Inspection on 05/01/06 for St Andrews Residential Care Home

This inspection was carried out on 5th January 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 Andrews Residential Care Home 26/06/07

St Andrews Residential Care Home 18/05/06

St Andrews Residential Care Home 22/09/05

St Andrews Residential Care Home 03/03/05

St Andrews Residential Care Home 12/08/04

St Andrews Residential Care Home 03/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE St Andrews Residential Care Home 184 London Road Headington Oxford Oxfordshire OX3 9EE Lead Inspector Andy McGuckin Unannounced Inspection 5th January 2006 09:30 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 Residential Care Home DS0000013138.V275754.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 Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Andrews Residential Care Home Address 184 London Road Headington Oxford Oxfordshire OX3 9EE 01865 741752 01865 452705 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) St Andrews Residential Care Home Limited Mrs Barbara Dixey 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) St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 23. 22nd September 2005 Date of last inspection Brief Description of the Service: St Andrews is a residential home providing care, support, and accommodation to its residents. The home is registered for 23 residents over the age of 65. The home has 19 single rooms and two double rooms. Eleven bedrooms have the benefit of en suite facilities. The home is situated on the outskirts of Oxford city centre. The home is set back in its own grounds on a busy main route into Oxford. Local shopping and leisure facilities are available and the home has easy access to the city and beyond. The original home has been added to and extended. The garden has recently been landscaped and provides wheelchair access to all parts of the garden. The home is family run and has a homely atmosphere. The management and staff of the home have all been there for a number of years providing consistency of care for the residents. The home has recently lost a senior member of the staff, which has had an effect on the registered manager being able to meet some of the requirements and recommendations. St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of this home, which means the home was not informed that the inspector was going to arrive that day. The inspector toured the building and was shown residents’ bedrooms. The inspector spoke informally to both staff and residents. Random samples of records required for the inspection were inspected and found to be satisfactory. What the service does well: What has improved since the last inspection? 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 Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 6 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 Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 7 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): 1,2,3,4,5. The home provides prospective residents with sufficient information on which to make a decision. Standard 6 is not applicable to this home. EVIDENCE: The inspector was shown the home’s brochure previously. The brochure outlines what the home can and cannot provide. It is written in plain English and was easily understood. Each resident has a written contract/terms and conditions, which is signed. The manager assesses all prospective residents prior to admission. Admission is dependent on a mutual agreement that the home can meet the resident’s needs. Prospective service users are encouraged to visit the home prior to admission. Evidence was found that relatives and friends are made very welcome to the home and many people visited during the inspection. The home does not offer intermediate care. St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 8 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): 7,8,9,10,11. The quality and content of residents’ files could be improved. The health and personal care of the residents are being met. EVIDENCE: The inspector viewed a random selection of residents’ files. The information contained in the files was found to be adequate. A previous recommendation regarding the collection and storage of information has not yet been implemented due to recent changes in the senior management structure. The home has appropriate policies and procedures to manage the storage, recording and distribution of medication. A random selection of residents’ medication was inspected and one error was found in the recording. On checking, the medication had been given but not signed for. The registered manager must ensure that regular random checks are undertaken to detect any errors or omissions. The inspector spoke informally to four residents and received feedback from relatives’ questionnaires, that residents are treated with respect and that their privacy is being respected. The inspector made a previous recommendation that a more comprehensive picture of the care being provided could be recorded in a way which truly reflects the holistic care being provided by the home. This recommendation still stands. St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 9 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): 12,13,14,15. The home provides an appropriate level of planned activities for its residents. EVIDENCE: Many of the home’s residents have been in the home a number of years and as such are becoming more dependent on care being provided for them. Not all residents wish to participate in the activities provided. Planned activities are available and advertised. Staff were seen to have a good interaction with residents and provide activities in an informal way. Christmas was a lively time in the home and residents spoken to had a very good time. The home provides religious services within the home for those who wish to partake on a monthly basis. Residents who are able take as active a part in the local community as they are able or willing. Residents are encouraged to be as independent as they are able. The home has recently employed a chef who will take over full responsibility for the purchase, preparation and selection of menus. This will free up the manager’s time to be used more productively. On the day of the inspection the meal of the day was both appealing and nutritious. Residents eat where they wish. Meals are unhurried and form a positive focus to the day. St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 10 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): 16,17,18. The home has a formal complaints procedure, which is known to residents and their relatives. EVIDENCE: The size and management structure of the home ensures that concerns and complaints, if any, are dealt with at source and without delay. The home has a formal complaints procedure, which is known to residents and their relatives. No complaints have been logged since the last inspection. Evidence was found through reading case files and speaking to residents that their legal rights are being promoted and that they are protected from abuse. Many residents had attached Power of Attorney or had relatives or representatives assisting them. St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 11 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): 19,20,21,22,23,24,25,26. The home is maintained to a satisfactory standard. The home has sufficient amenities to meet its residents’ needs. EVIDENCE: The home is well maintained and fit for its purpose. The layout of the home can be confusing for those not used to it. It does however have the advantage of being able to provide privacy for those in the front corner of the building. The inspector was shown around the home and with residents’ permission was shown their bedrooms. All bedrooms were individually styled with residents’ personal possessions much in evidence. Residents’ bedrooms in the purpose built extension are spacious and provide en suite facilities. The home has sufficient toilet and bathroom facilities. The home has sufficient communal areas, which can provide for entertainment or for peace and quiet. The home has appropriate equipment to assist staff in the safe moving and handling of residents. The home has many residents with continence problems; this is being managed by regular cleaning. On the day of the inspection two rooms smelt slightly; the inspector was informed that the maintenance person responsible for the deep cleaning of the carpets had been off for some time. St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 12 Some bedrooms have the residents’ own furniture, which in some cases presents a less than favourable appearance. This is accepted by the home as the resident’s choice. St Andrews Residential Care Home DS0000013138.V275754.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): 27,28,29,30. The home employs staff in sufficient numbers to meet the needs of the current resident group. EVIDENCE: The home has recently lost a senior member of staff, which has impacted on plans that the management had for the future management of the home. The home staffing levels for care staff are satisfactory. The appointment of a chef will free up the manager to be more productive in other areas. Staff supervision has re-started and is taking place on a regular basis. Staff files seen during the inspection were found to be satisfactory. Evidence was found that staff are being trained in areas that will allow them to do their job in a competent and professional manner. Some staff files were unavailable for inspection due to being in an office which could not be accessed. All records must be available for inspection at all reasonable times. The inspector was informed that there are plans to combine two offices into one. The inspector would recommend that this takes place. St Andrews Residential Care Home DS0000013138.V275754.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): 31,32,33,34,35,36,37,38. The home is managed and run in a professional manner. EVIDENCE: The registered manager is experienced and trained to manage the care provision offered by the home. The registered manager is supported to do this by a staff group of sufficient numbers and experience in the care of the elderly. There is much evidence of the proprietor’s involvement in the home to support the Manager. The proprietor is currently undertaking the Certificate in Care and Management. The home has sufficient policies and procedures to assist in the protection of potentially vulnerable adults. The home is managed in a professional manner and the inspector was informed that it was financially sound. Accounts are available for inspection if required. The health, safety and welfare of the home’s residents are being promoted and protected. An Environmental Health assessment was carried out in November and the report made one minor requirement. St Andrews Residential Care Home DS0000013138.V275754.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 2 3 St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 16 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 OP9 OP37 Regulation 17 17 Requirement The registered manager must ensure that medication given is recorded accurately. Records required for the inspection process should be available for inspection at all reasonable times. Timescale for action 01/02/06 01/02/06 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 OP7 Good Practice Recommendations Residents’ care records should be presented in a more appropriate manner, for example, by using a Kardex system. St Andrews Residential Care Home DS0000013138.V275754.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Residential Care Home DS0000013138.V275754.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. 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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