Inspection on 23/11/05 for St Cecilia`s

This inspection was carried out on 23rd 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 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 Cecilia`s 21/11/06

St Cecilia`s 02/03/06

St Cecilia`s 06/01/05

St Cecilia`s 29/07/04

St Cecilia`s 22/03/04

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Cecilia`s Glendale House 19 - 21 Stepney Road Scarborough North Yorkshire YO12 5BN Lead Inspector Pauline O`Rourke Unannounced Inspection 23rd November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Cecilia`s DS0000007735.V271356.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 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 Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Cecilia`s Address Glendale House 19 - 21 Stepney Road Scarborough North Yorkshire YO12 5BN 01723 503111 01723 501080 j.edmond@stceciliasch.co.uk 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) St Cecilias Care Services Limited Mr Michael Andrew Padgham Care Home 21 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (21), Old age, not falling within any other of places category (21) St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users in category (DE) must be aged 50 years and over. Date of last inspection Brief Description of the Service: St Cecilia’s is a large adapted property. The home is located on a main road giving direct access to the town centre. Public transport passes the door. It was originally two separate houses but these have been converted to provide accommodation for service users in single and shared bedrooms. Some bedrooms have an en-suite provision. For those without there are sufficient communal facilities. There are a number of communal areas throughout the home. The home does not have a passenger lift and consequently service users occupying the first floor must be reasonably ambulant. The secluded and private rear garden is provided with outdoor seating and specifically designed for the category of service user accommodated. St Cecilia’s is managed on a day-to-day basis by Jo Edmond; she works closely with Mr Padgham who oversees the home both are registered managers of the home. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection including preparation time, including pre-inspection and post inspection work took place over 12 hours. A tour of the building was conducted. A number of the service users records, staff records and records about the management of the home were inspected. 5 of the staff on duty were spoken with. Due to communication difficulties with the service users most of the inspection time was spent observing the service users. What the service does well: What has improved since the last inspection? What they could do better: At this inspection there was nothing identified as needing attention. However, given that the registration of the home has recently changed to allow them to admit people over 50 years of age who have a dementia then the training plan should continue to be developed for staff. This will ensure the quality of the service currently provided is not lost. The manager also needs to continue to develop the quality assurance programme St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 6 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 Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 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 Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 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): 3 and 6 The service users can be assured that their care needs will be met. EVIDENCE: Service users admitted to St Cecilia’s have an assessment provided by the manager. A care management assessment, where appropriate is also provided. The assessment allows the home to admit only those service users whose needs can be met in St Cecilia’s. The manager also works closely with the local community psychiatric team, where necessary to ensure follow up support is available once a placement has been made. The home does not provide intermediate care. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 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, 8, 9, and 10 The health, social care and personal needs of the service users are met EVIDENCE: Clear and comprehensive care plans for every service user were in place. A sample of these was inspected and each one was well detailed, pertinent to the individual and maintained up to date. The care plans are reviewed on a monthly basis unless circumstances change and they are then reviewed as necessary. Staff spoken with had a clear understanding of the needs of the service users. Evidence was available in the service user files to show that they access their GP district nurse, chiropodist, dentist or other health professional as required. The senior carer on duty is responsible for the administration of medication and all the senior carers have completed training in the ‘ Safe Handling of Medication’. A monitored dosage system is used in the home. The storage and administration of the medicines was seen to be satisfactory. One service user did not get up until the middle of the morning and the staff gave the St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 10 morning medications when she got up and subsequent medication was given at the appropriate intervals and not at the next drug round. Throughout the day the interactions between the staff and service users were observed. Staff were always respectful in their dealings with the service users and gave each individual the time they needed. The staff were attentive to the needs of the service users many of whom could not clearly communicate their needs. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The service users are able to keep their own routine within the home and join in with social activities. The service users have a varied and balanced diet. EVIDENCE: Records inspected, and observations made during the inspection all identified that routines within the home were relaxed and geared to meet the needs and wishes of the service users where at all possible. If a service user did not get up until mid-morning then the routine within the home was adjusted accordingly. Activities are organised on a regular basis within the home. A professional entertainer performers in the home once a month and motivation sessions are held on a regular basis. Activities also take place on a daily basis and this can be a sing-a-long, talking with the service users, reminiscing or interacting with the visitors. A record is kept of activities provided. A visitors’ policy is in place and all visitors sign a visitor’s book on entering the home. Staff spoken with confirmed that they work with relatives and keep them informed about all events in the home. They were aware of when families were not available and when to contact them in an emergency. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 12 A three-week menu is used in the planning of the meals and an alternative is offered rather than a choice. The staff are aware of the service users likes/dislikes and foods they should avoid for medical reasons. They gather this knowledge from the service users, their families and medical histories. Local products are used and there was fresh fruit and vegetables in the kitchen. There are diabetic diets and liquidised diets provided for. The food for liquidised meals is prepared separately so that the service user can enjoy the different elements of the meal. Staff take specialist advice regarding diets when necessary. The mealtime observed was relaxed and support offered by the staff was done so discreetly. The timings of the meals are flexible and if a service user has their breakfast at 11:00am then their lunch is served between 2 and 3 pm and not at 12:00 just because it is lunchtime. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Complaints or concerns brought to the attention of the manger would be acted upon. Service users are protected from possible abuse through staff training EVIDENCE: St Cecilia’s has a detailed complaints policy. This policy is provided to all the service users and is displayed around the home. There have been no complaints made to the CSCI or the home in the last 12 months. There is an Adult Protection Policy in place. Staff spoken with had received training in Adult Protection issues and they had a good understanding of their responsibilities if they believed any inappropriate behaviour was taking place. Policies are also in place regarding the management of service users money. Staff are also subject to a criminal records bureau disclosure and a protection of vulnerable adults check to ensure that they are suitable to work in a care setting. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The service users live in a home that is clean and well maintained. EVIDENCE: The home presented as comfortable and homely. Evidence was available to show that decoration is renewed when necessary in the bedrooms and communal areas. It does not have a passenger lift and consequently those service users accommodated on the first floor need to be reasonably ambulant. The back garden was private and secure. It was designed for the needs of the service users and included a ‘sensory’ element in the form of plants and a water feature. It had appropriate seating and was accessible by ramps. The records show that the building complies with the requirements of the Environmental Health and Fire and Rescue departments. It is recommended that the proprietor change the sign on the front door to reflect the current registration of the home. The premises were clean and from a discussion with a member of the domestic staff, it was evident that emphasis is placed on the cleanliness and hygiene St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 15 standards. The laundry room and its facilities are appropriate for the needs of the service users. The washing machines had an integral sluice cycle. The laundry facilities complied with the Water Supply Regulations. A policy and procedure for the control of infection was in place. It was observed that the staff had access disposable protective clothing St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 Service users are supported by staff that receive regular supervision and have access to training. EVIDENCE: The staffing levels throughout the day were appropriate to meet the service users needs. Care staff, and ancillary staff work together to ensure the service users have the time and attention they require. Several of the staff are qualified overseas nurses and others have completed their National Vocational qualification level 3. Care staff are encouraged and supported to undertake their National Vocational Qualification level 2. The manager continues to work towards a 50 rate of qualified staff. The staff files of three staff members employed in that time were inspected and were found to contain all the necessary documentation as required by the Care Homes Regulations 2001. The manager is commitment to training and a training plan is in place to ensure that staff have complete a variety of in-house and external training course covering, health and safety, medication training, training on basic care practices, dementia awareness, adult abuse, managing incontinence, and challenging behaviours. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 17 St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The service users live in a well managed home. Policies and procedures are in place to ensure the service users’ financial interests are safeguarded. The health and safety of the service users and staff is promoted. EVIDENCE: The registered manager has recently completed her National Vocational Qualification level 4 and Registered Managers Award. The manager clearly had a good understanding of the needs of the service users. It was clear that she has established a good relationship with both service users and staff. From discussions with the manager it was evident that there are clear lines of accountability and responsibility between her and the registered provider. The manager has tried to implement a quality assurance programme but the questionnaires she sent out as part of the programme were not returned. Other evidence seen regarding quality assurance were service user and staff St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 19 meeting minutes, Commission for Social Care Inspection reports, staff supervision and training records complaints received and the accident records. This information needs to be pulled together in a report format that identifies areas of good practice and areas where improvements can be made. The home does not handle service users personal allowance. Families are encouraged to handle finances where service users cannot. The staff spoken with during the inspection said that they had received training in, back care, first aid, food hygiene, COSHH, and fire training. The equipment used in the home is serviced at the prescribed intervals. Health and safety notices were displayed around the building. Accidents are properly recorded and where necessary reported to the Commission for Social Care Inspection. Information from the accident records is used in the care planning process. All staff can access Induction and Foundation training, this provides them with basic skills required to undertake the role of care worker. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 3 3 X X X X X 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 3 X 2 X 3 X X 3 St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations The registered manager should prepare a quality assurance report from information already in the home. St Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Cecilia`s DS0000007735.V271356.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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