CARE HOMES FOR OLDER PEOPLE
Holy Cross Care Home Limited 150 Abbey Foregate Shrewsbury Shropshire SY2 6AP Lead Inspector
Gurinder Cheema Announced Inspection 7th December 2005 11:45a 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.V271051.R01.S.doc Version 5.0 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.V271051.R01.S.doc Version 5.0 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.V271051.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd November 2004 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.V271051.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first annual inspection of the year. Care homes are inspected at least twice a year. The inspection was unannounced and took place on 7th December 2005 between 11:45am and 1:45pm. The manager, staff on duty and service users were all very welcoming and helpful throughout the inspection. All of the National Minimum Standards inspected were met highlighting that the overall quality of care provided is very good. Written comments and feedback via questionnaires were sought prior to the inspection from a number of individuals. These included: Service users, staff, General Practitioners, Health and Social care professionals and service users’ carers. Only questionnaires from service users and relatives were received back and these were all found to be very positive. The care home has a history of meeting national minimum standards and providing a good service for people; consequently on this occasion mainly those standards identified as “key” by CSCI have been inspected. What the service does well:
Information available for service users is good. Personal care needs are assessed and met, with each service user having their own care plan, which were found to be regularly reviewed. These are detailed and appropriately documented giving clear instructions to staff on service users individual care needs. These are also accessible to all service users. A number of service users and relatives were met both in private and in groups. The comments received were all very positive and included: “I’m very happy and they are doing wanders with her (mum), her health is much better since being at the home” “My sister is very happy here, its first class” “Well cared for, this place is lovely” Risk assessments are comprehensive and information regarding individuals is provided to staff before they begin caring for the individual. The home has a detailed complaints policy and procedure and this was noted to have been regularly followed. All care staff administering medication have been appropriately trained. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 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.V271051.R01.S.doc Version 5.0 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): 3 The home has a satisfactory and functional admissions procedure proving an effective needs assessment and evaluation of suitability for both privately funded residents and those placed by the local authority. EVIDENCE: Four residents files were inspected during this inspection. They provided evidence that residents receive a care management or hospital discharge assessment prior to admission. Records examined contained community care assessments and / or hospital discharge assessment sheets identifying health and personal care needs. The home also has its own assessment process, which is carried out prior to the admission of each resident. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 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 and 10 There is a clear and consistent care planning system in place that provides staff with the information they require to meet residents’ needs. EVIDENCE: A total of four service users files were inspected during this inspection and they identified that the comprehensive care plans continue to be reviewed monthly. These are generated as a direct result of a seven-day initial ‘in-house’ assessment process. The plans are designed to identify all residents’ care needs and to which all staff are required to take notice. Files are colour coded to specific areas within the home. Care Plans are kept in the residents’ living areas for access as working documents by staff. The case tracking of residents taken from the inspector’s observations revealed a good service being provided based on identified need and resident preferences. Residents and their representatives continue to be involved in the construction and reviewing of their care plans wherever possible as part of the home’s
Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 Page 10 quality monitoring system. Of the care plans inspected in detail, all were observed to be ‘active’ and regularly reviewed as residents’ needs changed. Health care professional visits are recorded separately for monitoring purposes and resident’s health continues to be a high priority at Holy Cross. Medical care is provided by a doctor of the residents’ choice. The Home maintains a good rapport with the local district nurses and the health and remedial services, which the home can contact on residents’ behalf. A range of visiting professionals add to the services and facilities and includes; Chiropodist; Optician; Dentist; Physiotherapist; Occupational Therapy as well as the beautician and Hairdresser for that feeling of well-being. Pressure sores are prevented where possible with encouragement to be more active around the home. The home has competed medication training for all staff that may be involved in its administration. The inspector observed the administration of medication during the lunch time period. Medication is stored in a locked cupboard and trolley. Controlled drugs are appropriately stored and a register kept with two signatures and running totals. The Home has produced guidance for staff with regard to procedures to be followed if mistakes are made. There is liaison with the local pharmacist daily and visits weekly. There are currently two residents that self medicate and they are closely monitored by staff. The Home has a policy concerning values of privacy and dignity. Residents were observed being addressed with respect and staff knocked on bedroom doors prior to entering. There are appropriate locks fitted to the bathrooms and WCs to provide privacy for residents not requiring assistance. There is no dedicated treatment room however residents use their own bedrooms or the main office for private meetings or medical examinations. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 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 Staff work in close liaison with service users and their relatives to understand their individual lifestyles and preferences in order that these can be continued when they moved into the home. EVIDENCE: Daily and weekly activities continue to be organised on site. All activities involve resident input at the planning stage. Volunteers are used to support residents in activities outside the home. Family visitors are also encouraged to visit and help as required. Currently Christmas activities are being organised with lunches in small groups and a large group is also being taken to a local hotel. There are now three information boards in the home, which are used to advertise forthcoming activities and events. There are four residents that go out independently and there is a monitoring system in place to ensure that they and all residents have the opportunity to regularly venture into the community. All group activities are recorded in a diary specific for this purpose to assist in the monitoring process and the planning of future events. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 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): 16 and 18 The home has a satisfactory complaints system and there is evidence that residents feel that their views are listened to and acted upon. EVIDENCE: There is a complaints book available for both staff and residents’ use. There were a number of complaints recorded during the last 12 months and these were seen to be managed appropriately. All entries were noted with action taken and the outcome. The residents’ complaints procedure is contained within the Service User Guide. There is a complaints / compliments book available for comments in the reception area. There has been one complaint received at the Commission for Social Care Inspection office that was sent in by the provider. This was discussed in detail and the outcome is yet to be resolved. Adult protection procedures are in place. Procedures include physical intervention; restraint; racial harassment; financial / property and whistle blowing. Staff are aware of these procedures and a good level of communication within the staff team was noted. The home has a copy of the current Shropshire County Council Multi Agency Adult Protection Procedure. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 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): None EVIDENCE: These standards were not fully inspected at this inspection. However, the environment appeared to be clean, tidy and free from any offensive odours during this inspection. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 Page 14 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): None EVIDENCE: These standards were not fully inspected at this inspection. However, there appeared to an adequate number of staff on duty during this inspection. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 Page 15 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): 38 Health, safety and welfare of service users and staff are promoted by safe working systems in place. EVIDENCE: There is evidence of regular checks and maintenance of the equipment used in the home including electrical wiring and Gas Safety. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 Page 16 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 X 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 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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 OP3 Good Practice Recommendations It is recommended that the home re-assess the service users that are bordering under the category of dementia and seek to make an application for variation if identified. Holy Cross Care Home Limited DS0000058624.V271051.R01.S.doc Version 5.0 Page 18 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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