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Inspection on 15/06/05 for St Andrew`s, Cullompton

Also see our care home review for St Andrew`s, Cullompton for more information

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 Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home had a dedicated team of carers who are kind, gentle and caring. The premises are well maintained. The decoration and furnishings throughout the home are of a high standard.

What has improved since the last inspection?

Environmental and individual risks have been reassessed. Window restrictors have been fitted to all first floor windows, all radiators have been covered and all basin hot taps have been fitted with thermostatic valves to reduce the risk of residents being scalded. Staffing levels have been improved at the home to meet National Minimum Standards.

What the care home could do better:

Pre admission assessments must be more comprehensive to ensure that potential residents needs can be met by the staff and environment at St Andrews. When a resident is admitted to the home a plan must be written to include how their needs are to be met by the staff at the home. A photograph of each resident must be kept in the home. All care staff should be supervised at least 6 times a year.

CARE HOMES FOR OLDER PEOPLE St Andrews 1-5 Pye Corner Church Street Cullompton EX15 1JX Lead Inspector Michelle Oliver Announced 15 June 2005 09:30 hrs 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 D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Andrews Address 1-5 Pye Corner Church Street Cullompton EX15 1JX 01884 32369 01884 32369 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 Brenda Wise Mrs Angela Beryl Cunningham Care Home 23 Category(ies) of DE(E) Dementia - over 65 (23) registration, with number MD(E) Mental Disorder - over 65 (23) of places OP Old age (23) PD(E) Physical dis - over 65 (23) St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Two double rooms [one at Pye Corner & one at St Andrews] to be occupied by the named couples currently in residence until such time as one of each couple or both couples leave the home. The rooms will then revert to single occupancy. 2 The Manager must gain an NVQ level 4, in care, by September 2005 Date of last inspection 28 February 2005 St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 5 Brief Description of the Service: St. Andrews Care Home comprises of a main building, which can accommodate up to 19 residents, and a smaller house situated in the grounds, which can accommodate up to 4 residents. The home provides personal care together with accommodation and board up to 23 older people who may also have a physical disability and /or mental disorder such as Alzheimer’s Disease or a related disorder. The home is situated within a short level walk from the main street in Cullompton, which offers a wide range of shops, cafes and the local health centre. The home is approached by way of a level paved area and there are ample facilities for car parking. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the first statutory inspection of the current year; it was carried out by Michelle Oliver, started at 0915 and finished at 1.30 pm. There were 21 residents living at St Andrews on the day of inspection and the inspector saw and spoke to the majority of them. The inspectors spoke at length with 3 service users. The inspectors toured the premises and inspected a number of records, including care plans, quality assurance audit, fire log book, duty rotas, medication records and menus. The registered provider and manager were present throughout the inspection. The staff were friendly and professional throughout the inspection and helped where they could. What the service does well: What has improved since the last inspection? What they could do better: Pre admission assessments must be more comprehensive to ensure that potential residents needs can be met by the staff and environment at St Andrews. When a resident is admitted to the home a plan must be written to include how their needs are to be met by the staff at the home. A photograph of each resident must be kept in the home. All care staff should be supervised at least 6 times a year. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 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. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 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 standard(s) 3 & 6. Service users benefit from good admission practice. Assessments undertaken before a resident is admitted to the home must be improved. EVIDENCE: Two residents were unable to recall an assessment of their needs being undertaken before moving to St Andrews, one said that two members of staff had visited him at home. The assessment does not currently meet the National Minimum Standard. This was discussed with the manager who agreed that an existing assessment form “ needs assessment” which is not currently being used a pre admission assessment will be used from the date of the inspection. The home does not admit residents for intermediate care. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 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 & 9 It is not clear how service users’ health and welfare needs are to be met. EVIDENCE: The home promotes residents’ welfare in co-operation with families and health care professionals. The inspector looked at care plans detailing the care needs of 3 residents. Although care plans have generally improved and include a lot of information relating to residents health and welfare needs they do not include details of how residents’ health and welfare needs are to be met. The quality of record keeping does not reflect the quality of care being given. Two of the care plans looked at did not include a photograph of the resident. Since the last inspection a record of Controlled Drugs is being kept using a hard backed book with numbered pages to ensure safe recording, administration and disposal of medication. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 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) 14 & 15 Residents are encouraged and helped to exercise control and choice over their lives. A varied balanced diet is provided served in a pleasant atmosphere. EVIDENCE: The inspector was told by the provider and manager that residents are encouraged to look after their own finances for as long as they wish or are able. Information was unavailable as to how many residents maintained their own benefit books or the number who handle their own financial affairs. The provider told the inspector that neither he or the manager act as appointee for handling financial affairs for residents at the home. Information was unavailable as to the number of residents subject to Power of Attorney or Guardianship. The provider said that either family or solicitors handle residents financial affairs. Residents confirmed that they enjoy the meals at St Andrews. The home has a light and airy dining room where most of the residents choose to have their meals. Those residents who need assistance with meals were helped discreetly and individually by staff. A resident said “ we think we are very fortunate to have such a dedicated and capable cook”. A relative commented “ Food, excellent. Tasty, home made and nutritious and appropriate for our relative. The staff take time to when assisting with eating” St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 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) 18 Arrangements for protecting service users are satisfactorily protecting them from the risk of harm or abuse. EVIDENCE: Those residents spoken to all confirmed that they felt safe at the home. Records of staff training confirmed that all staff have undertaken training in the prevention of abuse. All staff have watched the video “ No Secrets” and discussed issues in groups. The provider confirmed that no finances, apart from some personal allowances, are handled by the home. A record is kept of residents personal allowances. This was looked at and was correct. He also confirmed that the home’s policies regarding residents money and financial affairs preclude staff from being involved in assisting in the making of or benefiting from a residents’ will. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 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 , 25 & 26. The home is safe, well maintained and kept clean. EVIDENCE: The inspector walked around the shared areas of the home and some private rooms. All areas were clean and well maintained. Comment cards received prior to the inspection confirmed that the home is always clean and tidy. Decoration, furniture and fixtures throughout the home are of a consistently high standard. A comment card received from a relative said that “the accommodation is excellent. Clean, tidy, modern and well presented”. Another commented that the home is “free from usual institutional smells” Since the last inspection all windows have been fitted with window restrictors, all radiators have been covered and all basin hot water taps have been fitted with thermostatic valves, to promote the safety of all residents St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 14 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. Staff are employed in sufficient numbers to meet the needs of service users. There has been some progress with staff training since the last inspection. EVIDENCE: The allocation of staff on each shift was adequate to meet the needs of the current residents. Residents confirmed that their needs were generally met in a timely way. Residents said that staff were kind and caring and always there to help. A relative commented that “staff give excellent care. They always know about residents and care is given kindly, personally and one to one” Domestic and other ancillary staff are employed in sufficient numbers to ensure that standards relating to food, meals and cleanliness are maintained. All staff have received first aid, moving and handling, abuse awareness training and fire safety training recently. Newly appointed staff confirmed that they had received an induction period, which appeared to consist of shadowing senior members of staff, reading policies and procedures and “getting to know the residents.” St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 15 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) 33, 36 & 38 There is clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. EVIDENCE: The manager shows great empathy towards residents and their families and gives clear leadership, guidance and direction to staff. Residents feel the manager is approachable and seeks to ensure all their needs are met. Attention has been made to the safety of residents and staff with improved environmental risk assessments and fire safety measures in place. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 16 A Quality Assurance audit, carried out on 14th March 2005 asking residents and their families or representatives their views of the home, showed that all of the residents felt the home is satisfactory. The manager speaks to all the residents daily to make sure that measures are in place so that the residents have a say in the running of the home. Residents debates are held 3 monthly. Staff confirmed that they are supervised regularly but no records are kept of this. This was discussed with the manager. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 17 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 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 4 STAFFING Standard No Score 27 3 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 x x 3 x x 3 x x 2 x 3 St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 18 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 op7 Regulation 15[1] Timescale for action The registered person shall, after 15.08.05 consultation with the service user or a representative, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. Records to be kept in a care 15.07.05 home in respect of each service user: A photograph of the service user. Requirement 2. op7 Shedule 3[2] 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 op3 Good Practice Recommendations For all individuals who are self funding and without a care management assessment/ care plan the registered person carries out an assessment to include all as detailed in NMS op3.3. All care staff receive formal supervision at least 6 times a year. 2. op 36 St Andrews D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 D54 D06_s22036_standrewscullompton_v224348_150605 stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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