Inspection on 12/12/06 for St David`s Nursing Home

This inspection was carried out on 12th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St David`s Nursing Home 04/09/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE St David`s Nursing Home 52 Common Lane Sheringham Norfolk NR26 8PW Lead Inspector Mrs Susan Golphin Unannounced Inspection 12th December 2006 09:15 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 David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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 David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St David`s Nursing Home Address 52 Common Lane Sheringham Norfolk NR26 8PW 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) 01263 822671 01263 820005 Lakeshore Healthcare Limited Mrs Caroline Whitbread Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 04 November 2005 Brief Description of the Service: St David’s is a care home providing personal care and nursing care for up to 35 older people. The home has recently been acquired by Mr Jeffrey Manning of Lakeshore Healthcare Limited. The registered manager is Caroline Whitbread. The home is situated near to the town centre of Sherringham Norfolk. The home is well situated in a residential area and within easy access of the town and local amenities. The accommodation for residents is on the ground and first floors of the building which can be accessed by a shaft lift. The home is set in extensive gardens with established trees and lawns. There is off street parking to the front of the premises. The fees range from £338.00 to £535.50 per week. additional charges are made for personal requisites, private telephone facilities, newspapers, hairdressing and private chiropody. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers the service to people. The key inspection has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This report gives a brief overview of the service and the current judgments for each outcome group. What the service does well: What has improved since the last inspection? What they could do better: Minor concerns about the staffing levels in relation to the dependency levels of the residents remain. Two of the comment cards returned whilst overall gave positive feedback on the service they also added that at times they felt that St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 6 the staff were stretched in meeting residents needs. The staff confirmed that they have little time to meet the social and emotional needs of residents at times and especially at crucial times of the day and when there is a shortage of staff on shift due to sudden absences or illness. It is acknowledged that the new management team are in the process of reviewing and revision current staffing issues and it is acknowledged that this situation is work in progress. A long term business plan was agreed following the change of ownership and will be realised in order of priority. General updgrade and refurbishment is planned both internally and externally and this will improve the immediate standards of furnishings and carpeting in the communal areas. Two of the bathrooms and facilities are not in use and would benefit from upgrading and modernisation. A review of the current smoking policy for the home is also under review to ensure that the procedures and practice are in line with current and recent legislation. 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. The summary of this inspection report can be made available in other formats on request. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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 David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents files were seen on the day of the inspection. A further three residents were spoken to about the service and their care. One resident has been admitted recently for a period of respite care . The resident and her relative, visiting at the time confirmed that they were satisfied with the service overall and had been provided with sufficient information about the home to make an informed decision and choice of placement. The information relating to the health care needs of residents is detailed and reflects personal wishes and needs and is clear and up to date St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were seen during the course of the inspection. The plans are informative and provide a good overall view of each resident’s needs and wishes. It is acknowledged that work is in progress to improve the process and demonstrate that resident’s or their representatives are more involved with each stage of the process including the assessment and reviews. This would provide a more three dimensional and individual lifestyle plan of care. See recommendation . In the previous inspection report it was stated that the plans are handwritten and not easy to read in some instances and a recommendation made to look at ways in which the daily reports and records could be presented in an easy to read format. See recommendation None of the residents could recall being involved in the review of their care plan or discussing what is written about them on a daily basis. However all the St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 10 residents interviewed said that they would not be any more involved in the process than they are currently. All the residents seen on the day spoke positively about the care they receive from the staff and two residents were able to give good examples of individual care and support. Comment cards received from relatives were mixed with one friend expressing disquiet about the limited bathing facilities and also expressing the opinion that there are insufficient numbers of staff on duty at times. Other comments were complimentary about the standards of care and the staff’s efforts to motivate and stimulate residents. There is a robust medication policy in place and the medication is supplied in a monitored dose system. One of the senior nurses has the responsibility for reordering and auditing the system and stock every two weeks. A small number of MAR sheets were seen and were up to date and in good order. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards12,13,14,15 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a small range of activities each week including exercise sessions and musical entertainment. During the discussions with staff it was said that there are plans in place to introduce other games and social events but this will be after the Christmas holiday. See recommendation From the information and notices displayed in the reception area and around the home there are a number of interesting events taking place during the Christmas period both in the home and in the community. Residents said that they were looking forward to the entertainment and added that the staff and everyone did their best to make the home feel festive. There is a designated member of staff allocated to organise the exercise group who has received training instruction to deliver the activity through a training body called EXCEL. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 12 Visitors to the home confirmed that they are welcomed and encouraged to visit and residents can see people in their own rooms or the communal rooms in private. The residents were complimentary about the food and said that they are able to make a choice from two or three options. The menu is delivered weekly to each person and they are then able to select their meals each day. Residents confirmed that they are offered a good and varied diet and the inspector was able to observe the catering staff involved in the serving and distribution of the main meal of the day. The meals seen on the day looked appetising and plentiful. Staff were also observed assisting people with their meals in an appropriate way. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was on leave on the day of the inspection and is the person dealing with a minor concern raised with CSCI . It was agreed that post inspection the manager would be contacted for an update on progress and to report on any action or outcomes to date. The concerns relate to care planning; resident stimulation; and standard of premises, especially residents rooms. Residents seen confirmed that if they have any issues they would raise them with the nurses or the manager. Only one resident out of the four seen said that they were aware of the formal complaints procedure, the remainder said they felt sure that if they had to complain they would do so through their family. One relative said that they found the staff very accessible and responsive to enquiries and would feel comfortable raising concerns with them. During the discussions with staff and on looking through their training records the staff have a good understanding about protecting vulnerable people and have received training either in specialist sessions or as part of their NVQ 2 training. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,26 Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was undertaken and a random selection of residents rooms seen. Some areas of the home are in reasonable order and well maintained. The conservatory is now in use as a dining room and provides a pleasant environment. Other parts of the home are showing signs of wear and tear and are in need of upgrading and refurbishment including paintwork, decoration and carpets in the corridors. Both of the small sitting rooms have well worn and poor quality seating and furniture and would greatly benefit from complete refurbishment. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 15 Two of the residents rooms seen on the day have wood block / laminate floor covering which give the rooms a stark look and would benefit from carpeting to add warmth and colour to the rooms. The CSCI acknowledge that the home has recently been acquired by new owners and that there is a long term business plan is in place to upgrade the environment and premises where needed and that the plan is being implemented as soon as possible ( see recommendation). Two resident’s rooms also seen on the day are attractively set out and furnished with personal items reflecting their individual choice and lifestyle. Some priority should be given to improving and modernising the bathing facilities in the home so that residents are able to choose the best option for their needs or to meet their disability. Two of the bathrooms are not in use currently and this could limit choice and accessibility to residents.( see recommendation). The home has a small group of residents who smoke and they use a specific area at the end of the corridor within a wide stairwell which is not ideal. The area they use is open plan and the smoke is permeating to the first floor and into other resident’s rooms nearest to the designated smoking area. The management are aware of the problems and are looking at ways in which a designated smoking area can be maintained without it impinging on the nonsmoking environment and also at the future policy for the home in respect of recent changes in legislation. ( see requirement). St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is ( adequate). This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the duty rota was checked and corresponded with the personnel on duty. In addition to the permanent staff there was one agency member of staff on duty covering staff absence due to sickness. The rota showed two trained nurses on duty and four care staff on duty in the morning and one nurse and four carers in the afternoon /evening with an additional member of staff designated to make residents beds and complete similar domestic tasks. Given the numbers of residents being accommodated (33) and the dependency levels of at least half of the group the staffing level is at a minimum. Relatives comment cards expressed the view that they did not always feel there were sufficient staff on duty to meet all resident’s needs. During the discussions with staff they were confident about being able to meet residents day to day care needs but also acknowledged that there was little time spent supporting residents socially or emotionally given the nature of the practical and physical tasks. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 17 Residents confirmed that staff are attentive and respond to their requests quite quickly. One resident said that she sometimes feels there is a long wait for a response to the call bell at crucial times of the day but added that it only happens ‘now and then’. The care and nursing staff are supported by catering and domestic staff. The staffing levels were the subject of a requirement at the last inspection and whilst there has been some improvement in establishing the stability of the staff group there is a continued need to look at dependency levels and resident needs which should be complimented by sufficient numbers of staff to meet all the residents health care needs. Given improved staffing levels the outcome of this standard would be good( see requirement). Four staff training files were seen on the day including two skills for care induction booklets. They contained information about courses attended and completed and certificates confirming training in relevant subjects such as first aid; moving and handling; fire procedures; and protecting vulnerable adults. From the information submitted in June as part of the key inspection process, nine of the staff (50 ) have an NVQ 2 qualification or higher. During the course of the day staff were observed attending to residents in a confident and competent way and demonstrated a knowledge and understanding of residents needs. There is a robust recruitment and selection process in place for all staff and the records seen were in place and well maintained. Training at all levels is encouraged and promoted and staff talked positively about the support and supervision they receive. The inspector was informed that a new supply of updated and recently revised induction / foundation booklets for skills for care have been ordered and will form the basis for inhouse and formal training including NVQ. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33, 35,38 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is under new ownership as from 01/12/06. A detailed business plan has been drawn up as part of the acquisition. Work on upgrading the premises and furnishings and fabric of the home will begin immediately. Remaining projects and reviews will be phased in as planned and with the minimum disruption to the resident group. The effectiveness of the plan will be reviewed at the next inspection. The quality assurance process is in place and the results for 2005 published. The questionnaires are issued to resident’s relatives and staff. It is not clear St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 19 from the information provided at this inspection if other health care professionals views are sought as part of the process. ( see recommendation) The outcomes of the review are evaluated and used to change practice or procedures where appropriate. The home have no responsibility for the management of residents finances. Invoices are raised by the home if there is any expenditure made on a resident’s behalf. A full fire risk assessment has been completed and the document made available at the inspection. The assessment identifies any possible hazard or risk and the measures in place to manage the risk. Weekly checks are carried out on all the fire prevention equipment and water temperatures. There is a policy and procedure in place for the maintenance of safe working practices, and in keeping with relevant legislation. A small sample of accidents and incident reports were seen on the day. They were clear and concise and gave a good account of incidents and accidents, however the form does not state if and when the accident or incident is followed up or whether the information about residents is cross -referenced in their care plan or daily record and audited. Information regarding follow up or any action taken arising from a recorded incident or accident should be maintained in a format which can be easily accessed for audit purposes. ( see recommendation). Since the last inspection the call bell system has been replaced and upgraded. The system appears to be working well and the call site easily identified and responded to. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 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 x 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 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 2 2 x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 21 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 OP26 Regulation 13.4 Requirement The registered providers are required to review and revise the facilities provided for residents who smoke to ensure that the provision in place also ensures that residents and staff who do not smoke are protected from fumes and smoke. The registered providers are required to review the current staffing levels to ensure that suitably qualified competent and experienced staff are working in the home in such numbers as are appropriate for the health and welfare of service users. Timescale for action 31/03/07 2 OP27 18 31/03/07 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 OP7 Good Practice Recommendations It is recommended that the management continue to review the care planning process to ensure that the DS0000068537.V324822.R01.S.doc Version 5.2 Page 22 St David`s Nursing Home 2 OP12 3 OP19 4 5 OP21 OP33 information is clear and legible to all who need to use and access the plans, and offers a balanced view of residents personal needs including their social and emotional needs and wishes. It is recommended that the management look at ways in which the social interests and choice of activities for residents so that they can be accessed on an individual and personal level as well as group basis. It is recommended that the registered providers and management continue with the plan to refurbish and upgrade those areas of the premises showing signs of wear and tear and in need of replacement. It is recommended that the registered providers review the current bathing facilities and upgrade to a standard that brings the facilities back into use. It is recommended that the homes quality assurance questionnaire is issued to other health care professionals and their views sought on the standard of service. St David`s Nursing Home DS0000068537.V324822.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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