Inspection on 12/10/05 for St Davids

This inspection was carried out on 12th 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 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 Davids 23/02/07

St Davids 28/06/05

St Davids 24/11/04

St Davids 27/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE St Davids 36 Somerville Road Boldmere Sutton Coldfield West Midlands B73 6HH Lead Inspector Karen Thompson Unannounced Inspection 12th October 2005 10:30 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 Davids DS0000016782.V258547.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 Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Davids Address 36 Somerville Road Boldmere Sutton Coldfield West Midlands B73 6HH 0121 354 4183 0121 354 7526 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) Mrs Jane Whalley Mr Keith Whalley Mrs Jane Whalley Mrs Hazel Rawlings Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28 June 2005 Brief Description of the Service: St David’s is located on a quiet residential road in Sutton Coldfield. It is well situated to access community facilities such as shops, place of worship, Good Hope hospital and Sutton Park. The property has been extended to provide accommodation for 15 elderly people. The home has three floors the top floor only being used for office and staff sleep-in accommodation. All bedrooms are single and are located on the other two floors, all vary in size and fourteen have en-suite facilities. The bedrooms are well decorated and furnished to a high standard and some of the residents have their own telephone installed. The home provides two assisted bathrooms and there are toilets located throughout the large building. All communal rooms are located on the ground floor and consist of a dining room, large lounge and a conservatory that overlooks a well-maintained garden. All communal rooms offer a high standard of furnishings. There is a ramped access to the rear garden that has seating available for the residents. The home has a lift to provide access to the first floor. To the front of the home are a well-tended garden and some space for off road parking. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The report findings are based on an unannounced inspection. Information for the report was gathered from a number of sources: partial tour of the building, examination of records and documents, talking to staff, talking to residents and relatives, direct and indirect observation. 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 Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 6 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 Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3.4.5 The admission process and procedure is thorough ensuring that residents and their relatives know before admission that their care needs will be met by the home. EVIDENCE: Inspection of records confirmed that pre admission assessment had been carried out covering all the areas required. The Care Manager and staff were able to demonstrate an individual approach to meeting resident’s needs. All residents and relatives spoken to expressed satisfaction at the assistance given to them by staff. One resident stated, “If you’re off colour one day staff will cosset you a bit”. Relatives and residents spoken to were offered trial visits to the home, which consisted of seeing the vacant room, having lunch and meeting staff and other residents. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10 The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. Systems in relation to medication are robust to protect residents. Residents dignity and privacy is respected EVIDENCE: Residents care plans are based on a comprehensive assessment. Care plans are reviewed monthly with resident involvement. One resident commented that the home was “wonderful and they wouldn’t go back on my own for anything, as everything you want is here”, they went on to comment further that “the staff anticipate your wishes”. Records were able to demonstrate that residents were seen by a variety of health care professionals. During the inspection one resident became unwell and the appropriate health professionals were contacted. Medication management was good. Residents are supported to self medicate if they wish and risk assessments are undertaken together with a regular compliance checks. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 9 Residents were observed to be spoken to by staff in a respectful and polite manner. Staff were observed to knock on residents bedroom doors before entering. One resident who became unwell was assisted sensitively and discreetly. The home has a communal telephone in an alcove off the hall. Residents clothes were observed to be nicely laundered, one resident comment that “laundry is excellent” St Davids DS0000016782.V258547.R01.S.doc Version 5.0 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. Residents are helped to exercise choice and control over all aspects of their lives, and to maintain contact with relatives and the local community as they wish. EVIDENCE: Residents spoken with confirmed that there were no rigid rules or routines in the home and they were free to spend their time as they chose. Residents during the inspection were observed taking part in a group activity. The home has a visiting library service every six weeks where books can be ordered in advance. Family and friends were observed around the home and confirmed that and there were no restrictions visiting. One relative commented, “You can visit when you want”. Residents spoken to stated they go out when ever they wanted. Resident’s opinions and preferences are actively sought. Bedrooms were personalized with resident’s own possessions. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 11 The lunchtime meal was nicely presented and residents were assisted discreetly. Residents comments with regards to meals were positive and included “the food is lovely”, “They know I don’t like some vegetables and so they do me something else”, and “ can’t fault staff, food or cleanliness”. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 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): 16.18 Systems are in place to ensure that residents are protected, although further staff training is needed to ensure they are familiar with the adult protection procedure. Residents and relatives concerns are listened to and taken seriously and acted upon. EVIDENCE: No complaints have been received by the home since the previous inspection. The complaints procedure required minor adjustments and evidence of this being done was forwarded to the Commission just after the inspection. Staff have undergone recent training in regards to adult protection, staff demonstrated good knowledge of this subject. Staff need to be familized with the local multi agency guidelines to ensure the local procedure is followed. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 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): 19.20.24.25. The standard of environment provides residents with an attractive, safe, comfortable and homely place to live. Resident’s private accommodation is suited to their needs and personalised according to their tastes and preferences. EVIDENCE: The home was clean and well maintained. The garden is well maintained and fully accessible to residents. All bedrooms with the exception of one have an ensuites facility. One resident commented that it was “nice to have own toilet”. There are communal assisted bathing facilities in the home. The inspector visited a number of residents in their own room which varied in size and were personalized with resident’s own possessions. Bedroom doors are lockable from the inside, which staff can access in an emergency, but these locks do not allow for residents to lock their room when they are not in them. Residents are provided with a lockable facility if they want one. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 14 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. Resident’s needs are met by adequate numbers of staff being available. Staff training is afforded a high priority ensuring that they are trained and competent to care for residents. EVIDENCE: A minimum of two staff are on duty during the waking day with one waking night care assistant and a member of staff sleeping in at night. The home has two Care Managers operating on a job share basis who are not counted in the care staffing hours. The home has additional staff for catering and cleaning. Over fifty percent of staff has completed NVQ 2 in care. Staff have undergone recent training in Adult protection and there is ongoing training in understanding dementia and Alzheimer’s. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 15 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): 31.32.36.38 The Managers ensure smooth running of the home in a competent manner. Health and safety is well managed ensuring the welfare of residents and staff is promoted and protected. EVIDENCE: This is a well managed home with a friendly, open and positive environment. The management team were able to demonstrate clear leadership and competency to run the home. Staff were receiving supervision six times a year. The health and safety requirements from the previous inspection had been met. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 16 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X X 3 3 X STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 X X X 3 X 3 St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 17 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. 1 2 Refer to Standard OP18 OP24 Good Practice Recommendations The Registered Person must ensure that staff are familiar with the procedure to follow in regards to adult protection as outlined in the Multiagency guidelines The Registered Person discusses with residents the fitting of a door lock that enables them to lock their room on leaving but is also accessible to staff in an emergency. St Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Davids DS0000016782.V258547.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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