Inspection on 11/04/05 for St Davids Residential Care Home

This inspection was carried out on 11th April 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 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 Residential Care Home 18/03/09

St Davids Residential Care Home 11/12/07

St Davids Residential Care Home 06/03/07

St Davids Residential Care Home 23/11/05

St Davids Residential Care Home 24/11/04

St Davids Residential Care Home 21/06/04

Similar services:

Claremont House

Claremont House

Chesham House

Oak Ridge

Argyll House

Oliver Court

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

CARE HOMES FOR OLDER PEOPLE St Davids Residential Care Home 36-38 Nelson Road South Great Yarmouth Norfolk NR30 3JA Lead Inspector Hilda Stephenson Unannounced 11 April 2005 11:00 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 Residential Care Home Version 1.10 Page 3 SERVICE INFORMATION Name of service St Davids Residential Care Home Address 36-38 Nelson Road South Great Yarmouth Norfolk NR30 3JA 01493 842088 01493 842088 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) Dr Ajit Kumar Verma Mrs Gayatri Verma Miss Toleen Chang Care Home 18 Category(ies) of DE(E) Dementia - over 65 (2) registration, with number MD(E) Mental Disorder - over 65 (1) of places OP Old Age (18) St Davids Residential Care Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to eighteen (1) Older People, not falling into any other category, may be accommodated. 2. Up to two (2) Service Users, over the age of 65 years, who have dementia and are named in the Commissions records, may be accommodated. 3. One (1) Service User, over the age fo 65 years who has a mental disorder and is named in the Commissions records, may be accomodated. 4. Total number accommodated not to exceed eighteen (18). Date of last inspection 24 November 2005 Brief Description of the Service: St David’s is registered as a care home providing personal care and accommodation for 18 older people. Dr and Mrs Verma own it. The home is located near to Great Yarmouth south coastline approximately 100 metres from the seafront. It is half a mile from the town centre where local shopping and amenities are found. The home is a three-storey building with access to the bedrooms by a shaft lift; only stairs can access two of the bedrooms. There are 12 single bedrooms and 3 shared bedrooms some of these have en-suite facilities. The communal rooms are situated on the ground and basement floors. The home has a small patio area at the front of the premises with off street parking. St Davids Residential Care Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three hours and was carried out during the middle part of the day during the lunch time period. A partial tour of the first two floors of the premises was undertaken, staff records and rotas plus care plans and assessment documents were examined. Four of the five staff on duty and seven of the fifteen residents were spoken to. The residents looked well cared for and the home was found to be clean, tidy and with no unpleasant aroma. What the service does well: What has improved since the last inspection? All the requirements from the previous inspection have been completed including asking residents for their choice of meals, improvements with the recruitment procedure and staff supervision. The Service Users Guide is now given to all residents when they are admitted to the home to let them read all about the facilities offered at St David’s. Two bedrooms have been redecorated. St Davids Residential Care Home Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Davids Residential Care Home Version 1.10 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 Davids Residential Care Home Version 1.10 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) 1,3 & 5 Residents are given information prior to admission, are invited to visit and an assessment is completed to ensure the home can meet their needs. EVIDENCE: The home has a Service Users Guide including clear written details for both residents and their relatives available prior to admission. The Manager visits all residents to assess their personal needs with the written assessment included with the care records. One resident who has lived at the home for some time stated ‘I get everything I need here, I came to visit the home first and saw my room, the manager came to see me, then my social worker came to see me a few weeks later’. The manager organises a review meeting after the first month so each new resident can discuss whether he or she wish to stay at the home. The Social Worker and relative are also invited to ensure St David’s is the right place for the resident. St Davids Residential Care Home Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9 & 10 Care plans and health needs are identified and reviewed and are met by knowledgeable staff who have a good understanding of the residents needs. EVIDENCE: Each resident has a basic care plan that is reviewed at regular intervals. Two care plans were read and it was found that all the care plans have been renewed although they are not always easy to read, due to the documents being contained in one folder. The manager should have personal folders for each resident to ensure confidentiality. One resident who spoke to the Inspector said’ I know I have records about me and I see them now and again’. Residents are involved when the staff review their care. One of the care records did not contain an assessment of the risk of the resident’s daily outings; this should be highlighted for staff to follow to ensure his safety outside the building at all times. St Davids Residential Care Home Version 1.10 Page 10 Another area of potential risk was identified as no identification is included with the medication records and on occasions a new member of staff administers the medicines after training. To reduce the potential for any errors a photograph of residents should be obtained and added to the medication records. St Davids Residential Care Home Version 1.10 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Social activities are well organised to include both group and individual interests including the two main mealtimes as a sociable event. EVIDENCE: Residents confirmed that the cook asks them if they wish for the main cooked meal or one of the alternatives for their lunch and tea. Breakfast and Supper times are variable to suit the resident’s time when they get up or go to bed. The dining room is bright and comfortably furnished to ensure that residents can sit with their friends or on their own if they wish. Staff were assisting residents with their meal in a discreet and dignified manner to ensure that those who are frailer manage to eat and drink to their satisfaction. Most days during the week the staff encourage residents to participate in games, cards, dominoes, scrabble or general discussion so that the day is more structured. Occasionally an entertainer is invited to sing or play popular music, with the majority of residents stating ‘they enjoy these sing-alongs’. The staff visit those residents who prefer to stay in their room to ask if they want to chat or have a game of cards etc. St Davids Residential Care Home Version 1.10 Page 12 One resident goes to the local shop on a daily basis and organises the shopping for other residents such as collecting their newspaper. One resident stated ‘she was looking forward to the warmer weather so she could go to the seafront and enjoy the crowds’. St Davids Residential Care Home Version 1.10 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has a satisfactory complaints system in place and there was evidence that the staff listen to residents’ views or concerns. EVIDENCE: The complaints procedure is displayed in the hall alongside the previous inspection report. The manager records any complaints and the action that had been taken. One resident stated ‘I would speak to Toleen if I have a problem’, I know you are the Inspector but I have no concerns here, the staff are very good’. The Manager visits each resident each day, to make sure that they are comfortable. Several residents confirmed this. A procedure was in place for staff to follow in response to any allegation of abuse. Staff records indicated that the majority have attended recent adult protection training, with the subject discussed during the induction of new staff. St Davids Residential Care Home Version 1.10 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 In general the home was clean, tidy and free from odour. There is limited outside space. EVIDENCE: St David’s consist of a three-storey town house with access from Nelson Road. There is a small patio at the front of the premises with pots containing flowers and seating for those who wish to sit outside. A partial tour of the communal rooms was undertaken. Stairs can only access two bedrooms; the manager considers the risk to residents when they move into these rooms confirming that if they become frail there would be a possibility that they may need to be moved to a more accessible room. This information is included in the information that is given on admission. Access to the upstairs is by a shaft lift. The dining room is bright and has adequate furnishing to provide a sociable area for residents to take their meals. The main lounge on the ground floor contains a television and music centre and has a variety of comfortable seating. St Davids Residential Care Home Version 1.10 Page 15 There is a second lounge on the lower ground floor where residents are able to smoke which also contains a library of books and reading material. Two residents were using the library during the inspection saying’ they like the peaceful atmosphere this rooms provides’. The home was clean, tidy and had no unpleasant aroma. St Davids Residential Care Home Version 1.10 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 & 28 The staffing levels are adequate during the week but fall below an acceptable level at weekends. Staff are well trained and competent. EVIDENCE: During the working week the staffing levels are adequate with the Manager being supported by two care staff, one cleaner and one cook. This reduces to two care staff during the evening and overnight. The Manager or Senior Carer is on call to support the staff. During the weekends two care staff and one cook is on duty, which is the minimum number required although currently the number of residents are reduced. When the home is full it would be debatable whether this number of staff can meet each residents needs, due to fact that the home has two residents with higher needs due to their dementia. The manager should review the staffing levels when the home has a full complement of residents. The manager confirmed that extra staff are brought in when appointments or outings are arranged. Nine out of the twelve care staff have undertaken or completed the NVQ training with evidence of improved care practices being seen. St Davids Residential Care Home Version 1.10 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) 31, 37 & 38 The management of the home is satisfactory but the records are not well managed. EVIDENCE: The Manager has worked at the home for the past ten years and holds relevant management qualifications and keeps her own skills up to date by attending regular training events, recently completing infection control and food hygiene. The records are kept within the office with confidential records kept secure. It is required that the care plans should be stored in individual files rather than condensed in two folders, due to the need to ensure confidentiality. The manager should consider whether these are kept for the convenience of staff or for the residents. It was difficult to read the two care plans due to the written information being stored this way. St Davids Residential Care Home Version 1.10 Page 18 The care plans contain some risk assessments to highlight areas of concern and the action to be taken to enable residents to maintain their lifestyle. The home does not have a fire risk assessment and this should be completed immediately to highlight the areas within the home in case of fire. The staff have undertaken a variety of training with two thirds having commenced or completed the recommended NVQ training. Several residents stated ‘the staff are very caring and will do anything for you’, There were no relatives seen during this visit. St Davids Residential Care Home Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x x x STAFFING Standard No Score 27 2 28 4 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x 2 2 St Davids Residential Care Home Version 1.10 Page 20 No 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 7 Regulation Requirement A risk assessment must be completed to ensure the safety of a resident who goes out of the building as part of their daily routine. Care plans must be kept in individual files with information relevant to each resident contained within these. The manager should review the staffing numbers especially at weekends to ensure that residents needs are being met, due to the home having two residents with a dementia who have a higher dependency. The Manager must complete a fire risk assessment for the building to highlight areas of concern in the event of a fire. Timescale for action Immediate 2. 7 30/6/05 3. 27 Immediate and ongoing 4. 38 Immediate 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 9 Good Practice Recommendations It is reccommended that photographs are included beside Version 1.10 Page 21 St Davids Residential Care Home the medication records to reduce the risk of a medication error. St Davids Residential Care Home Version 1.10 Page 22 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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. 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