Inspection on 10/05/05 for St Agnes Retirement Home

This inspection was carried out on 10th May 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

St Agnes Retirement Home 08/11/05

St Agnes Retirement Home 08/12/04

St Agnes Retirement Home 12/07/04

St Agnes Retirement Home 30/03/04

St Agnes Retirement Home 05/02/04

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 St Agnes Retirement Home 7 Neva Road Weston Super Mare North Somerset BS23 1YD Lead Inspector Carolle Wise Scanlon Announced 10 May 2005 th 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. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Agnes Retirement Home Address 7 Neva Road Weston Super Mare North Somerset BS23 1YD 01934 514266 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 Gail Joanne Norton To be appointed Care Home - Personal Care only 26 (26) Category(ies) of Old Age registration, with number of places St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age of persons who may be received in the home - 65 years and over. 2.May accommodate two people who are aged 59 years and above, who may also have a learning difficulty. This condition applies to specific residents and will no longer apply should these residents leave. Date of last inspection December 8th 2004 Brief Description of the Service: St Agnes is a retirement home providing care for a total of 24 service users. The home provides care for those residents of 65 years old and for two people with learning disabilities. St Agnes is situated in a quiet residential area of Weston-Super-Mare. It is within easy reach of the town centre area, has local shops, parks and the sea front nearby. The house stands in gardens to both the front and rear. The accommodation is arranged over two floors, the first floor accessible via a stair lift. The basement area contains its laundry, workshop storage and staff room facilities. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Completed comment cards were received from various sources and these included, three GP’s, a district nurse and 14 service users. The inspector met with 3 staff members, the homes manager designate, Mr Roy Orme, the home’s co-proprietor Mrs Gail Norton and care manager Mr Stephen Poole. 12 service users were met during the course of the inspection. Documentation reviewed included care pans and risk assessments, fire records, staff training and personnel records. Since the last inspection the management structure has altered with a new manager designate Mr Roy Orme. This was a positive inspection. What the service does well: What has improved since the last inspection? What they could do better: The home has not had a registered manager in place for over a year. Although the management structure of the home has been solid it has lacked a responsible registered manager. The manager designate Mr Roy Orme has now applied to the CSCI to undertake a ‘fit person interview’ in the near future. Care planning and risk assessments need to inter relate in that if there is a change in the risk the associated care provision needed should be documented in the care plan. Telephone answering and improved communications between staff and other health care providers to provide a more seamless service. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 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. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 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 St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 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) 2,3,4 &5. Residents’ needs are appropriately assessed before admission to the home and information about the home and its services is given. EVIDENCE: Residents met had some awareness of their contract with St Agnes and the records sampled verified these facts. Those residents funded by social services had St Agnes contracts also. The home was advised that it was appropriate to give terms and conditions to residents who have social service contracts. A resident who was a recent admission to the home was able to describe the information and the assessment they received prior to moving in. They felt that it provided them with a good overview of what to expect and of the services the home offers. Six records sampled showed this to be a comprehensive assessment and demonstrated within the care records that the home could meet their care needs. The care needs in some cases included referrals to other health and social care professionals such as district nurses, GPs, chiropodists and dentists etc. Not all the service users met took up the offer to visit the home prior to moving in, but their families in most cases did and let them know what they thought. Those that chose to look around themselves felt that the homely surroundings suited them well. The homes St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 9 documentation suggests the offer a month’s trail period and 2 residents recalled a ‘settling in period’. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, &10. The health and personal care needs of residents are well met. There is a friendly, relaxed atmosphere in the home, with evidence of a good rapport between residents and staff. EVIDENCE: Chatting with the residents they discussed their care needs and the care offered. It was evident that residents had awareness of their care planning documentation although not necessarily the terminology. Residents said that they were asked from time to time to look at and sign if happy to, a form that has their ‘care’ written on it. This demonstrated good practice and encouraged resident involvement. The inspector sampled six care plans all were regularly reviewed and updated in line with any change in needs. However when risk assessments are reviewed and changed the care to be given to reduce the risks should be translated into the plan of care. The staff demonstrated a good awareness of the needs of the residents. The 14 resident feedback comment cards report very positively on the care received at St Agnes. Several residents had requested to speak to the inspector and offered glowing reports on the staff and the home. Staff were observed to have a good rapport with the residents. No issues regarding privacy or dignity were observed during the inspection or reported. Several residents found the staff to be very kind and appropriate in their address. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 11 St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 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 standard(s) ,12,13, 14 &15. The homes routine affords a degree of flexibility for residents to choose how to spend their day. There are sufficient choices of activities to meet the needs of the current resident group. Special dietary requirements and preferences are taken account of with a balanced and varied menu. EVIDENCE: Musical entertainment was held in one lounge area in the home on the day of the inspection. The residents met said they looked forward to the music afternoons. A few short ‘tea-dances’ with the residents and manager designate was observed. They fully enjoyed the music and dancing offered by the home as well as other activities. These include piano evenings, Tai Chi, group quiz, indoor games and group reminiscence to name a few. The comments made by the residents suggested that the activities on offer took full account of their preferences and were more than sufficient. Two noted they would enjoy a few more activities but they couldn’t think of what they would like to do and felt that as summer was approaching they would go out more. Staff were seen to be open and welcoming to family and friends of the residents who came and went during the course of the inspection. The menus and food were highly praised by all the residents met. Plain home cooking and a balanced variety are offered by the St Agnes cook and enjoyed by the residents. An alternative to the main meal is available in practice with special dietary requirements and preferences taken account of and recorded. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 13 The kitchen was clean, recordings made of the food temperatures, fridges and freezers with an appropriate cleaning rota in place. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 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 standard(s) 16 & !8 Residents are aware of who to approach in the case of a complaint and felt comfortable doing so. The home has policies and procedures in place in order to protect the residents. EVIDENCE: Staff consulted during the inspection demonstrated a good awareness of adult protection and ‘whistle blowing’ policies and procedures. Some had received training and would have no hesitation in raising issues should the need arise. It was suggested that all staff receive adult protection awareness 6training as good practice. The home has a ‘niggles’ book in the lounge area. It is a relatively new initiative and the manager designate felt that the residents were a little reticent to write anything in it yet. He had written a comment himself, which he hoped would encourage residents to start using it. The residents met felt comfortable and confident that any issues raised would be taken seriously by the homes management and dealt with promptly. St Agnes has an ‘open door’ approach regarding any niggles or complaints and day-to-day issues would be dealt with as they happened. There have been no formal complaints made to the home or via the CSCI since the last inspection. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 22, 23, 24, & 26 Recent investment has further improved the standard of the environment for the residents, with future improvements planned. This home is providing a homely relaxed place to live in. EVIDENCE: The lounge, dining and small conservatory area, which is mostly open plan have been refurbished to a good standard. The area is bright and filled with the natural light of the rear garden. Investment has also been made in a modern fish tank, which is a conversation piece amongst residents and staff alike. The toilet off the conservatory has also been redecorated and appeared fresh and clean. The plumbers were at the home on the day of the inspection refurbishing the shower ensuite in room 4. There has been further investment into a new emergency call bell system that enables each resident to have individual call bell pendants. New pipe works are planned for June/July 2005 regarding the gas central heating system and electrical systems are being renewed shortly after this, benefiting the home with extra lighting, renewed emergency lighting and updated fire alarm systems. Residents are informed of St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 16 any works planned by the home and their input valued. The home has resident meetings in which any issues such as refurbishments are informally discussed and colour schemes regarding their home décor canvassed and taken account of. The standard of housekeeping is very good with the home looking bright clean and airy. Contacting the home via telephone was at times difficult according to the health professionals returning comments and information sharing regarding any residents attending hospital. The home had already installed a new telephone system at the time of the inspection in an attempt to combat this, with further staff training planning regarding communication. The residents said they are looking forward to the better weather and getting into the garden again. The rear gardens are well maintained laid to lawn with shrub/flower bed borders. The private residents rooms visited looked clean and had been decorated with the residents’ own personal possessions arranged by themselves. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 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 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) 27, 29,&30 Staff turnover since the last inspection had a negative impact on morale, but is now improving. Staff worked hard to ensure that consistency of care to the residents was not disruptive. EVIDENCE: 18 residents were in the home on the day of the inspection. During the course of the inspection call bells and the doorbell was answered promptly with visitors having no difficulties locating staff. Care staff number 11 with 55 of staff NVQ Level 2 qualified. Staff complete training provided by Red Crier. Units are completed and a knowledge paper is then forwarded to the company for assessment. This training includes units on first aid, health and safety dementia, diet and nutrition, risk assessments and fire awareness to name a few. The staff have also completed additional courses in manual handling and medication together with ongoing NVQ training. Four staff currently hold a first aid certificate. Future training has been planned around the care needs of the current resident group, this includes, nutrition, dementia, challenging behaviour and bereavement. Personnel files verified this training. Copies of the certificates gained by the staff were also mounted on the walls of the home for the residents to see. Staff recruitment procedures were generally sound with copies of staff identity, application forms and Criminal Record Bureau checks held on file. However staff references were not found on all files reviewed and new staff must be POVA register checked otherwise this potentially may leave the residents at risk. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 18 7 staff have left St Agnes since the last inspection which did impact on staff morale, as the staff preferred to ‘back fill’ the shifts rather than use agency staff, to ensure consistency of care approach. The staff and management team worked hard to provide a balance of experienced staff and new staff on each shift. Staff met felt had that ‘things had improved’ regarding staffing and a sense of ‘team’ has developed as a consequence. Residents remarked that some staff had ‘come and gone’ but the staff they had got to know provided good care with good humour and they had no particular issues regarding consistency. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 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 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) 32, 33, 36, 38. EVIDENCE: Residents’ were aware of the management structure changes and that Mr Roy Orme was applying to the commission to be the registered manager and Mr Stephen Poole is now the Care Manager. Although the management structure remains solid the appointment of a registered manager is important to the future development and care practices within the home. Both Mr Orme and Mr Poole were both seen by the residents’ and staff as approachable and the reporting avenues were clear in that Mr Roy Orme is the manager designate. The inspector recommended that job descriptions were devised to ensure safe working practices and define roles and responsibilities. Staff said they felt comfortable raising issues about the day-to-day events in their staff meetings. Staff supervision when described by the inspector they felt they did not receive however staff files revealed signed supervision dates. The manager suggested that they received regular supervision but appraisals had yet to commence but St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 20 the diary verified the managers comment that they were planned for the forth coming week. Mr Orme has completed the Registered Managers Award. He has 3 years experience in the care sector two of which at a senior level. Residents gave examples of how they are involved in changes to the home such as the décor, residents meetings and one to one chats with the staff. One of the proprietors’ Gail Norton, has started to undertake regulation 26 visits and forwards the record to the CSCI. The pre inspection questionnaire completed by Mr Roy Orme suggested that all contracts and procedures are in place to safe guard the interests of the residents. The home is to obtain copies of the infection control policy guidance, update the manual handling policy and adult protection files. The home remains viable as demonstrated by the accounts forwarded to the CSCI from dates 1/4/03-30/9/04 and the level of investment into the fabric of the home. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 2 3 x x 3 x 3 St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 22 yes 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. 2. Standard OP29 OP32 Regulation 19 8 Requirement New staff are to be POVA checked and references sought prior to appointment. Registered manager is to be appointed. Timescale for action 10/7/05 10/8/05 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. 3. 4. Refer to Standard OP8 OP16 OP32 OP38 Good Practice Recommendations Risk assessments when changed should be ttranslated into the plan of care to e provided. Adult Protection awareness trainingfor all staff members Develop clear job descrpitions regarding the Manager and Care managers roles and responsibilities. Policy uodates on infection control, adult protection and manual handling to be undertaken. St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Riverside Chambers Castle Street Tangiers Taunton Somerset TA1 4AL 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 St Agnes Retirement Home D53-D02 S45717 St Agnes Retirement Home V221989 100505 Stage 4.doc Version 1.30 Page 24 - 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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