CARE HOMES FOR OLDER PEOPLE
Holy Cross Care Home Limited 150 Abbey Foregate Shrewsbury Shropshire SY2 6AP Lead Inspector
Pat Scott Unannounced Inspection 16th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 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. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Holy Cross Care Home Limited Address 150 Abbey Foregate Shrewsbury Shropshire SY2 6AP 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) 01743 343138 01743 343138 Holy Cross Care Home Limited Miss Deborah Jane Welsman Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57) of places Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Holy Cross is a privately owned Care Home registered with the Commission for Social Care Inspection to provide a service for 57 Older people. The home is situated on Abbey Foregate close to Shrewsbury town centre. It is a well established Home set in elegant and comfortable surroundings. Ms Jane Welsman and Mr Leslie Jones own the Home. Ms Welsman has day-today management responsibility for the Home assisted by care manager. The accommodation, originally a vicarage, has recently been further extended and refurbished to provide a 52 bedroomed facility over three levels. There is an established Staff group providing residents with consistency in a warm comfortable atmosphere. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 16th February 2006 commencing at 09.30 until lunchtime. The National Minimum Standards for Care Homes for Older People focus on achievable outcomes for service users – that is the impact on the individual of the facilities and services of the home. Evidence was looked for that the standards were being met and a good quality of life enjoyed by service users through: • Discussions with service users, staff and managers. • Observation of daily life in the home • Scrutiny of written records. The statement of purpose was used to assess how far the home’s claims to be able to meet service user requirements and expectations were being fulfilled. The risk assessment from the last inspection was taken into account to determine the key standards focused on and depth of inspection. The Commission does not currently have any concerns regarding this home. What the service does well: What has improved since the last inspection?
The home was the subject of a Primary Care Trust infection control audit during January 2006. The registered provider has implemented some of the salient points contained in the information produced following the audit.
Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 6 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. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 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 Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 Staff have an excellent understanding of the service users support and leisure needs and use this to assist them to exercise choice and control in their lives. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Details of leisure activities are displayed in the foyer and in service user’s bedrooms. Service users confirmed that they can spend their day in whatever way they preferred and there are many different seating areas within the home enabling people to sit in private or in company. Choice was also reflected in the way they could personalise their rooms, have contact with family and the quality of the meals. Service users spoken with stated that they may receive visitors at any reasonable time of the day and that they are always made very welcome by the staff. Service users are provided with three main meals, plus supper. At present, it was stated by management that alternatives are offered at lunchtime (the main meal) if someone doesn’t like the planned meal. A service user asked about this confirmed that they could have whatever they wanted if they did not “fancy the dish of the day”. The home demonstrates consultation with service users about their preferred dishes through the quality assurance
Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 11 questionnaires and from daily interaction. Service users are aware of the choices available to them but the menu displayed each day should reflect the choice on offer. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The standard of the environment within this home is generally good providing service users with an attractive and homely place to live. The laundry is very well organised ensuring that service users clothes and bed linen are always clean and fresh. EVIDENCE: A general tour of some bedrooms and communal spaces demonstrated that the home is generally in a good state of repair and comfortably furnished. Elderly frail service users stated that they found it easy to find their way around the home. Some walls were in need of a re-paint which is in hand. Laundry equipment is in place to meet the standards. Service users confirmed that their clothes are well laundered. A hand-wash basin has not been installed in the laundry room and the registered provider has given an undertaking to address this issue. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 14 Soap dispensers and paper towels are to be provided in all service user bedrooms and toilets/bathrooms. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There is a good match of well-qualified staff offering consistency of care within the home. The standard of vetting and recruitment practices is lacking which does not ensure that suitable staff are employed to care for service users. Staff receive training appropriate to their roles which ensures that residents needs can be met at all times. The arrangements for the induction and training of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: The home demonstrated that recruitment procedures are not fully carried out through two staff files examined. Both care workers had commenced work prior to the criminal records bureau check and two written references being obtained and the proof of identity having been recorded. The home meets the 50 ratio of care staff trained to NVQ2 or above. Staff observed carrying out their duties were seen to be responsive and understanding of individuals wishes and needs.
Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 16 There were enough care staff in numbers and skill mix to meet the needs of service users. Domestic and catering staff are employed to ensure the critical care role is not impeded. Relevant training has been provided and staff spoken with confirmed this. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 The registered provider/manager is experienced and competent and management systems and practices ensure that the home is well run for the benefit of the residents. Service users views are regularly sought and they perceive them as having an effect in changing how the home is run. EVIDENCE: The manager was seen around the home talking to service users and was receptive to opinions that they had. She is nearing completion of the relevant qualifications required by the standards. A care manager and senior carer who are also participating in the same management courses supports her.
Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 18 Quality assurance surveys are conducted and a record kept of the findings and how they were acted upon. Weekly meetings take place where service users can air their views. None of the service users spoken with said they would have any hesitation about talking to staff or the management about any concerns. Quality assurance was seen to take place throughout the inspection whether it was in conversations with service users, monitoring of their welfare, leaving someone to sit in peace and then returning to ensure all was well. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 19 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 X X X N/A 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 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 3 X X X X X Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 20 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 2 Standard OP26 OP29 Regulation 13(3) 19(1) Requirement Timescale for action 31/05/06 To install the hand-basin in the laundry To ensure the ‘fitness’ of workers 28/02/06 prior to their start of employment. 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 OP15 Good Practice Recommendations To display the full menu choices each day. Holy Cross Care Home Limited DS0000058624.V274729.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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