Inspection on 15/06/05 for St Andrew`s Care Home

This inspection was carried out on 15th June 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 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 11/02/06

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 Andrews Care Home St Andrews Nursing Home Main Street, Ewerby Sleaford, Lincs NG34 9PL Lead Inspector Kathryn Emmons Unannounced 15 June 2005 10:30 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 Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service St Andrews Care Home Address 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) St Andrews Nursing Home Main Street Ewerby Sleaford Lincs NG34 9PL 01529 460286 01529 460286 Jasmine Healthcare Limited Mrs Pamela Mary Morris Care home with nursing 29 Category(ies) of DE(E) Dementia - over 65 (3) registration, with number OP Old age (26) of places St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26 January 2005 Brief Description of the Service: St Andrews care home is situated next to the church in the small country 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 Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The homes manager and the nurse in charge assisted the inspectors during the unannounced inspection. Two inspectors undertook the inspection spending three and half hours in the home .The inspectors toured the home and spoke with the homes manager and 5 care staff. There were 2 relatives spoken with. Part of the inspection was to investigate an anonymous complaint that was made to the commission. The main method of inspection used was called “case tracking” which involved selecting residents and tracking the care they receive through checking of their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? Since the last inspection a system has been implemented to notify the Commission of any incident affecting a resident. The records contain the relevant information. Building work is to commence in the near future on an extension to the back of the home; part of this programme is to redecorate many of the areas of the main house. Training for care staff remains a main focus for the manager and staff continue to receive training relevant to the work they do. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 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 Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 Residents can be admitted to the home having confidence that the preadmission assessment reflects that their needs can be met. Residents have terms and conditions of residence, so that they can be informed of their rights in respect of living at the home. EVIDENCE: The nurse in charge confirmed that the homes manager prior to admission to the home assesses all residents. A letter is then sent to the resident confirming their assessed needs can be met. Relatives confirmed that as part of this process they had seen the homes service user guide. This document was also on display in the home and is regularly updated. Resident’s care files evidenced that residents were given terms and conditions and contracts informing them of the service they could expect. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9,10 Medication arrangements maintain residents safety. Care plans identify resident’s needs but residents need to be given a choice to be involved in the production of the plan. The ethos of the home upholds resident’s rights to be treated with dignity and respect. EVIDENCE: Through case tracking 3 residents care plan files were inspected. The relative of one of these residents and both of the other residents were spoken with. These residents were not able to say they had been involved in their care plan production and the care plan itself did not demonstrate this in all cases. The nurse in charge confirmed that care plans were being reviewed and when this happened residents or their relatives were being involved. The care plans were clear to follow and contained sufficient information for care to be delivered correctly and safely. Reviews were taking place within agreed time scales. Medication administration record sheets for all residents were inspected. These had been completed as per the homes policy and there was a clear audit trail of medication from delivery to administration to reordering. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 10 Staff when interviewed were able to give examples of how they maintained residents dignity. Resident spoken with stated that staff were kind and attentive. Observations by the inspectors evidenced that staff spoke to resident in an appropriate and valuing manner. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 11 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 Residents are provided with a homely environment, which upholds their rights as individuals to choose how to exercise control over their lives. EVIDENCE: At the time of the inspection the home’s activity coordinator was holding a board games morning. Residents spoken with stated that there was a varied programme with “something to suit everyone”. Activities take place in the home and trips out are also organised. Outside entertainers attend the home on a monthly basis. Residents said that staff did have time to speak to them, normally in the afternoon or early evening. Residents spoke about the lifestyle they led in the home and confirmed that hobbies and interests they had outside of the home where possible, were encouraged in the home. Visitors to the home spoken with by the inspector confirmed that they were always made to feel welcome at the home and that staff were always available to give an update on a residents welfare. Relatives gave examples of good care practice they had observed on many occasions. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 12 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 Residents are protected by the homes robust complaints procedure. EVIDENCE: An anonymous complaint was made to the commission regarding several issues of concern. These were the alleged attitude of the manager towards staff, availability of the manager, servicing of equipment and fire safety practices and training. The findings of the investigation are reported upon with in the relevant sections of the report. The home has a complaints procedure in place and this is on display. Residents spoken to said that if they had any worries they would speak to the manager or one of the care staff. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 13 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) 19,24,26 Residents live in a clean and tidy home and are protected by the homes policies and procedures for infection control and hygiene arrangements. Some bedrooms are in need of redecoration. EVIDENCE: A tour of the premises evidenced a clean and tidy home with no adverse odours noted. Pathways outside the home and corridors inside were clear of potential hazards and there was room for residents to move freely. Residents who gave permission for their rooms to be viewed were satisfied with the décor and cleanliness. One vacant room viewed was noted to be in need of redecoration. The manager confirmed that decorating had been planned in conjunction with the new extension project. Residents spoken to were satisfied with the laundry arrangements in the home and said that clothing was always washed and ironed well. The home employs a laundry assistant 5 days a week. The home has a policy for the management St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 14 of cross infection, MRSA and hygiene arrangements. These were available for inspection and staff read policies as part of their ongoing training. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 15 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) 27.30 Residents are cared for by an enthusiastic and trained care team .The home need to ensure the correct skill mix of staff are on duty at all times. EVIDENCE: Part of the complaint alleged that when the manager had worked a night shift they had not stayed awake for the entire shift. The investigation evidenced that the manager has worked the shift and had employed an extra care staff to work in addition. Agency staff were not available and the manager confirmed that she may have sat in a chair and fell asleep for a few moments. It was evidenced that this was an isolated event. The duty rota demonstrated that the home is staffed above the minimum staffing level during the daytime. 5 staff of different skill mix were interviewed by one of the inspectors. The care staff were able to give appropriate answers to questions asked of them regarding the home practices and procedures. Staff evidenced that they were receiving training to do the job role they were employed to do. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 16 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) 31,33,38 The home is well run by the manager, with good guidance and leadership for staff. Record keeping is of a good standard and the health and safety and welfare of residents is promoted. EVIDENCE: The registered manager of the home is Mrs Pam Morris. Mrs Morris is a qualified nurse with many years experience in the care sector caring for older people. Part of the complaint alleged that the manager was dismissive of care staff, aggressive and shouted at staff. In addition it was alleged that the manager was often absent from the home. On the day of the inspection all staff interviewed said they had a good rapport with the manager and that she was available 24 hours a day. A system is in place for contacting the manager if she is not in the home. These parts of the complaint were not upheld. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 17 The manager is also 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. Part of the complaint alleged that equipment in the home was faulty and fire safety training was not taking place. Servicing records for equipment such as hoists, lift, machinery, suction machine were all inspected and were in date. Residents spoken to said they were not aware of any equipment they had wanted to use not being available due to not working. The fire logbook was inspected and fire safety tests were carried out weekly. Staff confirmed they knew what to do in an emergency and one resident told the inspector that they remembered the fire alarm sounding each week when it was tested. The last external fire training was provided in January 2005 and another session had been arranged for June/July 2005. This part of the complaint was not upheld. St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 2 x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 3 x x x x 3 St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 19 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 7 Regulation 15 Requirement The registered person must ensure that residents or their relatives are involved in the compilation of care plans and subsequent reviews. The registered person must ensure that all bedrooms are decorated to a satisfactory level The registerd person must ensure that the correct skill mix of staff are undertaking a waking night duty. Timescale for action 31 October 2005 2. 3. OP 24 OP 27 23(2)(d) 18 31 Januuary 2006 30 September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations St Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 20 Commission for Social Care Inspection 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 Andrews Care Home C53-C04 S59766 StAndrews V233525 150605 Stage 4.doc Version 1.20 Page 21 - 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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