Inspection on 15/11/05 for Sceats Memorial Home

This inspection was carried out on 15th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sceats Memorial Home 12/08/09

Sceats Memorial Home 18/02/09

Sceats Memorial Home 16/01/08

Sceats Memorial Home 17/08/07

Sceats Memorial Home 06/09/06

Sceats Memorial Home 03/03/05

Sceats Memorial Home 18/06/04

Sceats Memorial Home 19/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Sceats Memorial Home 1-3 Kenilworth Avenue Gloucester Glos GL2 0QJ Lead Inspector Peter Still Unannounced Inspection 15th November 2005 11:15 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 Sceats Memorial Home DS0000016573.V267580.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. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sceats Memorial Home Address 1-3 Kenilworth Avenue Gloucester Glos GL2 0QJ 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) 01452 303429 Sceats Memorial Housing Association Limited Mrs Iris Anne Burton Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: This is a well known and popular Care Home which provides personal care to the older person. It is situated in a residential area on the outskirts of Gloucester City. It offers accomodation over two floors in two, extended victorian houses. Bedrooms are single and have wash hand basins. Communal toilets and bathrooms are near to all bedrooms and main communal rooms. There are three lounges, one dining room and a sun room on the front of the property. The building is accessible by wheelchair, the first floors are reached by stair lifts, but some bedrooms are not easily accessed unless the individual is confidently mobile and advice would need to be sought from the Manager as to which bedrooms are affected. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 11:15hrs and 16:30 hrs and the manager, deputy manager and senior carer provided support and evidence. Twenty-nine residents were at the home and ten were spoken with. Including senior managers, eight staff and two relatives were also talked to. Various records were reviewed and there was a tour of the building. The home was friendly and most residents talked about being very happy living at the home. One resident expressed difficulties with their move to the home and staff were aware of this. Some requirements have been identified within this report and need attention. What the service does well: What has improved since the last inspection? Further work to improve the environment has been completed and there are plans to continue with internal decoration. Poor quality beds have been replaced and new headboards are about to arrive for others. The carpet in bedroom 19 has been replaced. A quality assurance system has been started and can be developed to provide helpful feedback on ways of improving the home in the future. A pre Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 6 admission document has also been produced to ensure important information is available to the home prior to an admission. What they could do better: Fire doors must be checked to ensure they close properly and are not propped open. Where residents wish to have their doors open, the provider should consult with the fire officer to gain guidance on suitable alterations to the doors. A hot water unit in a bedroom needs to be made safe so that residents cannot scald themselves. The heating in the sunroom, at the entrance of the home needs to be warm enough for residents and their supporters. The treatment room needs to be improved. Decoration to the home should continue. Whilst it is positive that a simpler staff supervision system has been introduced, the supervision content needs to be considered and it may be helpful for the manager to consider attending a supervision-training course, which would help to provide information on current best supervision practice. Consultation with residents has started and it will be helpful to develop this and find further ways of encouraging involvement from residents and their supporters. Whilst a number of residents enjoy an active social life outside the home, many do not and there should be consideration of how transport for residents could enable more residents to enjoy activity, such as trips out and shopping. Bathrooms are clinical in appearance and could benefit from ideas from residents and staff about how they could be softened and made a little more homely. Sceats Memorial Home DS0000016573.V267580.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. Sceats Memorial Home DS0000016573.V267580.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 Sceats Memorial Home DS0000016573.V267580.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): 3 A new assessment document helps to ensure that important information is available to the home so that care needs can be met. EVIDENCE: People who wish to live at the home spend a day getting to know the home and during this time the manager ensures the pre admission assessment form is completed. It was understood that the document, which covers a wide range of key aspects, had been produced since the last inspection. A copy is also given to families to complete and three were seen. When a new system has been put in place, it is often possible to make further improvements and it may be helpful to include the production date of the document and a review date. New residents are given a copy of the Homes Service User Guide and a record to evidence this was dated 17/10/05. A contract of residency was also seen, dated 06/09/05. Sceats Memorial Home DS0000016573.V267580.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 Care plans and good liaison with the local primary care team ensures resident’s needs are met. EVIDENCE: Three care plans were seen and found to be reviewed monthly. Personal cleansing and eye treatment records were up to date. Staff involved with medication, have provided specimen signatures so that managers can check who provides medication to residents and one was dated 28/03/05. During the inspection, a resident went to the office concerned about a damaged fingernail, which was catching and painful, needing specialist care, and the manager said it would be followed up. At the time of the inspection, the drug trolley was in the Appliances room, near to a sluice facility and one disposable glove, which looked as if it had been used, was on top of it. Clearly cross contamination may be an issue. Two members of staff saw the glove and talked about the infection control course they had recently attended, appearing confident about the issues. One member of staff immediately removed the glove and the manager on hearing Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 11 about the potential problem, decided to immediately remove the trolley from the room on a permanent basis. Sceats Memorial Home DS0000016573.V267580.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): 12,13,15 Residents make choices, which help with an independent life style. The home does not have its own transport and further consideration of helping residents to go out from the home may be positive. The dining room provides a pleasant environment for residents to enjoy meals. EVIDENCE: A number of residents enjoy an active lifestyle and take advantage of local groups and activities. Some residents spend much of their time at the home and consideration of transport arrangements to help residents enjoy trips out and shopping may be helpful to consider. Two residents spoken with said they particularly enjoy the freedom at the home and of being supported to do the things they like to do. The last residents house meeting, which are held, now, every six months was on 24/06/05 and the record showed a wide range of topics. There was an indication that eighteen residents did not want to talk within a large group and opportunities were available for residents to talk to staff in the office. Key workers also find out what residents needs and wishes are. Ways of promoting consultation and input to the running of the home should be pursued. A Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 13 number of different activities had been arranged at the home including a Christmas raffle and Bingo. Relatives are encouraged to visit and two talked about the home, giving praise for the care provided. A relative was able to use the entrance conservatory/sun room in privacy though it was noted that the room was quite cold and its heating should be considered. At lunchtime residents were seen to be enjoying their meal in a recently decorated dining room, which was colourful and had pleasant tablecloths and individual napkins. Each table had its own flower decoration and the member of staff responsible for ensuring it was so well kept should be praised for their work. The room looked very inviting and was clean. The kitchen, which is adjacent to the dining room, was also clean and well organised. A bowl of fruit in the kitchen, was understood to be put out for residents at meal times. It may help to encourage residents to eat a little more fruit if it is constantly available in the dining room. The menu was seen and appeared to be varied and balanced. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 14 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 Staff that are aware of the homes policy and procedures and have reinforcement training concerning the protection of vulnerable adults protects residents. EVIDENCE: Staff sign to record that they have read the homes policy and procedure documents. Staff are due to have reinforcement training, at the home, concerned with adult protection. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 15 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): 19,24 Work is needed to ensure resident’s bedrooms are safe and decoration to further parts of the home will be of benefit. EVIDENCE: Two bedrooms and the entrance hall way to the home and a corridor had been redecorated within the previous six months and looked bright and clean. This was considered to be a good start. Bedroom 4 was found to have a Heatstore hot water unit installed and the water from it was too hot and should be made safe. The senior manager checked the water as well as the inspector and agreed that it was very hot. This bedroom also had a long institutional looking strip light, which was dirty and its replacement should be put into the maintenance programme for the home. The door to the bedroom was wedged open with a chair, which was not acceptable. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 16 The fire door to bedrooms 12 & 13 was on a rising butt self closing device, which was not working, losing any value from the fire door and both bedroom doors were seen to be wedged open. A number of fire doors at the home were not closing properly or were wedged open and a requirement will be made that an audit is completed of all fire doors and that steps be taken, with advice from the Fire Prevention Officer, to provided special door closing devices which residents are happy with and that the Fire service agree are acceptable. The treatment room for the home, which is used by professionals and residents’, was in poor condition. There was brown staining to a wall and the skylight had mould on it. The room needs to be freshened up and be made to look less institutional. Bathrooms in the home were mainly white and clinical in appearance and it may be possible for residents and staff to think of inexpensive ways of making them look more homely. It was noted that a maintenance person works at the home 30 hours a week and he may be able to undertake some tasks, within a programme of works. A previous inspection noted that there should be an audit of resident’s beds and the home has since disposed of four and others have had new bed trims provided. Also thirteen new headboards have been ordered. The last inspection noted a number of environmental points and it was noted that most of these had been responded to. A requirement regarding fire doors being propped open, will however be repeated and the provider should consider the safety of residents in this respect. An employer also has a responsibility to ensure a safe work place for staff and people who visit the home. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 17 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, 29, 30 EVIDENCE: The staffing levels on the day of inspection were considered to be satisfactory to meet the needs of residents. Residents said that staff are attentive and respond when asked. One resident was poorly and in bed and staff said they make regular checks. The home has a mainly established team of staff, providing good continuity for residents. It was noted that a new member of staff was wearing a portable staff communication device but did not know how to use it. It will be recommended that new staff are only given the device once they are confident with the training in how to use it. Six monthly fire training for day staff was in place, with one file being reviewed. Three monthly training for all night staff was due to start soon. One staff file reviewed showed that all appropriate recruitment checks had been undertaken. Another file showed that staff had received training in the preparation and handling of food. The home has had ongoing difficulties in ensuring compliance with a requirement to provide a team of staff where 50 have an NVQ level 2 qualification, or above and this was noted in the last inspection. This particular standard was not inspected on this occasion; nevertheless the manager should Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 18 review the current position and take steps to ensure staff undertake the training if a shortfall remains. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 19 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): 31,33, 36 Resident’s benefit from the continuity of a long serving manager and a Responsible Individual that senior staff find very supportive. Not all staff have had recent supervision, which may place residents at risk. However a new supervision programme will support the process. EVIDENCE: The manager has worked at the home for thirteen years and feels fully supported by her two senior staff. The manager was helpful during the inspection and demonstrated a willingness to listen to any points made, which may improve the service and modernise practice. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 20 The responsible individual, who represents the provider, has clearly worked hard to support the home in responding to requirements and recommendations from the last two inspections and this was considered to be valuable. The responsible individual has taken a key lead in the development of a new quality assurance system and a questionnaire has been produced, which covers a wide range of key issues. This is considered to be a good start and can be built upon. It will be necessary to ensure residents and supporters are encouraged to be involved with it and to review the outcome and provided feed back. There are some environmental points noted within this report, which will need attention and whilst work place risk assessments were not reviewed on this occasion, the manager should ensure these are satisfactory along with the risk assessments for each resident. A new staff supervision programme has been introduced since the last inspection, following previous discussion with the inspector. Whilst the format provides a good start, it should be reviewed to ensure sufficient content, which enables the member of staff and manager to raise issues important to them and the management of staff. The supervision notes reviewed were all very similar following a themed approach. The current theme was fluid intake. It was considered that some key issues such as this may be the subject of part of a staff meeting, rather than a staff supervision session. A recommendation will be made to develop the content of supervision. There is a new management supervision plan with dates for supervisions but only seven staff had received recent supervision and a requirement will be made to ensure a minimum of six are provided within an annual plan. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 21 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 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X 2 X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X X Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 22 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 OP25 Regulation 23 Requirement Timescale for action 03/02/06 2 OP36 18 3 OP19 13 Bedroom 4 has a hot water unit, providing water to the sink, which is too hot and steps must be taken to ensure it is safe for the resident. Staff must receive adequate 03/02/06 supervision, a minimum of six times a year. (Previous timescale of 15/08/05 not met) Ensure fire doors are not 19/12/05 propped open. 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 OP12 OP36 Good Practice Recommendations Consider transport arrangements, which may help residents with limited mobility to enjoy such things as shopping and trips out. The content of supervision should be developed and the manager should consider training to help ensure staff supervision meets the needs of staff and management of the home, in line with current best practice. DS0000016573.V267580.R01.S.doc Version 5.0 Page 23 Sceats Memorial Home 3 OP19 4 5 OP25 OP19 Continue with redecoration to the home including the Appliances room. Make bathrooms less institutional in appearance and plan to replace the strip light in bedroom 4. Consider if action is needed to ensure the sunroom is warm enough for residents and relatives to use. Complete an audit of resident’s bedrooms and their wishes, where they do not want to have their door closed. Take advice from the Fire Prevention Officer and agree suitable devices for the doors and install them. Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Sceats Memorial Home DS0000016573.V267580.R01.S.doc Version 5.0 Page 25 - 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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