Inspection on 08/11/06 for St Brelades

This inspection was carried out on 8th November 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 Brelades 02/06/08

St Brelades 23/01/06

St Brelades 18/07/05

St Brelades 15/03/05

St Brelades 21/06/04

St Brelades 12/01/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Brelades 5/6 Beacon Hill Herne Bay Kent CT6 6AU Lead Inspector Christine Lawrence Key Unannounced Inspection 8 and 9 November 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 Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Brelades Address 5/6 Beacon Hill Herne Bay Kent CT6 6AU 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) 01227 375301 St Brelade’s Retirement Homes Limited Mrs Catherine Margaret Anne Chuck Care Home 37 Category(ies) of Dementia - over 65 years of age (36), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (36) St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. LD (E) is restricted to one person whose date of birth is 20/10/1934. Admissions are restricted to those Service Users whose category is DE(E) March 2006 Date of last inspection Brief Description of the Service: St Brelade’s is a care home which will eventually provide personal care and accommodation for 37 older people with dementia. The home has almost completed the change from a mixture of older people and older people with dementia. The home only provides care for women. It is owned by St Brelade’s Retirement Homes Limited who also own another home close by. The home is located on the seafront and close to Herne Bay town centre with all of its amenities and facilities. The home was opened in 1991 and consists of two large houses joined together. Thirteen of the single rooms have en suite toilet facilities and so do seven of the shared rooms. There is a patio area to the front of the house and a garden area to the rear. The fees are between £450.00 and £500.00. Information about the home, including the last inspection report will be made available on request. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection for St Brelade’s took place over two days and was undertaken in combination with the inspection of the home close by (The Cumberland) which is owned and managed by the same people. Twenty one relatives’ comment cards were received by the Commission for Social Care Inspection and the information they contained is used for this inspection. Records were viewed, a tour of parts of the building was made and the inspector spoke to the manager and other staff. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 6 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 Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 is not applicable to this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs assessed prior to moving into the home and thus can be assured that the home judges that it can meet those needs. EVIDENCE: The deputy manager usually carries out pre-admission assessments, although other senior staff might also undertake this role. These pre-admission assessments are based on visiting a prospective resident in their own home or in hospital. The information is then used to compile a care plan. Information is sometimes received from a placing authority and examples of this were noted on records. Mrs Chuck also gave examples to the inspector of not St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 8 admitting someone when the pre-admission assessment had identified that the home would not be able to meet their needs. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs are clearly set out in plans ensuring that these needs will be met. Residents are protected by the home’s policies and procedures regarding medication and they can be confident that their privacy and dignity will be considered important. EVIDENCE: A total of 10 care plans were viewed during this inspection. The home has recently changed its system for care planning and now uses the Standex method. They contain information about actions to be taken by staff to provide appropriate care for individuals. They are based on pre-admission assessments. They contain risk assessments and are regularly reviewed to ensure they are up to date. They cover a range of health and welfare care needs. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 10 Records are maintained to show the involvement of health care professionals such as dentist, optician, chiropodist and community nurses. The home retains the services of a local general practitioner who visits weekly on a regular basis. The care plan format includes tools for monitoring nutritional needs and risk assessments regarding skin integrity and mobility. Staff members who give out medications are either registered nurses or have undertaken a safe handling of medication training course. There are policies and procedures in place including allowing for self-medication which was noted appropriately in one resident’s records. Storage and record keeping is appropriate. The inspector observed medication being given correctly and sensitively. A copy of the Royal Pharmaceutical Society of Great Britain’s guidelines is available to staff. The manager and other staff confirmed that dignity and privacy are an important part of the care provided at St Brelade’s. The Mission Statement for the company emphasises this and each member of staff has a copy of this in their Orientation Folder which is part of their induction. Staff spoken to also confirmed that the ‘shadowing’ of an experienced member of staff during induction allows for these attitudes to be reinforced. Medical examinations would take place in the residents’ own room and personal care would be in own rooms or bathroom areas. There are 8 shared rooms, 7 of which have en suite toilets and all have screens for privacy when required. Some residents have their own phones and there is also a portable phone for residents to use which would allow for privacy. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and stimulation are well managed and as much as possible provide daily variation and interest for residents. Residents are enabled to maintain their contact with friends and family. Wherever possible, within the limitations of an individual’s dementia, residents are given opportunities to make choices, therefore allowing for some level of control over their lives. The meals in this home offer both choice and variety and catering for special needs. EVIDENCE: There are different lounge areas within the home and staff try to ensure that residents are in the most appropriate atmosphere. Games, puzzles, listening to music form part of the daily stimulation that the home tries to provide. There are also regular pottery and art and crafts sessions. Some residents enjoy television. Other people were observed reading newspapers, chatting with staff etc. Life histories are completed whenever possible, usually with the St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 12 help of relatives to ensure that staff are aware of what a resident’s past interests might have been. All the relatives who completed comment cards for this inspection indicated that they are made welcome in the home and that they can visit their relative in private if they wished. Residents who wished were able to move freely around the building. Staff explained that residents would be encouraged to make choices about which clothes to wear if this was something that they were able to do. There are different areas for residents to eat according to their needs and wishes. Staff were observed to help residents, either by encouragement or actually assisting them to eat. The food being served during the inspection looked and smelt good. There is a choice of drinks and residents likes and dislikes, as well as special needs are noted. Staff were seen to try and respond to residents own wishes with regard to moving about after lunch, returning to own rooms or the lounge areas or sitting and relaxing at the table. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints would be handled objectively and in keeping with the home’s appropriate procedures and residents/their representatives can be confident that any concerns will be listened to, taken seriously and responded to. Staff are aware of adult protection issues and there are systems in place which create an atmosphere for protecting residents from abuse. EVIDENCE: There is a Complaints Folder maintained and the records show, and this is confirmed by staff members that even very minor things are noted and responded to. The home has a form entitled “Minor Complaint/Incident Form” which is used to facilitate this. The home’s procedure for complaints is clearly written and included within the service user guide. There is information about how to contact the Commission for Social Care Inspection. Mrs Chuck said the ethos within the home was very much about trying to deal with any small issues before they become of concern to anyone. Staff spoken to were very clear about their responsibilities relating to protecting residents. There are policies and procedures in place which include whistle blowing and systems relating to protecting residents’ finances. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well-maintained and clean environment. EVIDENCE: The building and grounds are well maintained and the décor within the home is kept looking fresh. The furniture and fittings are good quality and domestic in style. There are no outstanding requirements from the local environmental health department or the fire safety officer. One relative included in a comment card the fact that when visiting the home noted that they were “…impressed by the cleanliness…”. This reflects the inspectors’ experience on the day of the inspection that the home was clean St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 15 and had no offensive odours. Clothes washing machinery (ozone system) provides appropriate washing cycles for foul or infected items. There is an appropriately secured cupboard for storage in keeping with the Control of Substances Hazardous to Health Regulations and there are hand-washing facilities. There are appropriate policies and procedures in place. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by sufficient staff who are competent and trained. Residents are supported and protected by the home’s recruitment procedures. EVIDENCE: The staffing levels are good at St Brelade’s. There are sufficient carers, cleaners, food preparation staff, maintenance staff and a management team. A rota is kept which shows who is working when and where and with what role. Carers work consistently with small groups of residents which enables them to get to know people and their needs and preferences. More than 50 of care staff have achieved National Vocational Qualifications (NVQs). In fact the majority have level 3 qualifications. This is considered an important part of staff training and everyone is offered this opportunity within 6 months of starting work at St Brelade’s. The head of care in The Cumberland, who also sometimes works in St Brelade’s is responsible for coordinating the NVQ candidates. There is another senior member of staff, a trainer/administrator who oversees the induction and ongoing training St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 17 programme. Staff members spoken to confirmed that they were given opportunities for training. Staff records seen during this inspection were well maintained and provided information which showed that the recruitment procedures include two written references, Criminal Records Bureau checks, terms and conditions of employment and the provision of copies of Codes of Conduct published by the General Social Care Council. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the home being managed by someone who is competent, experienced and knowledgeable. Residents’ financial interests are safeguarded. Staff and residents have their health and safety promoted and protected. EVIDENCE: Cathy Chuck is the registered manager of St Brelade’s. She is currently undertaking Level 4 NVQs in management and care. She has many years experience of managing. The deputy manager is currently undertaking Level 4 NVQs. The clinical manager is a qualified nurse. There is also a head of care St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 19 at St Brelade’s and as previously mentioned the head of care from The Cumberland (who has achieved her registered managers award) who also undertakes duties in St Brelade’s. There is also a trainer/administrator who is currently undertaking Level 4 NVQs. This group of people work together to provide a management team which is clear about the ethos of the home and the lines of accountability. The company is an ‘Investors in People’ organisation. Mrs Chuck has established a system of consulting with residents’ representatives through sending out questionnaires. The care plans are written and reviewed wherever possible with the involvement of the residents’ representatives, ensuring their views are taken into account. Mrs Chuck confirmed that she would respond to any request from the commission for a report relating to the quality of care in keeping with Regulation 24(2). If any purchases are made for residents at the request of a relative, or if any extra services are provided then the appropriate person will be invoiced by the home. All residents are represented by a relative or another person responsible for their finances eg solicitors, local authority finance officer. The home is not directly involved with the finances of any resident. One of the maintenance staff has designated responsibility for undertaking regular health and safety checks throughout the building. A spot check on maintenance and service contracts showed that these are in place and monitored. It was recently identified that the periodic inspection of the electrical installation needs updating. This has been arranged for early March. Fires safety checks and accidents and incidents are appropriately recorded. Risk assessments are in place for a number of areas and activities within the home. There is a range of policies and procedures relating to health and safety. St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action 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 OP31 Good Practice Recommendations The registered manager should complete her qualification course St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Brelades DS0000023555.V307340.R01.S.doc Version 5.2 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. 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