Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 26/10/05 for St Cuthberts Residential Home

Also see our care home review for St Cuthberts Residential Home for more information

This inspection was carried out on 26th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home have a stable staff team with very little turnover of staff, they are friendly and caring and service users who were able to express themselves commented on the friendly and approachable staff team stating, the staff are all lovely`. The home provides a good range of activities with lots of choice for service users both in a group setting and individually.

What has improved since the last inspection?

The home has had all the communal areas of the home refurbished with decorating and carpets replaced to a good standard. Service users commented on how much better the home was looking. The staff team have worked hard to gain NVQ qualifications and the home has now achieved 50% of the staff qualified.

What the care home could do better:

It is disappointing to see that so many of the requirements made in a previous report have still not been addressed and a number of service users families have written in detail about their concerns about the service. This was discussed with the Manager and she is to try and alleviate some of these concerns with families. The care plans must be improved to include more detailed information that will assist and guide staff in their everyday practice and will help to make sure the needs of the service users are met at all times.

CARE HOMES FOR OLDER PEOPLE St Cuthberts Residential Home Riga Square Hylton Red House Sunderland SR5 5DD Lead Inspector Mrs Eileen Hulse Announced Inspection 26th October 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 Cuthberts Residential Home DS0000015746.V253349.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 Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Cuthberts Residential Home Address Riga Square Hylton Red House Sunderland SR5 5DD 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) 0191 549 9988 0191 549 9978 European Care (UK) Limited Mrs Frances Anne Shields Care Home 40 Category(ies) of Dementia (5), Mental disorder, excluding registration, with number learning disability or dementia (1), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (40), Physical disability (10) St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: St Cuthbert’s is a purpose-built care home for 40 older people. The home is sited in the centre of the Red House Estate in Sunderland. It is close to a sheltered housing scheme, pub, church and local bus routes. The home was built in the mid 1990’s and benefits from a modern, spacious design with wide corridors and good sized communal facilities. The home provides 40 single rooms, 30 of which have en-suite facilities. There is a good choice of lounges on both floors. There are accessible toilets and bathrooms with adapted facilities. The standard of décor and furnishings in lounges and dining rooms is generally good and the home offers warm, comfortable accommodation. Some furnishings in bedrooms now needs replaced due to wear and tear over the past years. The home is registered to provide up to 10 places for older people with physical disabilities. There is good access into and around the home, though it is advised that occupational therapy services should be involved in identifying adjustments to bedroom en-suites to suit individual people’s needs. The home is also registered to provide 5 places for older people with mental health needs and 5 places for older people with dementia care needs. St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 26th October 2005 by one inspector (Eileen Hulse). The date and time of the inspection was announced to people who use the service including the Manager and staff and was carried out as part of the annual inspection programme. Prior to the inspection, questionnaires were sent out to all of the service users living in the home and their families. 14 service users completed the questionnaires with the help and support of their individual key workers and 3 completed questionnaires were received from relatives. There was one relative visiting at the time of the inspection and comments made were: • • ‘The home seems ok and the staff seem ok’ ‘The staff are quite informative and let me know things’ Comments from the completed questionnaires were also used to assess how relatives feel about the service provided at St Cuthberts. Relatives were not happy about the service provided and their comments included: • • • • • • • • ‘Evenings and weekends sometimes wait a long time for the door to be opened’ ‘Kept informed of issues with my relative only when I ask’ ‘Staff not always visible’ ‘There is room for improvement with overall care’ ‘Service users clothing often returned to wrong person despite labelling’ ‘Need more staff to help service users’ ‘Lack of care towards service users’ ‘Can never find staff they are always in staff room’ Completed questionnaires comments from service users included: • • • • • ‘I would like to be more involved in decision making’ ‘Sometimes my privacy is respected’ ‘Sometimes I feel well cared for’ ‘I do like the food’ ‘The staff treat me well’ The inspection took 11hrs to complete that included 2hrs 15 mins to prepare for the inspection. The focus of the inspection was to gain insight into the quality of life and services received by service users who live in the home. Time was spent with service users, observing the practice of staff throughout the inspection and talking with the Manager and staff who were on duty. Some records were inspected including care plans, community activities, staff qualifications, service users financial records and quality assurance systems. A tour was St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 6 made of the communal and personal areas of the premises and a lunchtime meal was shared with the service users. 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 Cuthberts Residential Home DS0000015746.V253349.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 Cuthberts Residential Home DS0000015746.V253349.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): 6 The home does not provide intermediate care at this time. EVIDENCE: St Cuthberts Residential Home DS0000015746.V253349.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 and 8 The care plans have not improved. Although all service users have a plan of care, they are not completed in enough detail to ensure that all the care needs are identified and met on a day-to-day basis. Arrangements are in place for the home to access healthcare professionals and this ensures the healthcare needs of service users are met. EVIDENCE: A sample of care plans examined showed the care planning process is carried out but not in an organised way, some of the needs identified tends to be poorly recorded with little or no information to guide staff in their practice. One care plan sampled stated the service user ‘likes bath water hot’ but does not state the permitted bathing temperatures and ‘prefers own toiletries’. Other areas of the care plan have been left blank such as the weight chart, professional visits and foot care records. Evaluations are included but these are difficult to complete as no monitoring of the care plans is carried out. The files are bulky and unorganised and information is not easy to find. All service users are registered with a General Practitioner of their choosing. District nurses are very involved with the home and the nurses records St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 10 evidenced that they visit the home a number of times in a week. Some service users make visits to their preferred dentist, optician and chiropodist, but for other service users the domiciliary dentist and chiropodist make visits to the home between six weeks and 6 months depending on the urgency of the requested visit. Records evidenced that service users attending hospital out patient appointments are escorted by a member of staff in transport provided by the health authority. St Cuthberts Residential Home DS0000015746.V253349.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): 13 and 15 There are no restrictions on visiting the home by relatives or friends and members of the local community, this ensures service users can choose when and who they want to see. Although the lunchtime meal was pleasant, a number of concerns regarding the mealtime arrangements are still evident and do not promote the choice and dignity of the service users. EVIDENCE: Service users can have visits from relatives and friends at any time and can receive visitors in the privacy of their own rooms. Visitors are encouraged to share a meal with their friend or relative. However, this was not evidenced during the inspection. Every month a social evening is held for service users and their visitors and members of the local community are involved at this event, the community members also attend the homes Sunday worship service followed by Holy Communion. The inspector shared a lunchtime meal with service users. The arrangements in place were pleasant, tables were set with placemats, condiments, milk jugs and sugar basins and serviettes. It was a two course meal comprising of roast beef, Yorkshire pudding with carrots, sprouts, mashed potatoes and roast St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 12 potatoes with a choice of cheesecake, yogurt or fruit and ice cream for sweet. The meal was hot, nutritious and pleasantly presented with good sized portions, however, no choice was given to the amount or type of food offered including the amount of gravy. Service users chatted with each other throughout the meal and were given sufficient time to sit and enjoy their meal without being hurried. Service users made mixed statements about the meals they receive and comments made were as follows: • • • ‘I enjoy all of my meals’ ‘There is never any teaspoons for the sugar’ ( Staff were observed to wash the teaspoons so that there was enough to go round ) ‘The meals are ok I suppose’ Although there were individual teapots for each table, they were not left on the tables. When the inspector asked one of the care staff why service users who could clearly manage to pour their own tea were not able to do this, she stated, ‘Service users are not allowed to use the teapots, we could never let them use the teapot’. Two members of staff sat with service users who required help and support to eat their meal, however, another member of staff stood over a service user whilst feeding him which compromises the dignity of the service user. New menus have recently been devised but they are still reviewed as having very little choice as the meals do not have much variation. For example the choices were recorded as, liver and sausage casserole or burgers in gravy, mince and dumpling or steak and mushroom pie St Cuthberts Residential Home DS0000015746.V253349.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): These standards were not inspected at this time. EVIDENCE: St Cuthberts Residential Home DS0000015746.V253349.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 A large number of refurbishment requirements have been addressed making the home a safe and comfortable environment for service users to live in. The home is clean, pleasant and has no unpleasant smells making it a comfortable environment for service users to live. EVIDENCE: All communal areas of the home such as the lounges and dining rooms have been decorated and had the carpets replaced. Toilets and bathrooms have been decorated and some of the bedrooms have replacement chairs and new carpets laid. Service users made some comments on the building that included: • • • ‘I have been here twelve months and I like the place’ ‘The smoking room is far too small’ ‘Don’t the new carpets look lovely’ St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 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): 28 Good staffing levels are maintained and these reflect the needs of the service users currently living in the home at this time and the home have the required numbers of staff with an NVQ qualification. This allows for sufficient support to be provided to service users. EVIDENCE: The home have 50 of staff qualified to NVQ Level 2 and therefore meet the standard and also have five domestic staff that have completed NVQ Level 1 in hospitality and catering. Rotas showed that staffing levels are maintained and in adequate numbers for the numbers of service users currently living in the home. Individual discussions were held with some staff who were on duty and comments they made included: • • • • • ‘It’s a good home to work in with a good atmosphere’ ‘The Manager is ok and gives us good support’ ‘All the senior staff team are very approachable’ ‘The new decoration and carpets have boosted the morale of the staff, its made a big difference’ ‘We have a lot of one to one contact with seniors but formal supervision every 6 months’ St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 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): 33, 35 and 38 The home has no formal quality assurance system in place and therefore cannot monitor if the service is successful. Service users financial interests are well maintained with good recording systems in place. This ensures that service users finances are held safely and securely. Fire records are also up to date and well maintained. EVIDENCE: There is no formal quality assurance system in place although the information to implement such a system is available located in various places and files and is not collated into a quality system. Therefore, the information is not reviewed regularly to implement changes and is not detailed into an action plan for the staff team to follow. A sample of finances held by the home for safekeeping for service users was found to be correct with the records up to date and well maintained. St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 17 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 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? yes 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 OP4 Regulation 12/14 Requirement The Provider must apply to the CSCI for a Variation to Registration in respect of a small number of places in the SI(E) category.(Previous timescale of 28 June 2005 not met) Careplans must include sufficient information to ensure care needs can be met (Previous timescale of 01 nov 2005 not met) Service users must be able to have maximum choice regarding their meals (Previous timescale of 01 nov 2005 not met) Dining arrangements must be reviewed (Previous timescale of 01 nov 2005 not met) Worn furniture must be replaced within the home’s programme of refurbishment.(Previous timescale of 01 nov 2005 not met) Adequate ventilation systems must be provided to the smokers’ lounge.(Previous timescale of 01 nov 2005 not met) An Annual Development Plan must be developed that includes DS0000015746.V253349.R01.S.doc Timescale for action 01/12/05 2 OP7 15 01/02/06 3 OP14 12 01/01/06 4 5 OP15 OP24 16 16 01/01/06 01/03/06 6 OP25 23 01/02/06 7 OP33 24 St Cuthberts Residential Home Version 5.0 Page 19 8 OP38 12 the objectives identified through the home’s Quality Assurance reviews, and a copy must be supplied to the CSCI.(Previous timescale of 01 nov 2005 not met) Health and safety issues must be addressed (Previous timescale of 01 nov 2005 not met) 01/02/06 01/12/05 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 Refer to Standard OP25 Good Practice Recommendations Extra heating must be provided to gable end bedrooms to ensure a satisfactory temperature in these rooms. St Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Cuthberts Residential Home DS0000015746.V253349.R01.S.doc Version 5.0 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!