Inspection on 28/06/05 for St Davids

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 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 Davids 23/02/07

St Davids 12/10/05

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 B73 6HH Lead Inspector Karen Thompson Unannounced 28 June 2005 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 Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Davids Address 36 Somerville Road, Boldmere Sutton Coldfield B73 6HH 0121 354 4183 0121 354 7526 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 Jane Whalley Mrs Jane Whalley and Mrs Hazel Rawlings 15 Category(ies) of Old Age (15) registration, with number of places St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24 November 2004 Brief Description of the Service: St Davids is located on a quiet residential road in Sutton Coldfield. It is well situated to access community facilities such as shops, places of worship, Good Hope hospital and Sutton Park. Once a large detached house it has been extended to provide accommodation for 15 elderly people. The home has three floors the top floor only being used for office and sleep-in staff accomodation. 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 service users 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 comprise of a dining room, large lounge and a conservatory which overlooks a very well maintained secluded garden. All communal rooms offer a high standard of furnishings. There is a ramped access to the rear garden which has seating available for the service users. The home has a lift to ease access to the first floor. To the front of the home is a well tended garden area and some space far off road parking. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The findings of this report are following an unannounced inspection. The inspection was carried out over one day and took six and half hours. Information was gathered from a number of sources: tour of the building, examination of records and documents, lunch with service users, talking to 8 service users and 1 relative, direct and indirect observation. The management of the home is provided by two managers who jobshare the position. 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 E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 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 standard(s) 3.4.5 The admission process and procedure is thorough ensuring that service users know before admission that their care needs with be met by the home EVIDENCE: Pre admission assessments are carried out by either managers and cover all required areas. Service users needs appear to be well met, and those spoken to were happy with the care given. The Care Managers and staff were able to demonstrate an individual approach to service users and meeting their needs. The first twenty-eight days are viewed as a trial period and details of this are within the contract. The home is not at present formerly reviewing service users stay at the home after the trial period, but does review all service users needs on a three monthly basis. It is strongly recommended that new service users are reviewed the end of the trial period and records of this review are kept. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 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 standard(s) 8.9.10. The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. Systems in relation to medication are robust to protect the service user. EVIDENCE: Staff have received accredited training in safe handling of medicines. The majority of medication audits undertaken were correct and systems have improved in the checking of medication received into the home. Service users are supported to self medicate their own medication if they wish and risk assessments are undertaken together with a regular compliance check. The inspector witnessed good interaction with staff. Service users commented that they were “happy with the care” The home has a telephone in an alcove off the hall for service user to access, some service users were observed to have their own telephone in their bedroom. The inspector was shown a number of letters from relatives, which were positive in their praise of the care given by the home. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 9 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) 12.13.14.15. Service users 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: Service users informed the inspector that they were free to go to bed and get up when they liked. Service users were observed reading the daily newspaper and the home has a library visiting service. One service users gardening interest in maintained with the provision of a greenhouse and plants. On the day of inspection two service users were attending a local luncheon club and the home has a young volunteer who visits once a week to play board games with some of the service users. A service user spoken to during the inspection had recently been out with another service user and their family and had thoroughly enjoyed this outing. Service users choice, preferences and dislikes in respect of food are documented during the care planning process. Service users spoken to stated they were asked what they would like and a choice was always available. The menu shown to the inspector demonstrated a varied, wholesome and nutritious diet. The inspector had lunch with service users. The meal was nicely presented and service uses were assisted discreetly. Service users bedrooms were individualized with service users being able to personalize with their own furniture and possessions. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 10 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) 16.18 Systems are in place to ensure that service users are protected, although training for all staff has not been provided. Service users expressed confidence that any complaints would be taken seriously and acted upon. EVIDENCE: The home has received no complaints since its previous inspection. The complaints procedure was robust and this was observed displayed in service user’s rooms on the inside of the bedroom door. Service users commented that staff were always approachable with concerns and would help them. Appropriate arrangements for protecting service users within the home were in place. The Care Managers had purchased a training pack for all staff in relation to adult protection, only two members of staff have completed this at present. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 11 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) 19.20.21.22.23.24.25.26. The standard of the environment within this home is good providing service users with an attractive, homely and personalised place to live. Service users are able to exercise independence in part due to the provision of suitable equipment, facilities and adaptations in the home. EVIDENCE: The home was clean and well maintained. The home has its own maintenance operative working two days per week. The homes grounds to the rear of the property are enclosed, accessible to service users and well maintained. The one bedroom without an ensuite toilet has a bathroom directly opposite it, which was for the occupant’s own use. Baths were assisted and some toilets seats were raised for service users to assist in mobility. Bedrooms varied in size and bedrooms doors were lockable from the inside and accessible to staff in an emergency, but these locks did not allow for service users to lock their bedrooms when they were not in them. Locks should be fitted that enable St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 12 service users to lock their rooms when they leave them. Service users are provided with a lockable facility if they want one. Radiators were guarded. All hot water outlets that service users have access to are thermostatic controlled. Laundry facilities are located on the ground floor. Systems are in place to control the spread of infection. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 13 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) 27.28.29.30 Adequate staffing levels and a positive attitude towards learning and training shown by the management team ensures service users needs are being met by staff who are competent and trained to carry out their duties. EVIDENCE: A minimum of two staff are on duty during the waking day and 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, and a deputy manager who is not counted in the care staffing hours. The home has additional staff for cleaning and catering. Forty eight percent of staff have completed NVQ 2. Staff had received training in manual handling, first aid, fire safety, food hygiene and understanding dementia and Alzheimer’s. Staff recruitment procedures, policies and practices ensure that service users are supported and protected. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 14 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) 31. 32.33.35.38. This is a well managed home run for the benefit of service users. Systems were in place to protect the health, safety and well being of service users, but further work to reduce risks for service users in respect of fire prevention and fire protection is necessary. EVIDENCE: The management team consists of the owner who works part time as a Care Manager along with another part time Care Manager. They are both view learning as an ongoing process and have both completed NVQ 4in care and management. Service users spoken to during the inspection spoke positively about the management team and care staff. The home has a quality assurance system in place and is being assisted by a training and consultancy agency to implement this. The home holds money for four service users, which is kept securely. Service users money is kept separately and a record of transactions and receipts are St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 15 kept. The home has a risk assessment in place for the premises this needs to be reviewed to include the grounds. Systems for testing water purity were in place. Fire alarms, fire equipment and emergency lighting were being serviced and maintained regularly. There was evidence of hoists, gas and PAT testing also taking place. Fire training was in place. Staff at the home are in the process of receiving adult protection training. The home current lift certificate was forwarded to the Commission following the inspection. The home had recently undergone an inspection by West Midlands Fire Service a number of requirements have been made and the home is in the process of completing this work. St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 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 4 4 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 3 3 x 3 x x 2 St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 17 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 28 Regulation 18(1)(a) Requirement The Registered Person must ensure that 50 of care staff must be qualifed to NVQ level 2 or equivalent by 2005. (Outstanding Requirement 24th Nov 2004) The Registered Person must ensure that all staff have have completed adult protection training. The Registered Person must ensure that the home has a risk assessment in place for the premises and the grounds Timescale for action 31st Dec 2005 2. 38 13(6) 31st Sep 2005 31st Aug 2005 3. 38 13(4)(a)( b)(c) 4. 5. 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. St Davids Refer to Standard 5 9 Good Practice Recommendations It is strongly recommended that placements at the home are formally reviewed after the 28 day trial period and that records of this review are retained.. The home should purchase an up todate British National Formula to complement drug administration. E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 18 3. 9 The Registered Person must undertake regular staff drug audits to confirm staff competence in medicine . St Davids E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B4 2UZ 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 E54 S16782 St Davids V236160 280605 Stage 4.doc Version 1.40 Page 20 - 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!