Inspection on 11/01/06 for St Clare

This inspection was carried out on 11th January 2006.

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

The inspector 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 Clare 08/09/06

St Clare 09/09/05

St Clare 18/01/05

St Clare 25/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Clare 14 Park Lane Southwick West Sussex BN42 4DL Lead Inspector Mrs H Church Unannounced Inspection 11th January 2006 09:30 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 Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Clare Address 14 Park Lane Southwick West Sussex BN42 4DL 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) 01273 591695 01273 381703 Mr Christopher George Thrower Mrs Juana Dolores Thrower Mr Christopher George Thrower Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th September 2005 Brief Description of the Service: St Clare is a privately owned care home registered to accommodate up to eighteen residents in the category of older persons, over the age of sixty-five. The home is situated within the village of Southwick, West Sussex and is close to local shops and amenities. Accommodation is provided within fourteen single rooms and two double rooms generally used for single occupancy. The rooms are arranged over three floors with a vertical lift providing access to all floors. The home has several communal areas and a well maintained easily accessible garden. The registered manager/owner is Mr Christopher George Thrower. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, one of two required under the Commission for Social Care Inspection was planned to take part over the morning and lunchtime activities. The manager was absent but a senior member of staff assisted the inspector. The inspector noted that a number of residents were joining in the gentle exercise activity provided by an outside entertainer in the lounge. They were clearly enjoying this and interacting with each other as well as the instructor. To prepare for this inspection, previous reports were reviewed. The Statement of Purpose and Service Users Guide are provided to inform any enquirer or resident how they may expect the home to be run and how they can change the way things are done to improve their lives there. During the inspection, eleven residents, one visitor, the instructor and two members of staff gave their views to the inspector. One resident said she had been recommended it and she would gladly recommend it to other people looking for a lovely home to settle in to. Another resident said it was a “nice atmosphere” whilst another said she thought St Clare was “sought after”. All of the residents were able to give a clear account of their life at St Clare and without exception all comments were enthusiastic about the staff and the way care was provided. It was clear that residents are encouraged to say what they like or don’t like about the home. The visitor and visiting instructor both said they are always welcomed and were impressed with the care given. A number of records were examined to see if the home was meeting the National Minimum Standards. Included in these records were four care plans and a comparison was made from resident’s comments to see if the care being provided was as the residents described. The relatives were very enthusiastic about the care being provided to their relative, giving a glowing commendation to Mr Thrower and his management of the home. The residents were clearly happy and the staff unanimous in their support of the manager and his leadership skills. The care plans showed that the care provided is appropriate to meet needs and maintain independence and ensure that where possible resident’s lives continue to improve. There were no requirements or recommendations made at this inspection. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 6 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 All residents had been assessed before moving into the home. The staff at the home are meeting the residents identified needs. Relatives were given enough information to help them decide if the home would be suitable. EVIDENCE: The Statement of Purpose and Service Users Guide provide good information for all residents and representatives and this is being continually updated when new information changes this. Four care plans were examined and it was clear residents had been assessed to ensure the home would be able to meet their needs. Relevant risk assessments were in place and had been updated and care plans to instruct staff how to meet needs were reviewed. The inspector did suggest that these could be more informative although current staff were well informed about the care needed. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 All residents had an individual care plan set out for staff to follow. One resident is managing her own medication under supervision. Staff are meeting the health care needs of the residents in a respectful manner. EVIDENCE: Four care plans gave good, clear information of care needed with risk assessments giving staff information about the risks and how to minimise these. Medication sheets were completed accurately and it was clear that appropriate referrals are made to the Primary Health Care Team regarding any nursing intervention required, assisting when necessary and following up the care as directed. Staff were observed treating and caring for residents with respect and acknowledging them as individuals. The residents commented on the kind and helpfulness of staff and individual comments included “staff are very good”, “kind and helpful”, “lovely” and “can’t do enough for you”. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Activities are suited to the conditions and dependency levels of each of the current residents. Visiting is positively encouraged. Residents are served meals that are nutritious and appetising. EVIDENCE: Activities are listed in the hall where all the information is displayed to remind residents of the arrangements planned. Activities include art classes, (the inspector observed the results on the dining room walls), crafts, reminiscence, gentle exercises, music/sing-a-longs, bingo and birthday celebrations. The inspector observed the gentle exercise activity and apart from one resident who had a visitor, all residents were enjoying the session. The visitors told the inspector that they was always made welcome and the visitor’s book showed that visitors come every day at different times. The outside entertainer staff are always helpful and remain available in case they are needed. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 11 The resident’s again commented positively on the food and told the inspector of the Christmas meals they had enjoyed. The inspector noted the menu for that day and the alternatives being offered to those who wished or needed it. The comments included “they make a birthday cake and everyone gets a party”, “You can’t fault it”. The meal being prepared was clearly home made from fresh ingredients and residents confirmed this was the norm. From the residents comments it was clear that the menus are changed regularly from feed back at each meal. The cook is given residents preferences for dishes and these are included in the menu planning. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 12 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): 16,17,18. Residents are confident that any complaints they may have are taken seriously and acted upon appropriately. Recent training in adult protection procedures has ensured staff are equipped to protect residents from abuse. EVIDENCE: The home has a complaints procedure displayed in a prominent position and it is included in the Statement of Purpose and Service Users Guide. One resident said she knew who to complain to, but had no occasion to do so. The West Sussex Multi Agency guideline was available and training records showed staff members are continuously updated in procedures. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 13 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 - 26. The indoor areas used by residents are clean, safe and homely with good access to the front and rear gardens. The resident’s rooms are suitable for their needs and are homely. EVIDENCE: During a tour of the home it was clear that residents are encouraged to move around the home as they wish and have access to all communal areas. The lounge is comfortably furnished and the library/quiet room has comfortable chairs and an extensive range of the home’s own large print books as well as a selection left by the mobile library. The dining room tables accommodate four residents giving it a homely atmosphere. There is a passenger lift for those residents whose rooms are upstairs on the first or second floors. The front and rear gardens have been designed to assist residents to walk independently and are furnished with occasional garden furniture. A large fishpond with seating provides a focal point for residents. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 14 There are enough toilets and assisted baths to meet the needs of residents and thermostatic valves protect residents from scalding water temperatures. Radiators are guarded and the home was clean and hygienic. Resident’s rooms were visited and were homely and comfortably furnished with their own possessions around them. Training records were available to show that staff receive training in fire safety procedures and fire risk assessments were in place. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 15 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): 27,28,30. The duty rotas did indicate that enough staff are on duty over the 24 hours period to meet needs and that recruitment processes are robust and ensure residents are protected. EVIDENCE: The inspector joined the day staff as they assisted residents during the morning and at lunch. The rota confirmed the arrangements for the home. The numbers and skill mix of staff was appropriate to meet their needs. Two staff spoken with said they were happy working at the home and felt well supported by the manager. From the two records seen, recruitment records were consistent and staff received induction, good supervision and training. The recruitment paperwork is being revamped to take into account employment legislation and a more formal process of interviewing is to be implemented. Job descriptions are being updated to take into account new senior roles that have evolved and staff will receive these when completed. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 16 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): 31,32,33,36,38. The registered manager and joint owner is Mr Christopher George Thrower who runs the home in the best interests of the residents, promoting and protecting their health, safety and welfare. EVIDENCE: Mr Thrower has owned and managed St Clare since 1974. The care staff were unanimous in their praise of Mr Thrower’s leadership style and said that Mr Thrower supports them to carry out their roles, providing a good clear sense of direction that puts residents at the centre of all activities. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 17 Recruitment, induction and supervision records were in place confirming the home’s commitment to safeguarding resident’s best interests. All areas used by the residents meet the National Minimum Standards and give resident’s sufficient personal and communal space for them to maintain a happy lifestyle. The home provide all the necessary equipment and staffing hours to support residents care needs and ensure that carers and residents are given care safely with well maintained and up-to-date equipment. St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 18 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO 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. Refer to Standard Good Practice Recommendations St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI St Clare DS0000014730.V276705.R01.S.doc Version 5.1 Page 21 - 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!