Inspection on 29/11/05 for St Andrew`s, Cullompton

This inspection was carried out on 29th November 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.

Other inspections for this house

St Andrew`s, Cullompton 24/07/07

St Andrew`s, Cullompton 27/07/06

St Andrew`s, Cullompton 15/06/05

St Andrew`s, Cullompton 28/02/05

St Andrew`s, Cullompton 06/08/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE St Andrews, Cullompton 1-5 Pye Corner Church Street Cullompton Devon EX15 1JX Lead Inspector Michelle Oliver Unannounced Inspection 29th November 2005 9:00 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 Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Andrews, Cullompton Address 1-5 Pye Corner Church Street Cullompton Devon EX15 1JX 01884 32369 01884 32369 standrewscarehome@yahoo.co.uk 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) Mrs Brenda Wise Mr Barry James Wise Mrs Angela Beryl Cunningham Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (23), Old age, not falling within any other category (23), Physical disability over 65 years of age (23) St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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. Mrs Angela Cunningham must gain an NVQ level 4, in care, by September 2005 15th June 2005 2. Date of last inspection 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 Alzheimers 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, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on Tuesday 29th November 2005 over a period of four and a half hours. The manager was present throughout the inspection. Four members of staff and fifteen residents were observed or spoken with during the visit. A tour of the buildings was made and a number of records were inspected. This included residents plans of care, fire log book and risk assessments. What the service does well: What has improved since the last inspection? What they could do better: Environmental risk assessments must be comprehensive and consistent. A lounge is being used as a resident’s private accommodation. No risk assessments have been undertaken since this change of use. The purpose of the home’s statement of purpose is to provide all potential residents, relatives or representatives with information to enable them to make an informed choice before deciding to live at the home. The information included in the home’s current statement of purpose is not up to date. Records required for the effective and efficient running of the business are not always maintained. The commission has not been informed when the provider is absent from the home for more than 28 days as required. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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 Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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 Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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): 3 Residents benefit from good admission and assessment practice which ensures that the home is able to meet their needs. EVIDENCE: Care needs are well met through a full assessment process that is carried out before a resident decides to live at the home. Care plans are completed from this information. The assessment includes all the information necessary on which to base a plan of care for individual residents. A comprehensive assessment was seen for a resident recently admitted to the home. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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. Continued improvement has been made to the content of individual care plans. EVIDENCE: Three care plans were inspected. All included information relating to the health and welfare of individual residents and are reviewed regularly. Residents confirmed that their health and social care needs are met. A district nurse visited the home during the inspection and said “the best thing about the home is that staff have time for the residents and they are all very patient. Staff promote and encourage residents’ independence”. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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 & 13. Social activities are well managed for people living in the home. Opportunities are available for residents to take part in appropriate exercise or physical activity. Residents are encouraged to maintain contact with their families or friends as they wish. EVIDENCE: Residents were sitting in the lounge, in their own rooms if they preferred and some were walking freely around the home. Residents’ preferences and interests are recorded in their individual care plans. Activities are arranged during the afternoons. A variety of group and individual activities are provided including word games, skittles, and bingo. Watching DVD’s of their choice, carpet bowls, games and gentle exercise sessions and residents’ debates. Some residents enjoy going into Cullompton which is within easy walking distance. A programme of weekly activities is posted on a notice board close to the dining room. Residents are encouraged and supported to maintain links with their families and with the community. A visitor said that they visit their relative every day, and are always made very welcome. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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. The home has a satisfactory complaints system and residents feel that their views are listened to and acted upon. EVIDENCE: One complaint was made to the Commission for Social Care Inspection since the last inspection. A complaint that the owner had benefited from a resident’s will and had acted as their power of attorney was upheld. However, it was clear that the resident had freely chosen to arrange the legacy and that the owner had resisted the residents request for him to act as their agent. The matter was arranged through the residents’ solicitor who has confirmed the owners resistance both to being made legatee and to becoming power of attorney. The owner was advised that acting as a residents’ financial agent is a breach of regulation and that being the beneficiary of a residents’ will breaches good practice guidelines. There was, however, no evidence of dishonesty or dishonourable conduct, and independent confirmation from the resident’s solicitor of his acting in good faith. There is a detailed complaints procedure with timescales that is displayed in the entrance hall. Residents, and a relative, said that they had no complaints but if they have any issue or concerns they would have no hesitation raising their concerns with the manager or one of the staff. The manager aims to deal with any issues “before they become complaints”. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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): 20 Not all residents have access to communal facilities at all times. Residents living in the smaller house, situated in the grounds, no longer have the use of a lounge in that building. EVIDENCE: A lounge, in the smaller building situated in the grounds, has been adapted to create private accommodation for a resident. This means that there is no lounge in a building in which they live. They may choose to go to one of the two lounges in the main building, a short walk away, but this may not always be convenient for them and involves having to go outside. This will not be easy in inclement weather. There was no evidence of the residents being consulted about this change. Several members of staff now live in the building and its character and main purpose have profoundly changed. The alteration was not discussed with the Commission or Fire service. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 Page 13 The Commission will be seeking early discussions with the owner to ensure that the service users’ interests are properly recognised and met. Residents confirmed that they felt that they felt safe and that the home is well maintained. The home was attractively decorated and well maintained internally and externally. The standard of furniture, furnishings, fittings and equipment is of a high quality. Residents’ rooms were personalised with sentimental items, photographs and small pieces of furniture and all expressed their satisfaction with the accommodation provided. The home was very clean and free from offensive odours throughout. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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 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): None of these standards were assessed. They will be inspected at the next inspection. EVIDENCE: St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 37 & 38. Staff receive very clear guidance and direction from the owner. Residents are not always consulted about changes at the home. With minimal adjustment records required for the effective and efficient running of the business will be provided. Some practices within the home are unsafe potentially putting residents at risk. EVIDENCE: The manager was registered with the Commission in November 2004 and has worked at the home as a senior carer for many years. She has achieved NVQ level four in Management and is expecting to complete an NVQ level four in Care by April 2006. The Commission has not been notified when the owner is absent from the home for periods exceeding 28 days. The manager said that she was unaware of this regulation. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 Page 16 Residents were not consulted before a decision was made by management to convert a lounge into a bedroom. As a result of this decision three residents do not have the use of a lounge in their home and have no choice but to cross an outside cobbled courtyard to the main building or remain in their rooms. The manager gives a clear lead and direction to staff. Residents said that she was approachable, always ready to listen and nothing was too much trouble for her or her staff. The manager does not deal with residents’ finances. Personal allowances are kept for some residents and accurate records and receipts are kept of all transactions. Safe working practices and risk assessments are not consistently undertaken. All staff at St Andrews are involved in preparing and serving food for residents. However, appropriate training in food hygiene has not been undertaken. This practice puts residents’ health, safety and welfare at risk. Risk assessments relating to a former lounge currently used by a resident as private accommodation have not been undertaken. This potentially puts the resident at risk of harm or injury. A stairway leading from the first to the ground floor was partially blocked. This presents a hazard to residents, staff and visitors who may use these stairs. Records show that staff undertake regular training in the prevention of fire. Fire alarms and emergency lighting are regularly checked. The Mid Devon District Council Environmental Health Department have not yet completed their investigation into the death of a resident who fell from a first floor window in December 2004. Associated requirements for improvements to environmental safety have been complied with. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x x 1 x x x x x x 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 x x x x 3 3 1 1 St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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 OP1 Regulation 6 Requirement Timescale for action 2 OP1 16[1] 3 OP20 23[a] The registered person shall keep under review and , where appropriate, revise the 30/12/05 statement of purpose and service user’s guide and notify the Commission and service users of such revision within 28days. [The statement of purpose states that a lounge is provided in the smaller building. This information is not up to date] The registered person shall provide facilities and services to service users in accordance with the statement required by 30/12/05 regulation 4[1][b] in respect of the care home. [ this relates to facilities included in statement of purpose submitted 21.11.03 where it is stated that accommodation includes two lounges and one quiet lounge] The registered person shall not use the premises for the purpose of a care home unless the premises are suitable for the 30/12/05 purpose of achieving the aims and objectives set out in the DS0000022036.V259412.R01.S.doc Version 5.0 Page 19 St Andrews, Cullompton 4 OP33 12[2] 4 OP38 13[4][c] 5 OP38 13[4][c] 6 OP37 38[1][a] [2][3][4][ 5] statement of purpose. [ this relates to the change of use of a lounge to resident’s accommodation] The registered person shall enable service users to make decisions with respect to their welfare The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. [ this relates to the original lounge in the smaller building not being assessed before being used as a resident’s private accommodation.] The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. [ this relates to a stairway being partially blocked] Where the registered provider proposes to be absent from the care home for a continuous period of 28 days or more, the registered person shall give notice in writing to the Commission of the proposed absence. 30/12/05 30/12/05 30/12/05 30/12/05 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 Refer to Standard OP38 Good Practice Recommendations Stairways should be kept free from hazards. St Andrews, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Exeter 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, Cullompton DS0000022036.V259412.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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