Inspection on 26/01/06 for Sarah Ann Rest Home

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Sarah Ann Rest Home 02/01/07

Sarah Ann Rest Home 27/09/05

Sarah Ann Rest Home 18/03/05

Sarah Ann Rest Home 21/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sarah Ann Rest Home 15 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX Lead Inspector Mrs Julie Garrity Unannounced Inspection 26th January 2006 13:00 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 Sarah Ann Rest Home DS0000005389.V280912.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. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sarah Ann Rest Home Address 15 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX 0151 476 8500 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) Mrs Pauline Joan Mary May Mr James Frederick May Mrs Pauline Joan Mary May Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 13 OP. Date of last inspection Brief Description of the Service: Sarah Anne is registered to provide personal care for a maximum of thirteen Older People of both sexes. The home has been opened for fifteen years and is privately owned. There are nine single and two double rooms, a lounge, and a dining room. A large basement contains the kitchen, laundry, office and a staff flat. The home does not have a ramp from the outside the building and limits access. There is a lift to all floors and alarm call systems in all rooms, toilets and bathrooms. Sarah Anne is a converted building in a quite residential area, close to a number of amenities including easy access to public transport both trains and buses and local shops within walking distance. The home has a mini-bus for transport of residents where required. There are gardens at the front and back are secure and accessible to service users when weather permits. Parking is available at the front of the building and there are double yellow lines outside the Home. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over the period of one day. The inspector arrived at the home at 13:00 and left at 16:00. The inspector spoke to the acting manager, eight residents, one visitor and three staff. The inspector completed the inspection by looking at the home records, a tour of the building, formal and informal interviews and information from previous inspection reports. The inspector followed a plan written before the start of the inspection to ensure that all areas that need covering are done so. Feedback was given to the manager and owner during and at the end of the inspection. The home has been assessed on all the core standards during the 2005/06 inspection year. What the service does well: What has improved since the last inspection? The acting manager has invested significant time and effort in improving the care plans and the medications management, both of these areas have significantly improved. The acting manager is actively seeking to meet care standards and is planning to obtain her own copy of the care standards to review. An application form for the acting manager has been sent and the acting manager intends to apply for the registered manager with Commission for Social Care and Inspection (CSCI). Sarah Ann Rest Home DS0000005389.V280912.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. Sarah Ann Rest Home DS0000005389.V280912.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 Sarah Ann Rest Home DS0000005389.V280912.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): None of the standards in this area were fully reviewed at this inspection. EVIDENCE: Care plans have an assessment done for each resident before they are admitted to the home. Sarah Ann Rest Home DS0000005389.V280912.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): None of the standards in this area were fully reviewed at this inspection. EVIDENCE: The management of medications and written care plans have improved. Care plans now detail the resident’s needs and some of the actions that staff need to take to meet those needs. The home is very good at maintaining residents independence. One resident detailed how the home supports her and what she chooses to do on a daily basis. Which included “going to bed when I want, getting up when I want, going out when I want. I pretty much do what I want”. The home also supports those residents who wish to keep and take their own medications. Unfortunately the risks around this activity have not been assessed and recorded, which leaves those residents at risk. Sarah Ann Rest Home DS0000005389.V280912.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): 15 The residents enjoy the food provided and are supported to make choices, such as the food they like to eat, where to have it and at times to suit them. EVIDENCE: Sarah Ann is a family run Home the acting manager has worked in the care home for many years and is the daughter of the owners this is reflected in the daily routines of the residents several of who said that they were treated “like a member of the family”. This includes the arrangements for meals, which can vary greatly from one resident to another and show that the residents are supported to choose a variety of meals. One resident described how they had their meals at a different time to the majority of the residents, they said, “its great, I eat when I’m hungry and it’s always nice”. All the residents spoken with were complimentary about the food. One resident it was “very nice, but a little samey”. The acting manager explained that the residents are regularly asked about the food available and was happy to discuss resident’s choices and ideas with them. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 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 the following standard(s): 16, 18 The home needs to make sure that all residents, relatives and staff are aware of how to raise concerns and the ways in which all staff can protect residents. EVIDENCE: Several residents said, “I’ve never needed to complain”, “there’s nothing to moan about” and “any problems get fixed”. All residents and staff said that they would report any concerns to the manager. Staff have not received training in Protection of Vulnerable Adults or received any information on raising concerns with organisations outside of the home. The acting manager does not have access a copy of the Local Authorities policy and procedure, which would inform her of her role and responsibilities. Discussions with all staff detailed that they were not sure of how to raise concerns in this area or what actions would need to be taken. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 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 the following standard(s): 19 None of the standards in this area were fully reviewed at this inspection. EVIDENCE: The owner and manager discussed the lack of suitable disabled access to the building and the difficulties that had arisen from this. The owner is in the process of finding out the cost and the best way to provide suitable access and agreed that this would be completed within the next three months. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 13 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 are sufficient staff available to meet the needs of the residents. However the lack of training and employment checks for staff, induction of new staff and employment is unsafe practice and does not safeguard the residents. EVIDENCE: The staff are well thought of by residents who made comments such as “very nice staff” and “they work hard”. All the residents and staff said that there was enough staff available to meet the needs of the residents. Many of the residents are very independent and staff support this independence in an appropriate manner. A review of staff records detailed that not all had the correct employment checks before they started work such as two references, proof of identity, Protection of Vulnerable Adults checks and police checks. This approach runs the risk that unsuitable staff will be employed. Training records were patchy, certificates were available for some staff but not for all, training was out of date for some staff for moving and handling and fire training. Training specific to the needs of the residents and for good practice such as Protection of Vulnerable Adults, medications competency and diabetes was not available. Training specific for care assistants known, as NVQ was available for all the staff with several having undertaken this training. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 14 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): 33, 35, 38 There is no quality assurance system that reviews the resident’s opinions, which prevents the home from making sure it is able to increase the quality of the service provided. Resident’s finances are managed in a manner that safeguards their interests and allows them to access their funds as needed. Health and safety practices in the home are in need of development in order to protect the resident’s safety and welfare. EVIDENCE: Informal discussions with residents are held on a regular basis. A resident said, “I’m always asked what I want and need”. However the home does not have a formal quality assurance system that produces an annual development plan that helps them plan for the future and increase the quality provided. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 15 The home holds very little funds for residents the majority are dealt with by the residents themselves or their families. Where the home does handle residents money, receipts and records are available that are kept up to date. Certificates are available for general maintenance on the day of inspection all the fire extinguishers were checked. The home does not have risk assessments that identify the risks to residents such as medications, falls or residents who leave the home on their own. Necessary training for staff for fire safety, health and safety and moving and handling training was out of date for several staff. The home does not monitor the resident’s accidents and take appropriate actions, one resident was found to have a bruise that was unexplained, this was not recorded as an accident and no action was taken to identify the cause in order to prevent. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 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 X X X X X X X X X X X X 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 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 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. 1. Standard OP7 Regulation 13 (4) (a) (b) (c) Requirement Timescale for action 26/03/06 2. OP18 13 (6) 3. 4. OP19 OP29 23 (2) (a) 19 (1) (5) A review of residents risk assessments must be undertaken and all residents who leave the Home, undertake the management of their medications or are at risk of falls must have an individual risk assessment in place. All staff must be given a copy of 26/05/06 the homes policy regarding complaints, whisleblowing and Protection of Vulnerable Adults. Training must be arranged for staff in recognising the signs of potential abuse and reporting them appropriately. A copy of the Local Authority Protection of Vulnerable Adults policy must be obtained and the manager must be aware of her role and the role of external investigators in any potential Protection of Vulnerable Adults investigations. Access must be created that 26/04/06 allows for disability access such as a ramp. All staff must have 2 references, 26/04/06 proof of identity, Criminal Records Bureau and Protection of DS0000005389.V280912.R01.S.doc Version 5.1 Sarah Ann Rest Home Page 18 5. OP30 18 (1) (a) (c) 6. OP33 24 (1) (2) (3) 7. OP38 17(1) a) b) (3) a) b Vulnerable Adults check prior to employment. All staff with all the checks but Criminal Records Bureau can be employed in exceptional circumstances, with negotiation with CSCI and must not work unsupervised. Staffing training records must be 26/05/06 updated to reflect the training of staff, identify any gaps in their training and plan how to update all staff training A quality assurance system must 26/07/06 be used that creates a plan for quality development and is taken from the expressed views of the residents and their families. Any unexplained or unobserved 26/03/06 falls or injury must be investigated as to the potential cause and CSCI informed. An accident form must be completed on all occasions. 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. Refer to Standard OP30 OP38 Good Practice Recommendations Staff competency should be determined and reviewed in particular for those staff responsible for medications A copy of all staff inductions should be retained. Residents accidents should be monitored on a monthly basis. Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Sarah Ann Rest Home DS0000005389.V280912.R01.S.doc Version 5.1 Page 20 - 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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