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Inspection on 28/06/05 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 28th June 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 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?

New care plan formats have been introduced and staff have began to complete the care plans. The new care plans should make the recording of care plans easier for the staff. A lot of requirements have been addressed since the last inspection and the staff team have received dementia and challenging behaviour training.

What the care home could do better:

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. Progress on the refurbishment of the home is slow and the carpets in the lounges and corridors need replacing urgently. The health and safety issues and dining arrangements need to be reviewed as a matter of priority.

CARE HOMES FOR OLDER PEOPLE St Cuthberts Residential Home Riga Square Hylton Red House Sunderland SR5 5DD Lead Inspector Eileen Hulse Unannounced 28 June & 8 July 2005 9:30am 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 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 B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Cuthberts Residential Home Address Riga Square Hylton Red House Sunderland SR5 5DD 0191 549 9988 0191 549 9978 none European Care (UK) Limited 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) Mrs Frances Ann Shields Care home only 40 Category(ies) of OP Old age (40) registration, with number PD Physical disability (10) of places MD(E) Mental Disorder -over 65 (5) DE Dementia (5) MD Mental Disorder (1) St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 2th & 15th November 2004 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 need replaced due to wear and tear over the past 8 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 B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days on the 28 June and 8 July 2005 by one inspector (Eileen Hulse), the inspection was un-announced and was carried out as part of the annual inspection programme. The inspection took 11hrs to complete that included 3hrs 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 chatting with service users and their families and talking with the Manager and staff who were on duty. Some records were inspected including care plans, staff training, care assessments, medication policy and complaints and POVA policies and procedures. A tour was made of the building that included communal areas and services user’s bedrooms following permission from them to do this accompanied by the Manager. What the service does well: What has improved since the last inspection? New care plan formats have been introduced and staff have began to complete the care plans. The new care plans should make the recording of care plans easier for the staff. A lot of requirements have been addressed since the last inspection and the staff team have received dementia and challenging behaviour training. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 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 standard(s) 1 and 3 A statement of purpose is available to service users and their representatives that gives detailed information to give them the choice to decide if they would like to live in St Cuthbert’s. The home have a good admission procedure that details all prospective service users must have an assessment carried out prior to admission that will ensure the care needs can be met by the home. EVIDENCE: The Provider operates a number of care homes and has produced a corporate Statement of Purpose, however, the Manager has subsequently amended this document to reflect the service specifically provided at St Cuthbert’s. It includes the aims and objectives of the service, qualifications of the staff team and all the information as outlined in Schedule 1 of The Care Homes Regulations 2001. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 9 Of the sample of care plans inspected, records evidenced all service users have within their plans of care, an assessment that had been completed by a Care Manager prior to admission. Also within the records, the Manager carries out a pre-admission assessment of potential new service users either at their own home or during a trial visit to the home to ensure the home is aware of all the care needs to be met. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 9 and 10 All service users have a plan of care but they are not completed in enough detail to ensure that all the care needs are identified and met on a day-to-day basis. The medication arrangements and systems in the home are good and this helps staff to ensure medication is handled safely. Personal support is offered in such a way as to promote and protect service user’s privacy and respect. 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. 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 areas are not always fully completed. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 11 All senior staff who are responsible for the handling of medicines have received accredited medication training and the company who provide the monitored dosage system provide regular updated training for the staff every three months. Care practices were observed throughout the day and these provided evidence of service users being treat with dignity and respect at all times such as calling service users by their preferred name and knocking on doors prior to entering. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12,14 and 15 Service users are offered the opportunity of participating in a wide range of leisure and social activities that enable them to lead fulfilled lives. Although the lunchtime meal was pleasant, a number of concerns regarding the mealtime arrangements were evident that do not promote the choice and dignity of the service users. EVIDENCE: It was clear from observations and discussions that people are supported to maintain their own lifestyles within the home, wherever capabilities allow. People can spend time in the privacy of their own rooms if they wish. Activities, entertainment and social events are organised for the people who live there and the home has a part-time activities co-ordinator who is enthusiastic and committed to promoting social care for the service users. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 13 Service users were very positive and comments included: • • • • ‘I am going out after lunch for a drink to the local pub’ ‘I do the shopping for other people living here’ ‘We can do what we want to do’ ‘Lovely staff here full of life and fun’ Relatives spoken with were also positive about the home and the care their relatives receive. Comments made included: • • • • ‘I can visit anytime and visit the home twice a day’ ‘My relative has settled really well here’ ‘Quite happy with the care, the staff are brilliant’ ‘The staff are very helpful to my (parent) they are wonderful’ The home hosts a weekly social evening (Bingo Night) and all relatives, visitors, tenants of a nearby sheltered housing scheme and people from the local community are invited. Those people who are still able to go out independently or with relatives are encouraged to do so. There are also occasional shopping trips for small groups of service users supported by staff. The activities co-Coordinator and one service user provide a daily sweet trolley service and a quarterly newsletter is circulated with details of any special events in the home and lists the programme of entertainment and parties for the forthcoming months. 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, however, no peppers were on the tables and no serviettes were available and service users used the tablecloths to wipe their hands on. It was a two course meal comprising of steak and dumpling or toad in the hole, with carrots, broccoli and new potatoes with yogurt or pineapple sponge and custard for sweet. The meal was hot, tasty and well cooked with good sized portions, however, no choice was given to the amount or type of food presented 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: • ‘Meals are alright you can get a lot worse somewhere else’ • ‘I wish I could have a cup of tea with my dinner’ • ‘I’m a good eater and enjoy my meals’ One service user required help to eat the meal, this was given by two members of staff but not in a dignified or respectful manner. Both members of staff stood up to feed the service user compromising the dignity of the person. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 and 18 The recording of compliments and complaints are well managed and maintained and help to provide the service users with confidence that concerns will be acted on. Service users legal rights are protected at all times. Staff have received training and appropriate guidance on the protection of vulnerable adults. This should help to protect service users against any abuse or suspected abuse taking place. EVIDENCE: Any complaints received by the home are responded to within the homes permitted times. All complaints are recorded into a book and a system has been implemented to audit all complaints and concerns that are raised. Relatives spoken with during the inspection stated that they had been given a copy of the complaints procedure and knew how to make a complaint should they feel it necessary to do so. Records show that no incidents of abuse or suspected abuse have taken place in the home and staff have recently received Protection of Vulnerable Adults training. Further dates have been identified for the remaining staff team to be trained in this area and to receive appropriate guidance about alerting and preventing abusive situations and should help staff to recognise the signs should they suspect abuse is taking place. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 24 and 25 A large number of refurbishment requirements remain outstanding and therefore, a safe and comfortable home is not currently being provided to service users. Service users bedrooms are comfortable and homely and provide a pleasant environment for people. EVIDENCE: Some improvements have been made to the decoration of the home but carpets in all the corridors, dining rooms and in two of the lounges are worn and badly stained and need to be replaced. Service users are encouraged to bring personal possessions into the home on admission. This was evident in all of the bedrooms, they are very homely and cosy and service users were proud to show their bedrooms on the day of the inspection. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 The home provides sufficient numbers and skill mix of staff enable all the service users individual needs to be met and operates a thorough recruitment and selection procedure when employing new staff. Procedures used to recruit and select staff are good and help to ensure the home employs suitable staff. EVIDENCE: All staff have an individual training manual that details the dates and names of courses they have attended, training needs that have been identified, copies of certificates and courses attended. Nine care staff have attained an NVQ qualification at Level 2 and five domestic staff have achieved Level1 in NVQ housekeeping. The Manager is aware of the need to have 50 of all care staff trained with a qualification by 2005. Records evidenced that all appointments have been made following a robust recruitment procedure. All prospective staff are required to produce photographic identification and two references one of which must be from their most recent employer. Staff do not commence employment until a Criminal Records Bureau check has been received. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Good recording systems regarding maintenance of health and safety within the home are used and are well maintained. However a number of issues were observed during the inspection that compromises the safety of the service users. EVIDENCE: Health and safety maintenance checks are recorded in a well organised file. Fire records for both maintenance and training for staff were found to be up to date, kitchen electrical equipment and water temperature charts completed satisfactorily. A number of emergency pull cords require lengthening to skirting board height so they can be reached by service users in an emergency, a wheelchair was chocking open a bedroom door and toilets must have lights and extractors fans working. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 1 x x x x 3 x x STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 4 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. Careplans must include sufficient information to ensure care needs can be met Personal care and continence equipment must be discreetly stored to safeguard the dignity of the people who live here. Service users must be able to have maximum choice regarding their meals Dining arrangements must be reviewed Worn or marked carpets to corridors and lounges must be replaced. Worn furniture must be replaced within the home’s programme of refurbishment. Adequate ventilation systems must be provided to the smokers’ lounge. An Annual Development Plan must be developed that includes the objectives identified through the home’s Quality Assurance reviews, and a copy must be Timescale for action Immediatel y 2. 3. 7 10 15 12 1 Nov 05 Immediatel y 1 Nov 05 1 Nov 05 1 Nov 05 1 Nov 05 1 Nov 05 1 Nov 05 4. 5. 6. 7. 8. 9. 14 15 19 24 25 33 12 16 23 16 23 24 St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 20 supplied to the CSCI. 10. 11. 38 12 Health and safety issues must be addressed Immediatel y RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 19 24 25 38 Good Practice Recommendations Create a larger store cupboard for the exclusive storage of COSHH products. Shelving or cabinets should be provided in en-suites for suitable and accessible storage of toiletries. Extra heating must be provided to gable end bedrooms to ensure a satisfactory temperature in these rooms. Bedrooms doors must not be propped open and the missing door closure to one bedroom must be replaced, as both these matters compromise fire safety within the home. St Cuthberts Residential Home B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 B52 B02 S15746 St Cuthberts V219726 28 Jun 2005 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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