Inspection on 22/07/05 for St Annes

This inspection was carried out on 22nd July 2005.

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 Annes 07/05/08

St Annes 04/07/07

St Annes 08/08/06

St Annes 16/02/06

St Annes 08/12/04

St Annes 22/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE St Annes 30 Lansdowne Road Luton LU3 1EE Lead Inspector Sally Snelson Unannounced 22nd July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Annes Address 30 Lansdowne Road Luton LU3 1EE 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) 01582 726265 01582 726265 Mr Cornelius Crowley Kathleen Lysaght Care home 20 Category(ies) of OP Old age - 20 registration, with number PD(E) Physical Disabilities over 65 - 20 of places DE(E) Dementia over 65 - 20 St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 8.12.04 Brief Description of the Service: St Anne’s is registered to provide residential care services for 20 older people who may also have dementia and limited physical disabilities. The property, close to Luton town centre, is well maintained and comfortably furnished. Since the last inspection two additional bedrooms have increased the accommodation from 18 to 20. Private accommodation is distributed on all of the home’s three floors and consists of 18 single bedrooms and one double bedroom. All of the bedrooms are fitted with washbasin facilities, nine have en-suite toilets and all had an emergency call bell. The rooms on the upper floors can be accessed by a newly installed passenger lift. Toilet and bathing facilities are located on each floor. There is a large combined lounge/diner that incorporates a smaller lounge only area on the ground floor. There is also a quiet lounge on the first floor. Hard standing to the front of the home provides limited car parking. Time limited road parking is available in the area. To the rear of the property is a large garden with a newly constructed patio area. Satisfactory arrangements are in place to support the service users to receive healthcare reviews and treatments. Service users are responsible for the cost of private chiropody and hairdressing services.. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 22nd July over a five hour period from 9.30 am. The manager, Kathleen Lysaght was present throughout. During the inspection service users, staff and visitors were spoken to. The care of three service users was tracked in detail. The inspector would like to take the opportunity to thank all those who took part in the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the building work has been completed and some areas of the home redecorated. The décor, particularly in the lounge is attractive and co-ordinated. Service users have access to the back garden with its newly completed large patio area. When the weather does not permit the service users to be outside they can view the back garden from the lounge. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 6 Recruitment practices have improved ensuring that all staff have the appropriate checks before being offered a position at St Anne’s. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 and 6 Good pre-admission assessments ensured that only service users where needs could be met by the home were admitted. EVIDENCE: There was clear evidence in the sampled care plans that the manager had carried out pre-admission assessments to support her in making the decision that St Anne’s could provide the necessary care. For one of the service users sampled the manager had had to travel some distance to make this assessment as the service user was living outside Bedfordshire. Following a pre-admission assessment and the decision, by the manager, to offer the prospective service user a place, an acceptance letter was sent. The letter offered the place for a trial period and was accompanied by additional information about the home and the terms and conditions of residency. A visitor confirmed that she had had the opportunity to look around the home, on her mother’s behalf, as part of her initial enquiry. She also stated that as her mother was not sure that residential care was what she wanted she had been accommodated for respite care in the first instance to give her a chance to get used to the inevitable change in lifestyle with the option of returning St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 9 home if appropriate. When she finally made the decision to remain at the home permanently her contract had been changed from respite to permanent. Contracts sampled were complete and included all the required information and the appropriate terms and conditions. The Statement of Purpose had been updated to reflect the changes made to the home since the New Year. In particular, the number of service users that could be accommodated had been increased from 18 to 20. The manager stated that she believed that 20 was still small enough to allow service users and staff to feel that they were one large family. In order to be able to care for service users with a variety of conditions staff had completed training as it became available. A number of staff had completed dementia care training to facilitate them in caring for service users with a primary diagnosis of dementia. The inspector however did not see anything in the home or in the care provided that had been specifically put into place because a number of service user’s had dementia. The home did not provide intermediate care at the time of the inspection. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9. The careful and sensitive way that care plans were written ensured that all the assessed needs of the service user were met. EVIDENCE: The care plans sampled had sufficient information for the inspector to feel confident that any member of staff, if necessary, could care for the service users. The care plans included details of the care needs and the proposed plan of care for a variety of issues. It was the precise detail included in the plan of care that ensured that the plans could be used as a working document. The care plans were reviewed and updated at least once a month and there was evidence that where care needs had altered between reviewing dates the plans had been updated accordingly. All of the service users were registered with a GP. Where possible the manager encouraged staying with a family GP. The home had a good relationship with the community nursing service who visited as necessary. On the day of the inspection a carer had arranged for a service user to be visited by her optician, as a new pair of spectacles were not providing the improvement the service user had hoped. The carer had asked the optician to St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 11 review the service user in the position in the home that she liked to sit to read her newspaper in case the problem was that of available light. One visitor reported that he was 100 happy with the care his father was receiving, particular as despite being very poorly and in hospital for a while his condition had improved at the home. He also reported that it was evident that staff were doing all that they possible could to care for him and prevent his readmission to hospital. Care plans were accompanied by appropriate risk assessments; it was noted that the nutritional assessment also included detailed information of the food likes and dislikes of the service user. One of the files samples included clear information concerning a diabetic diet for a specific service user. Where it was necessary to use bed-rails the consent of the service user or their next-of–kin had been obtained and documented. It was noted that specialist community health staff were used appropriately and equipment borrowed from community services, if it was in the best interest of the service user. The care plans samples had documentation for the loan of wheelchairs and backrests. The Inspector witnessed a medication round at lunchtime; medication given with the meal ensured that it was not given on an empty stomach. The inspector did note that the carer was inclined to walk away from the medication trolley in order to administer each dose and did not lock up the trolley. The Medication Administration Records (MAR sheets) confirmed that medications were received correctly, but that where a variable dose was prescribed the exact dose given was not recorded. The manager confirmed that this would be addressed in the progress notes that were completed three times a day. It was agreed that the MAR sheet was the correct place for medication doses to be recorded. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Service users were able to join in social activities and make a number of personal decisions about how they spent their day. Menus indicated that service users were offered a balanced nutritious diet. EVIDENCE: It was noted that visitors were welcomed into the home throughout the day and offered a cup of coffee or tea and somewhere private to meet with their relative/ friend if they should request it. One relative said, “ I feel that I come to visit the whole home, not just my father”. The service users had the opportunity to participate in a wide range of activities. All of the care staff took responsibility for the activities and for organising them. The home had a weekly activity schedule in addition to events, excursions and visits from entertainers arranged throughout the year. The home had various church services arranged which the service users appeared to enjoy. A new service user was missing her regular bingo sessions and one of the carers had made arrangements to take her and anyone else that wished to the town’s bingo hall. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 13 The inspection covered lunchtime. It was noted that as it was a Friday, fish was an option on the menu. The cook cooked the fish and a member of staff went to a local fish and chip shop to pick up chips as the service users had indicated a preference for this type of chip rather than an oven chip. Service users spoken to were happy with the food, both portions and choice. One service user felt that it was assumed that most older people preferred small and thin pieces of meat where in fact she enjoyed a chop or a piece of steak. The manager confirmed that food choices are discussed at monthly meetings with the service users and any comments reported back to the chef. The fish and chips were served with green beans and tinned tomatoes. All of the service users ate at tables that had been laid with cutlery, serviettes and condiments. Staff confirmed that an Oriental service user had a meal at lunchtime with the rest of the service users and was bought food she was more familiar with by her family at night. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards will be assessed as part of the next inspection. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,24,26 The home was well maintained providing service users with a ‘homely’ environment. EVIDENCE: The home was very clean and it was noted that throughout the inspection that dedicated staff were keeping it that way. Since the building work had been completed a new carpet had been laid in the lounge and attractive coordinating curtains were in place. The inspector viewed the bedrooms of the service users tracked. It was apparent that service users could add their own personal touches to their bedrooms with small items of furniture and ornaments. Most of the rooms had only one comfortable chair but a member of staff stated that additional chairs could be moved into a bedroom if a service user wished to use their room to entertain in. Service users on the whole preferred to have the additional space rather than an extra chair. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 16 Since the last inspection a large patio that was accessible to all service users had been built in the back garden. Three of the service users told the inspector that they spent a lot of their time in the garden and were miserable on the day of the inspection because the weather was such that they could not be out. The inspector noted that after lunch these three ladies did sit out for a while even though it was not particularly warm. Another improvement since the last inspection was the laundry area. This had been moved and was now fully operational. The laundry had only one washing machine and one tumble drier but as the owner also owned two other properties close by the manager confirmed that if there were any problems the other homes would help out and there would be minimal disruption to service users. As part of the refurbishment a toilet had been moved. The toilet was now accessed via a corridor rather than directly from the dining room. This move offered service users much more privacy. A lift had also been built. One member of staff said, “I can’t imagine how we managed before we had the lift”. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 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 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) 29,30 The manager’s commitment to training encouraged and supported the staff to equip themselves with the knowledge necessary to provide the best care for the service users. EVIDENCE: Service users said that the staff were friendly and kind. The inspector observed the staff working as a team and noted that they interacted well. They chose to have their coffee break together sitting with the service users. The manager explained how the staff would work over and above the call of duty to cover sickness and absences. The home had satisfactory recruitment procedures. Staff files sampled indicated that the correct references were obtained and staff had the necessary checks before being employed. All staff had been provided with copies of General Social Care Councils code of practice; there was documented evidence that they had read these codes and agreed to abide by them. It was noted that terms of employment had been amended appropriately as positions changed. For example, when hours were altered or additional responsibilities were taken on. The manager supported and encouraged staff training. Five staff members had NVQ qualifications (one at level 3), a further five where in the process of St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 18 completing NVQ’s and one had been accepted to start in September. Staff files also indicated that staff attended a variety of different trainings and were supported to keep them updated. There was evidence that comments and information from staff appraisals influenced the homes training programme. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 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 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) 31,32,36,37,38 The home had an experienced and committed manager with strong leadership who ensured that best practice safeguarded service users. EVIDENCE: Since the last inspection the manager had been awarded the Registered Managers Award. She was the first of the managers in the group of three homes under the same ownership to receive this qualification and would be a useful resource to her colleagues. There was clear evidence that the manager had the trust and respect of the staff and that they were grateful for her open and transparent method of management. Staff met regular with the manager and were supervised at least six times a year. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 20 During the inspection it was noted that a member of staff was wearing open shoes. The inspector discussed with the manager the need to risk assess if this was necessary and to refrain from allowing care staff to care for service users in this type of footwear. Records were kept securely. As requested at the last inspection the practise of keeping the daily progress notes in the kitchen had been altered. However the inspector was not happy that these records were now in the laundry room as this was another area where access was best kept to a minimum to prevent cross infection. All the required testing of systems and equipment was being carried out and the home had good policies and procedures for the protection of service users. St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x 3 3 2 St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 22 no0 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. 2. Standard 9 9 Regulation 13 17 Requirement The person administering the medication must not leave the medication trolley unattended Where variable doses of mecication can be administered the exact dose given must be recorded om the MAR sheet. Timescale for action 16.9.05 16.9.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 38 38 Good Practice Recommendations Staff should be encouraged to wear the correct footwear. The manager should give consideration to a safer place for the storage of progress notes St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Bedford Office, Clifton House 4a Goldington Road Bedford MK40 3NF 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. Extracts may not be used or reproduced without the express permission of CSCI St Annes I51 S14958 St Annes V235159 190705 Stage 4.doc Version 1.40 Page 24 - 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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