Inspection on 14/09/05 for St Audrey`s

This inspection was carried out on 14th September 2005.

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 14/02/06

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 September 2005 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.V266401.R01.S.doc Version 5.0 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.V266401.R01.S.doc Version 5.0 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 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.V266401.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2004 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.V266401.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of this inspection year and took place over one day when residents and staff were spoken with, records examined and a tour of part of the building undertaken. Time was also spent in the office looking at care plans and staff files. Discussions were held with the manager and separately with the deputy manager the administrator with the chef on duty and with a number of carers. The statements in this report reflect what was observed by the inspector on the day of this inspection and also from information gathered from the pre inspection documentation completed by the managers and from the comments made by residents and relatives on their comment cards, which were completed earlier in the year. This was a very positive inspection, feedback received was excellent and the standard of most aspects observed was high. One requirement was made following this inspection. What the service does well: This well established home continues to provide a warm secure and homely environment for its residents with personal care being delivered by an experienced and well trained staff team. Care practice observed was individualised and dignified. Staffing levels in the home are adequate to meet the current needs of the residents. The roles of staff are periodically revised so as to better meet the changing needs of the residents. Staff members spoken with were very positive about the home and appeared committed to their jobs. They confirmed that there is plenty of opportunity for them to progress within their role and training and development is very much encouraged. The home is immaculately clean and well cared for and the attractive gardens, which are well presented, and several quiet sitting areas were seen to be being well used by the residents and their visitors. There are well established procedures for seeking the views of residents and of involving those who wish to be involved in some of the business planning, administrative and quality evaluation processes concerned with the running of the home. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 6 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 Audreys DS0000019535.V266401.R01.S.doc Version 5.0 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.V266401.R01.S.doc Version 5.0 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): 1,2,3,4,5 Standard 6 is not applicable to this home, as intermediate care is not offered. Information available to prospective residents and their families is comprehensive and informative enabling an informed decision about admission to be made. The atmosphere in the home is relaxed offering a welcoming environment to prospective residents. EVIDENCE: The home has a comprehensive pre-admission assessment procedure that is well documented. All prospective residents are visited by a manager either in their own home or other setting for a full needs assessment before being invited to visit St. Audrey’s themselves. Care is taken to ensure that these visits are arranged so that the prospective resident is given time to meet other residents share a meal or some activities and that they are not in anyway rushed into making any decision about admission. The process of admission is also handled sensitively by the staff for the prospective residents families with sufficient information and time allowed for them to be-able to assure themselves as to the suitability of the home to meet the needs of their relative. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 9 The pre- admission information includes the Service User Guide, (which was last revised in June 2005), A Statement of Terms and Conditions, information about the fees, the Complaints Procedure, a copy of the latest Inspection Report and the annual statement from the company. One recently admitted resident confirmed that her admission process had not been rushed and that she had been made to feel very welcome in the home and had a very comfortable room, but she complained to the inspector that she had not understood that her admission was permanent and could not agree with this. One of the managers immediately spoke with her to reassure her that she could end her stay at St Audrey’s when ever she wished and that the staff would assist her with any arrangements; she also suggested setting up a prompt meeting with her relatives and social worker to enable time for discussion and further reconsideration. The home currently holds a short waiting list and has two vacancies for which assessment visits to prospective residents have already been made. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 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 and 11 Personal care and assistance offered to the residents is of a high standard, thus meeting their individual needs whilst retaining dignity and respect. Care staff are unobtrusive and sensitive in their approach. Comprehensive care plans are kept and these are regularly reviewed. The home has a robust medication storage and administration procedure but recent deficiencies have occurred with the process of administration of controlled medication. EVIDENCE: A number of care plans examined evidenced that these contain good detail are maintained up to date and are subject to a regular reviews, both multidisciplinary reviews and individual reviews with the residents key worker. The manager showed the inspector a newly revised and streamlined format into which all care plans are being changed so that the information is more easily accessible and that some parts of these plans can be also kept as a computer record. Residents spoken with were aware of their care plans said that they did contribute to their compiling and knew that they were able to sign them if they wished. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 11 Residents seen to be requiring help with meals were observed to be receiving this discretely with staff encouraging them to eat as independently as possible offering assistance where needed in a sensitive manner that promoted and protected their dignity. The inspector noted that the dining room was buzzing with conversation during the lunch period. There have been no changes in the arrangements for medication storage and administration 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 and records also made by the supplying pharmacist of their regular audits of the system. However since the last inspection problems with the administration of the Controlled medication have arisen on two separate occasions. These were, fortunately, quickly recognised by the administrating staff (all staff who administer medication are appropriately trained to do so) and action to rectify the error was quickly taken in consultation with the pharmacist and the residents GP. Following this the home undertook a review of their administration procedures and have commissioned additional training and surveillance for all the staff who undertake administration of medication duties so as to ensure that these problems do not reoccur. A requirement is made. The manager stated that the home continues to have very good working relations with its local Doctors, the community nursing teams and with the associated paramedical services. Doctors and district nurses visit promptly and where required refer residents quickly for hospital assessment and treatment. Residents were seen to have equipment appropriate to meet their needs this being provided following an OT assessment. A chiropodist was seen to be visiting residents in the home on the day of this inspection. Residents are able to see a chiropodist of their choice. The records made by the district nurses who make regular visits to the home were seen to be properly kept. On the day of this inspection none of the residents had any pressure sores but for one resident who had a suspect area the nurse was treating this preventatively. All staff undertake training concerning bereavement and care of the dying. Relatives are able to stay in the home at this time if they wish. The resident wishes concerning their care at this time and funeral arrangements were seen to be recorded on their care plans. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 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 and 15 A varied activities programme is offered and staff try to accommodate every residents individual preferences. Feedback and suggestions are sought on all aspects this promoting autonomy and choice. Visitors are always welcome in the home and all the current residents retain good ties with family and friends and several visiting on the day of this inspection were seen to be taking their relatives out into the community. The residents all spoke very appreciatively of the food and of the variety of good cooking that is provided by the chef manager and his team. EVIDENCE: A new activities organiser has recently been employed and the manager has taken this opportunity to review her duties so as to better meet the activity needs of the residents. Each resident has been personally consulted as to the activities, if any, in which they would like to participate. Individual person centred activity programmes are now being developed along with greater consultation with the residents on an on going basis. The inspector was shown photographs of a recent very successful days outing to the sea and the manager discussed a number of other such outings that are being planned. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 13 The records evidenced that the home continues to have very many visitors several make daily visits to their relatives. Many of the more mobile residents also make regular trips out into the community. The residents expressed their satisfaction with the quality and variety of the food provided and several said that they were looking forward to the improvements, enlargement and provision of a food service area, to the dining room, work which is commence shortly. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 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): 16,17 and 18 The home has a robust complaints procedure and follows the Adult Protection Procedures as set out in the Hertfordshire’s joint agency guidelines. EVIDENCE: Copies of the home Complaints procedure were seen in the entrance hallway along side the latest inspection report and a good practice suggestion box, which was said by the manager to be very well used. There have been no complaints since the last inspection. A number of complimentary letters were shown to the inspector. The residents spoken with were aware of the complaints procedure but said that they would first talk to one of the managers if problems arose as they were very approachable and they (the residents) had confidence that the managers would sort things out promptly. Staff confirmed that they had received training on adult abuse and those spoken with were also aware of the whistle blowing procedure. There have been no incidents relating to abuse since the last inspection. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 15 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): 19,20,21,22,23,24,25 and 26 The home and its surroundings offer a pleasant, comfortable and safe environment for its residents. The home, which is very well appointed, is kept extremely clean and well maintained and the spacious bedrooms are very well personalised offering an individual homely, lived in feel. The home offers sufficient communal spaces and numbers of toilets and bathrooms to meet the requirements of these standards. EVIDENCE: Service users are encouraged to bring personal items such as furniture, ornaments and pictures into their room when they move in. Several residents confirmed that they had made their rooms just as they had at home and that they felt very happy with them. They appreciated being able to choose their own soft furnishings and care records demonstrated a good attention to detail such as “ are blankets or a duvet preferred?” and on admission instructions being given for flowers or other welcome token to be placed in the room. Most rooms have en-suite facilities including provision of either a bath or shower. In addition the home has a number of larger assisted bathrooms so that the needs of all the residents can be adequately met. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 16 The communal rooms, lounges, TV room and large entrance hall sitting area very adequately meet the space requirements for the number of residents and offer a number of choices of location. Work to expand the size of the dining room is to commence at the end of September and the residents have been involved in the choice of furnishings and colourings for the new room. The intention is to so design this new dining facility so that the chef can serve food individually in the dining room in a more domestic and homely manner. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 17 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): 27,28,29 and 30 The staff team appear to be enthusiastic about their work, to take great pride in the service and in the home; to work well together as a team and to work meeting the residents needs in a competent manner. The home has a robust recruitment procedure, which ensures the safety of the residents. 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 staff have worked at the home for many years and in the main recent vacancies have occurred due to natural causes. The manager reported that recent advertisements had failed to attract carers of a quality acceptable to the home but that because of their retention of a stable group of bank and agency workers the continuity of care for the residents had not been disrupted. The records evidenced that the correct recruitment procedures were being followed with the necessary CRB checks awaited before the appointed staff could take up their duties. All new staff are recruited with the expectation that following their induction training they will commence an NVQ level 2 qualifying course. The home has a very good training record and has already exceeded the requirement for fifty percent of care staff to hold this qualification. Four of the senior carers have achieved levels 2 and 3 and the managers have either already achieved or are studying for NVQ level 4 and the Registered Managers Award. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 18 The homes yearly training programme is compiled from the individual staff members training needs which are recorded from their supervision meetings. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 19 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): 31,33,35,36 and 38 This home which has a very strong ethos of being run with the greatest possible involvement of its residents and for their best interests is led by an experienced and qualified manager. The staff team work well together and appear to be dedicated to providing a first class service thus enhancing quality assurance. Close consideration to the health, safety and welfare needs of the residents is given and this results in a warm caring environment where the residents seemed relaxed and happy. EVIDENCE: The manager communicates a clear sense of leadership within the home and promotes a sense of belonging to its service users. Pride and dedication is taken in every aspect and the home is beautifully maintained. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 20 The staff records demonstrated that their supervision meetings are now of a frequency that meets the minimum requirement and that an appraisal system is in place for all staff. Other records showed that as part of the annual business planning cycle, a process which involves both residents and staff of all levels, regular questionnaires and other quality assurance measures are taken up the results of which form part of the homes annual statement. The manager discussed with the inspector the quality targets that have been set for the home for the next year. The residents all handle their own monies, or have relatives or legal advisors that do so for them, so that the home does not have an individual allowance holding system. Each resident has a lockable facility in their own room and recently residents who wish are able to have their own safe to ensure the secure keeping of their valuables. All residents are offered a key to their own rooms. The home has an entry locking system and recent strengthening measures have been taken to ensure the external security of the building. St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 21 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 18 3 3 3 3 3 3 3 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 x 3 3 3 3 x 3 St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 18(1)(c) (i) Requirement Staff must be adequately trained in the administration of medication so that errors do not occur. Timescale for action 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Audreys DS0000019535.V266401.R01.S.doc Version 5.0 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. 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