Inspection on 11/02/06 for St Andrew`s Care Home

This inspection was carried out on 11th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

St Andrew`s Care Home 12/06/07

St Andrew`s Care Home 15/06/05

St Andrew`s Care Home 26/01/05

St Andrew`s Care Home 08/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE St Andrew`s Care Home St Andrew`s Nursing Home Main Street Ewerby Sleaford Lincs NG34 9PL Lead Inspector Julie Western Unannounced Inspection 11th February 2006 09:00 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 St Andrew`s Care Home DS0000059766.V282082.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. St Andrew`s Care Home DS0000059766.V282082.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Andrew`s Care Home Address St Andrew`s Nursing Home Main Street Ewerby Sleaford Lincs NG34 9PL 01529 460286 01529 460286 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) Jasmine Healthcare Limited Mrs Pamela Mary Morris Care Home 29 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (26) of places St Andrew`s Care Home DS0000059766.V282082.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2005 Brief Description of the Service: St Andrews care home is a Victorian former vicarage situated next to the church in the village of Ewerby. The home is managed by Mrs Pam Morris who is also one of the business partners of the company who own the home. There is an extension being built to the back of the home home to provide further bedrooms and communal areas. Accommodation is provided in a mixture of single and double bedrooms provided over two floors. St Andrew`s Care Home DS0000059766.V282082.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 2 ½ hours. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting three residents and tracking the care they received through the checking of their records, discussions with residents and care staff and observation of care practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. Three of the 29 residents, five of the care and ancillary staff and four visitors were spoken with. The Manager was present throughout the inspection. What the service does well: What has improved since the last inspection? The home now has a bed that has been block booked by the Primary Care Trust for intermediate care and policies and procedures have been amended to take this into account. Several bedrooms have been redecorated, with some bedrooms having new carpets. Care plans have been revised and are now very comprehensive and clear. St Andrew`s Care Home DS0000059766.V282082.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. St Andrew`s Care Home DS0000059766.V282082.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 St Andrew`s Care Home DS0000059766.V282082.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): 1-5 The home clearly sets out what it intends to do for its residents and this information is freely available to residents. A comprehensive initial assessment ensures that the needs of residents can be met. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. EVIDENCE: The statement of purpose was examined and was clear and comprehensive. A copy of the service user guide was sent or given to all prospective residents or their families, as was a copy of the most recent inspection report. The Manager herself, or a suitably qualified staff member carried out the pre-admission assessments of residents, either in their own homes or in a hospital or care setting. The Manager described how recently a prospective resident had come to the home to assess it for herself, staying some three hours. Letters were sent residents, confirming that their needs could be met and all received contracts and terms and conditions. St Andrew`s Care Home DS0000059766.V282082.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): 7-10 The home’s records give a clear indication of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: The three care plans looked at in depth had recently been revised and contained clear and comprehensive assessments; they were reviewed regularly and were signed by the service user or relatives/advocates. They included risk assessments, weight charts, Waterlow scores, body maps and a brief life history of the resident, often completed by relatives or friends. There was a clear medication policy and the most recent visit by the pharmacist on 10/2/06 read ‘meticulously completed, tightly controlled, no errors, no missed signatures’. Residents said they felt safe and well looked after; one said ‘they pay attention to detail and are very obliging’. A visitor said that the staff were very knowledgeable and well qualified. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. St Andrew`s Care Home DS0000059766.V282082.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): 12-15 Social activities are extensive and well promoted, creating a variety of events and activities which residents are informed about. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: A senior staff member was responsible for co-ordinating activities and residents spoken with said they could choose from various activities in the home. Regular activities included aromatherapy, manicures, board games, quizzes and trips to the local garden centre and coffee shop. Recently the home had received a visit from a local farm park with various pets, including rabbits, gerbils, guinea pigs, rats, a dog and a Shetland pony, which came into the building; all residents said this was very enjoyable, as was the visit from a team of Morris dancers before Christmas. On the day of the inspection one of the residents had a birthday and was surrounded by flowers and balloons in the main lounge; her relatives were taking her out to celebrate. Menus were examined and service users were observed eating the mid-day meal. All service users spoken with said the quality of the food was very good and that they enjoyed the meals. One said ‘it’s very good – they would give you what you wanted’ and described a buffet at weekends with an extensive choice of food. St Andrew`s Care Home DS0000059766.V282082.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’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. EVIDENCE: The home had received two complaints in the last twelve months; both were not upheld and both were responded to within the given timescales. Residents and visitors spoken with all said they did not wish to complain but knew how to make a complaint. There was a clear adult protection procedure, which was linked to the Local Authority procedures. Staff members spoken with had all received training on adult abuse as part of their induction training and were knowledgeable about complaints. St Andrew`s Care Home DS0000059766.V282082.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, 20, 23, 26 The residents live in a comfortable, pleasant and safe environment with both private and communal space being on the whole suitable for their needs. EVIDENCE: The home has a rolling maintenance rota and risk assessments are carried out on the premises to ensure that residents are safe from any potential hazards. A handyman has recently been employed for 2-3 days a week and repairs now take less time to complete. Recent renovation has included the redecoration of several bedrooms; the Manager said that it was the practice of the home to decorate rooms as they became vacant. The standard of decoration internally was generally satisfactory and afforded residents a good degree of comfort; the Manager said that the older part of the building would be upgraded once the extension was finished. The home was clean and smelled fresh throughout. Externally, the driveway and car park were muddy with some skips and builders’ rubble in evidence due to the extension: the Manager said that on completion, the car park would be extended and the driveway re-covered with tarmac. St Andrew`s Care Home DS0000059766.V282082.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): These standards were not inspected. EVIDENCE: Although these standards were not fully inspected, the staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents; residents and staff thought there were enough staff members on duty to complete their tasks. St Andrew`s Care Home DS0000059766.V282082.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): 31, 32, 35, 38 The home is managed competently and the staff team are supported in carrying out their respective roles. Residents are included in decisions affecting them and strong policies and procedures underpin the care practices to ensure safety for residents. EVIDENCE: The registered manager of the home is a qualified nurse with many years experience in the care sector caring for older people and is one of the directors of the company, who own the home and 2 others. Discussion has taken place regarding the current arrangements for the manager of the home and the company have decided to recruit a new manager so that Mrs Morris can work fully in the role of Operations Director. No pensions were kept at the home; the personal allowance monies kept by the home for three residents were checked and found to balance. Policies and procedures were comprehensive and kept up to date. St Andrew`s Care Home DS0000059766.V282082.R01.S.doc Version 5.1 Page 15 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X 3 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 3 3 X X 3 X X 3 St Andrew`s Care Home DS0000059766.V282082.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? none 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. 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. Refer to Standard Good Practice Recommendations St Andrew`s Care Home DS0000059766.V282082.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Andrew`s Care Home DS0000059766.V282082.R01.S.doc Version 5.1 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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