Inspection on 14/02/06 for St Audrey`s

This inspection was carried out on 14th February 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 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 Audrey`s 10/01/07

St Audrey`s 14/09/05

St Audrey`s 22/11/04

St Audrey`s 08/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Audreys 15 Church Street Hatfield Hertfordshire AL9 5AR Lead Inspector Mrs Jan Sheppard Unannounced Inspection 14th February 2006 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 Audreys DS0000019535.V283044.R01.S.doc Version 5.1 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 Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Audreys Address 15 Church Street Hatfield Hertfordshire AL9 5AR 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) 01707 272264 01707 258243 Lynn.Beech@HentageCare.co.uk www.heritagecare.co.uk Heritage Care Mrs Lynn Beech Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 Brief Description of the Service: St Audrey’s is a large Victorian house that was extended and refurbished in 1996 to provide a care home for 38 elderly people. The home, which is run by Heritage Care, is situated in Old Hatfield and is part of the Hatfield House Estate. The house is close to the amenities of the local shops and the town centre. The main railway station is near by and the area is well served by public transport and major roads. The home is very well appointed and stands in spacious grounds with attractive rural views from many rooms. Accommodation is provided in single bedrooms most of which have en-suite facilities and are sufficiently large to be comfortable bed sitting rooms. St Audrey’s offers a high standard of residential care for those residents who still value their independence and wish to be comfortable in a caring and safe environment. The home was first registered with the Local Authority Inspection Unit on 30th July 1996 under the Registered Homes Act. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of this inspection year and took place over one day when some of the residents, staff and visiting relatives were spoken with, records examined and a partial tour of the building undertaken. The statements in this report reflect what was observed by the inspector on that day. Not all of the standards were examined as they were all inspected during the previous inspection on 14th September 2005 to which reference may be made. On the day of this inspection care was seen to be being delivered in an unobtrusive manner, which enabled the residents to retain their own abilities as far as this was safely possible for them to do. All of the residents and all except two of the relatives/visitors, spoken with by the inspector were entirely complimentary about the care that they or their relative received and the manner in which this was delivered to them. The requirement made following the last inspection has been met; two requirements and one recommendation are made following this inspection. What the service does well: What has improved since the last inspection? Since the last inspection an extension to the dining room has been built which will give more space and will enable the chef to serve the food according to each individual residents wishes directly to them from a serving area in the dining room rather than meals being plated up in the kitchen. The post of activities organiser has recently been filled this giving activity hours for each weekday and has enabled the programme to be revised and extended. During last autumn the home commenced a series of outings using a “ Jambulance” bus, which is fully equipped to cope with mobility and other disabilities. These outings proved to be very popular and residents confirmed they were a considerable improvement on anything previously offered. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 6 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 Audreys DS0000019535.V283044.R01.S.doc Version 5.1 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 Audreys DS0000019535.V283044.R01.S.doc Version 5.1 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 & 5. Standard 6 is not applicable to this home, as intermediate care is not offered. All prospective residents receive an assessment visit from one of the homes managers and they and their families are given the opportunity to visit the home before admission arrangements are discussed. Information offered to prospective residents in the form of the homes Statement of Purpose and Service Users Guide is comprehensive and informative enabling an informed decision about admission to be made. EVIDENCE: The care plans of the two most recently admitted residents to the home were examined. These evidenced that a thorough needs assessment had been completed and that opportunities for visiting the home had been given. Both residents confirmed that their admission process was handled sensitively and that staff had been very kind and helpful over the time when they actually entered the home. “I was very sad about leaving my own flat”, one said,” but everybody has been very sympathetic and helpful and my room is very nice homely and comfortable”. The other new resident confirmed that she now felt very well settled into the home. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 9 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 and 10. Detailed care plans are compiled for all the residents; these were seen to be subject to regular review. The home has a robust medication storage and administration system, which apart from one minor omission was found to be well maintained. EVIDENCE: During the inspection personal care and assistance offered to the residents was seen to be competently delivered meeting their care needs and in such a manner that retained individual dignity and respect. Residents spoken with all confirmed that they felt themselves to be very well cared for. A number of care plans examined evidenced that they were uniformly kept with a detailed standard of recording and with evidence of the residents involvement with their regular reviews. There have been no changes in the arrangements for the storage and administration of medication since the last inspection. The records on the MAR sheets were seen to be accurately maintained with regular management checks as to their accuracy well documented. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 10 A system for recording medicines in and out of the home was seen to be well recorded. The records relating to the administration of Controlled Medication were seen to be correctly kept. One liquid medication was found not to be being stored at the correct temperature. A requirement is made as medication must be stored as per the manufacturers instructions so that effectiveness is not compromised. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 11 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 and 15. A choice of activities is offered throughout the week. Visitors are always welcome in the home and several were seen to be visiting on the day of this inspection. Residents were very complimentary about the food. EVIDENCE: Since the last inspection there has been a change of activities organiser who has, following consultation with the residents, introduced various changes and additions to the activities programme. The programme is displayed on a notice board in the main lounge. Residents spoken with all said that they had sufficient activities, which they could choose whether or not they attended. Quizzes and Bingo were popular with several whilst others said that they hated these and kept well away!. Every resident spoken with said that they liked the recently introduced hand message and manicure session which had unfortunately on the day of this inspection been cancelled due to the sickness of the therapist. Others spoke appreciatively of the outings participated in by many of the residents and arranged in the autumn in the large “Jambulance” coach; the trip to Southend was particularly mentioned and the prospect of another to Woburn in the spring that was being planned. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 12 The home has increased the number of outings for both large and small groups with venues such as garden centres and a local large supermarket for shopping and coffee being mentioned as popular. Staff explained about the arrangements for Easter activities that were being planned. The inspector noted that no Valentines activities were evident in the home on the day of this inspection and several residents remembered the celebrations of last year. Two relatives complained to the inspector that the activities programme was insufficient and that what was advertised often did not take place. Without exception the residents were very complimentary about the food. The chef discussed with the inspector how he regularly consulted with the residents concerning their choices and asked their opinions concerning new dishes and he was seen after lunch had been served sitting talking with the residents in the dining room. Residents told the inspector of the delicious home made soups which are made fresh every day and also of the beautiful birthday cake made yesterday for a residents celebration meal. Another resident explained that she could still enjoy a roast dinner if the meat was softened and that this was done for her without spoiling the overall appearance of the meal. The records evidenced that meals for five residents have to be presented as a puree and that two residents had requested that the various ingredients of the meal are all mixed together rather than served separately. The chef said that whilst he did not approve of this form of presentation he carried out the residents wishes in this respect. One of these residents told the inspector that what ever the meal looked like for him the important thing was the taste, which he confirmed, was very good. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 13 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): 16,17 and 18. The home has robust complaints procedure and follows the Adult Protection Procedures as set out in the Hertfordshire’s joint agency guidelines. EVIDENCE: Copies of the homes complaints procedure were seen in the entrance hallway along with the latest inspection report and a good practice suggestion box. There have been no complaints nor any incidents concerning adult protection since the last inspection. Residents and relatives spoken with during this inspection (all except for two relatives), expressed their satisfaction with the services St. Audrey’s offers and confirmed that they had no complaints. One resident said if there is ever anything I want done differently “I only have to mention it and staff immediately change things”. The issues raised by two relatives were discussed with the homes manager along with the fact that they told the inspector that they would be reluctant to bring up the issues with staff themselves for fear of reprisals for their relatives. This matter is being addressed by the manager outside of the requirements of this inspection so as to ensure that all residents and relatives understand the complaints process and have confidence that any comments they make will be listened to and appropriate action taken. Recommendation is made. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 14 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 and 26 The home meets the space and environmental requirements for these standards. It provides a pleasant comfortable safe and homely environment for its residents. The areas of the home visited were clean and tidy and had no offensive odours. EVIDENCE: A tour of the ground floor only was made during this inspection. This revealed it to be clean, well decorated, with well-appointed rooms that were warm and had a homely appearance. Without exception all the residents said that they were very happy with their rooms and confirmed that they had every facility that they needed. Refurbishment works to enlarge the dining area have recently been completed and residents confirmed that the builders worked very quietly giving them the minimum of disruption. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 15 Several residents said that they were looking forward to the internal furnishings being completed so that they could move in and confirmed that they had been consulted about colours styles and patterns etc. Staff discussed with the inspector the plans to refurbish the laundry room, which are expected to commence later in the year. The chef confirmed that all the kitchen equipment was working satisfactorily and had been subject to an Environmental Health Inspection during January. A new larger dishwasher had been installed since the last inspection. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 16 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 and 30. The home appeared to have adequate staff to meet the daytime care needs of the residents on the day of this inspection. Staff are experienced and undertake regular training. EVIDENCE: The home continues to retain a core group of experienced and well trained staff who are able to offer continuity of care for the residents. Many of these carers have worked at the home for many years. The numbers on duty were seen to tally with the planned duty rota. The records evidenced that as the home has appointed more permanent staff fewer agency staff are used and when they are these staff come from one agency only and have often worked at the home before. The numbers of staff holding professional qualifications, NVQ s at levels two and three considerably exceeds the requirement for 50 . The manager and deputy manager either already hold or are studying for NVQ level 4 Registered Managers award. An NVQ trainer from Heritage Care who was visiting students in the home on the day of this inspection discussed with the inspector the ways in which training for each home is planned. The homes own records showed that a yearly plan is made up from the individual training requirements of each member of staff, which core retraining planned on an annual basis. A new refresher POVA training course has been arranged for all staff to attend during 2006 and to fully meet the requirements made during the previous St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 17 inspection a Medication training course for all staff has been booked for 23rd March 2006. During this inspection the staff who all appeared to be enthusiastic about their work and to take great pride in the service and in the home, were seen to work well together as a team and to work meeting the residents needs in a competent manner. All residents questioned all confirmed that they were happy with the manner in which care was given to them, “ the girls are all very kind they often seem to anticipate my needs”, and one resident told the inspector. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 18 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): 31,32,33,36 and 38. The home which has a good reputation in its locality continues to be well run by experienced and well qualified staff many of whom have worked there for several years and who work well together as a team. The residents interests and safety are supported by the good maintenance of the homes records and the following of procedures concerning risk and safety. One safety requirement concerning hot water temperature is made. EVIDENCE: The staff were observed to be working well together with good team cooperation. The majority of the staff wore name badges making identification of their names and roles easy for residents and visitors. The staffs relaxed and unhurried attitude when assisting the residents appeared to contribute to the homes warm caring environment and to contribute also to the relaxed and happy appearance of the residents. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 19 The staff records demonstrated that regular supervision meetings and an annual appraisal is arranged for each member of staff. Risk assessments concerning the building and its environment as well as the individual risk assessments found on residents care plans were all seen to be maintained up to date and to be regularly reviewed. The records relating to the water temperature in the outlets in residents bedrooms evidenced that some are consistently above the recommended 43 degrees. Appropriate risk assessments concerning these were seen. A requirement is made that these temperatures are fully regulated this to ensure the safety of the residents at all times. The fire appliance testing records were examined and found to be maintained regularly with notes concerning any problems actioned for further attention. Regulation 26 reports of the registered persons unannounced audit visits to the home are sent regularly to the Commission along with Regulation 37 reports as and when required. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 20 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 x 2 St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 21 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 OP38 Regulation 13(4)(a) 23(2)(p) Requirement Water temperatures in residents rooms must be maintained at 43degrees to ensure safety at all times. Timescale for action 28/02/06 2 OP9 13(2) Liquid medication must be stored 28/02/06 at the correct temperature. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 22 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 16 Good Practice Recommendations The home must ensure that all relatives are fully informed of their rights to make a complaint without any fear of reprisals. St Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Audreys DS0000019535.V283044.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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