CARE HOMES FOR OLDER PEOPLE
Santralla 8 The crescent Scarborough North Yorkshire YO11 2PW Lead Inspector
Karen Ritson Unannounced 30 June 2005 10:00 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 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. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Santralla Address 8 The Crescent Scarborough North Yorkshire YO11 2PW 01274 487207 N/A N/A Pennine Care Services Ltd. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Julie Elizabeth Walker Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection N/A Brief Description of the Service: This is the first inspection carried out following the purchase of Santralla by Pennine Care services. The home is a large terraced house set in The Crescent in Scarborough, conveniently placed for the the local bus and train services, shops and other facilites. The home provides personal care and domestic support for up to twenty two service users of either sex.The home has a level area to the front of the building where service users may sit out when the weather permits. There is a lift to most of the rooms. Those service users in rooms which are not serviced by the lift must be reasonably ambulent, however the lift is available to the main floor and only a few stairs need to be negotiaited for these people. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on June 30th and took 11 hours to complete which includes time for preparation and for writing the report. Six service users were spoken to and three members of staff. Whilst particular comments by service users are described in more detail in the main body of the report, all were complimentary about the way in which care was offered at Santralla. Staff said they felt well supported and that they had sufficient time to carry out their duties. This home was taken over by Pennine care at the beginning of 2005. The proprietors, manager and staff have worked together to make improvements in the way care is offered and to improve the experience of those people living as Santralla. What the service does well: What has improved since the last inspection? What they could do better:
There are plans to further enhance the environment. Paperwork is on the whole detailed and informative, however, daily activities could be recorded in a way, which better builds a picture of each individual’s day. The manager is open to exploring improved methods of working with service users and is tackling the changes proposed by Pennine Care with enthusiasm and commitment.
Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 6 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. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 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 standard(s) 1, 2 and 3 Service users have sufficient information to make a decision about admission and are assured their needs may be met. EVIDENCE: The home has produced a statement of purpose and service user guide to cover all required areas and each service user is given terms and conditions of residence which is signed and dated. Service users said they had received sufficient information to make a decision about admission to the home. An assessment was seen for each service user, which was comprehensive and indexed to cover all areas. Service users said they were confident their needs could be met. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9 Service users care needs are met. EVIDENCE: Care plans are detailed and thorough, with all specialist interventions included. It is clear where health care professionals have been consulted. Daily records do not always provide a detailed picture of activities of daily living. Suggest consideration to be given to daily reports to build a picture of daily activities for each individual. Service users said they felt staff knew what individual care needs were and that they were well cared for. Medication is suitably stored in a trolley, which is locked to the wall. A Nomad system is employed which appears to work well. All staff who administer medication are to receive refresher training from the pharmacy in the week following the inspection. Three members of staff have completed a distance learning medication course through York College. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 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 standard(s) 15 Service users receive a good quality diet with sufficient choice. EVIDENCE: Menus were seen and a midday meal observed. Service users said they enjoyed the meals very much and that the food was consistently of a good quality. The home employs a cook. Specialist diets such as diabetic and soft diets may be provided when required. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16 and 18 Service users are enabled to complain and their welfare is protected. EVIDENCE: Service users said that they felt able to speak to management or any member of staff about concerns and that they would be listened to and their concerns acted upon whenever possible. The home has produced an advice sheet for service users and visitors in addition to the complaints policy and procedure, which is available in the entrance hall. The home does not yet hold service users meeting but this is planned. All staff have been issued with the GSCC code of conduct booklet. Policies were seen on abuse prevention, and related areas. Staff are to receive refresher abuse awareness training in the near future form Pennine in house training. Staff said they knew what constituted abuse and service users said they felt safe in the home. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 and 26 Service users live I a well maintained, safe and improving environment. EVIDENCE: Since Pennine care purchased this home there have been considerable improvements to the internal décor and more are planned. The kitchen has a new dishwasher, the boiler has been replaced and there is a new freezer. The kitchen is to be rearranged to provide a split between working areas. The laundry now has a new washing machine and tumble dryer. The room previously used as an office is to be redecorated and is being used as a smoking room for service users. The lounge has been redecorated and has new chairs. Carpets for the all communal areas arrived on the day inspection. A new large screen TV has been provided. The service users rooms are being redecorated beginning with the empty rooms. Several newly decorated rooms were seen; these had new wallpaper/paint, new carpets and new matching curtains and bedding and were tastefully finished. Some rooms were only accessible by a few stairs, with no lift. Those service users whose rooms were in this area were spoken to and all could manage
Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 13 them with assistance. All bathrooms are to have non-slip flooring. A new fire detection system is planned. The grounds are accessible to service users, however access is to be further facilitated by the provision of a ramp to the main door and a levelled area to the front of the building. Service users said the environment was much more pleasant since the changes had begun although several said the new lounge chairs were not as comfortable as the old ones. They said that the changes had been explained to them and that they were looking forward to the new carpets and the completion of decoration in all service user rooms. The environment is safe, risk assessed, and complies with the environmental health department and the fire service, although visits are due again from both. The cleaner was spoken to and she expressed her commitment to keeping the environment clean and pleasant for everyone. This commitment was obvious from a tour of the building. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed. EVIDENCE: Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed. EVIDENCE: Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 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 Standard No 16 17 18 Score 3 x 3 x x x x x x x x Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 17 na Are there any outstanding requirements from the last inspection? 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 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 8 Good Practice Recommendations Recommend improved daily diary recording to give a more detailed view of each service users day. Santralla J53-J04 Santralla S62594 V232475 210605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection York Area Office Unit 4, Triune Court Monks Cross York, YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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