Inspection on 22/11/05 for St Bridget`s Home

This inspection was carried out on 22nd November 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Bridget`s Home 22/06/06

St Bridget`s Home 25/07/05

St Bridget`s Home 29/11/04

St Bridget`s Home 10/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 St Bridget`s Home Ilex Close Rustington Littlehampton West Sussex BN16 2RX Lead Inspector Mrs J Aston Unannounced Inspection 22 November 2005 09:00 St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 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 Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 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 Adults 18-65. 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 Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Bridget`s Home Address Ilex Close Rustington Littlehampton West Sussex BN16 2RX 01903 783988 01903 859235 sara.willis@ic-uk.org 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) Leonard Cheshire Mrs Sara Margaret Willis Care Home 38 Category(ies) of Physical disability (38), Physical disability over registration, with number 65 years of age (38) of places St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only persons in the category PD (18-65) to be admitted to the home Date of last inspection 25th July 2005 Brief Description of the Service: St Bridgets is a private residential care home registered to accommodate thirty-eight people with a physical disability. The premises are purpose built, set in their own grounds in a residential area between Rustington Village and the sea front. Residents accommodation is provided on the ground floor of the main building and in three separate bungalows. The proprietors are The Leonard Cheshire Foundation. The Responsible Individual for the organisation is Mr Peter Bray and the Registered Manager is Ms Sara Willis. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken on Tuesday 22nd November 2005 from 9am until 3pm. This was the second visit to the home this year and completes the annual inspection programme for the year. The Inspector undertook a tour of the premises during which two residents; two District Nurses and three members of staff were spoken with. The Inspector also spent time talking with the activities co-ordinator, the Occupational Therapist, the cook and the Volunteer co-ordinator. A sample of records relating to new staff, Health & Safety and training were examined. What the service does well: What has improved since the last inspection? Three of the bedrooms have been decorated since the last inspection. Mrs Willis has now developed a redecoration and maintenance plan for the home that will ensure that the accommodation is kept to a good standard. There is a plan to redecorate/refurbish zone 2 that was highlighted as needing attention at the last inspection. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 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 Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4, 5. Prospective service users have an opportunity to visit the home. Each service user has an individual written contract. EVIDENCE: A resident recently admitted to the home visited the home on a weekly basis before admission. This gave the resident a good opportunity to experience life in the home before moving in. A written contract has been provided to a new resident that outlines the terms and conditions of the home and is signed by the resident or representative. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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, 8, 10. Residents are assisted to make decisions about their lives and have opportunities to have their say about all aspects of life in the home. Information held in the home relating to residents is handled appropriately. EVIDENCE: A resident spoken with during the inspection confirmed that St Bridget’s provide support and assistance to ensure that he is able to lead a fulfilling life as independently as possible. He felt his decisions and rights were respected but any potential risks were discussed. There are a number of ways in which residents can have their say about any aspect of the home. There is a residents committee that holds regular monthly meetings, a residents meeting with the management of the home every two months and an open meeting for anyone to attend six times a year. Residents also have regular individual review meetings. Information held about each resident is stored appropriately and securely. St Bridget’s have policies and procedures in place in respect of data protection and confidentiality of information. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 10 It was noted that members of staff have to sign a policy in respect of the handling of information stored on computers. The manager confirmed that guidance on confidentiality of information is given during the induction training for new members of staff and further discussed at staff meetings. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14, 15, 16, 17. Opportunities for personal development are wide ranging and well organised. Residents are able to take part in appropriate leisure activities. Residents are assisted to maintain appropriate relationships and are provided with information about their rights. The food provided is of a good standard and promotes individual choice. EVIDENCE: The Inspector spent time talking with the activity co-ordinator. It is clear that St Bridget’s provides every opportunity for a resident to further develop their education or independence. The activity co-ordinator has worked hard to establish and maintain excellent links and outreach support from Chichester College. Residents enrol in courses that are undertaken at either St Bridget’s or Chichester College. Residents who undertake courses at St Bridget’s have support from trained instructors from Chichester College. Residents are supported to obtain qualifications in their chosen subject. Activities range from cooking, literacy, numeracy, ICT, art and craft and drama. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 12 Residents are also supported within this framework with leisure activities. Within St Bridget’s there is also a computer suite and most residents have television and music equipment in their rooms. The activity co-ordinator has also set up a self advocacy group that raises awareness of the rights of disabled people and assists them to be more assertive. Residents are supported to maintain relationships with family and friends. Visitors to the home are made welcome at any time. A private company, Caterlink has managed the catering within St Bridget’s for the last three years. Menus over a four week period have been compiled and menus change to reflect seasonal differences. Menus are on individual tables daily. The Inspector gained the view that residents have opportunities on a daily basis to choose between the daily menus or an alternative and this applies to breakfast, the main meal of the day and supper. A vegetarian meal is always provided. A resident’s choice is cooked every week. Special diets are catered for however currently the number of these is minimal. Hot and cold drinks are available from the dining room at any time. There are fresh fruit juice, milk and water dispensers for self service and a hot water boiler on at all times for hot drinks. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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, 20. Residents’ health and emotional needs are closely monitored and appropriate advice or treatment sought. Appropriate policies and procedures are in place in respect of the administration of medication however all members of staff must adhere to these to ensure safe practice. EVIDENCE: Residents are generally registered at the same Doctors surgery but a number of Doctors are available at the practice so residents can have a choice about whom they see. A nominated Doctor holds a surgery at the home on a weekly basis and residents are free to consult the Doctor confidentially. The manager informed the Inspector that St Bridget’s has a good relationship with the practice and feel well supported by them. Currently the practice is in the process of instigating annual health care checks and plans for each resident. Care plans at St Bridget’s record the health care needs of each resident. Residents are supported to have regular dental, optical, hearing and chiropody checks usually using community facilities but visiting professionals are used where necessary. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 14 During the inspection two District Nurses were in the home visiting four residents. They informed the Inspector that members of staff at St Bridget’s are very good at ensuring that measures and equipment are in place to prevent pressure areas. They feel the care and support provided to residents is good. On the day of the inspection the Inspector was notified of two incidents involving mistakes being made in the administration of medication. The Inspector is aware that the correct policies and procedures are in place to ensure safe administration of medication however the incidents occurred due to members of staff not adhering to these procedures. Therefore a requirement has been made for the Manager to take action to ensure that all members of staff are fully aware of the procedures and adhere to them. The Manager must confirm in writing to the Commission what actions have and will be taken. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. Arrangements for residents to make their opinions and any concerns known are satisfactory. EVIDENCE: St Bridget’s have a complaints policy and procedure and complaint records are submitted monthly to the Leonard Cheshire Head Office. The Manager maintains an atmosphere in the home that supports residents to air their concerns. Residents are able to make complaints to any member of staff and the manager makes herself available to listen and to act upon concerns or complaints. A resident said that they were happy to approach the Manager with any concern and confident that they would be listened to. The Inspector was informed that there have not been any complaints made since the last inspection. The Commission have not received any complaints about the home. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25, 26, 28, 29. St Bridget’s provides comfortable and well equipped accommodation for the people who live there. Some communal areas require re-decoration. Residents have specialist equipment and advice to maximise their independence. EVIDENCE: The accommodation at St Bridget’s is provided within a main building and three bungalows within the grounds of the home. One of the bungalows is currently unoccupied and awaiting redevelopment. The main building of the home provides resident accommodation on the ground floor so residents can access all parts of the home. There is easy access to the grounds of the home. Residents’ bedrooms were comfortable, appropriately decorated and furnished and have been personalised. Three bedrooms have been redecorated since the last inspection. Residents’ bedrooms can be locked if so chosen by the resident. The Inspector was informed that a lot of residents have chosen not to have a key to their rooms. It is recommended however that the locking of bedroom doors be encouraged particularly due to two previous incidents of theft within the home. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 17 This should be encouraged particularly in the more isolated areas of the home as security of personal belongings cannot be guaranteed in a very busy home. On the day of the inspection a lot of residents bedroom doors were left open and unoccupied. This was found at the last inspection and a requirement made that residents bedroom doors should be closed at all times as they are fire doors. The Inspector was informed that this matter has been referred to the Health & Safety Officer for Leonard Cheshire. The Inspector recognises that this restricts the independent movement of residents however St Bridget’s must adhere to the Fire Authority’s legislation and guidance. At the last inspection it was identified that some areas of the home required redecoration mainly due to the heavy wear and tear in the home. At this inspection the Manager demonstrated that a maintenance programme had been developed to ensure that all areas of the home are kept to a good standard. The progress in maintaining this will be monitored at the next inspection. St Bridget’s employ an Occupation Therapist for twenty four hours per week and an Occupational Therapy assistant for twenty two hours per week. A Physiotherapist is also employed for sixteen hours per week and a Physiotherapist assistant for eleven hours per week. The Occupational Therapists work hours to ensure that they maximise the availability of their services for advice, assessment and minor repairs. These services are well organised and have good systems in place to ensure good communication with residents and care staff. The combined services provide excellent support for residents at St Bridget’s that ensures that they have the correct equipment and support in place to maximise their independence. The Inspector noted during a tour of the premises that overhead hoists used in bathrooms and toilets had been serviced within the last few months and there were records to demonstrate that other equipment in the home was regularly checked for safety and maintained. The difficulty for the home with individual pieces of equipment is storage space. Some bathrooms are cluttered with equipment and this does not always promote a homely feel. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 36. Residents are protected by the home’s recruitment policy and practices. Members of staff receive a good level of training and are appropriately supervised. EVIDENCE: The records relating to new members of staff employed since the last inspection were examined. The records demonstrated that all the necessary recruitment checks had been undertaken prior to employment. A spot check was undertaken on criminal record checks for volunteers working in the home. It was found that the necessary checks had been undertaken. Training records examined demonstrated that an induction programme is provided to new members of staff, mandatory Health & Safety training is provided a regularly updated and staff are supported through National Vocational Qualifications (NVQ). The Inspector was informed that currently: • Four members of staff have completed NVQ level 3 • Ten members of staff have completed NVQ level 2 • Eight members of staff are currently working towards Level 2. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 19 Once completed this will mean that St Bridget’s will have met the target of 50 of the staff team trained to NVQ level 2 as required by the National Minimum Standards for Younger Adults. Leonard Cheshire provides a range of training for members of staff in topics relevant to the work they are expected to perform. Fire training sessions are regularly organised by St Bridget’s for staff to attend every six months for day staff and every three months for night staff. Seven sessions have been organised since January this year. At this inspection it was noted that thirty eight members of staff were required to attend the December training. Although their training was not out of date this does not demonstrate good management or planning of mandatory training. A requirement has not been made at this inspection but this will be revisited at the next inspection. A senior member of staff is always on duty to ensure that members of staff receive appropriate supervision whilst working. Records indicated that members of staff have received individual supervision. It is recommended however that the Manager keep an overall record to demonstrate that individual supervision is a planned event throughout the year. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 42. The Manager is experienced and qualified to run the home. The health, safety and welfare of residents are protected. EVIDENCE: Ms Willis has completed the Registered Managers Award and has the necessary skills and experience to run the home. A resident said that they found her approachable and were confident that they would be listened to and supported. Records seen on the day of the inspection indicate that annual safety inspections are undertaken on equipment and utility supplies and maintenance systems are in place to ensure the safety of residents. It was noted during a tour of the premises that temperatures of hot water for bathing are recorded and hot water outlets are fitted with safety valves. Mandatory training in fire, moving and handling, first aid, infection control and food hygiene is provided and updated. St Bridget’s has a current insurance certificate for the home. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 21 At this inspection however as previously mentioned in the report there are some Health & Safety matters that the Manager must address to ensure residents’ welfare and safety: Fire doors being left open. Members of staff not adhering to the policies and procedures for the safe administration of medication. Security of the premises and residents belongings. Thirty eight members of staff requiring Fire training. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X 3 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 4 X LIFESTYLES Standard No Score 11 4 12 X 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Bridget`s Home Score X 3 2 x Standard No 37 38 39 40 41 42 43 Score X 3 X X X 3 x DS0000014729.V268309.R01.S.doc Version 5.0 Page 23 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 YA24 Regulation 23 (4) Requirement Fire doors must be kept shut at all times. The Manager must provide written confirmation of the action taken to meet this requirement. Previous timescale of 9/9/05 not met. The Manager must confirm in writing to the Commission of the action taken to ensure the safe administration of medicines. Timescale for action 19/12/05 2. YA20 13 (2) 19/12/05 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. 2. 3. Refer to Standard YA23 YA26 YA36 Good Practice Recommendations The organisation Adult Protection procedure should be reviewed in line with the local authorities multi disciplinary Adult Protection procedure It is recommended however that the locking of bedroom doors be encouraged It is recommended that the Manager keep an overall record to demonstrate that individual supervision is a planned event throughout the year. St Bridget`s Home DS0000014729.V268309.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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