at records relating to health and safety in the home. Staff regularly undertake fire training and drills. Fire alarm system is tested weekly and emergency lighting monthly. Equipment such as hoists and lift are services annually. We noted that the home has not notified us of incidents in the home such as deaths or hospital admissions. The homes policy regarding individuals who have had falls stated that staff should use a hoist to “lift” individuals from the floor. This is not safe practice and the home does have the necessary equipment to assist individuals from the floor in a safe manner namely by the use of a Mangar elk lifting cushion. St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12 Requirement The registered manager to make sure that unnecessary risk to the health or safety of individuals are identified and so far as possible eliminated. This relates to the use of assessment tools as part of care planning. Too identify individuals health risk associated with nutrition and skin integrity. The registered manager to make sure that persons employed to work at the care home receive training appropriate to the work they are to perform. Timescale for action 01/01/10 2 OP30 18 28/02/10 3 OP38 37 This relates to all staff having received Safeguarding and Infection Control training. 16/11/10 The registered manager shall give notice to CQC without delay of the occurrence of death, outbreak in the home of any infectious disease, any serious injury to an individual, serious illness, any event which adversely affects the well being or safety of any individuals in the DS0000008161.V378284.R01.S.doc Version 5.3 Page 24 St Phillip & St James Residential Home home, any theft, burglary or accident in the care home, any allegation of misconduct (suspected abuse). 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 OP27 Good Practice Recommendations As part of reviewing of care needs of individuals undertake dependency scoring this to be used as part of admission process and to make sure there are adequate staff on duty to meet the needs of individuals in the home. Review the arrangements for communal space in the home and the provision of toileting facilities. 2 OP21 St Phillip & St James Residential Home DS0000008161.V378284.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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