Inspection on 07/05/08 for St Annes

This inspection was carried out on 7th May 2008.

CSCI found this care home to be providing an Good service.

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 04/07/07

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 Mr Neil Fernando Announced Inspection 7th May 2008 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.V364057.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.V364057.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 stannes@live.co.uk 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.V364057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2007 Brief Description of the Service: St Annes is a residential care home registered to accommodate up to 20 older people who may also have dementia and limited physical disabilities. This is one of three care homes for older people, located in close proximity to each other and privately owned by Mr Cornelius Crowley. The accommodation offers 1 shared and 18 single bedrooms, which are located on all three floors. Bedrooms are fitted with wash hand basins and nine have en-suite toilet facilities. Communal toilet and bathing facilities are located on all floors. 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. An emergency call bell system is available. Both a passenger and stair lift is available to access the first and second floors. There is a good size well-maintained garden, with patio areas and seating facilities, and shrubs and mature trees. Residents spoken to say that the garden is well used during the warmer season. Hard standing to the front of the home provides limited car parking. Time limited road parking is available in the area. Access to the M1 and Luton town centre is nearby. A copy of the service user’s guide and inspection report is available for residents and visitors to read. The fees for this service vary between £431 and £515 per week; the exact fees are reflected in individual contracts for the residents. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We, the Commission for Social Care Inspection, undertook this announced key inspection on 7 May 2008. We spoke with 10 residents, 1 visiting relative, the manager and 3 staff members. We did a tour of the accommodation and viewed a range of records the home must keep. We also discretely observed staff care practice and their interaction with residents. We received a completed “AQAA” (Annual Quality Assurance Assessment) – a document, which gives the manager the opportunity to tell us how the agency is meeting the standards and regulations. To date, we have received surveys from 3 residents, 7 relatives and 5 staff. The manager was present throughout the inspection. What the service does well: What has improved since the last inspection? St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 6 The three requirements and two recommendations arising from the last inspection report dated 4 July 2007 have been addressed. This has resulted in the following improvements: All assessment documentation has been reviewed and updated, in order to reflect the assessments for residents with dementia. The care plans are clear and detailed, and measurable instructions are now recorded; this enables staff to address the identified needs of each resident. All windows above ground level have been fitted with window restrictors to ensure the safety of residents and security of the building. An ongoing programme of maintenance and redecoration is in place; this ensures a safe and good standard of physical environment for residents. The domestic arrangements have been reviewed and cleaning hours increased, as appropriate. This means that care staff members are now able to focus their time on undertaking care tasks for residents, leaving housework duties to the domestic staff. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Annes DS0000014958.V364057.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): Standards 1, 2, 3, 4 and 5. Standard 6 is not applicable to this home. Quality in this outcome area is good. Detailed information about the home is provided to all prospective residents and full assessments are completed, so that all parties can be sure the home can meet the individual’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Appropriate details about the home are provided in the service user’s guide, which is given to all residents, prospective residents and their families. Fees for the home and what the fees include are clearly set out. All residents also have a written contract, which states the room to be occupied, and the amount and how fees are to be paid. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 9 The AQAA indicates “A detailed needs assessment is carried out at their home, at our home, hospital or other, by a manager or senior staff member. Where possible, we obtain a copy of a previous/ current care plan. A decision is made to determine whether the individual needs may or may not be met”. The records examined for three residents including the last person admitted to the home contain copies of care plan from previous placement, summaries from referring agencies and pre-admission assessments of needs, completed by the manager or duty manager. Initial individual care plans are completed using this information. Information about the prospective resident is also sought from their family, health and social care professionals. The prospective resident and their family are encouraged to visit the home and meet with residents and staff. All new residents are offered a trial period. The home also provides care for people with dementia and all staff have received training in aspects of dementia care. The building is constructed to provide a safe yet accessible environment for individuals who may be confused and the grounds are attractive and secure. St Annes DS0000014958.V364057.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): Standards 7, 8, 9 and 10 Quality in this outcome area is good. The residents observed during the course of the visit appeared to be well cared for. Procedures followed ensure that medication is safely administered and residents’ dignity and respect, promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for three residents were checked. Very good details and up to date information is being maintained. Residents’ needs including health, personal hygiene, dressing, mobility, communication, food and religion are clearly identified and being addressed. The key worker and residents have signed the care plans examined where appropriate. It is recommended that their representatives’ signature should also be obtained; this would St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 11 demonstrate that they have contributed and are in agreement with the contents of the care plans. Care plans contain evidence that individual health needs are being monitored and met; some residents spoken with confirmed that they had visits from a chiropodist, GP, district nurse and saw the dentist. Care records show that residents’ dietary needs are closely monitored and their weight regularly checked. Each resident has an internal monthly review undertaken by staff, involving the resident and their representative as appropriate. If there is a change to a persons care needs before the next review is due, the care plan is amended so that care staff are aware and will provide support in the most appropriate way. “Any change in our residents is noted in their care plan”, said a staff in their survey. Risk assessments are completed and updated for each resident. We observed staff using a variety of equipment to assist residents to transfer from and to chairs. All such assistance was provided in a professional and sensitive manner, thus ensuring everyone’s safety. This also demonstrates that staff training in moving and handling residents is being properly followed through in practice. Procedure for administering medication in the home was checked and storage and recording complied with all current guidelines. All staff authorised to administer medication have received training on this subject. The administration records for six residents were examined and these were in order. Residents spoken with said that they receive their medication on time. Residents are clear that staff treat them with dignity and respect and that their privacy is upheld. These views were confirmed by the interaction between staff and residents, observed during the visit. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. Most residents live the life they want to and it meets their expectations; this ensures that they have choice and control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home practices a person centred approach and therefore, treats residents as unique individuals. The routines of daily living are made as flexible as possible to suit the needs and choice of individuals. Care plans and activities programme viewed show how residents’ identified social and recreational needs are being met. Many residents spoken with generally expressed satisfaction in this area. “The girls provide more than enough activities for us here”, said one resident. However, three residents felt that the level of social activities “could be improved”. The manager has been informed and she would be looking into this matter. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 13 Policy and procedure on equality and diversity is available; the manager is aware that this needs to be further developed to include human rights. Representatives of different faiths visit the home regularly so that residents can attend services and speak with the representative of their choosing about their spiritual needs. The home offers a shared bedroom for people who express a wish to share. Staff spoken to demonstrated a good understanding of issues regarding equality and diversity. Staff are clear that social contacts with family and friends are encouraged. Everyone spoken to confirmed they can have visitors and there are no restrictions on where visits take place. Without exception, all residents spoken with said they received regular visits from their relatives. The family member of one resident said, “Staff are always courteous and welcoming, always a big smile on their face”. Residents said they are able to do what they want. They can get up and go to bed when they want and wear what they want. One person said she can lie down in the afternoon in her room and is able to decide when she does this. Meals are served in the dining areas of the two combined dining/lounge areas. Tables are set and there are condiments on tables. Staff members sit with those people who need help to eat. This may be by physically helping residents or by simply giving them encouragement and reminding them what to do. The staff members whom we saw doing this were attentive to what they were doing and did not become distracted by other people or rush the residents they were helping. Residents are involved in menu planning, so they can enjoy food they prefer and like. The menu caters for different cultural and dietary needs as well. All residents expressed a high level of satisfaction with respect to food available. “Good and excellent food”, was the common theme. A visiting relative said, “The kitchen is always clean and the variety and quality of food is excellent”. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. The systems in place for dealing with complaints and adult protection are being implemented to good effect. Residents are therefore assured that their concerns will be addressed and their safety, protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA indicates the home, “Ensure that all service users and/or their families/representatives have a copy of our complaints procedure and understand it”. The procedure on complaints is available to all staff. Information on how to make a complaint is included in the statement of purpose and the service user’s guide. The home also displays its complaints procedure in the hallway of the accommodation; stakeholders have the opportunity to comment on the complaints procedure at their general meetings. Those residents spoken to and surveys from 10 relatives including 3 residents indicates that they know how to complain should the need arise. Staff when interviewed gave satisfactory responses on their responsibilities when receiving a complaint, which is consistent with the home’s guidance and procedure. The complaints record was St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 15 viewed. There has been no complaint recorded since the last inspection; neither has any complaint been made to the commission about the home, during the same period. Written policies and procedures are in place to protect residents from abuse and neglect. The policies include the SoVA (Safeguarding of Vulnerable Adults) and Whistle Blowing. Staff have received training on safeguarding adults; those spoken to, were able to explain the procedures they would follow in the event of a suspected abuse. There have been no adult protection matters since the previous inspection in July 2007. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 16 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): Standards 19, 23, 25 and 26 Quality in this outcome area is good. St Annes is a clean and well-maintained environment. Residents are therefore assured of a pleasant, hygienic and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A brief tour of the building was undertaken, which included the communal areas, 8 bedrooms and some bathroom and toilet facilities. These are decorated and furnished in a style to reflect the period features of the building. Some of the rooms look out onto the front yard and rear garden. All areas viewed are accessible and well maintained. The home employs a maintenance person and any maintenance work is addressed promptly. There is a rolling St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 17 programme of refurbishment in place; two bedrooms, ground floor toilets and the kitchen have been upgraded since the last inspection in July 2007. Residents are encouraged to bring items of furniture, pictures and photographs to make their rooms as homely as possible. Evidence of these was seen in the bedrooms viewed. Residents are able to retain the key to their own bedrooms, as appropriate. The home was clean and free from any offensive odours. Residents have access to a good size garden, which is attractively presented with patio areas and seating facilities, and shrubs and mature trees. Residents were seen in the garden enjoying the afternoon sunshine. There were no health and safety hazards noted. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. Systems are in place for recruiting, training and supporting the staff team as a result, the residents are protected and are in safe hands. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA indicates, “As declared in our statement of purpose, we have experienced, competent and well trained staff. We avoid using agency staff, in the event of absences, fellow staff will cover shifts or our core group from our sistering homes on the same road will assist”. The staff rotas indicated that sufficient numbers of staff are rostered on to meet the needs of the people using the service. The home had no staff vacancies and did not use agency staff to provide care. Staff spoken with said they have received all mandatory training. Records viewed show that the manager has implemented training with clear training records which include PoVA, moving and handling, health and safety, first aid, fire, infection control, basic food hygiene and safe handling of medicines. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 19 Updates and refreshers are planned throughout the year. The home has a training programme for 2008 where other areas of training needs are being identified for future implementation. 10 of the 17 care staff have completed their NVQ level 2 and another 3 are currently working towards it. This provides a good ratio of qualified and experienced staff on each shift, thus ensuring a good standard of service delivery. The homes recruitment procedure is comprehensive and its application, robust. Three staff files were seen. They all contained evidence of application forms, CRB/PoVA checks, two references and proof of identity, thus meeting the requirements of the regulations. Many residents and relatives made positive comments on the skills of the staff team. One relative responded in a survey, “When the residents are calling out for something to be done, the staff go at once to see what their need is. The staff always speak to them in a kind, gentle manner”. “Staff are very nice” and “They are very good” are typical examples of comments from residents spoken with. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 20 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): Standards 31, 32, 33, 36, 37, and 38 Quality in this outcome area is good. The home is being well managed. This means that care and staff managements systems are being implemented to good effect, which benefit staff and ensure the safety and welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has managed the home for over 13 years; she clearly has extensive management experience and skills in the residential care field for older people. She holds the City and Guilds in Care Management and has St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 21 completed the Registered Manager’s Award. The manager has also followed a 13-weeks course on dementia, during Summer 2007. The continuity in the management of the home has enabled the service to meet its aims and objectives. The manager operates an open door policy, which promotes effective communication with staff, residents and relatives. The manager is also well supported by the registered provider. There is good evidence to show that quality assurance systems are in place to seek the views of residents, families and other stakeholders. Where issues are raised, the manager takes action as appropriate. A copy of the annual survey, including outcomes and remedial action taken if any, is also sent to the Commission. The proprietor has carried out monthly visits to the home, in order to ensure that appropriate standards are being maintained; reports on these visits are available at the home. The manager carries staff supervision out every other month and a record is maintained. Staff spoken to confirmed that they receive regular supervision; they reported a good deal of satisfaction with respect to the support and guidance they receive from the manager. Records examined were found to be in good order. Staff have received all mandatory training, which enables them work safely and promote health and safety. There were no health and safety issues noted. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 22 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 3 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 3 3 X X X 3 X 3 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 3 3 X N/A 3 3 3 St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Given the mental frailty of the residents, care plans should include the signature of their representatives where appropriate; this would demonstrate their involvement in the care planning process and their agreement with the contents of the care plans. St Annes DS0000014958.V364057.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V364057.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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