Inspection on 07/11/06 for St Anne`s (Holsworthy)

This inspection was carried out on 7th November 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) 24/01/06

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 Key Unannounced Inspection 7th November 2006 09:00 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 Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 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.V313436.R01.S.doc Version 5.2 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.V313436.R01.S.doc Version 5.2 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 24th January 2006 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.V313436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection at St Annes was an unannounced inspection and took place from 0900 to 1515. The registered manager was on duty but was working as a carer on the day of the inspection and was therefore very busy. During the course of the day both the registered providers visited the home to speak with the inspector. Prior to the inspection of documentation at the home a pre inspection questionnaire had been received at the CSCI. An inspection of the premises took place as well as the case tracking of four service users. A number of service users were spoken to during the course of the day. All the service users expressed very positive comments on the kindness of the staff at the home but three service users expressed concerns about the staffing levels at particular times during the day. At this time the home is running nearly at full occupancy which has not been the case and staffing levels may not have been fully adjusted to meet numbers and needs. This should be reviewed as a priority. The range of weekly fees are from £280 to £360. What the service does well: What has improved since the last inspection? All the staff who have medication administration responsibilities have now received accredited medication training. It is noted that the induction training that staff receive has improved and expanded since the inspection of the 24th January 2006. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 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.V313436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose and service user guide documentation provide prospective service users with details of what the home provides helping an informed decision about admission to the home. The registered manager assesses all service users prior to admission to the home to ensure that the home will be able to meet their care needs. EVIDENCE: The home has a statement of purpose document in place that meets all the requirements of The Care Homes Regulations (2001). The statement of St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 9 purpose document is available in the home as is the service user guide. This information is provided to the service user and or their family member or representative. St Annes is run on a Christian philosophy but it is noted that the statement of purpose states “although this home is Christian based, all denominations are welcome.” All potential new admissions to the home are assessed by the registered manager. A pre admission assessment document is completed and signed and dated as required by this standard. Where the assessment has been undertaken through care management arrangements the registered manager has accessed a copy of their assessment. The home offers respite care as well as longer stays. A large number of the service users who are admitted to the home have lived locally. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required. Medication arrangements were found to be satisfactory on the day of the inspection. The service users at the home made particular references to the kindness of the staff. EVIDENCE: Each service user has a detailed care plan in place identifying problems and the action required to address these care needs/problems. As noted in the inspection report of the 24th January 2006 care plans are generally being St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 11 reviewed but again there are some care plans where they had not been reviewed for two months. The daily records support the care plans and all the staff are involved in this recording. Advice from health care professionals and other agencies is sought when required. Risk assessments and moving and handling assessments are also in place. It is recommended that more information on nutrition be transferred from the pre admission assessment documentation into care planning. Specialist equipment is provided for the service users as required. Medication is stored in a locked and secure trolley. All the staff at the home have now received accredited medication training including the registered manager. Administration records were found to be completed correctly on the day of the inspection as were the records in relation to the controlled drugs at the home. It is recommended that the medication records are used to log in the medication received at the home. During the course of the inspection the service users who were spoken to expressed very positive comments on the kindness of the staff. Documentation is held in the front of care planning to guide staff on practice which respects the dignity and privacy of the service users. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans and daily records evidence that the social care needs of the service users are being met. Visitors to the home are encouraged and welcomed. The service users spoke positively about the standard of the meals being provided at the home. EVIDENCE: The social care needs of the service users are identified in their care plans and the daily records (and activity book) evidence that these needs appear to be being met. Information is included in care planning re family history. A discussion with the manager suggested that more is happening at the home than is being recorded and a recommendation is made to address this. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 13 There are a number of activities that are available for the service users to join in with at the home should they so wish. Bingo and quizzes and more individual pass times such as scrabble or going out for a drive are available. Regular Christian church services take place at the home for those service users who wish to join in. There are plans for a visit to a local garden centre soon, as well as a trip to the pantomine. The service users apparently all enjoyed a recent fire work evening. The mother of one of the registered providers 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). Visitors to the service users are encouraged into the home and the daily records indicate who has visited. The service users can entertain visitors in their own rooms or if they prefer a lounge. 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, although they all had a favourite cook!. A record of the meals provided is in place and a choice is available at all times should a service user dislike the main choice. The main meal of the day is served at 1.00pm and on the day of the inspection this was roast lamb with roast potatoes, green beans, swede, peas and carrots. This was followed by home made rice pudding. Some of the service users enjoy being able to eat in their rooms. Breakfast is served to everyone in their bedrooms. A satisfactory inspection of the kitchen took place recently. The main cook is qualified to the basic food hygiene certificate level and is presently undertaking “safe training, better quality” training. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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 but all staff must now be trained 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. It is recommended as a priority that all staff receive training in adult protection to ensure the safety of the service users at all times. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Anne’s is a very comfortable, pleasant and safe environment for all the service users, visitors and staff. EVIDENCE: St Anne’s 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. Since the last inspection two bedroom carpets have been replaced as well as one of the corridors and the drive has been tarmac’d. As discussed St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 16 at the time of the inspection one bedroom radiator is not working and attention is required to repair one of the baths. It is understood that repairs are planned and in hand. Part time cleaning staff are employed. On the day of the inspection the home was found to be very clean although odour control could be improved in the immediate entrance to the home. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels should be reviewed to ensure that the care needs of the service users are being met at all times. Good practice recruitment procedures must be followed at all times to ensure the safety of the service users. Some important training requires updating to ensure that the staff have the necessary skills to care for the service users. EVIDENCE: During the course of the inspection three service users suggested that there are times when staffing levels are not satisfactory. They gave examples of call bells ringing for a long time and it was noted that this was happening (first thing in the morning) when the inspector was in the home. It is appropriate to review the staffing levels in the home to ensure that the care needs of the service users are being met at all times. Recruitment procedures were found to be not satisfactory for one staff member on the day of the inspection. This can place service users at risk and St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 18 recruitment procedures should be reviewed as a priority as discussed on the day of the inspection. A good number of staff have obtained an NVQ qualification in care and more staff are interested in undertaking these studies. Some statutory training records require updating to evidence that statutory training is fully up to date, this includes fire drill training and first aid for example. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified and experienced to do her job but due to her care responsibilities is unable to fulfil all her management responsibilities at this time. EVIDENCE: On the day of the inspection the registered manager was working on the floor as a carer. This was discussed with the registered providers. It is understood that it is important for the manager to be hands on where she can but that she must have additional support to undertake her tasks and duties. It was suggested during the course of the inspection that some of the senior staff be St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 20 given specific responsibilities to enable the manager more time to complete her tasks. Standard 33 is not met as the home has not undertaken a quality assurance and or monitoring of it’s service. Staff meetings are now taking place at the home. The home encourages all service users and or their representatives to undertake responsibility for their finances. The statement of purpose documentation states this information. A staff member has recently undertaken health and safety training and it is anticipated that this staff member will take on some more responsibilities in this area. Policies and procedures are in place to guide staff on health and safety requirements and legislation. St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 21 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 3 St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 22 NO 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. 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. 4. 5. 6. 7. Refer to Standard OP7 OP8 OP12 OP16 OP18 OP27 OP29 Good Practice Recommendations To ensure that all the care plans are consistently reviewed monthly. To include information on nutrition in care planning. To record all information that evidences that the social, cultural, religious and recreational needs of the service users are being met. A copy of the homes complaints procedure should be displayed in the home. For all the staff to be trained in adult protection as a priority. To review the staffing levels at the home to ensure that the care needs of the service users are being met at all times. To ensure that correct recruitment procedures are in place at all times. DS0000009221.V313436.R01.S.doc Version 5.2 Page 23 St Annes (Holsworthy) 8. 9. OP30 OP31 To ensure that all training is evidenced at all times. 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 supervision. 10. OP33 6. OP36 St Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Annes (Holsworthy) DS0000009221.V313436.R01.S.doc Version 5.2 Page 25 - 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. 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