Inspection on 25/07/05 for St Bridget`s Home

This inspection was carried out on 25th July 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Bridget`s Home 22/06/06

St Bridget`s Home 22/11/05

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 Bridgets Home Ilex Close Rustington Littlehampton, West Sussex BN16 2RX Lead Inspector Mrs S Rodgers Unannounced 25 July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service St Bridgets Home Address Ilex Close, Rustington, Littlehampton, West Sussex, BN16 2RX 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) 01903 783988 01903 859235 stbridgets@south.leonard-cheshire.org.uk Leonard Cheshire Mrs Sara Margaret Willis CRH(PC) Care home only 38 Category(ies) of PD - Physical disability 37, PD(E) Physical registration, with number disability over 65 years of age. of places St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 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 29 November 2004 Brief Description of the Service: St Bridget’s is a private residential care home registered to accommodate thirty-seven 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 Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and was carried out as part of the routine programme of inspection. Preparation for this inspection focused on a review of previous inspection reports and general correspondence. During the course of the inspection the inspector toured the home, spoke with residents either privately in their own bedrooms or within the communal areas of the home in order to gain a sense of how the home is being run and how they experienced living at the home. Two staff were spoken with privately in order to gain a sense of the support and training they receive in order to carry out their jobs and to gain insight into how their knowledge of the aims and objectives of the homes philosophy of care From speaking with resident the inspector gained the impression that residents are satisfied with the standard of care/support they receive. However one resident commented ‘that it is not the quality of service it’s the quantity of service that’s the problem’. Residents commented that there is a lack of staff especially at weekend. Mrs Willis advised that all shifts are covered, and to achieve this they have to use agency staff. Residents spoken with confirmed that they felt the home did enable and support them to develop and maintain an independent lifestyle taking into account their individual needs. The inspector also took the opportunity to observe the interaction between both residents and staff. It was noted that the atmosphere within the home was jovial and relaxed and that the staff carried out their duties in a respectful manner taking into account the dignity and privacy of residents. Staff spoken told the inspector that they felt supported by the management and that they are encouraged to undertake training. Staff also made reference to the lack of permanent staff and the effects it has on the home especially at weekends. Staff spoken with were able to demonstrate that they are aware of their responsibilities and what action they should take if the suspected abuse of a resident. The physical environment is generally well maintained however some areas of the home would benefit form redecoration i.e. the dining room as some wallpaper is peeling from the walls. The home is generally clean and free from offensive odours however some carpets would benefit from being professionally cleaned or replaced as they are stained. Since the last inspection an application was made to increase the number of registered beds from 37 to 38. The application was granted and a new certificate of registration was forwarded to the home. Following the last inspection carried out on the 29th November 2004 the one identified requirement has been addressed in part and efforts to address the requirement in full are still ongoing. Four new requirements have been identified at this inspection. The manager is requested to advise the inspector St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 6 of the proposed timescales for completion of the identified requirements by the date shown in the timescale for action box. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 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 standard(s) 2 The pre admission assessment enables the management and the prospective resident to satisfy themselves that the needs of the individual/their needs can be met by the home EVIDENCE: The pre admission assessments reviewed at this inspection demonstrate that each new resident undergoes an assessment prior to admission. Information form that assessment is used to develop an initial care plan so that staff are aware of the needs of the individual on the day they are admitted to the home. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 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 standard(s) 6,9. Residents are aware of their assessed and changing needs and personal goals. Residents are supported to take risks so as to develop and maintain an independent lifestyle. EVIDENCE: Care plans reviewed at the inspection clearly demonstrate that residents participate in their reviews and are involved in the decision making process of how their assessed needs and personal goals will be met. Resident’s spoken with confirmed that they can make choices concerning their own lifestyles. They confirmed that they make the decision on what activities they wish to do whether it is at college, a day centre or within the home. Residents who attend day centre or college told the inspector that on they days they attend these outside services they have restricted choice of when they have to get up however they did confirm that when they are not going to these services they are able to get up at a time more suitable to them. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 10 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 standard(s) 12, 13. Residents are enabled to participate in activities appropriate to their needs and preferences. Residents have access to activities within the local community. EVIDENCE: Residents care plans clearly identify activities in which they participate. Residents spoken with told the inspector that they are supported by staff to access college, day centres and work placements. An activities co- coordinator is employed by the organisation, which enables residents who do not wish to go out to college or day centres etc to have the opportunity to develop new skills. Residents also have access to the homes computer room, which houses approximately eight computers, two members of staff are employed with knowledge of computers to assist and teach residents’ how to use the equipment. Residents spoken with confirmed that they are able to participate in activities as and when they choose. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 11 Residents have access to local shops and leisure facilities with in the local vicinity. The home also holds a summer Fayre to which members of the local community are invited. Residents if they wish can and do attend the local church and holy communions and services are held with in the home for those who do not wish to or cannot attend the local church. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 12 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 standard(s) 18,20 Personal support is provided in a manner that is required and preferred. Systems are in place to enable residents to self-administer medication. EVIDENCE: Care plans clearly demonstrate that support is provided in a manner preferred by residents. Each care plan has information regarding individuals personal likes/dislikes which also identifies how and when they want their care service to be provided. Whilst touring the premises it was noted that there were a number of unnamed toiletries left in many of the bathrooms, this could indicate that there are communal toiletries being used on each resident. If the toiletries belong to individual they should be returned to residents rooms after use. Following the last inspection service users consent to medication forms have been implemented to demonstrate that those residents who do not wish to or cannot self medicate are in agreement that the staff can order, store and administer their medication. There are lockable facilities in each bedroom for the safe storage of medication for those who wish to self-administer. Appropriate systems are in place for the ordering, recording, storage and administration of medication St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 13 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 standard(s) 22 Systems are in place to protect residents form abuse, neglect and self –harm. EVIDENCE: Records seen demonstrated that care staff receive training with regards what action to take should they suspect abuse that a resident is being abused. The members of staff spoken with gave a good account of action they would take if they had witnessed or suspected that abuse was taking place. However the policies and procedures produced by the organisation do not fully take into account the local authorities multi disciplinary procedure that dictates that all allegations are referred to Social Services. This policy should be reviewed to ensure that the appropriate action is taken so that any investigations that needs to be carried out by social services or other agencies are not jeopardised. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 14 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 standard(s) 24, 27,30 The living accommodation is generally laid out well and appropriately equipped with suitable and sufficient bathing and WC facilities to meet the needs of service users. EVIDENCE: Whilst touring the home the inspector was able to see that resident’s personal accommodation is of a good standard. Residents are encouraged to personalise them with furniture and personal items giving each room an individual homely atmosphere. All radiators have covers to reduce the risk of accidental burning and the inspector was advised that valves to regulate the temperature of hot water to basins and baths have been fitted. All rooms have lockable safe so that valuables or medication can be stored safely. Miss Holmes advised the inspector that all works identified in the most recent fire inspection report have been carried out. The home was generally clean and free from offensive odours however some areas of the building i.e. dining room would benefit from redecoration as wall paper is coming away from the walls and some carpets would benefit from being cleaned or replaced as they are badly stained. An audit of the premises should be undertaken and a programme of works required should be undertaken. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 15 The number of bathing and WC facilities are sufficient in number to meet the needs of the current residents. It was noted that bedroom doors of empty bedrooms were left ajar. All fire doors must be closed at all times unless fitted to an approved automatic closure system. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The use of high numbers of agency staff may result in residents not receiving the appropriate amount of assistance they require to meet their care needs EVIDENCE: Duty rotas seen at the inspection identify that there continues to be a shortfall in permanent staff, which results in a significantly high need to use agency staff. Residents spoken with feel that this results in them not always receiving the amount of assistance need. This issue was identified at the last inspection and action is being taken to recruit more permanent staff. At the time of this inspection two new staff were close to starting and two other prospective employees were undergoing recruitment checks. Mrs Willis told the inspector that the recruitment programme will continue until all post are filled. As this is an on going process and that the majority of duties are generally covered with agency staff a requirement will not be made at this inspection however this standard will be monitored at the next inspection. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 The views of residents are sought and underpin the homes self-monitoring, review and development. EVIDENCE: A quality assurance and development system is in place. Residents confirmed that their views on how the home is run are sought. They confirmed that they have regular resident meetings at which they can express their views. Although the majority of residents spoken with felt that their views were taken into account some felt that their views were not always acted upon and they were not always informed why. Monthly visits are carried the reports submitted to the commission indicate that the views of residents, relatives, advocates are sought. St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 2 Standard No 11 12 13 14 15 St Bridgets Home x 3 x x x Standard No 31 32 33 34 35 36 Score x x 3 x x x Version 1.20 Page 19 H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc 16 17 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x x x St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 20 No 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. 2. 3. Standard 18 24 30 Regulation 12 (4)(a) 23 (4) 23 (d) Requirement Communal toiletries must not be used. The dignity of residents must be maintained at all times. Fire doors must be kept shut at all times. All parts of the home must be kept clean and reasonalby decorated. Timescale for action 09.09.05 09.09.05 09.09.05 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. Refer to Standard 23 Good Practice Recommendations The organisation Adult Protection procedrue should be reviewed in line with the local authorities multi disciplinary Adult Protection procedure St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI St Bridgets Home H60-H11 S14729 St Bridgets Home V221832 180605 Stage 4.doc Version 1.20 Page 22 - 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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