Inspection on 08/08/06 for St Annes

This inspection was carried out on 8th August 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Annes 07/05/08

St Annes 04/07/07

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 Leonorah Milton Unannounced Inspection 8th August 2006 11:30 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.V307029.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.V307029.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 01582 726265 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.V307029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 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.V307029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report sets out the significant evidence that has been collated by the Commission for Social Care (CSCI) since the last visit to and public report on, the home’s service provision in February 2006. Reports from the home, other statutory agencies, and information gathered at the site visit to the home, which was carried out on 8th August 2006 were taken into account. The visit to the home included a review of the case files for two service users, conversations with six service users and four members of staff. Much of the time was spent with service users the ground floor lounge/diner, where the daily lifestyle was observed. A partial tour of the building was carried out and other records were reviewed. The manager was absent on the day of the inspection visit but the deputy, who had worked in the home for a number of years, was on site to assist with the inspection process. What the service does well: The home was well managed. It was evident from discussions with members of staff and documents available that the manager had put systems into place to ensure that the home operated smoothly during her absence. It is however advisable that no other staff guidance notices are put up in the communal areas of the home as these somewhat detract from the homely appearance of the premises. The building provided a comfortable and homely environment. This homely atmosphere was enhanced by the attitude and practice of the home’s staff who had created a welcoming, friendly ambiance that was conducive to the service users’ well being. Indeed, service users passed many favourable comments about members of staff and were evidently relaxed in this pleasant atmosphere. There was a high degree of customer satisfaction. The results of the most recent quality review showed that service users had no complaints about the service. Comments passed at this inspection included, “I am very happy to live here”, “I transferred from another home and prefer it here”, “Everything here is good”. It was noted that the approaches of personnel to service users were patient and sensitive to their needs and particularly so towards service users who had short term memory loss. It was encouraging that service users who wished to wander were not restricted unless it was in their best interests or those of another service user. St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 6 Service users reported that they were satisfied with the arrangements for the day-to-day routines in the home. They confirmed that a range of activities was available to them for recreation and diversion and that meals and beverages served to them were plentiful and to their liking. 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. St Annes DS0000014958.V307029.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.V307029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Satisfactory information was available to service users to enable them to make an informed choice about moving into the home. Sufficient information had been sought about service users’ needs before they moved into the home to ensure that the home had the capability to properly care for them. EVIDENCE: A copy of the home’s statement of purpose and its service user guide was attached to the notice board in the main lounge. The documents provided a comprehensive and user-friendly guide to the service. The guide had been updated since the previous inspection in response to a requirement and contained a sample of a contract and a copy of the report on the last inspection carried out by the CSCI. St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 9 The case files seen at this inspection showed that a basic assessment of need had been carried out prior to admission. One showed that the service user and a member of their family member had contributed to the assessment. The home did not provide an intermediate care service. St Annes DS0000014958.V307029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Plans of care were detailed and provided sufficient guidance for personnel to enable them to care for service users properly. Service users’ healthcare needs had been well met. EVIDENCE: The plans of care seen were of a good standard and covered the details specified by the National Minimum Standards. Each plan had been personalised to give a comprehensive guide to show how individual needs were to be met. Included in the plans were assessments of the risks involved with moving and handling tasks and in relation to nutritional needs. Also noted were individual preferences for meals, hobbies, recreational pursuits, healthcare needs and needs at death. Those service users who were able to contribute to the inspection confirmed that they had been able to see their doctors promptly when the need had St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 11 arisen and had received regular routine treatment from a chiropodist and an annual optical check up. A member of staff was observed administering medications. Her practice met safe guidelines. She was able to show during discussions that she understood safe practice. Records indicated that personnel with the responsibility for handling medicines had undergone training to do so. The storage of medicines had improved since the last inspection. A lockable fridge had been obtained for the storage of medicines that required cold storage. Members of staff on duty were observed to treat service users with friendly courtesy. One service user stated that staff, “are courteous to me”. Another stated, “They treat me with respect”. Another said, “They treat me well and knock on my bedroom door before entering”. St Annes DS0000014958.V307029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Service users had been supported to achieve a lifestyle that, were practical and safe to do so, met their expectations. EVIDENCE: The needs of the service users residing in the home were diverse. The home had successfully managed to provide flexible daily routines to meet these diverse needs. Service users comments included, “I can do what I want…..I often get up very early and staff don’t mind”, “I feel I am able to do as I want, I can come and go as I want”, “There are lots of entertainments and activities”. Service users described a recent garden party as “jolly” and “fun”. Another service user stated that their visitors came frequently and that they were able to go out of the home as they wished with their friends or family. The provision for meals had been based on regular consultation with service users to gauge their preferences and dislikes. The cook explained that a monthly “surgery” was held with service users about the provision of meals and adjustments were made to menus accordingly and in relation to seasonal St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 13 foods. The menus and food stocks seen showed a varied choice that included fresh fruit, vegetables and salad. A cooked choice was available for the teatime meal as well as a cold snack. Service users said that they were satisfied with the meals, “The food is nice and there is plenty of it. If you don’t like something, they will get you something else”; “The food is very nice. You get lots of cups of teas”; “The food is good”. St Annes DS0000014958.V307029.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home had robust procedures for the protection of service users and to enable them to complain. EVIDENCE: Previous inspections had shown that the home had a satisfactory complaints procedure. At the site visit it was noted that the procedure was advertised in the home for service users and their representatives. There had been no complaints to the Commission or the home since the previous inspection. It was evident that service users had been supported to raise concerns and that these had been dealt before they became more serious complaints. Service users confirmed that they felt able to voice their opinions. One stated, “We have regular meetings and opportunities to say how we feel”. Another spoke about the accessibility of the manager and said that she was very open and would, “sort out our problems”. The deputy stated that action had been taken to ensure that staff left in charge of the building felt able to report any issues involving protection of service users. Notices were posted about reporting procedures and contact telephone numbers for the manager and senior personnel in other homes in the vicinity that were owned by the proprietor. Members of care staff spoken to confirmed St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 15 that they had undertaken training in protection procedures and in conversation showed that they understood their individual responsibility in these matters. Recruitment records were not available at this inspection. Previous inspections however had not raised any issues about recruitment and had showed that the necessary checks on personnel had been carried out before employment had commenced. St Annes DS0000014958.V307029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The premises provided a comfortable and well-adapted environment that was suitable for the needs of its current service users. There were however some risks of cross contamination that may result in the spread of infection to service users. EVIDENCE: As had been noted previously the home had been well maintained and had lots of homely touches. Bedrooms on the whole had been individualised by service users’ personal possessions. Adaptations to the building meant that the home could accommodate people with some physical disabilities, although not all of the bedrooms were suitable for wheelchair users. During the tour of the building with the deputy it was noted that one bedroom had an unpleasant odour. The carpet in this room must be cleaned and if necessary replaced. St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 17 It was also noted that several bedrooms were without door locks. The proprietor subsequently submitted a sample questionnaire in relation to service users’ choices to have locks on bedroom doors. The principal remains however, that all bedroom doors must be lockable to ensure that service users have a real choice on admission and that service users’ belongings can be secured if they are absent from the home. The door to the bathroom on the upper floor did not have a lock. The lock on the toilet on this floor did not work properly and secure the door from the inside. The laundry room where foul linen was washed also contained a cupboard that housed the district nurses’ dressings, documents and similar. Whilst some of the nurses’ documentation had been stored elsewhere in response to a requirement, these remaining arrangements were unsatisfactory. Alternative storage, where there is no risk of contamination, must be provided for these items. St Annes DS0000014958.V307029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Members of staff had sufficient knowledge and experience to care for service users properly. EVIDENCE: The majority of the staff had worked in the home for a significant time and were well versed with service users’ needs and the operational systems of the home. Rotas showed that sufficient numbers of staff had been scheduled to work throughout the day. The home had continued with its practice of only having one waking member of night staff. This arrangement had been questioned at previous inspections and had been qualified by written risk assessment. The Commission will continue to monitor this arrangement in the light of dependency levels in the home. It was evident that staff worked well together and that service users had benefited from this good teamwork. Service users were most complementary about the personnel in the home. “ They are very kind to me”, “The night staff are very good”, Staff are good to me”, “Staff are friendly and kind” and “They are all good to me here”. St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 19 The staff in turn showed a regard for service users and a loyalty to the home and the manager. One spoke about the good teamwork and stated that you couldn’t find better employers. Two others mentioned the happy working atmosphere in the home. Records indicated a good level of training and further planned for this year. Topics covered included statutory health and safety matters and other issues pertinent to the care of frail older people such as catheter care, diabetes, dementia awareness and skills in supervision. A recent employee stated that she had found her induction to be helpful and that she had felt supported by the manager and the rest of the team to settle into her new job. The records available indicated that the majority of care staff (twelve) had achieved a National Vocational Qualification in care and that four others were working towards this award. Given that the organisation takes a corporate approach to training and it was identified at another home under this ownership that the records of training didn’t always identify the content of training courses, St Annes in common with the other homes, must ensure that training is relevant to the home’s statement of purpose and maintain records to show the same. St Annes DS0000014958.V307029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Systems were in place to ensure effective management of the home and to monitor service users’ welfare. EVIDENCE: Previous inspections had established that the manager was qualified and experienced to run a care home. Service users and staff were positive about her input into the home. One service user said that she, “liked the boss” and another described her as very approachable. Previous inspections had also noted that the manager did not attend the home on a full time basis. The Commission had been informed that she carried out work at home. Whilst it is accepted that the home was operating smoothly and that service users had been well cared for it is never-the-less a little St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 21 concerned that the plethora of staff guidance notices do not become a replacement for hands on management. Service users had evidently been given the opportunity to comment on the operation of the home. Minutes were seen of meetings with service users carried out this year on 30th March, 29th April and 20th June. A report was also seen on the quality audit carried out in January 2006. There was no access to monies held on behalf of service users at the visit to the home. The deputy explained that the manager had left a “float” in case any unplanned purchases came about. This system must be revised. Service users, or where appropriate their representatives, must have unrestricted access to their money and records of the same. Records indicated that supervision had been provided for staff on a regular basis. Staff confirmed that they had received supervision. Health and safety of arrangements seen at this inspection were mostly satisfactory. Visual checks during the tour of the building showed that equipment had been serviced regularly, records indicated that staff had received health and safety training and appropriate written guidance was available to staff. Accidents had been recorded properly and showed the manager’s comment where appropriate. The home had a policy of referring service users to the “falls management clinic” where a need was identified. The only health and safety concern arising from this visit was the risk of cross infection in the laundry. St Annes DS0000014958.V307029.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 x 3 x x x 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 1 x x x x 2 STAFFING Standard No Score 27 2 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 3 x 2 St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP25 Regulation 13(4)(c) Requirement The integral heating systems throughout the home must be sufficient to provide comfortable ambient room temperature that do not rely on secondary heating methods. Issued at the previous inspection with an action date of 30/06/06. It was not possible to assess the heating systems, but it was noted that freestanding heaters had been removed. This requirement is therefore carried forward until inspection is possible. Timescale for action 31/10/06 2. 3. OP21 OP26 23(1)(a) 13(3) The doors to bathrooms and 30/09/06 toilets must be provided with workable locks. 30/09/06 Documents, such as district nursing notes and similar in relation to the care of individual service users, must not be stored in the laundry to minimise the risk of cross contamination. The previous action date of 28/02/06 had not been met in full. DS0000014958.V307029.R01.S.doc Version 5.2 Page 24 St Annes 4. OP26 16(2)(k) 5. OP35 12 6. OP37 17(2) Sch 4 Service users bedrooms must be 31/10/06 free of offensive odours. In this instance the carpet of the bedroom that was discussed with the deputy must be cleaned and if necessary replaced. Service users, or where 30/09/06 appropriate their representatives, must have unrestricted access to monies and records of the same held on their behalf. Training records must be 30/09/06 maintained to show the course content/training provision. 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 OP14 Good Practice Recommendations Service users should be informed that they have the right to see records made about them unless their assessed levels of ability precludes this. Issued at the previous inspection of 16th February 2006. Not assessed at this inspection. Case files should contain risk assessments to show why service users are not able to manage keys to their rooms or lockable facilities. Issued at the previous inspection of 16th February 2006. Not assessed at this inspection. 2. OP24 St Annes DS0000014958.V307029.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area 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 DS0000014958.V307029.R01.S.doc Version 5.2 Page 26 - 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. 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