Inspection on 17/05/07 for St Annes Residential Care Home

This inspection was carried out on 17th May 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 Residential Care Home 02/08/06

St Annes Residential Care Home 28/10/05

St Annes Residential Care Home 09/06/05

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Annes Residential Care Home 1-4 Rockcliffe Whitley Bay Tyne & Wear NE26 2BG Lead Inspector Allan Helmrich Key Unannounced Inspection 1:00 17 and 18th May 2007 th 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 Residential Care Home DS0000063195.V333617.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 Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Annes Residential Care Home Address 1-4 Rockcliffe Whitley Bay Tyne & Wear NE26 2BG 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) 0191 252 9172 0191 251 0891 Mr Trevor Nesbit Mrs Julie May Charlton Care Home 40 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (33) of places St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2006 Brief Description of the Service: St Annes is converted from three Victorian style terraced houses. It is situated on the seafront between Cullercoats and Whitley Bay and has excellent views of the seafront towards St. Marys Island. The home is on three floors. A passenger lift, two short staircase lifts and some ramps, provide access to all areas of the home. The home is registered to provide care to 40 older people, 7 of whom have a dementia. There are 34 single bedrooms, 16 of which have ensuite toilet and hand basin. There are 3 shared bedrooms, 2 of which have ensuite facilities. The communal facilities consist of; a lounge, two dining/lounge areas, a dining room with adjoining conservatory and an amenities room used for crafts and hairdressing. The home is well maintained with a large landscaped garden at the front. Inspection reports and information about the home are readily available. Weekly fees are in the range £361 £420. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s periodic unannounced key inspection visit. The inspection was conducted over two separate days and took 9 1/2 hours. On the first day, time was spent with the deputy manager. On day two, time was spent talking to the manager, some care staff and several residents. Some of the home’s care records were reviewed and the systems that maintain residents safety. Some residents’ case records were specifically assessed against the style of care provided. This is called ‘Case Tracking’. Questionnaires were provided for residents and visitors to the home. Responses were received from seven residents/visitors and four relatives. Information provided by them is used in the report. What the service does well: The home is well managed and run in the best interests of residents. There is a stable staff team of experienced, mature carers. There is a thorough assessment of residents’ needs. A good activities programme is in place and residents are encouraged to be involved. Residents are treated with great warmth and respect. The home is very welcoming to visitors. Comments from visitors questionnaires are; The home is always very nice and feels very homely. Very good communication skills at the home. I am quite impressed by the way staff support each other. A good age range across the staff team and very little staff changes. The home has strong leadership and a lady who leads the entertainment who is very committed. The home is very clean. Comments from residents questionnaires are; Information provided is very good. St Anne’s is fantastically good. Care staff always do their very best for the care that I need. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 6 Staff always listen and act on what I say. I took part in the Easter entertainment and really enjoyed it. All the meals are very nice. The meals could not be better. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Annes Residential Care Home DS0000063195.V333617.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 Residential Care Home DS0000063195.V333617.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): 1, 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good range of information is available to prospective residents. The admission process reduces the possibility of admitting someone whose needs cannot be met. Intermediate care is not provided. EVIDENCE: A brochure or a more comprehensive guide to St Anne’s is available to anyone enquiring about the home. New residents are provided with a welcome pack containing information about the range of services available. It also contains photographs of key staff. 10 out of 11 returned questionnaires confirmed the information provided by the home was of a good standard. Residents spoken to were happy with the arrangements made when they moved into the home. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 9 A range of information about the home and the service it provides is on display in the home, together with recent inspection reports. One resident referred to the last inspection report in her questionnaire. Four care plans reviewed contained details of an assessment done by management before a place is offered. This assessment was done before admission to the home and included information provided by care managers. This ensures the home can provide the level of care needed by the resident. Following admission senior care staff ensure that any problems are identified and that the home has appropriate equipment to meet the residents needs. Standard health assessment forms are completed but these are not always concluded with a statement of any risks assessed. Within four to six weeks of admission each resident is given information by senior staff about their care plans and to ensure their care needs are being met. The resident then has the opportunity to sign the care records. The care records are clear and easy to read. Staff spoken to used the care records to provide appropriate care. The home does not accept referrals requiring rehabilitation but a room is dedicated to respite care. St Annes Residential Care Home DS0000063195.V333617.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): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are addressed although some plans are not regularly reviewed. The home has appropriate procedures for handling and administering medicines. Residents’ privacy and dignity is maintained. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 11 EVIDENCE: Four care plans were reviewed. They all contained a social assessment and a plan for daily living. Care plans describing to staff how care is to be provided are written and risks in daily living are assessed. Risk assessments are written with how these can be reduced. Each resident’s health is assessed. Residents, weights are regularly recorded and care plans are generally reviewed monthly to ensure the care provided meets the individual’s needs. Systems are in place to meet the needs of any resident with a pressure sore and residents at risk are provided with the equipment to support them. The assessment of care plans was of varying quality. Some plans had not been assessed and others had a good monthly summary in place but the individual care plans were not regularly assessed. The system for the administration of medicines was checked and found to be good. Staff who dispense medicines are trained and records are maintained for ordering, receiving, administering and disposal. Medicines are stored safely. Residents seen were dressed appropriately in their own clothes. Staff were seen to treat residents respectfully and deal with any personal issues with dignity. Locks on bathroom and toilet doors checked during a tour of the building worked smoothly to enable people with less mobility to use them. Residents spoken to during the inspection all said that staff provided good care and were respectful. This was confirmed in the returned questionnaires. St Annes Residential Care Home DS0000063195.V333617.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): 12, 13, 14, 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents enjoy a range of appropriate activities. There are many regular visitors in the home. Good meals are provided. EVIDENCE: The homes provide support for residents to be as independent as they are able. Religious and social needs are met. Church visitors provide support for any resident requiring it and a religious service with communion is provided on a monthly basis. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 13 The home employs a person to lead the daily activities. There are regular bingo sessions, film nights, pub nights with quizzes and safe darts. Each week there are relaxation and exercise sessions and throughout the summer activities are organised in the home’s garden and there are local outings. Residents are given the opportunity to go shopping supported by care staff. Each resident’s preferences regarding activities are recorded in their care records. A range of menus provided prior to the inspection showed that wholesome meals are provided. During a tour of the premises the kitchen stores were inspected. A range of fresh vegetables, salads and fruit were available. Four residents spoken to after lunch said that they had enjoyed their meals. The kitchen records showed that one resident had been provided with a meal outside of the menu choices. Most residents have good family support. Although no visitors were spoken to many were seen during the inspection coming and going freely with their relatives. Residents are encouraged to be as independent as possible. Residents stated they choose what to do and when. Some residents stated they choose not to be involved in the home’s activities. There are regular house meetings with minutes taken. Residents are encouraged to give their opinions about the running of the home, and these comments are taken seriously and acted upon. St Annes Residential Care Home DS0000063195.V333617.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): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel that they are listened to, and that any concerns they may express will be taken seriously and resolved. Residents are safe and well protected in the home. EVIDENCE: Each resident is given a copy of the home’s complaint procedure when they enter the home. A copy of the process is on the home’s notice board for visitors to read. Copies are available in large print if required. Everyone who responded in questionnaires was aware of how to complain and one resident stated that any complaints she brings to the attention of management are addressed immediately. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 15 The manager is qualified to provide basic awareness training in protecting vulnerable people. Each member of staff has been provided with a booklet, produced by the home, titled recognition and prevention of abuse and a video provided by the local authority is used for refresher training. Residents spoken to said they felt safe in the home and staff spoken to understand how to protect vulnerable people. St Annes Residential Care Home DS0000063195.V333617.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): 19, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe, clean and well maintained. EVIDENCE: The home is converted from three terrace houses. It has been refurbished to a good standard. Residents’ bedrooms are individually styled and contain many personal possessions. Several bedrooms have been refurbished recently with new carpet and furniture. One room did not have a locked drawer provided. Residents spoken to during the inspection are happy with the standard of appointment. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 17 Lounges contain comfortable furniture arranged to encourage conversation and interaction between residents. A programme of cleaning is in place, the home is clean and no odours were detected. The kitchen is well equipped and a good standard of hygiene was observed. The laundry contains appropriate equipment to meet disinfection standards and laundry staff are provided with information and instruction regarding laundry. St Annes Residential Care Home DS0000063195.V333617.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): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained staff employed in sufficient numbers meet residents needs. The home operates a thorough recruitment process to ensure residents are safe. EVIDENCE: The staff rotas were examined. Staffing levels are unchanged at four carers plus a senior, 8.00am – 2.00pm; three carers plus a senior, 2.00pm – 10.00pm; one senior and one carer, 10.00pm – 8.00am. This level of staffing should meet the needs of the current residents. In addition the home employs an activities person, an administrator and ample catering, housekeeping, domestic and laundry staff. The manager is supernumerary. The home uses an induction, foundation and training record that meets the SKILLS requirements. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 19 Staff are well trained. 70 of care staff have achieved NVQ level 2 in care or above. The manager maintains a list of all training undertaken by staff. This is regularly reviewed and any training requirements are obtained. This is a good basis for providing appropriate care for residents in the home. The personnel records for the three most recently employed members of staff were inspected. The files contained applications forms, appropriate references, evidence of checks made by the Criminal Records Bureau and information required to confirm the identity of the person employed. A list of the information provided to staff is retained in the individual files. These showed that staff receive handbooks and care council codes of conduct. Many of the staff team have worked in the home for several years and throughout the inspection residents praised the quality of care provided. Staff spoken to stated that a good range of appropriate training is provided, that clear direction is provided by management and that good support is available from other staff. This helps them provide a good service to the residents. St Annes Residential Care Home DS0000063195.V333617.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): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced manager supports residents. The quality of care provided is monitored in the home. A system to monitor residents’ financial interests is in place but this could be improved. Residents are safe. Systems to monitor welfare and good hygiene are in place. St Annes Residential Care Home DS0000063195.V333617.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager has been in charge of care homes for older people for several years. She has the Registered Managers Award which demonstrates her knowledge and experience in managing a care home for vulnerable people. Residents spoken to during the inspection stated that the manager is always available to discuss matters relating to the running of the home. Questionnaires returned contained praise for the manager and the standard of care provided. A quality monitoring system is in place that involves the use of questionnaires. The manager is currently assessing all aspects of the care provided and is producing action planes to address any shortfalls found. Two staff spoken to stated that the home is well run. Meetings are held regularly with the workforce and a record is kept of those in attendance and the issues discussed. Many residents control their own monies. A system is in place to hold monies should residents require this service. Transactions are recorded but not evidenced by two signatures, receipts are not always obtained and management does not do regular audits. Systems are in place to ensure the home is safe for residents. Certificates were seen to demonstrate maintenance tasks carried out by external contractors were done. Water temperatures are checked and a risk assessment is in place to show the water system is free from Legionella. Accidents in the home are recorded. A fire risk assessment has been produced and regular fire checks are recorded and staff training provided to ensure residents are safe. Each member of staff has a booklet regarding health and safety in the home. Kitchen staff are working through a system to promote better food standards in the home. Infection control systems and systems to ensure a good standard of hygiene is maintained is the responsibility of the homes domestic supervisor. St Annes Residential Care Home DS0000063195.V333617.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 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 St Annes Residential Care Home DS0000063195.V333617.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. 1. Standard OP7 Regulation 15(2)(b) Requirement The manager must ensure that systems are in place to monitor that monthly assessments of care plans take place. Timescale for action 30/06/07 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 OP3 OP7 OP19 OP35 Good Practice Recommendations Assessments done to determine the amount of care needed should be concluded with a statement of any actions required. Consider using a comprehensive monthly evaluation of residents well-being in addition to the required monthly evaluations of care plans. Provide a lockable space in the newly refurbished bedrooms. Ensure that all monies held on behalf of residents can be audited fully. Two signatures should evidence the transactions, a receipt should be obtained whenever possible and a full description provided of items purchased. Regular audits should be done on the accounts and these should be signed. DS0000063195.V333617.R01.S.doc Version 5.2 Page 24 St Annes Residential Care Home Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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