Inspection on 01/09/05 for St Ann`s

This inspection was carried out on 1st September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Ann`s 11/06/07

St Ann`s 27/06/06

St Ann`s 02/05/05

St Ann`s 13/12/04

St Ann`s 13/04/04

St Ann`s 13/01/04

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 Anns The Crescent Kettering Northants NN15 7HW Lead Inspector Judith Roan Unannounced 1 September 2005 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 Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Anns Address The Crescent Kettering Northants NN15 7HW 01536 415 637 01536 415 637 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) Collycare Limited T/A B & M Care Ms Teresa Ann Haywood Care Home 39 Category(ies) of DE(E) Dementia - over 65 (21) registration, with number of places OP Old Age (39) PD (E) Physical Disability - over 65 (4) St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Up to 7 service users with Dementia may be accommodated on the First Floor A maximum of 14 service users with dementia may be accommodated on the ground floor A maximum of 4 service users with a Physical Disability can be accomodated on the first floor. Date of last inspection 02/05/2005 Brief Description of the Service: St Ann’s is a care home providing personal care and accommodation for 39 older people over the age of 65 years. The home is separated into two selfcontained units. On the ground floor, the home can care for 14 Older People who have dementia. On the first floor the home can care for Older People including up to 7, who have a mild form of dementia and up to 4 with a physical disability. Collycare Ltd trading as B & M Care owns the home. The home is purpose built and set on two floors, located in Kettering Town and within walking distance of the train station, town centre shops and amenities. 27 of the bedrooms are single occupancy and 20 have en suite toilet facilities. A passenger lift provides access to the first floor. The home has a small enclosed garden which is well maintained and has a small raised fishpond accessed directly from the ground floor lounge. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 3 residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The inspection took place during the afternoon, over a period of 5 hours and was carried out on an unannounced basis. What the service does well: What has improved since the last inspection? The manager has begun to work on the requirements made at the last inspection. Staffing levels have been addressed during break times to ensure service users need are met. There is evidence that care plans are reviewed with service users and their representatives. Care plans are available for care staff to access. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 6 Accident and incident records are now stored in accordance with the data protection legislation. 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 Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 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 Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 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) 3,5 The home does not provide intermediate care therefore standard 6 is not applicable. The homes assessment processes do not fully ensure that service users needs can be met. EVIDENCE: A newly admitted service user had been visited and assessed by the homes manager prior to admission. However there was no evidence of the assessment carried out by the Care Manager and health care professionals involved with the service user on file. The registered manager must ensure that all contributions to assessments are gained prior to a decision being made on whether the service can meet the service users identified needs. In discussion with service users and staff the inspector was assured that service users have an opportunity to visit the home prior to admission. The home also has a policy that the time of admissions is undertaken in the best interests of the service user. This was to ensure that adequate staffing was available to give one to one support to assist service users to become familiar with their new surroundings. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 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) 7,8,9,10 Service users can be placed at risk due to the lack of detailed plans in meeting physical health care needs. Medication administration ensures service users are protected. Care practices in the home do not ensure service users privacy. EVIDENCE: In speaking with service users and viewing care plans it was evident that service users are involved with their preparation. However some records were incomplete and failed to provide details of pressure area care for one service users who spent considerable time in bed. A Pool Activity Level form that indicates a persons ability to undertake tasks had not been completed. One service user had fallen in the night, this was recorded but there was no evidence that support at night was reviewed. In discussion with the manager it was agreed that the frequency of check visits would be reviewed. There was evidence that where appropriate specialist support was provided by health care professional. The home works closely with the primary health care services. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 10 Medication is stored, administered and recorded appropriately in accordance with the Royal Pharmaceutical Society guidelines. Whilst meeting with one service users a care worker walked into the room without knocking on the door and gaining their permission. This was brought to the attention of the Registered manager during feedback at the end of the inspection. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 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) 12,13,14 Service users are supported with their chosen daily activities and maintaining positive contacts with family and friends. EVIDENCE: Service users informed the inspector that they had a choice of activities within the home. Some service users choose to spend time in their own rooms reading listening to radio/music or watching television. Communal rooms are well used and the home arranges activities in consultation with service users preferences. Staff are undertaking training in relation to dementia care that will extend staff skills in promoting a person centred approach. Service users confirmed that family and friends are encouraged to visit the home. Several service users have a direct telephone line in their rooms to maintain regular contact. Support is available to service users if they wish to visit the shops or other community facilities. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 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) 16,18 Service users can be assured that they are heard and protected by a proactive response to complaints and any allegations of abuse. EVIDENCE: There have been no complaints since the last inspection. The complaints procedure is available for service users and their families. Service users spoken with were confident that their concerns would be listened to. Staff spoken with during the inspection were aware of the procedures in relation reporting abuse and had received abuse awareness training. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 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) 19,20,21,22,23,24,25,26 The homes environment was clean hygienic and was maintained to a good standard. Service users bedrooms were comfortable and indicated service users preferences. EVIDENCE: In the course of the inspection it was noted that the home was clean, hygenic and kept free from hazardous by a dedicated team. There are numerous bathrooms that have been fitted with specialist equipment to support service users needs. Service users bedrooms were warm, comfortable and enabled service users to use them as a personal sitting room during the day. There are several communal areas within the building that service use for various activities and to socialise. During good weather there is outside space with outdoor seating. Service users are encouraged to choose colour schemes and bedding of their choice. The bedrooms seen are fit for purpose. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 14 Service users are encouraged to bring small items of furniture from their own home that has special memories. There were no outstanding maintenance jobs at the time of the inspection. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 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) 27,29,30 Staffing levels, rota arrangements and skills ensure that service users needs are met. Recruitment and selection practices do not fully ensure that service users are protected. EVIDENCE: Staffing levels at the home ensure that sufficient staff are available throughout the twenty four hours. The registered manager has implemented routines that enable staff to take breaks and maintain staffing levels at the home to meet service users needs. At the time of the inspection the staffing included 5 care staff an assistant manager, a cook, a kitchen assistant, 2 domestics, an administrator and the registered manager. Three care workers provide support over night. Care workers were observed to be supporting service users as required. Support arrangements for staff are from the assistant manager during the day time shifts and at night there is an on call arrangement. The home has recently recruited new staff and these files were checked. All employment checks had been completed. Advice was given to the registered manager that one reference gained did not fully meet standards, as it contained no detail other than that the individual had worked for the agency. Staff have access to training and this is an ongoing process within the home. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 16 The inspector was informed that staff were undertaking a programme of training in relation to good practice in working with people that had a dementia. The home is very supportive of staff undertaking required training and to date the registered manager confirmed that 11 out of the 21 support staff have achieved National Vocational Qualifications in care at level two or above. The registered manager and the two assistant managers are presently working towards the registered managers award. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 17 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) 33,35,38 Not all management practices ensure the best interests of service users. Service users can be assured that their welfare, health, safety and financial interests are protected EVIDENCE: The homes recording systems and management of information does not ensure that all information can be tracked to ensure that service users needs are fully met. Shortfall in the information gained during the assessment process and lack of forms being completed does not enable staff to give a person centred service to service users. The registered manager does not act as an appointee for any service user. All monies held are kept secure and there is good accounting in place. These financial records are spot checked by the visiting responsible individual. Individual records were checked by the inspector and found to be correct. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 18 Health & safety checks are undertaken within the home and records are kept of ongoing maintenance of equipment and services. St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 19 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 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 x x 3 St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 20 yes 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 3 Regulation 12 (1) (a & b), 14 (1) Requirement Full information regarding a prospective service users needs must be obtained prior to a decision being made to admit them to the home. (Previous timescale of 15.01.05 not met) Up to date care plans must must be in place which cover all areas of care needs including pressure area care and other health care needs, that detail the required actions of the carer. Timescale for action 31.10.2005 2. 7,8 12 (1) (a & b), 17 (1) (a) schedule 3.3 (m,n) 31.10.2005 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. 2. 3. Refer to Standard 10 29 7,8,33 Good Practice Recommendations The manager needs to address work practices with staff to ensure service users privacy is maintained. The manager needs to review staff recruitment and selection practices to ensure that references received give required information The manager needs to ensure that service users information is recorded and acted upon appropriately St Anns C51 C08 S12921 St Anns V246960 010905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 1st Floor, Newland House Campbell Square Northampton NN1 3EB 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. 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