Inspection on 10/05/05 for St Anne`s Nursing Home

This inspection was carried out on 10th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Anne`s Nursing Home 07/06/07

St Anne`s Nursing Home 02/10/06

St Anne`s Nursing Home 16/11/05

St Anne`s Nursing Home 01/02/05

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE St Annes Nursing Home 1 Lawn Road Portswood Southampton SO17 2EX Lead Inspector Jan Everitt Unannounced 10 May 2005 9:30 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 Annes Nursing Home Version 1.10 Page 3 SERVICE INFORMATION Name of service St Annes Nursing Home Address 1 Lawn Road, Portswood, Southampton SO17 2EX 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) 0230 8058 5032 Pegmar Ltd Mrs Kathryn Dawn Imonikhe Care Home with Nursing 22 Category(ies) of Old age, not falling within any other category registration, with number (22), Physical disability (4), Physical disability of places over 65 years of age (22), Terminally ill over 65 years of age (22) St Annes Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: A maximum of 4 service users can be admitted in the PD category. These service users must be between 50 - 64 years of age Date of last inspection 1/2/05 Brief Description of the Service: St Anne’s Nursing Home is a care home providing nursing care for service users over 65 years of age. The home is registered to accommodate 22 service users, but the maximum accommodated at any one time is 20. The home is registered to provide nursing care to those with physical disabilities and those with life limiting diseases. There is a condition of registration that 4 service users may be accommodated in the category of Physical Disability who are between the ages of 55 and 65 years. The home is owned by Pegmar Lts and is the only home owned by this organisation in the area. The home is located on the outskirts of Southampton city and is therefore close to all the local amenities and is accessible by public transport. The home is a large Edwardian House over two storeys and is to be completely refurbished within the next year following the building of a large extension being erected on the land adjacent to the present home, into which the existing service users will move whilst the alterations take place. The home has 10 single rooms and 5 double rooms of which none have ensuite facilities. A passenger lift is installed to give service users access to the first floor. The home has extensive, well-maintained gardens of which the back area is accessible to service users. St Annes Nursing Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 10 May 2005. The inspector, who attended the home, was assisted with the inspection process by Mrs. K. Imonikhe, the registered manager. During the inspection twelve standards were assessed, 11 of which were core standards to be inspected over the current inspection year. The inspection found that of the twelve standards inspected, ten standards were met, one had a minor shortfall and one a major shortfall but that the overall quality of the care and services delivered in this home was good. A considerable number of service users were spoken with and two visiting relatives. All those spoken with expressed satisfaction with the services they receive in the home. Both of the relatives spoken to, highly praised the care their loved ones were receiving and confirmed that they had been consulted on the choice of home and have been made welcome into the home at any time. The inspector’s observations of the service users appearance, interaction with staff and surrounding environment, would suggest that the home provides a good standard of care and that the environment is being maintained to an acceptable level until such times as the building works have been completed and the home refurbished. A number of comment cards for service users and relatives were left at the home by the inspector, to be distributed. Two comment cards have been received, one from a service user and one from a relative both of which responded positively to the questions. The requirements made from this inspection have been discussed in the main body of the report. What the service does well: The home has a homely atmosphere and staff were observed to interact well with the service users and were observed to treating the service users and respecting their dignity. Assessment and documented records of care are well maintained and detailed. The senior carer maintains individual records of service users past life and interests and plans social events and activities around this information. A record of the level of participation and enjoyment of the social life of the home St Annes Nursing Home Version 1.10 Page 6 is also recorded in their individual files. Service users spoken with reported that the entertainment and activities met their needs. The trained nurses maintain good systems for the ordering, receiving, storage, administration and returns of medication. The storage of the medication is maintained in well-organised and clean cupboards and a trolley. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Annes Nursing Home Version 1.10 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 Annes Nursing Home Version 1.10 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 Service users are assessed before admission to the home to ensure their needs will be met. EVIDENCE: Service users are admitted to the home following a full assessment, which is undertaken by the senior nurse or/and the manger based on the activities of daily living. Assessments take place within people’s own homes or most frequently within the clinical area. Whenever possible health care professionals are consulted to obtain information as to the needs of the potential service user. Care assessments are received from care managers if they are involved with the placement to the home. The assessments enable the home to make an informed decision as to whether the home is able to meet that persons care needs. The inspectors evidenced a completed pre-admission assessment, which form part of the care plan documentation. The assessment tool is based on the activities of daily living and much of the information is gathered with the involvement of relatives. St Annes Nursing Home Version 1.10 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) 8, 9 & 10 Service users’ health care is fully met. The home’s medication policies and procedures ensure the protection of service users and their rights to self-medicate if they so choose. Service users’ rights to privacy, dignity, independence, fulfilment and choice are respected in this home. EVIDENCE: St Annes Nursing Home Version 1.10 Page 10 The pressure sore occurrence in the home was discussed with the manager at the time of the inspection and appropriate treatment and equipment is in place Service users are encouraged to mobilise around the home with assistance and this was observed during the inspection. Service users are invited to participate in the armchair exercise programme that is advertised on the notice board. All service users have access to a GP of their choice, if geographically possible. Service users’ dentures were observed to be clean and a dentist visits the home at regular intervals or when requested. The manager ensures that service users receive all NHS entitlements and services. Nutritional assessments are not undertaken routinely and the manager reported that she is about to introduce a tool for assessment but that the service users are weighed monthly to monitor their status. One service user was observed to be being fed via a feeding tube and the manager reported that the Primary Care Trust dietician now monitors her nutritional status. There are policies and systems in place for the safe handling of medication. There is a self-medication policy in place. There were no service users choosing to self-medicate at the time of this inspection. The senior trained nurse is designated to coordinate the ordering, receiving and storing of medication. Medication records were checked by the inspector and found to be in accordance with requirements. MAR sheets were well recorded. The understanding of the core values of privacy, dignity, independence, rights, fulfilment and choice, that underpin care form part of the induction programme that all new staff undertake. Staff were observed to be knocking on bedroom doors before entering and communicating and interacting with service users in a respectful manner. Service user spoken with reported that staff were kind and they were well cared for. Screens were observed to be in position in rooms that are shared to ensure privacy. Service users who share a room were asked if they enjoyed sharing a room and both reported to be happy with the arrangement. Locks are not fitted to bedroom doors and lockable storage space is not available in all rooms. This has been a requirement of the previous inspection and was discussed with the providers. All doors will have locks fitted to them and the new furniture will have a lockable facility when the refurbishment of the home takes place over the next twelve months. At the present time a Lockable storage space would be provided at the request of the service user by way of a locked box. St Annes Nursing Home Version 1.10 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 & 15 Service users’ lifestyle, social contact and activities meet their expectations and preferences in relation to their religious, social and recreational interests. Service users receive a balanced diet that is to their preferences and can be eaten in their chosen environment. EVIDENCE: A senior carer of the home organises the activities that take place in the home and are advertised on the notice board. The inspector viewed the records that are kept separately for every service user of a pen history of their lives and their past recreational activities. Records are maintained of when the service user participates in the organised activities and their tolerance levels as to the exercise programmes. The senior carer must be commended for the welldocumented records. A musical entertainer attends the home weekly and the service users report that they enjoy this. Service users are given choice as to whether they participate in the activities of the home. The inspector spoke with one service user who reported she enjoyed reading and that the visiting library supplied her with large print books. The local church minister will visit the home if requested to do so but does not visit on a routine basis. The inspector observed lunch being served, the meal was presented well and service users were observed to be enjoying the food. The chef distributes St Annes Nursing Home Version 1.10 Page 12 menus each day and discusses with service users their alternatives should they not want the main menu. Service users spoken with confirmed that they enjoyed the food served in the home. The menu is on a four weekly rotation. The manager reported that food is available throughout the day and night should it be requested by the service users. Diabetic diets and pureed diets are served and the inspector observed that those needing assistance with their eating were assisted with dignity. The home has a separate dining room but some service users choose to eat in their rooms or in the lounge area. The manager reported that staff are to receive training in nutritional assessment in June of this year. St Annes Nursing Home Version 1.10 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 standard(s) 18 The home strives to protect the service users from any form of abuse. EVIDENCE: The home has a copy of the Hampshire Adult Protection procedure. There is a whistle blowing policy in place. There have been no reports of abuse in this home. Staff are aware of the different forms of abuse and those spoken with confirmed their knowledge of what process they would take if they witnessed or suspected any form of abuse. Training on adult protection is provided during the induction period. The home has a policy in place to deal with incidents of aggression/violence. Bedrails are used in the home following a risk assessment and permission is sought from the service user and signed as consent for their use. The use of bedrails is generally discussed with the next of kin also. St Annes Nursing Home Version 1.10 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 standard(s) 19, 25 & 26 Service users live in a well-maintained environment, but which has an identified risk to their safety. Service users live in comfortable surroundings. The home is clean and hygienic. EVIDENCE: At the time of the inspection the lounge area of the home was being redecorated and the manager reported and it was observed by the inspector, that other areas of the home had also been repainted. It was acknowledged by the manager that there are areas of the home that are in need of some repair and redecoration and that the decoration taking place at the present time is an interim arrangement until the house is completely refurbished once the building of a home, on the adjacent land, is completed and the present service users will move into this house. The home is homely in appearance and the garden is used in the finer weather and the home has an annual BBQ. St Annes Nursing Home Version 1.10 Page 15 The Environmental Health Officer visited the home in April 05, the report was viewed by the inspector and the one recommendation to fit fly screens to the kitchen windows has not been complied with to date. Discussion with the manager confirmed that these would be fitted in the coming months. The radiators and associated pipe-work around the home that are not covered and have been discussed in previous reports, have been risk assessed. This standard will be complied with during the refurbishment of the home. The home is clean and free from odours. There is a separate domestic staff employed to maintain good standards of cleanliness. The domestic staff member undertakes all laundry. The laundry is accessed by a covered pathway close to the main house and is fit for purpose. The service user and relative spoken with reported that they did not encounter any problems with the washing and return of the laundry on a regular basis. There is an infection control policy in place. Soap dispensers and paper towels for hand washing were observed to be available to all staff. Disposable gloves and aprons are available to assist in the prevention and control of infectious diseases. Service users spoken with reported that they were comfortable in their environment and it that it will be nice to get back into sitting in the lounge area that was in the process of redecoration. St Annes Nursing Home Version 1.10 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 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 The home employs sufficient numbers of staff with a skill mix that met the needs of the service users in residence at the time of the inspection. EVIDENCE: Staff rotas were viewed. There were twenty service users in residence at the time of the inspection. One trained nurse and three carers were on duty throughout the day and one trained and two carers are on duty during the twelve-hour night period. The home is meeting the staffing level guidelines set by the previous registering authority. The home employs two domestic staff, one of which is on duty every day of the week and who also undertakes the laundry duties, and a two chefs. Some members of the home’s staff have been employed for some years and provide a stable core of staff within the home. Service users reported that staff were very kind and that they considered they were well cared for and treated with respect. The homes own staff covers staff absences and agency staff are used infrequently. St Annes Nursing Home Version 1.10 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) 38 The home promotes but does not fully protect the health, safety and welfare of the service users and staff. EVIDENCE: The risk assessment of the building needs to be reviewed and updated. On a tour of the building with the manager, slip rugs in identified areas of communal space and some bedrooms were observed to have curled up edges that would present a trip hazard to the service users and staff. This was discussed with the manager that these must be removed and replaced. The fire logbook was viewed. The alarm system and equipment were observed to be checked at appropriate intervals and serviced regularly. The fire training for the staff for the current year could not be evidenced. The manager reported that the fire officer attended the home in January 05 but this had not been documented. A requirement will be made around this issue. The home has a fire procedure that is displayed in the home. St Annes Nursing Home Version 1.10 Page 18 Policies are in place to maintain the safety of the home. The manager reports that mandatory health and safety training is available to staff but that the night staff are in need of updating. A requirement will be made from these findings. Accidents that occur in the home are appropriately reported and the manager audits these monthly. St Annes Nursing Home Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x x x 1 St Annes Nursing Home Version 1.10 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 OP 38 Regulation Reg 13(4) (a,b & c) Requirement You are required to update and review the environmental risk assessment The exposed radiators and pipework must be risk assessed and included in the risk assessement document 2. OP38 Reg. 23(4) (d) You are required to maintain records of all fire training undertaken by staff in the home and ensure all day staff have recevied this training at a minimum of twice yearly. and night staff have received this training quarterly. The small rugs identified througout the home as trip hazards must be removed immediately or/and replaced. Timescale for action 31.7.05 31.7.05 31.7.05 3. OP38 Reg 13 30.6.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Version 1.10 Page 21 St Annes Nursing Home 1. Standard OP8 It is recommended that a nurtritional assessment is undertaken on all service users on admission to the home to maintain a baseline record of their nutritional status. St Annes Nursing Home Version 1.10 Page 22 Commission for Social Care Inspection Blechynden Terrace Southampton SO15 1GW 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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