Inspection on 20/12/07 for St Georges

This is the latest available inspection report for this service, carried out on 20th December 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Georges 11/04/07

St Georges 26/02/07

St Georges 29/11/06

St Georges 28/02/06

St Georges 30/06/05

St Georges 13/01/05

St Georges 25/08/04

St Georges 10/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Georges Abbey Hey Lane Gorton Manchester M18 8RB Lead Inspector Val Bell Unannounced Inspection 20th December 2007 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 Georges DS0000021580.V355924.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 Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Georges Address Abbey Hey Lane Gorton Manchester M18 8RB 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) 0161 220 8885 F/P 0161 220 8885 Mr Haile Kidane Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2007 Brief Description of the Service: St Georges is a privately owned residential care home providing accommodation for up to 10 people aged 60 and above. The home is situated in the Gorton area of Manchester, close to public transport links into Manchester City Centre and Hyde. The home is a three-storey property, next to a church, and was previously used as a rectory. The accommodation is provided in one double bedroom and eight single bedrooms located on two floors. Access to the first floor is via a passenger lift and a central staircase. The third floor provides office space and a staff sleep-in room. None of the bedrooms have en-suite facilities. All bedrooms have a washbasin and vanity mirror. Accessible toilet and bathroom facilities are provided on the ground and first floors close to the living accommodation. There is a lounge on the ground floor with a separate dining room. A kitchen and laundry are also located on the ground floor. The fee for living at the home is £373.83 per week. There are additional charges for hairdressing, toiletries, day trips, holidays and clothing. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 25th September 2007. Site visits to the home form part of the overall inspection process and this home has been inspected six times in the previous twelve months. The lead inspector conducted this visit during daytime hours on Thursday 20th December 2007. The purpose of this inspection was to look at the core standards of the National Minimum Standards (NMS) and to assess the progress made in meeting the requirements outlined in the Statutory Enforcement Notice issued on 1st November 2007. This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visit, time was spent talking to three people living in the home. Discussions were held with the acting manager and two care assistants and a relative of a person living in the home wrote to the inspector to share her views on the quality of care provided in the home. An Annual Quality Assurance Assessment (AQAA), which is a self-assessment document, had been completed and returned to the Commission by the previous manager since the date of the last inspection. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: Staff working in the home have developed good relationships with the people accommodated. People are treated with respect and their right to make choices and decisions that affect their daily lives is upheld. Staff recognise and value people as individuals and take care to ensure that their needs in relation to disability are met. Relatives and people living in the home made positive comments on the quality of the service as follows: “The standard of care is absolutely impeccable. Empathy is shown to each resident. Carers speak nicely about my aunt, which reassures the family she is being well looked after. I would have no hesitation in recommending this home to others. The carers show compassion and always try to make my aunt feel comfortable and staff deal with sensitive issues excellently.” “Staff take time to listen to you if you have any concerns.” “It’s a small home and much more homely, which suits me.” St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 6 “The appearance of the home and the way it is run is very homely. It smells clean.” “Efficient management. Carer’s go above and beyond the call of duty. We are always made to feel welcome.” What has improved since the last inspection? What they could do better: Three requirements and two recommendations were made during this inspection. The Statement of Purpose and Service User Guide needed to be updated to inform people enquiring about the home that full disabled access to the building was not available. Two shortfalls in health and safety documentation were found. A fire risk assessment had not been written and risk assessments had not been undertaken to ensure that safe working practices were in place. These documents must be in place to ensure that the welfare of people living and working in the home is protected. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 7 Good practice recommendations were made to develop life histories with people accommodated in the home. This will provide staff with information on individuals’ life achievements and preferred lifestyles. A bedroom carpet was ill fitted and this potentially created a hazard to trips and falls. Finally, it was recommended that satisfaction surveys be issued annually to people living in the home, their representatives and visiting professionals. This will enable management to monitor, review and make improvements to the quality of the service provided. 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 Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. People can be confident that they will receive robust assessments to ensure that their needs will be identified prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement made at the last inspection to make safe the ramp access into the home had been addressed. However, full disabled access is not available as once inside the building access to the inner reception area is via a short staircase. Consequently, the home’s Statement of Purpose and Service User Guide need to be updated with this information There were nine residents accommodated at the time of this visit. Three of these were in hospital and one person was being discharged the same day. The manager said that none of the residents required care from two members of staff. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 10 The file belonging to a person admitted during December 2007 was examined for evidence of her needs being assessed. A care manager assessment of needs had been obtained and an in-house needs assessment had been undertaken. These two documents clearly recorded the support and care this person needed along with her preferences, likes and dislikes. In conversation with this person it was confirmed that she had been fully involved in her assessment, along with members of her family. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. People living in the home are treated with respect and have their needs met in a person-centred way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were assessed during the visit. Significant progress had been made since the last inspection. Care plans contained detailed information to inform care staff what they must do to meet the assessed personal and healthcare needs of people living in the home. Risks had been assessed and guidelines detailed what action should be taken to keep people safe. There was also evidence that people prone to falling were being referred to the falls co-ordinator for assessment and advice. Care plans and risk assessments had been reviewed regularly and updated as individuals’ needs had changed. A person recently admitted from another care home said, “Staff cannot do enough for you here. I’d recommend it to anyone.” She said that her family St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 12 were very satisfied with her current care and were no longer worried about her. She added that staff were responsive to her requests for assistance. Staff were observed to take time to sit and have conversations with residents. This was evidence of good practice. People living in the home were referred to by their preferred names and were treated with respect. A relative wrote to the inspector to share her views on the standard of care provided to her aunt. She made the following comments: “The standard of care is absolutely impeccable. Empathy is shown to each resident. Carers speak nicely about my aunt, which reassures the family she is being well looked after. I would have no hesitation in recommending this home to others. The carers show compassion and always try to make my aunt feel comfortable and staff deal with sensitive issues excellently.” It was evident that staff had developed good relationships with people living in the home and treated people as individuals. Staff also took care to make themselves understood when talking to people with hearing impairments by maintaining eye contact and positioning themselves at eye level with the person. People with physical disabilities were encouraged to maintain their independence be receiving support to mobilise as much as possible. The four recommendations made during the last inspection in relation to the administration and storage of medication had been addressed. All staff had received training in the administration of medication since the last inspection. Medication was stored appropriately and securely. Records were accurate and up to date and these were being monitored regularly. No excess stock was held in the home. Reasons for non-administration of medication had been written down on the medication record sheets. Guidelines for the administration of ‘as required’ medication had been developed, to instruct staff on when this medication should be administered. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. People living in the home are provided with stimulating and interesting activities on a daily basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Significant improvements had been made by ensuring that staff were deployed to organise structured activities every afternoon. The outcomes and experiences of people engaging in activities had been recorded in detail. Person-centred care was discussed with staff on duty. It was recommended that individual life histories be developed for people living in the home. Staff said they were keen to become involved with this. This will provide staff with valuable information relating to individuals’ life achievements and preferred lifestyles. Three people spoken to said that they were encouraged to receive visits from their family and friends. They also confirmed that they were encouraged to make choices and decisions that affected their daily lives, such as when to go to bed or have a lie-in. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 14 Three people spoken to said that they enjoyed the meals provided and felt that the food met their preferences and dietary needs. Since the last inspection the requirements made by the environmental health officer (EHO) had been met. The kitchen and food stores were clean and organised and cleaning schedules were up to date. This standard was not fully assessed as the manager said that the EHO was due to undertake a monitoring visit during the next week. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People living in the home feel confident about expressing their concerns and systems are in place to keep them safe from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints policy and procedure was in place and the manager said that new residents were issued with this information on admission. A person recently admitted to the home said that she felt safe and she knew who to talk to if she had any concerns. She added, “Staff take time to listen to you if you have any concerns.” The complaints procedure was on display in the home’s entrance hall. A number of compliments had been received from families but no complaints had been made. The service had adopted Manchester City Council’s policy and procedures for safeguarding adults from abuse and staff had received training on abuse awareness and the action to take if they suspected abuse. Staff on duty were able to explain what they would do to keep people safe from harm. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 30 Quality in this outcome area is good. The home is clean and hygienic and décor, furniture and fittings provide a comfortable and homely environment for the people accommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A vast improvement had been made to the overall quality of the environment since the last inspection. Communal areas had been redecorated as necessary and equipment used in the home had been maintained and serviced. Communal and private rooms were tidy, equipment was stored appropriately and all areas were clean and hygienic. Downstairs communal areas had been attractively decorated for Christmas and new lounge chairs had been ordered. A new dishwasher had been installed and a rise and fall bath seat had been provided. Staff and the provider had obviously worked very hard to make these improvements in the best interests of the people living in the home. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 17 A relative and a person living in the home made the following comments: “It’s a small home and much more homely, which suits me.” “The appearance of the home and the way it is run is very homely. It smells clean.” A minor shortfall was found in one of the bedrooms where the carpet had stretched due to wear and tear, causing a potential hazard to trips and falls. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. A trained and knowledgeable team of care staff meets the assessed needs of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rotas for the previous three weeks provided evidence that the home had maintained sufficient staffing levels to meet the assessed needs of residents. By reviewing the way staff were deployed, improvements had been made that enabled staff to spend more time with people living in the home, particularly in providing structured afternoon activities. One of the staff on duty said that she had received good training opportunities since working at St Georges and confirmed that she had attended medication training recently. She had also received training in abuse awareness. This member of staff knew the correct procedure to follow if she suspected a resident was being abused. A senior carer said she had achieved level 3 National Vocational Qualification (NVQ) in care and a care assistant on duty confirmed that she had NVQ level 2 in care. The manager said that two staff had been booked on Mental Capacity Act training. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 19 No staff had been recruited since the inspection on 25th September so the recruitment records were not examined on this occasion. However, the manager gave an assurance that the required pre-employment checks would be obtained before confirming new staff in post. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The home is managed in the best interests of the people accommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous deputy manager had been appointed as the manager since the last inspection following the registered manager’s retirement in November. The manager had achieved levels 2 and 3 NVQ in care and was currently studying for the Registered Managers Award. She will be undertaking NVQ level 4 in care once she has finished her current study. The manager said that she intended to submit an application to be registered with the Commission for Social Care Inspection St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 21 Two care assistants on duty both commented that things had improved significantly since the new manager had been appointed. These staff seemed much more aware of what was expected of them and appeared to be highly motivated. One of the carers commented, “I enjoy working at the home and particularly like the ‘family atmosphere.’” The manager said the owner had worked very hard to bring the environment up to standard and he and his wife had much more involvement in the day-today operations at the home, which she valued. She found the provider very supportive and willing to invest in improvements. The following are comments included in a letter from a relative of one of the people accommodated at the home: “Efficient management. Carer’s go above and beyond the call of duty. We are always made to feel welcome.” It was evident that people living in the home had been asked for feedback on the quality of the service they received on a daily basis and this was confirmed by a recently admitted resident. The new manager was developing monitoring systems to ensure that essential records were kept up to date. A recommendation was made to introduce annual quality assurance surveys for people living in the home, their representatives and health and social care professionals that visit the home. Two people living in the home were receiving support to manage their personal spending money. Full records and receipts for transactions made were held. A sample of health and safety records provided evidence that these had generally been kept up to date. However, the home’s fire risk assessment had not been completed although the manager said that that this was being developed for the home by a fire consultant. Additionally, it was required that working practices undertaken by staff in the home be risk assessed to protect the welfare of both staff and people living in the home. This requirement was made during the last inspection and has been reiterated in this report. However, the target date has been extended in order to give the new manager a reasonable length of time to complete the task. St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The Statement of Purpose must be reviewed and updated to include a statement relating to the home’s limited disabled access for people with impaired mobility. A copy of the updated document must be forwarded to the Commission for Social Care Inspection. The registered person must ensure that a fire risk assessment is in place, which details how people living and working in the home will be protected from harm in the event of a fire. The registered person must undertake risk assessments in safe working practices to protect the welfare of people living and working in the home. Timescale for action 20/02/08 2. OP38 17 (2) Schedule 4 (15) 20/02/08 3. OP38 17 (2) Schedule 4 (16) 20/02/08 St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 24 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 OP12 Good Practice Recommendations It is recommended that a person-centred approach be developed, by undertaking life history profiles with people living in the home. The ill-fitted bedroom carpet should be attended to before it becomes a potential hazard to trips and falls. It is recommended that annual satisfaction surveys are undertaken with people living in the home, their relatives/representatives and visiting health and social care professionals to provide feedback on the quality of the service provided. 2. 3. OP26 OP33 St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Georges DS0000021580.V355924.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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