Inspection on 07/06/07 for St Anne`s Nursing Home

This inspection was carried out on 7th June 2007.

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 Nursing Home 02/10/06

St Anne`s Nursing Home 16/11/05

St Anne`s Nursing Home 10/05/05

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 Anne`s Nursing Home 1 Lawn Road Portswood Southampton Hampshire SO17 2EX Lead Inspector Mark Sims Unannounced Inspection 07th June 2007 10:00 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 Anne`s Nursing Home DS0000061360.V338927.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 Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Nursing Home Address 1 Lawn Road Portswood Southampton Hampshire SO17 2EX 023 8058 5032 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) Pegmar Ltd Mrs Kathryn Dawn Imonikhe Care Home 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 Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 4 service users can be admitted in the PD category. These service users must be between 50 - 64 years of age 2nd October 2006 Date of last inspection Brief Description of the Service: St Annes 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. Pegmar Ltd owns the home 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 en-suite 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 Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the Second ‘Key Inspection’ of St Anne Nursing Home, a ‘Key Inspection’ being part of the inspection programme, which measures the service against core National Minimum Standards. The fieldwork visit, the actual visit to the site of the home, was conducted over six hours, where in addition to any paperwork that required reviewing the inspector met with service users and staff and undertook a tour of the premises to gauge its fitness for purpose, several issues outstanding from the last inspection were also considered during the fieldwork. The inspection process involves far more pre fieldwork visit activity, with the inspectors gathering information from a variety of professional sources, the Commission’s database, pre-inspection information provided by the service and linking with previous inspectors who have visited the home. What the service does well: Choice of Home: The home operates an admissions process, which encourages and welcomes visits by prospective service users. Documentation regarding the home, brochure, ‘service users guide’, etc, are made available, although the ‘service users guide’ and ‘statement of purpose’ do have to be download and printed before they can be issued. Health and Personal Care: The home’s care planning process is both well structured and ordered and provides staff with a useful tool containing significant information about the person and the care they require. Health and Social care contacts are being appropriately maintained and the service users medications, etc responsibly handled and administered. Daily Live and Social Activities: The service employs a part-time activities co-ordinator, who creates, with the resident an individual profile on their hobbies, interests and leisure pursuits. Visiting arrangements appear flexible and a number of families and relatives were seen during the fieldwork visit, with their next of kin/friends, etc. Complaints and Protection: Whilst the issue of the ‘statement of purpose’, not being readily available upon request, could impact on a visitors ability to familiarise themselves, the general view of the service users and their visitors is that they are both able and confident that any concerns raised with the staff, etc, would be effectively addressed. St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 6 Environment: The home is reasonably well maintained throughout, although one or two areas are becoming a little tired decoratively, although with the work ongoing to build a new home next door, the proprietary company are understandably hesitant about redecoration, preferring to maintain the current reasonable condition of the home. Staffing: The staff were found to be friendly and co-operative during the fieldwork visit. They have a clear understanding of the needs and wishes of the client group and were noted to have developed good relationships and a rapport with both the residents and their relatives. Management: The home appears to be well managed, with the residents, their relatives and the staff team all very supportive of the management. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Anne`s Nursing Home DS0000061360.V338927.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 Anne`s Nursing Home DS0000061360.V338927.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 3 and 6: Prospective residents and their representatives have the information needed when choosing the home and have their needs assessed. EVIDENCE: Pre-admission Assessment: The evidence indicates that residents are having their needs assessed prior to admission and that they are provided with sufficient information prior to deciding to move into the home. The evidence used to make this judgement includes: o The Annual Quality Assurance Assessment, which is a document used by the Commission and requires service to assess and demonstrate how they are meeting the national minimum standards: St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 9 ‘We do not assess without next of kin permission and that they have visited the nursing home. Full assessments are always carried out’. o Discussions with service users and their relatives when it was confirmed that they had visited the home, prior to their relative and/or friend being admitted to the home, several service users also confirming that they had visited the home prior to their admission. The pre-admission assessment document, which has be revised and/or updated since the last inspection to include questions about dates of catheterisation, mobility assessments, weight and vaccination histories if known. o Standard 6: The home does not provide and intermediate care facility. St Anne`s Nursing Home DS0000061360.V338927.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 7, 8, 9 and 10: The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service User Plans: The evidence indicates that the home’s care planning process is satisfactory and meeting the needs of the service users. The evidence used to make this judgement includes: o 1. 2. 3. 4. Five care plans, which were scrutinised during the fieldwork visit and found to contain: Pre-admission assessments Personal details Progress Sheet Waterlow Score DS0000061360.V338927.R01.S.doc Version 5.2 Page 11 St Anne`s Nursing Home 5. 6. 7. 8. Moving and Handling Assessment Risk Assessments Malnutrition Universal Screening Tool (must) Care Plans: i. Elimination ii. Mobility iii. Psychological Assessment iv. Night Care plans 9. Bath Chart 10. Monthly Review Sheets 11. Wound Charts 12. Photo ID 13. Body Mass Index (BMI) 14. Health Care Professional Visits 15. Weight Charts 16. Running Records. o o The views of seven service users, whom all indicated via a Commission questionnaire/comment card, that they received the care they required. The views of five staff spoken to during the fieldwork visit, who confirmed that the care plans are working tools, which are used to both plan, deliver, monitor and review care. Health Care: The evidence indicates that the health care needs of the service users are being appropriately met. The evidence used to make this judgement includes: o As indicated above five service user plans were inspected and found to contain specific information relating to health professional visits and/or involvement with health bodies/agencies, including: 1. 2. 3. 4. o Psychiatry Services and specific behavioural reports. Optician and outcomes of sight tests Ambulance service, details of referrals following accidents General Practitioner (GP) visits and diagnosis and treatment plans’ for ailments. The views of the seven service users who completed the Commissions questionnaires and who all indicated ‘they receive the medical support they need’. The view of a relative who, confirmed that any admission to hospital or accident is reported to them. o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 12 o The accident log and running records, which indicate that any accident which results in injury is being appropriately addressed and the proper health agencies are involved in assessing and managing the situation. The most recent event logged, involving a client falling a sustaining a head wound to which the emergency services were called, they felt no further action was required and handed back the care of the wound/injury to the qualified staff on duty. The management were, however, reminded of the need to report any incident that affects the wellbeing of the service user to the Commission, in accordance with regulation 37 of the Care Homes Regulation, as a number of incidents had not been brought to the regulators attention. Medication: The evidence indicates that the home manages service users medications appropriately. The evidence used to make this judgement includes: o o o o o o o The medication administration records (mar) were accurately maintained. Samples of the signatures and initials of all nurses involved in handling the medications were available. The medication is stored within Lockable cabinets and trolleys, which are housed/secured within a lockable treatment room. All MAR sheets contained photographs of the service users and information relating to known allergies. The home has a domestic remedies/homely remedies procedure agreed for each resident, signed by their GP. The home’s medication fridge records both daily maximum and minimum temperatures, which the staff document daily. The home’s controlled drugs cabinet conforms the standards set out within the ‘safe storage’ regulations and the controlled drugs register was appropriately maintained. The home also has records, which document when a medication is received into the home and policies and procedures, according to the dataset, a Commission tools completed by service prior to inspection, which guide staff practice in relation to the safe handling of a service users medication. o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 13 Privacy and Respect: The evidence indicates that people’s rights to privacy and respect are appropriately promoted. The evidence used to make this judgement includes: o It is stated within the AQAA that ‘for service users who have chosen to share screening is provided to ensure privacy’. During the tour of the premises it was confirmed that not all of the accommodation is single occupancy, with several shared bedrooms in use. On visiting several of these rooms it was noted that individual screens were accessible within each room. o The completed service user comment cards indicate that people feel the staff treat them with respect by ‘listening and act upon what they say’. A view mirrored by people spoken with during the day, when the attitudes of the staff to their roles, etc were praised be the service users and their relatives. o Observations during the fieldwork visit, revealed that staff are courteous on entering a persons bedroom, knocking the door before entering and polite, whilst remaining friendly, when conversing or chatting to the service users. Bathrooms and toilets, where noted to be largely communal and fitted with appropriate locks, which could be secured from the inside but released from the outside in the case of an emergency. o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 14 and 15: People who use services are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Activities and Entertainments: The evidence indicates that the activities and entertainments provided meet the needs of the people residing at St Anne’s Nursing Home. The evidence used to make this judgement includes: o The views of the service users, who confirmed, via the comment cards that ‘there are always activities arranged, by the home, that they can take part in’. Additional views expressed by people during the visit, when describing their participation in: DS0000061360.V338927.R01.S.doc Version 5.2 Page 15 o St Anne`s Nursing Home 1. 2. 3. 4. 5. 6. o Bingo. Aerobics St George’s Day Celebrations St David’s Day Celebrations Annual Barbeques Trips out with families. Photographic records of some of the events organised within the home and which are accessible and visible, including: a red nose day event and a Halloween party. The AQAA and the Dataset information also make clear that the home employs an activities co-ordinator. During the fieldwork visits the individual profiles being created for each client, where seen and people discussed the role she plays within the home in keeping people entertained and amused. o Visiting and Family Contacts: The evidence indicates that people are able to maintain appropriate contact with their families and friends. The evidence used to make this judgement includes: o Several groups of visitors were seen during the fieldwork visit, one visitor a regular to the home, who spends most days with his relative and who is invited to stay for meals. Other groups were more transient, in as much as they come in to visit their relative but do not stop for meals, although light refreshment was noted to be offered/taken. o The visitor’s book also provides a good indicator to the number of people visiting the home, although it is not accurate as not all visitors wish to sign in or out of the home. A relatives comment care also indicates that the care home, ‘always supports their relative to keep in touch’. The AQAA, also establishes that the home has an open visiting policy and that service users are able to conduct any visits in private should they wish. o o Choice and Control: The evidence indicates that people are encouraged to make decisions for themselves, although this is constrained at time by their physical and mental frailties. St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 16 The evidence used to make this judgement includes: o The view of the service users relative, to respond via the comment card system, was that ‘the care service supports people to live the life they choose’. This view was supported by the comments of the service users, a group of residents spoken to during the fieldwork visit discussing the range of activities provided, which they can participate in if they wish. People are also being offered a range of choices on a day-to-day basis, meals they eat, where they spend their time (lounge, garden, bedroom, etc), clothes they wear, how their bedrooms are set out and personalised. o o Meals and Menus: The evidence indicates that people enjoy a varied diet and are provided with a range of meals. The evidence used to make this judgement includes: o Two mealtimes were observed during the inspection, lunch and tea and both appeared quiet relaxed social occasions when the staff and the service users could chat and interact. The meals served during these periods appeared to be well presented and from observations, well received by the residents who generally ate well and appeared to enjoy the food provided. The latter observation supported by comments on the day, when the food was praised by the people spoken to and who thought their was sufficient choice and variety within their diet. o In addition to comments and feedback gathered during the fieldwork visit, the seven comment cards returned by the service users also confirm their appreciation for the meals serviced, all seven ticking ‘yes’ in response to the question: ‘do you like the meals at the home’. o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18: People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: Complaints: The evidence indicates that people are both aware of their rights to make complaints and happy to raise issues with the management. The evidence used to make this judgement includes: o Evidence taken from the dataset, which includes a summary of the home’s complaints activity for the past twelve months, indicates that: 1. No complaints were received in the last twelve months 2. No complaints therefore were partially substantiated 3. No complaints therefore were substantiated. o The comment cards of the service users and the relative, which indicates that people are both aware of the home’s complaints process and able/willing to use it. St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 18 o The dataset and AQAA, which both provide statements, from the management, that a complaints procedure is available and made accessible to service users and their relatives. Protection: The evidence indicates that people are appropriately protected from abuse and/or harm. The evidence used to make this judgement includes: o o o The home again states, via the AQAA, that policies for the protection of the service users are in place and accessible. The views of the service users and their relatives, as indicated above. The staff during interview, appeared to have a good understanding of their role in protecting service users from harm, and whilst they described themselves as a close team they stated they would not hesitate in bring poor practice to the attention of the nurse in-charge or the manager. The Dataset also indicates that referrals have been made to the local authority under the protection of vulnerable adults for investigation/consideration, since the last inspection. o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 19 and 26: The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: Environment: The evidence indicates that the environment is reasonably well maintained and meeting the needs of the service users. The evidence used to make this judgement includes: o As indicated earlier within the report, some areas of the home are beginning to look a little tired and worn, however, as the intention is to move everyone into the new home being built next door to the existing property, the proprietary company are understandably hesitant when it comes to a commencing a refurbishment and redecoration programme. DS0000061360.V338927.R01.S.doc Version 5.2 Page 20 St Anne`s Nursing Home To be fair the tour of the premise, indicates or suggests that whilst some areas are aging, decoratively, they are still generally in a reasonable condition and should therefore be okay until the new home is ready for occupation. o The people spoken with during the fieldwork visit clearly felt and/or feel the home is in a good condition and they are happy with both the communal environment and their personal rooms/space, which many people have personalised. The views of the people spoken with during the visit to the home, supports that of the people who completed the comment cards, with all seven people indicating that the home is always ‘fresh and clean’. Maintenance issues are managed by one of the proprietors and a maintenance operative, both of whom were seen during the fieldwork visit tending the gardens and grounds. o o Cleanliness and Hygiene: The evidence indicates that the home is clean and tidy throughout. The evidence used to make this judgement includes: o The tour of the premise, when in addition to considering the decorative condition of the home the inspector also monitored the cleanliness of the property, which was good. The views of the service users, which suggests they consider the home to be ‘fresh and clean’, as indicated above. The dataset information and observations, which establish that two domestic staff are employed at St Anne’s and that during the tour the home was being cleaned. The dataset also indicates that the home makes policies on the management and prevent of cross-contamination of infectious agents/bodies to staff, which were last updated in 2005. o o o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 27, 28, 29 and 30: Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staffing levels: The evidence indicates that the needs of the service users are being met by the supply and deployment of staff. The evidence used to make this judgement includes: o Copies of the staffing roster, seen during the fieldwork visit, indicates that the home is sufficiently well staffed and that carers are available, across the twenty-four hour period to meet the needs of the service users’. AM. Four carers One Qualified Nurse. PM. Three carers One Qualified Nurse. Night. Two carers One Qualified Nurse. St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 22 o Observations further evidence the fact that adequate staff are available to meet people’s health and social care needs, the staff on duty comprising: 1. 2. 3. 4. 5. 6. 7. 8. The managing/proprietor The Proprietor The nurse in-charge Four care staff One cook One Ancillary staff One Domestic staff member One maintenance operative. o The view of the relative, to respond via the comment card system, indicates that they believe the staff ‘have the right skills and experience to look after people properly’, adding within this section ‘nothing to complain about’. The service users also indicated via the comment cards system that ‘the staff are available when they need them’ and they ‘receive the care and support they require/need’. This picture was mirrored during the fieldwork visit, when people, during conversation, praised the staff for their commitment and attitudes to their roles. o o Training & Development: The evidence indicates that the training opportunities for the staff are reasonable. The evidence used to make this judgement includes: o Discussions with the staff, when it was established that people have been supported in gaining their National Vocational Qualifications (NVQ) at both level two and three. That internal courses, such fire safety and Moving and Handling, have recently taken place. o Information taken from the AQAA, which indicates that individual training programmes are in place and that NVQ level two and three training is made available, which supports the staffs statements. The current indicator being that 72 of the care staff working at St Anne’s Nursing Home, possess either an NVQ at level two or three, this information taken from the dataset. o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 23 o The view of the relatives, which indicate that the staff are considered to ‘have the right skills and experience to look after people properly’, as reported above. Recruitment and Selection: The evidence indicates that the recruitment and selection process is now being appropriately operated. The evidence used to make this judgement includes: o At this visit the file of the last two people recruited were reviewed and found to contain the following information: 1. 2. 3. 4. 5. 6. 7. 8. o An application form Two written references Dates of employment Protection Of Vulnerable Adults (POVA) clearance Criminal Records Bureau (CRB) check outcome Induction details Photo Identification Contract The dataset establishes that a recruitment and selection strategy/procedure exists to support the management when employing new staff. In discussion with the care staff, they confirmed that since their employment they had been receiving regular three monthly supervision with a qualified (nursing) member of staff and that annually they complete a more detailed appraisal. o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35 and 38: The management and administration of the home is based on openness and respect, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Management: The evidence indicates that the home is currently being managed to a satisfactory standard. The evidence used to make this judgement includes: o Information on the Commission databases indicate that the managing/proprietor has been in charge of the service for a number of DS0000061360.V338927.R01.S.doc Version 5.2 Page 25 St Anne`s Nursing Home years and that generally during that time the home has been considered to be well run. o The comments of the service users were all positive and suggest that they enjoy and appreciate living at St Anne’s Nursing Home, which strongly indicates that the management of the home must be appropriate. The staff also spoke positively about the home and its management, pointing out that the low turnover of staff, one person stating she had worked at the home for over twenty years, was an indication of how well run and organised the home was. o Quality Audit and Assurance: The evidence indicates that service users and/or their relatives are afforded the opportunity to comment on the service provided at the home. The evidence used to make this judgement includes: o Information already presented within this report, which indicates that people have their rights to comment on the service and influence the care and provision they receive include: 1. People had clearly been involved in the setting up or decorating and personalising their bedrooms. 2. The managers/staffs rapport with the service users and their relatives, who clearly, from observations, find it easy to approach and discuss issues with the management and staff. 3. Care plans that were reviewed and updated monthly. 4. Staff supervision sessions 5. Annual Appraisals. o It also became apparent when reading through the service user plans, that each month the relatives of the service users, as their representatives, are invited to join in the reviewing and updating of their next of kin’s care needs, signed outcomes of these reviews were seen during the visit. The AQAA also makes a clear statement around the home’s use of questionnaires to monitor people’s satisfaction with the service, although the inspector did not review these during the visit. o Service users finances: The evidence indicates that the arrangements within the home promote independent when managing finances. The evidence used to make this judgement includes: St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 26 o The home does not get involved with the residents’ finances, this statement was made via the AQAA. Health and Safety: The evidence indicates that the health and safety of the service users and staff is being reasonably well managed. The evidence used to make this judgement includes: o The AQAA and dataset information establishes that full health and safety policies/guidance documents are made available to the staff and that equipment is regularly maintained and serviced, gas, electrical installations, portable electrical appliances, hoists, baths, etc. Health and safety training is being provided according to the staff who stated they recently completed moving and handling and fire safety training courses. Maintenance issues are also being appropriately identified and addressed, an maintenance operative employed to undertake minor remedial works and redecorative duties, etc. The tour of the premise, which revealed no immediate health and safety issues or considerations. o o o St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 27 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 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 28 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. 1. Standard OP1 Regulation Requirement Timescale for action 10/08/07 Regulation The management must ensure 4 copies of the Statement of Purpose are made more readily available. To ensure that Service users and their representatives / visitors have access to information regarding the services and facilities provided. 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 Standard Good Practice Recommendations St Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Anne`s Nursing Home DS0000061360.V338927.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!