Inspection on 26/07/05 for St Bennetts Care Home

This inspection was carried out on 26th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Bennetts Care Home 18/11/08

St Bennetts Care Home 28/11/07

St Bennetts Care Home 31/01/07

St Bennetts Care Home 19/12/05

St Bennetts Care Home 22/02/05

St Bennetts Care Home 15/07/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

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

CARE HOMES FOR OLDER PEOPLE St Bennetts Care Home 346-348 London Road Leicester Leicestershire LE2 2PL Lead Inspector Keith Charlton Unannounced 26 July 2005 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 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 Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Bennetts Care Home Address 346-348 London Road Leicester Leicestershire LE2 2PL 0116 2745959 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr M A Mapara Mrs Karen Margaret Hulbert Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: - Date of last inspection 22/2/05 Brief Description of the Service: This is a refurbished home, centrally located on the London Road of Leicester, which offers a service to older people. The location is convenient for transport links.There are 3 lounges and 1 dining room on the ground floor.A large number of bedrooms are well over the National Minimum Standards size requirements.There are a majority of single bedrooms. Service users have a ramped way to the rear garden and a patio where they can sit. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection. The Home’s Registered Manager was on holiday so a Senior Care Assistant assisted with the inspection process. Planning for the Inspection included assessing notifications of significant events sent to the Commission for Social Care Inspection by the home. There was also a Pre-Inspection Questionnaire from the Registered Provider and Comment Cards received from service users and relatives for this inspection visit. The Inspection took place between 9.30 and 16.00 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with eight residents and three members of staff. A relative was spoken with who said staff were kind and helpful and were always welcoming to visitors. She was very satisfied with all services. The inspection was completed on 9/8/05 with the Registered Manager. What the service does well: Service users generally reported that staff are attentive and helpful, staff welcome visitors to the Home and service users generally liked the food provided to them. The last Inspection Report is available to service users and visitors in the hallway. The Registered Manager keeps up to date Care Plans for service users, which are reviewed on a monthly basis, and ensures that staff read the Care Plans. Staff understand how to act if abuse occurs or is suspected. Facilities are kept in a generally clean and tidy condition. The Registered Manager has enrolled twelve staff on National Vocational Qualification level 2 courses to increase their knowledge of the job. If service users complain the Registered Manager has taken up issues and resolved them. Water temperatures are kept in line with the National Standard of 43c to prevent service users being scalded. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: A number of Requirements from the last Inspection Report have not been actioned. One bathroom used as a storeroom needed to be locked to protect the Health and Safety of service users. A second floor bathroom needs a hoist to assist service users on this floor so they do not have to go to other floors to bathe. Three bedrooms were odouress, and needed their carpets cleaned. The Registered Provider still needs to submit details of the maintenance budget with regard to the Home’s business and financial plan. There has been a failure to deal with maintenance issues for some time in a number of areas - carpets to the lounges and dining room still need to be replaced, chipped skirting and paintwork still needs to be attended to on skirting, pipes and doorways where required all around the Home, a number of areas of the home are still in need of repainting – e.g. WCs E and F, where there are signs of damp that need to be eradicated, rotten window frames to some bedrooms and bathrooms, two dormer windows, one with a hole by it which lets in rain and crumbling plasterwork to a bathroom. The Home needs to ensure that the Quality Assurance system is acted on– publish service users views, consult with stakeholders etc. It was also noted that the Registered Manager still does not have a maintenance budget – it is again strongly recommended that this be set up, as then facility issues should then receive swift attention. For reasons of staff recruitment it is strongly recommended that new staff do not have to pay for their own Criminal Records Bureau checks. It is recommended that life histories of individual service users are kept in Care Plans so staff can understand all important aspects if service users lives. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 7 It is recommended that breakfast commences earlier than 9.00am so that service users getting up early do not feel they have to wait a lengthy time for this. 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 Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 3,4 Staff training is needed to ensure awareness of all service users needs. EVIDENCE: Some staff have received training in dementia, sight awareness and diabetes and stroke care but this needs to be extended for all staff. The Registered Manager has a detailed assessment tool to ensure that staff are aware of the care needs of newly admitted service users. However it appears that there may have been admissions of service users outside the categories of registration – if in doubt there needs to be a medical diagnosis before admission. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 The individual needs and choices of clients living in the home are well met and medication systems are generally robust. EVIDENCE: The Care Plan covers all aspects of the national standard regarding health, personal and social care needs e.g. behaviour, skin care, speech, hygiene, medication, medical checks, food preferences etc. The Care Plan has been produced with the service user and agreed and signed by them or their representative. Care Plans are reviewed monthly. It is recommended that life histories of individual service users are kept in Care Plans so staff can understand all important aspects if service users lives. Staff respond well to accidents if service users injure themselves, as per the accident records. Service users said if they were ill then the GP would be called. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 11 Records of medication administration were generally up to date and the medication was issued and recorded appropriately – only senior staff issue medication and they have all received proper training. It is the home’s policy to promote self-medication where possible and there is a risk assessment form to evaluate this. None of the service users focused upon self medicated and none wished to. They were satisfied the Home gave them their medication. It was noted that some service users self medicated for some medications – mainly creams. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 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 standard(s) 13,15 Service users have a good lifestyle, although meals continue to be seen as less than satisfactory by some. EVIDENCE: St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 13 Service users said they were generally satisfied with the activities except there were no trips out. The Registered Manager said this would be followed up and arranged. All service users said that that their visitors were made welcome by staff and offered a hot drink. The relative visiting at the time confirmed this. Service users were seen as being asked if they wish to have the main choice or an alternative meal. Meals within the Home are of a generally good standard according to service users though there were comments that meat was sometimes too tough. This was raised at service users meetings in October 2004 and April 2005 and the Registered Manager has tried various improvements as confirmed by Service Users Meeting Minutes but this is still an issue. The Registered Manager has set up a service users questionnaire for service users to comment and will be following this up with an Action plan to see if improvements can be made. However the meal seen by the Inspector looked, tasted and smelled generally appetising apart from oven chips – the Registered Manager said that freshly cooked chips would be provided. Breakfast is to commence at 08.00 instead of 08.45 so as to cater for service users who get up early. There were some suggestions put forward – to have more cabbage and macaroni and to be offered pot noodles – the Registered Manager is to follow these up. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 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 standard(s) 16,18 Service users are confident their concerns will be acted upon and staff know how to protect them from abuse. EVIDENCE: Service users said that they thought that if they had a complaint the Registered Manager would properly handle this. The home has a good complaints procedure, which has been amended to state that the complainant can go to the Commission for Social Care Inspection at any stage. The complaints book was seen - there was a recent complaint, which was professionally handled by the Registered Manager and an apology given to the complainant. Staff were asked what they would do in case of abuse and were aware of reporting this to outside agencies if not properly handled by the Management. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 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 standard(s) 19 Facilities are beginning to look dated and worn and required improvements have not been made. EVIDENCE: St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 16 It was disappointing to note that there continue to be a number of maintenance issues which have not been attended to which detract from what should be a picture of pleasant facilities, and where obvious issues appear they are not being dealt with by the Registered Provider, e.g. communal carpets in the lounge/dining room and ground floor corridors were still heavily stained in parts which still needs to be rectified – a professional carpet cleaner has stated to the Registered Manager that these stains will not be removed and therefore carpets need to be replaced, a number of areas of the home are in still in need of repainting – chipped skirting, pipes and doorways, WCs E and F where there are also signs of damp that need to be eradicated, rotten window frames to some bedrooms (e.g. rooms 17 and 3) and bathrooms, two dormer windows, one with a hole by it which lets in rain and crumbling plasterwork to a bathroom. One bathroom, used as a storeroom, needed to be locked to protect the Health and Safety of service users. Three bedrooms were slightly odouress and needed their carpets cleaned. A comment was received that service users do not use the second floor bathroom because there is no hoist – this needs to be provided. The Registered Provider still needs to submit details of the maintenance budget with regard to the Home’s business and financial plan. It was also again noted that the Registered Manager still does not have a maintenance budget – it is still strongly recommended that this be set up, as then issues should then receive swift attention. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Clients benefit from a dedicated staff group, however staff checks need to be tightened. EVIDENCE: This inspection has taken into consideration the number of staff/hours recommended by the Department of Health as detailed above. The home complies with the previous registration authority’s staffing requirement of care hours. The Home has increased its domestic staff so these functions are covered seven days a week. The home is now ensuring that staff have two written references and these are received before employment commences. The Registered Manager stated that new staff employed have their criminal records bureau checks applications completed as soon as possible and this was reflected in the Criminal Records Bureau checks on file. However in regard to a Protection of Vulnerable Adults check one was seen to be missing. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 38 Service users on the whole, benefit well from the management of the home. EVIDENCE: The Registered Manager has carried out a service users survey regarding food and is to extend this to other issues. Consultation with stakeholders is planned. There is a Health and Safety policy and risk assessments have been carried out for safe working practices. Training in Health and Safety, Moving and Handling, infection control and fire safety is needed for some staff. Hot water temperatures were checked and found to comply with the National Standard. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 x 4 x x 3 x x x x 3 St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 20 Yes Are there any outstanding requirements from the last inspection? 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. 2. Standard 3 19 Regulation 18 23 Requirement All staff need to have training on residents conditions and health and safety issues. Facilities need to be improved in regard to carpet and replacement, and repair of damaged or crumbling plasterwork to some bathrooms Damaged windows need to be repaired or replaced to ensure proper health and safety. A bath hoist is needed to a second floor bathroom. All areas of the home need to be kept odour free. The Registered Provider still needs to submit details of the maintenance budget with regard to the Home’s business and financial plan. Timescale for action 9/11/05 9/11/05 3. 4. 5. 6. 19 19 19 19 23 23 23 23 9/9/05 9/10/05 9/8/05 9/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations It is recommended that life histories of individual service D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 21 St Bennetts Care Home 2. 3. 4. 19 users are kept in Care Plans so staff can understand all important aspects if service users lives. The Registered Manager still does not have a maintenance budget – it is still strongly recommended that this be set up, as then issues should then receive swift attention. St Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 Bennetts Care Home D C51 C01 S6381 St Bennetts V240736 260705 Stage 4.doc Version 1.40 Page 23 - 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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