Inspection on 04/07/07 for St Annes

This inspection was carried out on 4th July 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 Annes 07/05/08

St Annes 08/08/06

St Annes 16/02/06

St Annes 22/07/05

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 Andrea James Unannounced Inspection 4th July 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 Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Annes Address 30 Lansdowne Road Luton LU3 1EE 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) 01582 726265 F/P 01582 726265 ccg1@easy.com Mr Cornelius Crowley Mrs Kathleen Bernadette Lysaght Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (20) St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: St Annes 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. Private accommodation is distributed on all of the homes 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 passenger lift. Toilet and bathing facilities are located on each floor. There is a large combined lounge/diner that incorporates a smaller lounge 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. Fees from 1st April 2006 were advertised as between £405 to £450. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, carried out on the 4th of July 2007, 11 months after the last key inspection. The inspection lasted for 6 hours. The Registered manager assisted with the inspection process. The inspection process followed a case tracking methodology where a sample of people using the service were selected at random. The users selected were spoken to, their files inspected and where possible their key workers and relatives spoken to. The report also consists of information gathered from the AQAA (Annual Quality Assurance assessment) received from the home. The inspector would like to thank the people using the service, care staff, relatives and the manager for their co-operation in the inspection process. What the service does well: The home provided a good standard of care to people using the service. It was evident from discussions with people using the service, care staff, relatives and the manager that the systems that existed were satisfactory in meeting the needs of the people using the service. The home had a stable staff team and most of the care staff worked for between 13 to 15 years with the users and as a result were knowledgeable and competent in providing a very good standard of care. The service was also good at meeting users with diverse cultural and religious needs, by providing a care package that could be delivered by all care staff. Care staff were trained in meeting the needs of people with dementia and the manager had recently embarked on further training to see how best to meet users needs that may have dementia. Relatives spoken to said the home provided a friendly environment for the users and those visiting the home. The home was good at ensuring users birthdays were celebrated and the care team were consistent in the care they delivered. People using the service also spoke positively about the care staff and felt that they treated them with respect and dignity. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should ensure: • They employ more domiciliary staff to undertake the housework duties, which would ensure care staff are able to spend more time with people using the service. The window in the lounge on the 2nd floor is fitted with a window restrictor. • Please contact the provider for advice of actions taken in response to this inspection. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 &4. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Satisfactory systems were in place to ensure people using the service receive sufficient information about the service and were subjected to good assessments prior to admission. As a result users were fully informed about the service prior to admission. EVIDENCE: A copy of the home’s Statement of Purpose was displayed in the foyer of the home. The people using the service received satisfactory Service Users Guide and were subjected to good admission assessments on admission. The admissions documentation would benefit from being improved to reflect the needs of people with dementia. The users also had satisfactory contractual agreements that were signed and dated and kept on individual users files. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 10 Relatives spoken to said they were also informed about the services offered by the home and were given the opportunity to visit the home. One user whose mother was from another culture also felt that her mothers needs were satisfactorily met. The manager explained that diversity was met for all users by introducing different meals to users and maintaining their religious beliefs of those wishing to pursue this. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. The home’s procedures for meeting the personal health care needs of people using the service were satisfactory, as a result users received a consistent standard of personal care delivery. EVIDENCE: The health care needs of people using the service were satisfactorily met. The care plan documentation showed monthly care plan reviews, satisfactory risk assessments, manual-handling assessments, and nutritional assessments. There was also evidence that people using the service were consulted about service delivery. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 12 The home had adopted a person centred approach to dementia and this was evident in the care plan documentation. Staff spoken to said they felt confident in meeting the needs of users with dementia. The home had satisfactory medication policies and procedures. The inspector was able to observe the morning medication, and the care staff appeared competent in administering medication to the users. The receipt, storage, administration and disposal of medication were all satisfactorily maintained with evidence to suggest safe systems were being upheld. Some users spoken to said the staff treated them with respect and their privacy was upheld. The inspector observed care staff speaking to people using the service in a respectful and friendly way. Relatives said the care staff were very friendly and always treated the users and visitors to the home with the “uttermost courtesy”. They were always offered a drink. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Systems were in place to ensure people using the service lived in a way that met with their expectations and satisfied their diverse needs, as a result users quality of life was good. EVIDENCE: The needs of the people residing in the home were diverse. The home had successfully managed to provide flexible daily routines to meet these diverse needs. The users spoken to gave examples of how the home met their needs, one user said “ I am ok, I like it hear I can do what I like”. Another said there are lots of activities for me to do”. The inspector was informed that an activities co-ordinator comes into the home once per week. The home kept an activities programme to evidence the regularity of activities, which are also undertaken by the staff team. People using the service spoke of various parties, garden fetes and an outing they had undertaken. A trip to Whipsnade Zoo was planned for the near future. The home had various pictures of past events showing the users having fun with family and friends. Records seen St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 14 suggested that in the month of June for example 9 hairdresser appointments were undertaken, 3 craft sessions, 26 sing- a –longs and 15 karaoke sessions. The people using the service said they had regular visits from their family members. The inspector was able to speak to two family members during the visit that both spoke positively about the home. The home provided wholesome meals to people using the service and also catered for users with different dietary needs. One relative said they were always offered choice to users, she gave an example of one user who was given a fried egg sandwich as she did not want the meal provided. Another user was catered for in accordance with cultural needs and relatives were encouraged to bring in meals for users who chose this option. The cook explained that a monthly “surgery” was held with users about the provision of meals and adjustments were made to menus accordingly and in relation to seasonal foods. The menus and food stocks seen showed a varied choice that included fresh fruit, vegetables and salad. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. The home had robust procedures that safeguarded people using the service from abuse or neglect, as a result users were not at unnecessary risk. EVIDENCE: The home provided all users and their relatives with a copy of the complaints procedures. Those spoken to by the inspector said they knew how to complain should the need arise. The home also displayed their complaints procedure in the hallway of the building and stakeholders were given the opportunity to comment on complaints procedure at their general meetings. There had been no complaints to the commission or the home since the last inspection. Staff spoken to said they received training on “Safeguarding of Adults” and records showed that a large percentage of staff received this training in the last 12 months. A referral was made to Social services where bruises were found on a user’s knuckles. This matter is being investigated by Social Services. The home followed procedures by reporting the incident to the appropriate authorities. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 16 Relatives, care staff and people using the service said the home operated an open door policy and felt able to speak to the manager should they have any concerns. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 &26. People using the service experience an adequate quality outcome in this area. We have made this judgement by using a range of evidence including a visit to the service. The environmental standards provided comfort to people using the service but some development was needed to ensure all areas of the home are homely and welcoming for users of the service, as a result some users could find their surroundings unwelcoming. EVIDENCE: The people using the service live in an environment that is safe, clean and comfortable for most parts. The home employed a maintenance person and the daily maintenance issues are addressed promptly, however the inspector was able to tour the building and found that some areas of the home detracted from the homeliness that the users are accustomed to. For example some rooms were in need of redecorating to include the need to replace some St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 18 curtains, which were torn and discoloured. The manager informed the inspector that they had replaced several of the users wash hand basins and as a result would be replacing carpets. The bedrooms inspected failed to have lockable facilities and as a result it was not clear how users would safeguard valuables if they wanted to. Some doors did not have locks fitted but the care plan documentation had evidence to show that users did not wish to have keys to their bedroom doors. There was evidence that some areas of the home had received redecorating and was therefore welcoming. The home had sufficient toileting facilities for people using the service and was due to change the existing bathroom on the second floor with a wet room to encourage more users the option of having baths. The home had disabled toilets for users with physical disabilities. The home provided a shaft lift and a stair lift to enable users to have access to their bedrooms and a hoist was provided for one user who needed to be manually transferred. The home was safe and clean throughout with the exception of one window, which was noted, to be open and did not have on window restrictors. This room was said to be used by users from time to time. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30. People using the service experience a good quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Systems were in place to ensure the people using the service received consistent service delivery from a skilled number of care staff, as a result users were protected. EVIDENCE: The home had a steady core of care staff that had worked in the home for between 13 to 15 years and as a result were knowledgeable and skilled in meeting the changing needs of the people using the service. The home’s recruitment procedures were satisfactory and as a result users were safeguarded. The home did not have any vacancies for carers at the time of the inspection and all the carers spoken to said they enjoyed the job and would not change anything about the way the home was managed. Users and relatives spoken to all spoke positively about the care staff. One relative said the carers are “ friendly, consistent” and they couldn’t improve on anything they did. One user said “staff always asks what I want and try to get it for me”. Another said “they treat me nice”. The numbers of staff were also adequate for meeting the number of users 4 care staff were on shift to meet the needs of 20 users. It was concerning that St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 20 carers also had to undertake a large amount of the housework duties. Carers were observed to have to work in the laundry room, Hoover the carpets, prepare hot and cold beverages and prepare evening meal for users. This detracted from the level of care time for people using the service. The home had a cleaner that only worked for a few hours per day. The manager informed the inspector that the night staff had improved from having 1 waking night and a sleep in carers to having two waking night staff to meet the needs of people using the service. The care staff spoken to all said they received the relevant training required for them to meet the changing needs of people using the service. Records seen showed that carers received regular training courses.96 of the staff team had undertaken training in dementia and 15 of the 18 care staff had achieved their NVQ level 2 in care.14 staff achieved medication training in January 2007 and all mandatory training was undertaken by all care staff. Records show that new employees also received induction, supervision and appraisals at the onset of their employment. The Induction programme was in line with Social Skills training. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 & 38. People using the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Satisfactory systems were in place to ensure effective management of the service and to monitor users welfare, as a result users best interests were considered. EVIDENCE: The manager appeared knowledgeable about the needs of the home and the care required for the people using the service. The home also had an acting manager who complimented the management team in ensuring the smooth running of the home. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 22 The home was recognised by the local council for their care of people with dementia and the, manager had recently embarked on a 12 week dementia course where she hoped the information learned will be able to further develop the care users with dementia receives. The users financial arrangement procedures were satisfactory but checking three of the users money kept in the office one users money was over by £1.00 the manager felt this was as a result of the £1.00 falling out from another users purse. Receipts were seen for all financial transactions and satisfactory signatures were seen when users money was taken or returned to safe. The home had a satisfactory quality assurance system that showed that 83.5 of users and relatives were happy with the service delivery an increase of 22.5 from the previous year. The home carried out monthly residents meetings and users spoken to said they felt able to voice their opinions to implement change. All staff spoken to said they received regular supervision, which was evidenced by the records seen when files were inspected. The home had satisfactory policies and procedures, which were reviewed on a regular basis. Records seen also suggested that satisfactory record keeping was undertaken to safeguard users of the service. The home had a health and safety policy and safe procedures were implemented within the home. Visual checks during the tour of the building showed that equipment had been serviced regularly. Care staff received health and safety training as a part of their mandatory training programme. A window on the second floor was observed to be open and did not have ant restrictors fitted. The inspector was therefore concerned for users safety who often had access to the room. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 2 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 2 3 3 2 St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement Timescale for action 30/08/07 2 OP7 15 (1) 3 OP38 13 (4) (a) All assessment documentation must be improved to incorporate assessments for users with dementia. Arrangements must be made to 30/08/07 ensure clear and measurable instructions are recorded in care plans for people using the service. Arrangements must be made to 30/08/07 ensure all windows above ground level are fitted with a window restrictor to prevent harm coming to people using the service. 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 St Annes Refer to Standard OP23 OP27 Good Practice Recommendations Arrangements should be made to ensure all users bedrooms are satisfactorily decorated to ensure comfort. Arrangements should be made to ensure more time is DS0000014958.V342020.R01.S.doc Version 5.2 Page 25 given to carers to carry out personal care to people using the service and housework duties are given to domestic staff. St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Annes DS0000014958.V342020.R01.S.doc Version 5.2 Page 27 - 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!