This inspection was carried out on 13th January 2006.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.
CARE HOMES FOR OLDER PEOPLE
St Bernadette`s Nursing Home 25-27 Trinity Road Scarborough North Yorkshire YO11 2TD Lead Inspector
Mary Slattery Unannounced Inspection 13th January 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Bernadette`s Nursing Home DS0000028011.V275302.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 Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Bernadette`s Nursing Home Address 25-27 Trinity Road Scarborough North Yorkshire YO11 2TD 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) 01723 366522 01723 501502 Complete Care Homes Limited Miss Ingrid Louise Campbell Richards Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Age Range 60 years plus Date of last inspection 22nd June 2005 Brief Description of the Service: St Bernadettes provides nursing care and accommodation for up to 27 service users from 60 years of age. The home is located in a residential area of Scarborough and the amenities and facilities of the town are approximately a mile away from the home. The accommodation provided is in single and double bedrooms over 3 floors. There is ramped and level access to the home and two passenger lifts giving access to the upper floors. There are gardens to the front and side, which are used by the service users and there is private parking facilities for visitors and staff. The home is owned by Complete Care Homes Limited and was registered with the Commission in 2002. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection of the home carried out on the 13th January 2006. A tour of the premises was carried out and time was spent observing the activity in the home, talking and listening to service users, staff and visitors. The focus of the inspection was on a number of key standards, inspecting the case records of a number of the service users to establish if they corresponded with their experiences of life in the home. The findings of the inspection were discussed and agreed with the registered manager and the nursing staff on duty. What the service does well: What has improved since the last inspection?
The staffing levels have been increased and staff have attended abuse awareness training. The staff recruitment procedure has improved and all the required records are in place and the required checks carried out before staff start work in the home.
St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 6 New carpets have been fitted in a number of the bedrooms and more are due to be fitted at a later date. 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 Bernadette`s Nursing Home DS0000028011.V275302.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 Bernadette`s Nursing Home DS0000028011.V275302.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 and 3. Up to date information about what the home offers to provide is made available. EVIDENCE: The Statement of Purpose and the service user guide are under review to include updated information about the new staff now employed by the home. Assessments are carried out on prospective service users before they are admitted to the home. A new admission took place on the day of the inspection and the assessment record was available to look at. Limited information had been gathered about the service users physical and mental health care needs. It is important that all staff that carry out assessments understand the process and the importance of recording their findings in greater detail to enable the staff to determine that they can meet the service users needs in a safe manner. St Bernadette`s Nursing Home DS0000028011.V275302.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 and 9. The systems in place for recording the findings of the risk assessments and to evidence that medication has been administered need to improve. EVIDENCE: A number of the risk assessments that had been carried out with regard to the safe moving and handling of service users were looked at. There was limited information about how task was to be carried out and about the equipment to be used. The monitored dosage medication system is in operation and the system and facilities were inspected. There were a number of gaps in the medication administration records and incorrect use of the codes. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 10 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 and 13. Good information is gathered about the service users lifestyles and good and regular contact is kept with family and friends. EVIDENCE: The majority of the service users living in the home are from the surrounding communities and this helps them keep in contact with their family and friends and with events in the local community. A proportion of the staff are from the local area and keep service users up to date with what is going on locally. Arrangements are made for spouses to visit on a daily basis, have lunch and be involved in the service users care where practicable. The staff keep relatives informed of any changes in the conditions of the service users and seek their opinion of the services provided on a regular basis. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 11 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): 18. The service users are protected by the staff recruitment practices and the staff’s awareness of abuse. EVIDENCE: The staff recruitment and selection procedure in place ensures that the required checks are carried out and references collected prior to staff taking up their position. The staff are aware of their responsibilities regarding the protection of vulnerable people and have had experience in using the local authorities reporting procedure. Further abuse awareness training is planned for March 2006. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 12 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, 24 and 26. The service users live in a warm, well maintained home with their possessions around them. EVIDENCE: The home was found to be warm, clean, bright and free from offensive odours. There is an ongoing programme of refurbishment and maintenance, new carpets have been fitted in some of the bedrooms, and new chairs are due to be delivered. The service users rooms reflect their individual tastes and they are encouraged to bring personal items with them to make them feel more at home. Some of the rooms are shared and screening is in place to ensure privacy when personal care is being delivered. A number of tubes of Steredent and a selection of toiletries are kept in the communal bathrooms, which are not locked. These substances if ingested, in particular Steredant, pose a serious risk to service users and therefore must be kept in a locked cupboard. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 13 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 and 29. The service users have benefited from an increase in the staffing levels and the appointment of an activities organiser. EVIDENCE: The staffing qualified nursing staff and care staff levels have been increased and this gives the staff more time with each service user. All new staff have a full induction to the homes policies and practices and they have opportunities to undertake training in relation to the care needs of the service users and NVQ training. The required CRB and POVA checks are carried out prior to appointment and all staff are supervised on a regular basis. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 14 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 and 38. The service users benefit from a well managed home where their needs and wishes are put first. EVIDENCE: The registered manager is a first level nurse and is to commence the registered managers award before the end of January 2006. The home’s policies and procedures are reviewed on a regular basis and updated as required. The registered manager is proactive in ensuring service users placements are reviewed by the local authority and the health authority. Views of the service users, their relatives and other stakeholders are sought and considered to make sure that the home is continuing to meet the service users needs. There is a health and safety policy and procedure in place and all staff attend health and safety training.
St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 15 Moving and handling training updates are to be held and this will give staff the opportunity to review their moving and handling practices to make sure that they are using the correct methods and equipment, it will also assist staff in carrying out written risk assessments in greater detail. All substances hazardous to health must be kept in a locked facility as detailed in Standard 19 of this report. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 16 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 1 X X X X 3 X 3 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 2 X 3 X X X X 1 St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 17 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. 2. Standard OP9 OP19OP38 Regulation 13(2) 13(4)(c) Requirement The registered person is required to keep accurate medication records. The registered person is required to keep all substances hazardous to health in a locked facility. Timescale for action 30/01/06 30/01/06 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 Refer to Standard OP3 OP7 OP31 Good Practice Recommendations It is recommended that the information gathered at the initial assessment of service users be recorded in more detail. It is recommended that the moving and handling risk assessment give more information about the task and the equipment to be used. It is recommended that the registered manager complete NVQ Level 4 or equivalent. St Bernadette`s Nursing Home DS0000028011.V275302.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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