Inspection on 09/08/05 for St Brendans

This inspection was carried out on 9th August 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 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 Brendans 23/10/08

St Brendans 06/09/07

St Brendans 05/02/07

St Brendans 20/02/06

St Brendans 20/09/04

St Brendans 17/05/04

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 Brendans 175 Ashburnham Road Luton Bedfordshire LU1 1JW Lead Inspector Ansuya Chudasama Announced 9 August 2005 th 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 Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Brendans Address 175 Ashburnham Road Luton Bedfordshire LU1 1JW 01582 728737 01582 726022 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 Jethra Kara Marian Porter Care Home 26 Category(ies) of OP registration, with number DE(E) of places St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20.09.2004 Brief Description of the Service: St Brendan’s 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 I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was undertaken 09.30am. It took place over 7 hours. The inspector spent the majority of the inspection observing practice and speaking to service users, staff, and management. The care records of three service users and other documents were also examined, and a tour of the two bedrooms took place. Feedback was given to the manager and the proprietor. What the service does well: What has improved since the last inspection? The home had met all the requirements looked at the inspection. The manager stated that the occupational therapist had still not completed her assessment of the premises and were not able to give a copy of the report. The home had replaced carpets in eight bedrooms, bought new commodes, new table clothes, towels, and bedding for service users. A new microwave, dishes, and curtains were purchased. St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 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 I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5,6. The home’s statement of purpose and service user’ guide and introductory visits provided potential service users, and their representatives with details of the services and facilities the home provided. This enabled them to make an informed decision about admission to the home EVIDENCE: The home had a statement of purpose and a service users’ guide and these were displayed on the notice board at the home. Some of the information needed rearranging in the documents. The service users spoken to stated that their families and some of them had visited the home prior to admission. Experienced staff also completed a pre admission assessment form by gaining information from service users, their relatives and other professionals. The form needed to be completed properly. It also needed to be signed and dated by the person completing the form. All service users had contracts with the home and met the standard. The owner and the manager had improved the opportunities for staff to receive training, and staff were therefore better equipped to meet the needs of the service users. The home did not provide intermediate care. St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 9 St Brendans I51 S14959 St Brendans V232216 090805 - 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) 7,8,9,10,11 The care plans illustrated that service users received good standards of care with a need for further development in some areas. Conversations with service users showed that their needs were being met EVIDENCE: All service users had care plans. Information on weight charts, burial arrangements, behaviour assessments, diet, personal hygiene, oral hygiene, mobility, communication, manual handling, was recorded. The plans needed expanding to include all information as stated in standard 3. The plans should also be signed by the service user whenever capable or by their family. Service users appointments to health professionals were recorded in a separate file and in the diary. The manager stated that this would be put in the individual service users’ file. The information not in the care plan was available in the other sections of the file and other documents. The service users’ file needed to be better organised. The staff spoken to were able to give detailed information in how they met the needs of the service users that were case tracked. The care plans were being reviewed on a monthly basis. Staff who gave out medication had received the training and the medication file seen was satisfactory. However there were a few gaps where staff had not St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 11 signed the Mars sheet. The manager stated that this would be monitored. One service user spoken to stated that the staff looked after them when they are “unwell and they called the GP out”. They also knocked on their doors before entering their room. All staff had received training on death and bereavement. St Brendans I51 S14959 St Brendans V232216 090805 - 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) 12,13,15 Service users were offered home made varied and nutritious meals to ensure they remained healthy. The home provided weekly activities and monthly social events so service users could enjoy a normal range of activities. EVIDENCE: Service users received a variety of nutritious meals. On the day of the inspection the cook was observed discussing the choices available for lunch. It was also stated that service users were asked for their choices for lunch and tea every day. The staff and the cook spoken to had good understanding of service users likes and dislikes of meals. The inspector sampled the food at lunchtime and this was tasty and hot. The staff were also observed helping service user with their food in a positive manner. The service users spoken to stated that the meals were excellent. One service user stated that she enjoyed curry and had this at least once a week. They also stated that they enjoyed living at the home. The bedrooms seen for two service users were clean and individualised to meet their needs. The service users spoken to stated that they liked their rooms and the staff. There was Information written on lifestyle and interest but it was not included in the care plan. The manager stated that this information would be available in the care plans. The home had a cat and all the service users were very fond of it and some helped staff to care for it. The service users spoken to stated that they wanted more activities. At present they stated that they played bingo once a week. On the St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 13 day of the inspection the staff were playing bingo with some of the service users and they seemed to be enjoying this. The care staff spoken to worked as an activities organiser for eight and a half hours per week. It was stated by staff that they also did manicures, reminiscence, gentle exercise, one to one conversations and quizzes with service users. The staff also took one of the service users to the shops to buy books and magazines. One service user went to day care five days a week. The home needs to display an activities list on a weekly basis so therefore service users know in advance the activities that are to be undertaken. Social events on a monthly basis did take place and service users confirmed this by stating that they recently had a karaoke and enjoyed this. The also held service users meetings to discuss their views and information about the home. The home welcomed families and friends and encouraged them to attend social events held at the home. St Brendans I51 S14959 St Brendans V232216 090805 - 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 There were systems in place to ensure that service users were protected and complaints were listened to and dealt with satisfactorily. Improvements were needed in the training of staff, in order that they fully understood certain areas of practice. EVIDENCE: The home had a complaints policy and this was displayed in the service user’ guide which was displayed on the notice board. Service users spoken to stated that they knew who to complain if they were unhappy. It was also stated that the staff listens to them and they could talk to the manager if they had any concerns. The staff spoken to were aware of policies and procedures designed to protect service users. They also gave examples of how they would be able to tell if some one was unhappy by their body language and the way they behaved. It was stated that they had got to understand the needs of the service users well. It was stated that service users opened their own mail and staff also helped those who were not able to read. Service users were called by their preferred mode of contact. This was observed on the day of the inspection. St Brendans I51 S14959 St Brendans V232216 090805 - 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, 20,23,24,26. The environment was well maintained, homely and comfortable and met service users needs. Some of the furniture needed replacing as it was old and worn out. EVIDENCE: The home was clean and pleasantly decorated. The service users were observed accessing all parts of the home safely. The furniture in the garden had plastic table and chairs that were worn out and needed replacing with attractive furniture. One gentleman brought his own cushion from his room to sit on the garden chair, as there were none available on the chairs. The manager stated that the garden furniture was going to be replaced this year. The home had three lounges. One was on the first floor and two were on the ground floor. The inspector observed that most of the service users enjoyed sitting in the lounge adjacent to the garden and at times the room seemed crowded. The lounge in the front was not used as frequently as the other lounge. The manager and the owner stated that they were going to look at different options to ensure that service users used all the lounges. The chairs in the dining room were small in size and needed to be replaced with those St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 16 that were suitable for the service user group. The fan in the kitchen had recently been cleaned, however the manager stated that it had stopped working since then. The manager stated that they tried to get the contractors to repair it as they had broken the fan. However they have refused to take the blame and the home now has to repair this. The working conditions in the kitchen were very hot. The provider said that an assessment of the premises had been started but this had still not been completed. She agreed to forward a copy of the assessment to the CSCI. The recommendation to have a handrail installed alongside the ramp from the sitting area to the garden was completed. Service users were observed wandering around the communal areas safely. St Brendans I51 S14959 St Brendans V232216 090805 - 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) 27,28,29,30 There were sufficient number of staff with relevant training to ensure that the needs of the service users were met. EVIDENCE: The home was fully staffed. The staff spoken to were very experienced and enjoyed working at the home and with the service users. It was stated that they worked well as a team and support from management was good. They were encouraged to bring up ideas and these were discussed in their team meetings. They also had good handovers at each shift. All staff had completed the induction and mandatory training as required in the standards. One domestic staff spoken to stated that she had done dementia training, challenging behaviour and was now doing NVQ training in cleaning. Other staff spoken to had not done epilepsy training however they had read information on this. Staff also welcomed refresher training on mental health. It was stated that the training provided by the home was good. The staff had supervision 4 or 5 times a year and the manager information was recorded in a book. The staff files inspected contained all the information. The home had plans to get all staff to have NVQ level 2 or 3 training. St Brendans I51 S14959 St Brendans V232216 090805 - 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) 31,32,33,36,38 The home was well managed to ensure the needs of service users were met. EVIDENCE: The manager had worked in the care profession since 1998. She had NVQ in level 3 and at present was undertaking the foundation degree in care management. The manager had also undertaken other training to update her skills and knowledge. It was stated by staff that the manager and the owner. The manager and the provider had worked hard to meet the requirements from the last inspection. The manager stated that staff supervision sessions were in the future going to be recorded on a separate sheet. The sessions were also going to be increased to at least six times a year. The procedures and arrangements for health and safety were satisfactory. Fire records were in good order and staff had received fire training. The manager kept a training log for all mandatory training to show that all staff completed annual updates. There were certificates of regular safety checks of St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 19 the lift, lifting equipment and electrical equipment. Water temperatures were recorded and in order. Window restrictors were provided for safety. Storage arrangements were provided to lock plastic gloves and pads. The service users guide also contained information on how the home dealt with emergency procedures. St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 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 Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 x 3 St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 21 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. Standard OP7 Regulation 15-1 Requirement All care plans must include all the information stated in the standard and assessments and reviews must be signed and dated by staff All staff must sign the medication sheets at all times when giving out medication. The registered provider must review and implement a system of quality assurance in line with the NMS. Timescale for action 20.12.05 2. 3. OP9 OP33 12 24 9.9.05 This standard was not assessed at this inspection but it will be inspected at the next inspection. 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. Refer to Standard OP12 OP9 Good Practice Recommendations Provide a weekly activities list in advance. Replace old worn out furniture with suitable ones that I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 22 St Brendans 3. OP30 meet service users needs. Provide training on epilepsy and refresher training on mental health. St Brendans I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Clifton House 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 I51 S14959 St Brendans V232216 090805 - Stage 4.doc Version 1.40 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!