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Inspection on 20/07/06 for Holy Cross Care Home Limited

Also see our care home review for Holy Cross Care Home Limited for more information

This inspection was carried out on 20th July 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All outcome sections in this report have been judged as good. Holy Cross has more strengths than areas for improvement. Where areas for improvement have been identified the CSCI are confident that the provider will manage these. The home is good at involving people in all aspects of the service. Management have a good day-to-day rapport with service users to ascertain their satisfaction and well being that is also backed up by a formal quality assurance process. Some service users spoken with welcomed the chance to be involved in the home and liked to know what was going on. The home is good at identifying individual wishes and needs and meeting these as safely as possible.

What has improved since the last inspection?

Staff recruitment is more robust with all checks being returned prior to appointment. The fire risk assessments have been reviewed by outside professionals and new procedures implemented in the home.

What the care home could do better:

It is poor practice to soak/clean commode pots in service users bathing facilities. This must stop and an alternative solution found.There must be a record of receipt of each service users medication into the home. Hand transcribed medication administration charts should be signed by two staff.

CARE HOMES FOR OLDER PEOPLE Holy Cross Care Home Limited 150 Abbey Foregate Shrewsbury Shropshire SY2 6AP Lead Inspector Pat Scott Key Unannounced Inspection 20th July 2006 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 Holy Cross Care Home Limited DS0000058624.V305128.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. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 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 None 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.V305128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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 a 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 makes their services known to prospective service users in: The Statement of Purpose and Service Users Guide. The latest inspection report is available in the entrance hall. The care home rates are reviewed annually and service users are notified one month in advance. The only additional charges to service users are for hairdressing, toiletries and newspapers. This is clearly laid out in the terms and conditions. Fees for Holy Cross as of 1st April 2006 are: £335-365. All service users pay monthly or weekly in advance. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, staff records kept in the home, medication records, discussion with people who use the service and relatives, discussions with the staff team, discussion with the manager, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? What they could do better: It is poor practice to soak/clean commode pots in service users bathing facilities. This must stop and an alternative solution found. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 6 There must be a record of receipt of each service users medication into the home. Hand transcribed medication administration charts should be signed by two staff. 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.V305128.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 Holy Cross Care Home Limited DS0000058624.V305128.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: Holy Cross admits elderly people requiring personal care and provides staff with training and guidance to enable them to be responsive to individual needs. Staff have access to training materials. Full needs assessments are conducted prior to service users being admitted. These documents confirmed that the assessment had been conducted professionally and sensitively and had involved the family or representative of the prospective service user. A recently admitted service user confirmed that he had received full information about the home and had been consulted with about what care he would require. Holy Cross Care Home Limited DS0000058624.V305128.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a service user receives, is based on their individual needs thus promoting good health. Staff have a good attitude to their work and the principles of respect, dignity and privacy are put into practice. EVIDENCE: All service users have a care plan in their bedrooms and four were examined as part of ‘case tracking’. These were up to date and had been regularly reviewed. A Community Nurse was visiting the home which demonstrated that staff actively promote the service users’ right of access to the health service both within the home and the community. Systems to receive, store, administer and dispose of medication in the home are in place and followed according to the home’s policies. An overall record for receipt of medicines into the home is kept, but the manager should ensure that individual receipt of service users medication is recorded. Hand transcribed medication onto the charts had not been signed. All senior care staff have undertaken the relevant training. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 10 Staff were seen and heard to respect service users’ privacy and dignity. They were allowed to go about their usual routines and sit where they liked. The staff were seen to constantly interact with service users and it was evident that relationships are close but still professional. Staff were seen to always knock on service users bedroom doors prior to entering. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to participate in social activity and keep in contact with family and friends. Residents receive a healthy, varied diet according to their assessed requirement. EVIDENCE: Social activities take place within the home on a daily basis. Service users are encouraged to keep up with personal hobbies. One person had been enabled to pursue his love of gardening. There was a lovely display of plants around the grounds. Another service user spoken with was looking forward to a trip out with her relative. She commented that staff had helped her to get ready and “look nice” for the event. She said she had been “thoroughly spoilt by staff in the home”. One gentleman enjoys a pint at his local pub before lunch Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 12 The menu is displayed each day and offers a choice of meal. The kitchen meets the requirements of the Environmental Health Officer who last visited on 9/5/06. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 13 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have access to a complaints procedure that enables them or their supporters’ views to be listened to and acted upon. Staff are provided with induction and on-going training regarding adult protection. This provides staff with the relevant knowledge to safeguard service users from many types of abuse. EVIDENCE: The CSCI has not received any complaints about the home. Nor have their been any adult protection issues. Service users were seen to speak easily to staff and were comfortable in their company. Staff are skilled in communicating with people to ascertain their well-being. The weekly ‘speakers corner’ event that takes place gives a forum for concerns and suggestions to be aired. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holy Cross is comfortable and homely and service users live in a safe, wellmaintained environment. EVIDENCE: The home offers a choice of environment between the old building and the new extension where facilities are more modern. Rooms entered into were personalised according to individual wishes and tastes. Communal areas were clean and comfortable. Service users have access to conservatory and garden areas. Some communal toilet/bathing facilities were without paper towels. The laundry is well equipped and staff implement procedures to minimise cross infection. It is intended that a separate hand washbasin will be fitted. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 15 However commode pots were being soaked in a service users communal bathroom in the old house, which is not good health and safety practice. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents. EVIDENCE: The files of two staff were seen which showed that good recruitment practices had been carried out. Records also showed that induction is provided. Staff confirmed that training is provided and there are many equal opportunities to improve themselves for the benefit of service user care. A training plan is in place to cover all mandatory topics as well as specialist subjects. NVQ training is on-going and the care manager is doing her NVQ 4 in management. Service users spoken with said they felt staff “knew what they were doing”. Staff are experienced in dealing with service users with very individual personalities. An example of this was observed between a carer and a service user who is very particular about timing of his personal care and the level of assistance he will allow. The carer dealt with the situation in a skilled and professional manner demonstrating her knowledge of the psychological needs of this individual. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 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): 31,32,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ethos of the home is based on openness and respect with effective quality assurance systems developed by qualified, competent manager to achieve good outcomes for service users in all areas of care. EVIDENCE: The owner/registered manager has the registered managers award and is participating in the NVQ 4 in care. Through discussion she demonstrated that she manages the service efficiently, providing quality care to service users. She seeks to develop the service, encouraging staff to improve their skills to create a confident staff team. The home actively encourages service users, where able, to manage their own money. Records are kept. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 18 Quality assurance takes place throughout the service in both a formal and informal manner. Meetings, surveys and day-to-day contact all provide records to show that service user satisfaction is at the heart of the service. Service users commented that they welcomed being involved in the running of the home. One person said, “The matron and manager always comes to chat with us”. The home keeps records to show that the health and safety of service users is promoted and protected. The fire records and hot water temperature checks were seen as examples of this. Fire safety has been reviewed and improved with plans for annual quality checks in this area. The manager also stated they were looking into a safe system for service users who like to keep there bedroom doors open during the day. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 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 3 3 3 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 X 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 4 3 X 3 X X 3 Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 20 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 OP26 Regulation 13(3) Requirement The registered provider shall install the hand-basin in the laundry. (Timescale 31/5/06 not met.) The registered provider shall record receipt of individual service users medication into the home. The registered provider shall make alternative arrangements to clean commode pots. Timescale for action 20/10/06 2 OP9 13(2) 20/08/06 3 OP26 13(3) 20/08/06 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 OP9 Good Practice Recommendations Hand transcribed medication should be signed by two members of staff. Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 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 © 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 Holy Cross Care Home Limited DS0000058624.V305128.R01.S.doc Version 5.2 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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