Inspection on 13/10/05 for Salvete

This inspection was carried out on 13th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Salvete 26/02/07

Salvete 09/06/05

Salvete 02/12/04

Salvete 13/07/04

Salvete 23/06/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Salvete 15/17 Rothsay Place Bedford Bedfordshire MK40 3PX Lead Inspector Andrea James Unannounced Inspection 13th October 2005 11:00 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 Salvete DS0000014962.V258037.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. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Salvete Address 15/17 Rothsay Place Bedford Bedfordshire MK40 3PX 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) 01234 261991 01234 405600 Mr Tushar Bhatt Dr Lata Bhatt Mrs Beverly Catlett Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (27), of places Physical disability over 65 years of age (27) Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 09/06/05 Brief Description of the Service: Salvete Residential Care Home is registered to provide residential services for 27 older people who may have physical disabilities and/or dementia. The home has been created from the combination of two, two-storey high houses with an internal link corridor through a garage. The garage is used for the homes office as well as a drug cupboard. The home is situated on a quiet culde-sac road. The main road leads to the river. There is also ready access to local shops and the town centre. The building includes a large communal lounge with a new conservatory. The home has all the necessary facilities and staffed to operate well. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 13th of October 2005 over a 3 hour period. The Registered manager and registered provider were available throughout the inspection process. The inspection followed a case tracking methodology where samples of the service users were chosen. These service users were spoken to and their files and records inspected in detail. The report also reflects the views of other service users, the care staff on duty, relatives to the home and the manager of the home. On the day of the inspection the home had 24 service users, with 4 care staff and 4 ancillary staff on duty. The home also employed an administrator and a maintenance person. The home was undergoing some refurbishments to improve their occupancy level and to increase the number of disabled toilets on the ground floor. A partial tour of the home was carried out to ensure compliance to the requirements of the national care standards. The commission requires that all homes should be inspected twice annually. This report is the second report carried out and as a result some standards that were assessed and were met on the first visit, was not assessed on this occasion. It is therefore important to read both reports to gain a full understanding of the services offered in the home. What the service does well: The home continued to provide a high quality of care to the service users and the feeling of homeliness was evident throughout the inspection. The service users, relatives and care staff spoken to all complimented the manager for the way she managed the home, and said the staff were friendly. One relative said she was happy with the care and the atmosphere was good, carers were extremely good at their jobs and the activities in the home were exceptional. Service users said the staff were very kind, and they do more than is expected of them. One service user said she couldn’t ask them to do more. The care staff were observed to be kind and friendly to the service users and relatives on the day of the inspection. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 6 The meals provided for the service users were of a good standard and the service users spoke of the different meals they were offered. The catering staff were also seen asking service users if they enjoyed their meals. The service users said they received choices and all their dietary needs were met. The quality assurance system displayed on the wall suggested 99 of the service users and staff were happy with the care. 100 were happy with the management of the home, 99 were happy with the environment, 100 happy with the meals provided and 98 were happy with the daily activities provided. The records inspected showed that more than 50 of the care staff had obtained their NVQ level 2 in care. What has improved since the last inspection? What they could do better: The care plans should be improved to ensure service users are consulted about their care package and that all care plans are reviewed on a regular basis, in meeting with the changing needs of the service users. The procedures for recording service users wishes in the event of their death should be recorded on file. All staff should receive regular supervisions in line with the National Minimum Standards. The commission would like to thank the service users, relatives, care staff and manager for their co-operation in the inspection process. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 7 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. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 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 Salvete DS0000014962.V258037.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 11. Satisfactory processes were in place to ensure the health, personal care needs and medication needs were being met which resulted in good care being offered to the service users. The home was poor at recording the wishes of service users in the event of their death, as a result service users wishes in this area could not be assessed as met. EVIDENCE: The home ensured satisfactory procedures were in place to make referrals to external professionals to meet the needs of the service users. On the day of the inspection district nurses were seen visiting the service users. One Relative spoken to said the care at the home was good and she was confident that the care needs of her husband was the “best” that he could receive. The care plans had good assessment of needs and those inspected suggested that the needs of the service users were identified. It was however of concern that some service users with high needs such, as MRSA had not had a review dated on their care plan for several months. There was also a need to record Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 11 where service users were consulted about the care package to be implemented. The risk assessments seen also failed to record the date of implementation and as a result, it was difficult to see when the risk was identified and how relevant the information was for the service users. Service users spoken to confirmed that the care they received was good and that they were referred to various external professionals in order to have their needs met. Relatives spoken to said the home were good at identifying the needs of the service users. The home had satisfactory death and dying policies but failed to effectively record the wishes of the service users in the event of their death. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Salvete DS0000014962.V258037.R01.S.doc Version 5.0 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): 18 Satisfactory processes were in place to ensure care staff understood how to protect the service users from abuse, as a result service users safety would not be compromised. EVIDENCE: The home had ensured the policies of abuse awareness was implemented in the home and had scheduled training for all care staff which was due to take place in the near future. The care staff spoken to confirmed that they were due to embark on abuse awareness training. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 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): 21, 23, 24 and 26 The home provided a safe and comfortable environment for the service users that, was clean and free from offensive odours as a result service users appeared happy and relaxed in their home. EVIDENCE: The environmental standards of the home remained safe and comfortable for the service users. The service users bedrooms inspected suggested that they were decorated to a high standard and service users were able to have individual items that ensured their comfort. The home was in the process of having two bedrooms extended to the back of the building and was also adding an additional disabled toilet. This caused little disruption to the home and the service users safety was not compromised. The service users had various areas in the home that they could congregate and they made use of all the facilities available to them. The home was clean and free from offensive odours throughout. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 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 and 30. The home had satisfactory processes to ensure the needs of the service users were met by employing sufficient numbers of staff that were trained and competent to their jobs as a result good standards of care was provided to the service users. EVIDENCE: The home was fully staffed despite two carers being on maternity leave. The home employed sufficient care staff and ancillary staff and had a team leader for all day shifts. The home ensured that a large percentage of the care staff received their NVQ level 2 qualification in care and the training records seen suggested further training was scheduled for other courses for example dementia care, medication and manual handling. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 16 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, 36 and 38 The management structures in the home was very good and as a result staff, service users and relatives were confident that their interests were being met. EVIDENCE: The manager was praised for her dedication and transparency in the way she managed the home. The service users said the manager was approachable and easy to talk to. The manager was observed to have effectively communicated with the service users, care staff and relatives in a positive and friendly way. The care staff felt able to speak to the manager at any time. They said they did not receive regular formal supervisions but felt confident that they could speak to the manager at any time. The home had a health and safety policy and the processes inspected on the day of the inspection were satisfactory maintained. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 17 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x x x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x 2 x 3 Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2) (b) Requirement Timescale for action 30/11/05 2. 3 OP7 OP11 15 (2) (c) 12 (3) 4 OP36 18 (2) Arrangements must be made to ensure all care plans are kept under review and are updated on a monthly basis. Where possible service users 30/11/05 must be consulted about the care package to be implemented. Arrangements must be made to 30/11/05 ensure the wishes of the service users in the event of their death are recorded in a detailed manner. Arrangements must be made to 30/11/05 ensure all care staff are supervised on a regular basis. 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. 2. Salvete Refer to Standard OP7 OP7 Good Practice Recommendations All risk assessments should show the date of implementation. All needs identified in the assessment tool where care DS0000014962.V258037.R01.S.doc Version 5.0 Page 19 intervention is required should also be identified in the care plan documentations. Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Salvete DS0000014962.V258037.R01.S.doc Version 5.0 Page 21 - 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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