Inspection on 24/01/06 for St Anne`s (Holsworthy)

This inspection was carried out on 24th 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 Anne`s (Holsworthy) 17/07/07

St Anne`s (Holsworthy) 07/11/06

St Anne`s (Holsworthy) 25/08/05

St Anne`s (Holsworthy) 01/12/04

St Anne`s (Holsworthy) 23/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Annes (Holsworthy) Whitstone Holsworthy Cornwall EX22 6UA Lead Inspector Elaine Bruce Unannounced Inspection 24th January 2006 09:15 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 Annes (Holsworthy) DS0000009221.V279458.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 Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Annes (Holsworthy) Address Whitstone Holsworthy Cornwall EX22 6UA 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) 01288 341355 01288 341355 Mrs Helen Medland Mr Herbert John Medland Mrs Dawn Parnell Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 28 adults of old age (OP) Two waking night care staff must be available on the premises Total number of service users not to exceed a maximum of 28 Date of last inspection 25th August 2005 Brief Description of the Service: St Annes offers care and accommodation to people in need of care by reason of old age. It is situated in the village of Whitston which is midway between Launceston, Bude & Holsworthy. The home, which is privately owned, is relatively new having been created from redundant farm buildings. It provides rooms of a good size, all with ensuite facilities for the service users. There are large communal areas in different parts of the home for the use of all. Externally the courtyard around which the home is built is tarmacd with a water feature, although at the time of this inspection, it was not working. There is good car parking available. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at St Annes was an unannounced inspection and took place from 9.15 am to 2.30 pm. The registered manager was on duty but was working as a senior carer on the day of the inspection and was therefore very busy. The registered providers were away on one weeks annual leave. The inspector looked at records, care plans and medication. Staff supervision and staff training were discussed in detail with the manager when she had some time from her caring duties. On the day of the inspection 23 service users were at the home. A number of these service users were spoken to during the course of the inspection. All the service users expressed very positive comments on the standard of the care that they are receiving at St Annes. What the service does well: What has improved since the last inspection? The staff have been spoken to about the statutory requirement for regular staff supervision to commence at the home. Duties have been allocated to senior care staff in supporting the registered manager with the supervision. It is anticipated that at the next inspection supervision documentation will be in place. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 6 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 Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 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 Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 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): These standards were not assessed at this inspection. EVIDENCE: St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 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): 7,8,9 and 10 The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required. Staff who administer medication must ensure that the medication administration records are appropriately signed at all times. The service users at the home are very satisfied with the standard of care that they are receiving. EVIDENCE: Each service user has a detailed care plan in place noting problems and the action required to address these care needs/problems. Care plans are generally being reviewed monthly with just a few requiring updating. Daily records support the care plans. Advice from health care professionals and other agencies is sought when required. Risk assessments and moving and handling assessments are in place as required. Medication is stored in a locked and secure trolley. Some of the staff who administer the medication have received accredited medication training St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 10 (seven)and more staff (three)are due to receive this training, including the registered manager. It was noted on the day of the inspection that some of the medication records did not tally with medication dispensed. This must be addressed by training and attention to following good practice guidance in the medication policy and procedure. During the course of the inspection a lot of the service users were spoken to, the majority in the privacy of their bedrooms and some in one of the spacious lounges. All the service users expressed very positive comments on the standard of the care that they are receiving at the home with particular reference to the kindness of the staff. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 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 the following standard(s): 12,13 and 15 The care plans and daily records evidence that the social care needs of the service users are being met. Service users spoke positively about the standard of the meals provided at the home. EVIDENCE: The social care needs of the service users are identified in their care plans and the daily records evidence how these needs are being met. There are a number of activities that are available for the service users to join in with at the home should they so wish. These include church services, bingo and quizzes and more individual pass times such as scrabble or going out for a drive. There are plans for a weekly bus trip out when the weather improves. The service users are due to visit the pantomime in February. A video afternoon and sing along afternoon are arranged periodically. The registered provider’s mother visits the home regularly and entertains the service users on the piano. Books are freely available throughout the home (to include books with large print). St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 12 Visitors to the service users are encouraged into the home and daily records indicate who has visited. All visitors are asked to sign the visitors’ book which is displayed in the entrance of the home. All the service users expressed very positive comments on the standard of the meals being provided at the home. The cook keeps a diary of all the meals provided and a choice is available at all times should a service user dislike the main choice, in particular at tea time. The main meal is served at 1.00pm and on the day of the inspection this was cottage pie followed by treacle sponge and custard. Two roast dinners are offered in the week one being a Sunday and usually the other is on a Tuesday. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 13 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 and 18 The home has in place a satisfactory complaints policy and procedure. Protection of vulnerable adults policies and procedures are in place to guide staff on good practice. There are plans for staff to receive training in this important area. EVIDENCE: The complaints policy and procedure is included in the service user guide. It is recommended that in addition to this the home should consider displaying the document in the home for reference. A good practice policy and procedure on adult protection is in place to guide staff and some staff have completed a module on abuse as part of their NVQ training courses. The present social services training course that is available was discussed with the manager and she is to make arrangements for some staff to attend this. As recommended the manager has accessed the local Cornwall County Council policies and procedures on adult protection but has yet to access policies and procedures from other areas. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 14 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 and 26 St Annes is a very comfortable, pleasant and safe environment for all the service users, visitors and staff. EVIDENCE: The home has been carefully converted from farm buildings into a care home, to a high standard. Corridors are spacious as are all the bedrooms and communal areas. The whole building has a pleasant and spacious feel with easy to follow circulation areas and safety features included for the protection of the service users. Externally and internally the home is very well maintained. There is ample communal space within the home available for the service users to include a very spacious main lounge, second smaller lounge, dining room and conservatory. All of the spacious bedrooms are provided with en-suite showers, wash hand basins and a toilet. Some of the bedrooms have very pleasant views over open countryside. Bedrooms on the first floor of the home can be accessed by the use of a shaft lift if required. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 15 Assisted bathing facilities are available in the home if required. All wash hand basins and baths have been fitted with pre-set valves to provide safe bathing to the service users. The service users are all provided with adaptations and equipment if needed to maximise their independence either in communal areas, such as the provision of hand rails or on an individually assessed basis. A good standard of quality furnishings and fittings are provided in the home but service users can bring furniture and other items of their own into the home if they so wish. Part time cleaning staff are employed. On the day of the inspection the home was found to be very clean. All maintenance records are in place for safety to include the testing of portable electrical appliances, the maintenance of the lift and bath hoists. An inspection of the premises by the County Fire Brigade in February 05 was found to be satisfactory. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 16 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 and 30 Staffing levels are satisfactory. Training is to be updated to the staff to ensure that they continue to have the skills to care for the service users. EVIDENCE: The staffing rota on the day of the inspection indicated that there were sufficient staff on each shift. It was though noted that the staff were very busy during the course of the inspection and that the registered manger was working as a senior care staff member that day. The registered manager has recently developed a yearly planner to ensure that staff receive all the statutory and good practice training that they should be undertaking. After each training session a questionnaire will be completed by each staff member to test them on the knowledge that they have acquired. The senior staff are to support the registered manager in assessing the questionnaires. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 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 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): 32,36 and 37 The registered manager has obtained her registered managers award and is therefore qualified to do her job. It is though important that she has sufficient dedicated time for administration duties to include staff supervision and training. EVIDENCE: On the day of the inspection the registered manager was working on the floor as a senior carer. It is important that the registered manager has sufficient dedicated time for administration duties which presently include training and staff supervision. Staff meetings are now taking place. It is recognised that at this moment these are not well attended but it is anticipated that this will evolve and improve. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 18 St Anne’s is planning on giving service users and relatives a questionnaire to formally ascertain their views on the quality of services provided by the home. Policies and procedures were generally found to be satisfactory. The accident book complies with the requirements of the Data Protection Act 1998. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 3 3 3 3 3 3 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 x 3 x x x 2 3 x St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP9 OP16 OP18 Good Practice Recommendations Medication administration records must at all times be signed appropriately. A copy of the homes complaints procedure should be displayed in the home. A copy of the Social Services procedure to be followed in the event of an allegation of abuse should be obtained. Where a person is funded by an authority other than Cornwall, a copy of that funding authoritys procedure should be sought. The registered manager should ensure that she has sufficient dedicated time to undertake all the administrative tasks associated with her duties. An objective assessment of the homes effectiveness and quaility should be undertaken. The registered providers may find it beneficial to seek advice from a consultant regarding this. To continue to develop and commence formal staff DS0000009221.V279458.R01.S.doc Version 5.1 Page 21 4. 5. OP31 OP33 6. OP36 St Annes (Holsworthy) supervision. St Annes (Holsworthy) DS0000009221.V279458.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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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