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Inspection on 20/02/06 for St Brendans

Also see our care home review for St Brendans for more information

This inspection was carried out on 20th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Many of the residents at the home feel that the standard of food is very good. One resident said " the food is excellent, there is a really good cook everyone thinks the meals here are good". The home offers residents a choice in their meals and residents also said that if they did not like any of the options on offer the cook would make them something else. Residents and staff at the home also think that the manager is `very organised` and `supportive`. The manager makes sure that she knows about all the residents` needs and works very hard to build a trusting relationship with them. She also thinks it is important to learn new skills and develop her own knowledge to improve the standard of care for the residents and is training to gain a qualification.

What has improved since the last inspection?

Written records known as care plans are in place for all the residents at the home. Since the last inspection they are all now being signed by the member of staff writing them and dated. This means that it is clearer who is responsible and when the home needs to review the guidance that they contain to make sure residents receive the care that they need. The home have also bought new dining room furniture, this makes the dining room look a lot better and provides a homely environment for the residents.

What the care home could do better:

Staff need to make sure that when a resident moves into the home that they keep an accurate record of any medication that they bring with them especially the amount. They also need to be clear in how they check the amount of medication that they have for each resident to see if the right amount has been given out. It was not clear if one resident had received their medication as prescribed and because the system at the home was not clear enough there was not a way of checking this. The home also needs to make sure that when they have asked the opinions of residents and relatives that they show how they have acted upon their comments. They need to show how they have used the views to change things in the home for example one of the policies in the home may change as a result of feedback from residents.

CARE HOMES FOR OLDER PEOPLE St Brendans 175 Ashburnham Road Luton LU1 1JW Lead Inspector Katrina Derbyshire Unannounced Inspection 20th February 2006 11:15 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 Brendans DS0000014959.V283687.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 Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Brendans Address 175 Ashburnham Road Luton LU1 1JW 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) 01582 728737 01582 726022 Mr Jethra Kara Mrs Bhavna Kara Marian Porter Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places St Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: St Brendans is a three storey period house in a residential area of Luton. It is on a bus route and within a short drive of nearby shops, post office, public houses and places of worship. Accommodation is provided on all three floors of the home, with 20 single bedrooms and 3 double bedrooms. Access to the upper floors is via stairs or a lift. There is a small lounge on the fist floor and two further lounges and dining room on the ground floor. The kitchen and laundry facilities are located on the ground floor. There is an attractive garden with an enclosed patio area at the rear of the home with raised flowerbeds and garden furniture. St Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 20th February 2006. The manager Mrs. Marion Porter was present throughout the inspection. During the inspection many of the areas within the home were visited and the inspector spent time with many of the residents’ in the sitting area of the home and dining room. The care of two residents’ was examined in depth by looking at their records and interviewing the residents’ and staff who look after them. Observations of care practice and communication between the residents’ and staff was also made at the inspection. The focus of this inspection was to follow up on any requirements and recommendations made at the inspection in August 2005. What the service does well: What has improved since the last inspection? Written records known as care plans are in place for all the residents at the home. Since the last inspection they are all now being signed by the member of staff writing them and dated. This means that it is clearer who is responsible and when the home needs to review the guidance that they contain to make sure residents receive the care that they need. The home have also bought new dining room furniture, this makes the dining room look a lot better and provides a homely environment for the residents. St Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Brendans DS0000014959.V283687.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 Brendans DS0000014959.V283687.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): EVIDENCE: These standards were not assessed at this inspection. St Brendans DS0000014959.V283687.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&9 Care planning systems in the home are to a good standard and provide sufficient information and guidance to staff in how to meet residents assessed needs. EVIDENCE: The home has introduced a new system for care planning; each residents care record contains clear guidance to staff on how and what records should be in place. Those plans seen were comprehensive and there was a plan in place for each assessed need. Staff when questioned were able to accurately describe the information contained within the plans and they were clear on following the guidance within them so each resident received individual care. Care plans seen were signed by the author and dated. Medication records and stocks were examined. The medication administration sheet of one resident and the stocks of medication indicated that there had been an occasion in the past two week period where staff had signed to show that medication had been given when stock levels showed that it had not. This is unsafe practice as residents are not receiving needed medication and a requirement has been made. Clearer systems also need to be in place to audit stock levels against administration records. St Brendans DS0000014959.V283687.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): 15 Dietary needs of residents are well catered for with a balanced and varied selection of food that meets resident’s tastes and choices. EVIDENCE: Menus were on display within the home; these showed that a varied and balanced diet including all the main food groups was on offer. Observations of lunch showed resident’s had been given a choice in their main meal, staff were seen to assist those who required help to eat their meals. Many of the residents commented that the food was good and they enjoyed their meals. St Brendans DS0000014959.V283687.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): EVIDENCE: These standards were not assessed at this inspection. St Brendans DS0000014959.V283687.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): EVIDENCE: These standards were not assessed at this inspection, however a previous requirement was noted to have been met as the home had purchased new dining room furniture. St Brendans DS0000014959.V283687.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): EVIDENCE: These standards were not assessed at this inspection. St Brendans DS0000014959.V283687.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 The manager has a clear development plan and vision for the home, which she has effectively communicated to residents, staff and relatives. EVIDENCE: St Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 15 The Home Manager informed the inspector that she is currently undertaking the Registered Managers Award and is aiming to compete this in 2006. The Home Manager has many years experience, which is directly relevant to the role of manager in the home. The interaction observed between her and the residents and staff was supportive and caring. Staff through interviews confirmed that the Home Manager was very supportive to them and provided sufficient and effective management. A quality assurance programme was seen to be in place within the home who had actively sought the views of residents and relatives. However the home needs to demonstrate how they have used their views to influence and change the running of the home, this was discussed with the manager and owner at the time of inspection. St Brendans DS0000014959.V283687.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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X St Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? YES 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 12(1)(a) & 13(2) Requirement Accurate records and systems must be in place to ensure all residents receive all prescribed medication and audits can be carried out. The registered provider must review and implement a system of quality assurance in line with the NMS.(previous requirement timescale of 09/08/05 not met) Timescale for action 30/04/06 2. OP33 24 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Brendans DS0000014959.V283687.R01.S.doc Version 5.1 Page 19 - 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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