Inspection on 11/12/07 for St Davids Residential Care Home

This inspection was carried out on 11th December 2007.

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 Residential Care Home 18/03/09

St Davids Residential Care Home 06/03/07

St Davids Residential Care Home 23/11/05

St Davids Residential Care Home 11/04/05

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 Andy Green Unannounced Inspection 11th December 2007 1:30 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 Residential Care Home DS0000027444.V356476.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 Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Davids Residential Care Home Address 36-38 Nelson Road South Great Yarmouth Norfolk NR30 3JA 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) 01493 842088 01493 842088 Dr Ajit Kumar Verma Mrs Gayatri Verma Mrs Toleen Hamlin Care Home 18 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (18) St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to eighteen (18) Older People, not falling into any other category, may be accommodated. One (1) Service User, over the age of 65 years who has a mental disorder and is named in the Commission’s records, may be accommodated. Up to ten (10) services users, over the age of 65 years, who have dementia may be accommodated. Total number accommodated not to exceed eighteen (18). Date of last inspection 6th March 2007 Brief Description of the Service: St Davids is registered as a care home providing personal care and accommodation for 18 older people. 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 is owned by Dr and Mrs Verma and it is located 100 metres from the seafront in Great Yarmouth. It is half a mile from the town centre where local shopping and amenities are found. The home has a small patio area at the front of the premises with off street parking. The weekly charge ranges from £333 TO £347 Copies of CSCI reports are available upon request from the home’s office. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection carried out an unannounced inspection of this service on 11 December 2007. We met with the manager, members of staff and a number of residents during the inspection. A variety of records were inspected including care plans, staff files, organisational policies and medication records. A tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: Reviews of care plans need to be more regular to ensure that they remain appropriate to the assessed needs of residents. All care plan documents need to be signed and dated. Formal recorded staff supervision must be in place to ensure that work performance and development needs are monitored. Fire alarm and emergency lighting test records must be adequately maintained. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 6 An up to date computer system would benefit the management processes in the home. 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 Davids Residential Care Home DS0000027444.V356476.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 Davids Residential Care Home DS0000027444.V356476.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are in place to make sure that that the care needs of new residents can be met. EVIDENCE: The manager visits all residents to assess their personal needs and the written assessment is included with the care records containing the resident’s personal daily requirements. Relatives are encouraged to take part in the assessment process much as possible. There have been no changes to the assessment process. The manager organises a review meeting after the first month so each new resident can discuss whether he or she wishes to stay at the home. The manager and relative are also invited to the review to ensure St David’s is the right place for the resident. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 9 There has been one admission to the home since the last inspection. Assessment details were kept within their care plans. The home does not provide intermediate care. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal care to meet their assessed needs, but reviews of care and recording needs to be improved. EVIDENCE: Each resident has a basic care plan to record guidelines for care and support. Three care plans were read and they contained the current care needs and review. The manager confirmed that the residents continue to be included where possible when the reviews are undertaken. It was noted however, that the reviews were not up to date in all cases and the manager stated that she would carry out an audit of all care plans to ensure they are up to date. A number of documents in care plans were not signed and dated and the manager was made aware of this. The care plans have a risk assessment of the individual risks for each resident to enable them to live a fulfilling independent life within the home. A key St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 11 worker system remains in place and each resident is allocated a member of staff who will help with personal shopping and general care to ensure that all aspects of care and support are catered for. Daily records are in place to record significant events during the day and are discussed at staff handovers to maintain continuity of care. Medication administration records were checked and all were completed satisfactorily. The deputy and senior staff continue to complete the ordering, administering and return of unused medication. Controlled drug records were also checked. It was noted that the controlled medication record book was in a poor state and a new one needs to be obtained. The manager stated that a new one would be purchased as soon as possible. All staff having responsibility for administering medication receive ongoing medication training. Staff on duty confirmed this to be the case. Residents spoken with stated that they felt that the staff were very friendly kind and respectful in their approach. Observation during the inspection visit evidenced that residents were treated with respect and in an appropriate manner by all the staff on duty. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide appropriate support to ensure that residents have access to activities appropriate to their needs. EVIDENCE: The staff continue to organise a variety of social activities for residents during the week depending on resident preferences. Some residents go out with their family, or the staff may arrange to take them out for shopping or social events. As the home is situated in a busy holiday resort residents have access to the local seaside amenities and, those who wish to, often go out for a walk with staff assistance during the warmer months. Visitors are always welcome to visit the home. Many of the residents do not have any relatives or visitors and the staff spend more time with these residents. The residents who do not wish to take part in organised activities have their wishes respected. Residents confirmed that the food provided was of good quality and the cook always provides an alternative choice to the advertised meal if they prefer. Breakfast and supper times are variable to suit the resident’s according to when they wish get up or go to bed. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 13 The dining room is bright and comfortably furnished to ensure that residents can sit with their friends or on their own if they wish. The dining room has been redecorated and refurbished in the last twelve months. Snacks and drinks are available throughout the day and the home caters for residents who are celebrating a birthday or special anniversary. The home still has a vacancy for a relief cook and currently the staff that have previously cooked are filling in, although this does not affect the care staff numbers. All staff preparing meals have undertaken food hygiene training. The kitchen was clean and tidy. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure to ensure that residents have their complaints or concerns responded to properly. EVIDENCE: The manager confirmed that complaints continue to be recorded and dealt with immediately, either by herself or by her deputy. A complaints policy is in place and a copy is kept in the front hall. The manager stated that there had not been any complaints received regarding the service and no complaints have been received by the Commission. The manager and care staff confirmed that they were aware of the adult protection procedure and had attended training during the year. The home had not received comment cards prior to this visit so verbal comments were obtained from 6 residents. No complaints were received during this visit. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment, which is clean and tidy. EVIDENCE: The home is well presented and free from unpleasant odours. There is an ongoing programme of maintenance throughout the year so that the home remains in a good decorative condition and repairs are carried out in a timely manner. The home has a maintenance person who is in regular contact with the home. The lounge areas and dining room are well furnished and have been redecorated to provide a comfortable and homely atmosphere. Residents confirmed that the accommodation provided met their individual needs. Residents are encouraged to personalise their bedrooms and we were able to see this was the case by looking at some of the rooms during our visit. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 16 Since the last inspection two bedrooms and a bathroom have been redecorated and a number of carpets have been renewed where necessary. The home has actioned work for a number of windows required from the last inspection and the manager stated that these repairs would be completed early in the New Year. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment and training processes help ensure that residents are protected from harm. EVIDENCE: The staffing levels are adequate with 3 staff in the morning, 3 staff in the afternoon and 2 staff overnight. The Manager, deputy or senior carers are on call to support the staff on duty. Two members of care staff and one senior is on duty during the weekend when the manager is off duty. The most recently appointed member of staff’s recruitment records were seen and found to be satisfactory. Two further staff files were also seen and had the required checks such as CRB, references and employment records to help ensure that residents are protected. The manager continues to use the Croners induction training package taking 13 weeks for new staff to complete. The manager provides a training programme including fire, moving & handling, food hygiene, first aid, dementia awareness and infection control. This was confirmed by members of staff during the inspection. The manager continues to liaise with other local care homes to pool training resources, which is a proactive measure. All staff are undertaking/involved in NVQ training. St Davids Residential Care Home DS0000027444.V356476.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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well managed, but supervision and health & safety arrangements need to ensure that residents receive a good and safe standard of care. EVIDENCE: The manager continues to attend all mandatory training and has achieved the City & Guilds Advanced Management. She stated that she is researching an NVQ 4 course with a local college. The manager continues to carry out an audit of the home gaining evidence from questionnaires to residents and visitors. Regular residents meetings to discuss future changes within the home are periodically organised throughout the year. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 19 The required contract checks such as fire equipment, lift, water and equipment were seen and have been satisfactorily maintained. The registration certificate and insurance are displayed in the main hallway. Weekly fire alarm and monthly emergency lighting testing records were inspected and found to be unsatisfactory and out of date. The deputy manager stated that she would start a new file with new clear recording sheets within 48 hours to ensure that fire records are maintained to help ensure the safety of residents and staff. Staff confirmed that they felt supported by the manager, but evidence of formal regular recorded supervision was not in place. The manager is aware of this shortfall and stated that this would be improved. It was also discussed that a more up to date computer system would give the home access to a wider range of services. This could include designing new forms and documents and access to e-mail to aid smoother communication and improved management The proprietor visits the home to provide ongoing support to residents, staff and the manager. St Davids Residential Care Home DS0000027444.V356476.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 X 3 2 X 2 St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 21 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. 1. 2. Standard OP7 OP36 Regulation 15(2)(b) 18(2) Requirement Care plans must be regularly reviewed to ensure that residents needs are monitored. Arrangements must be in place to ensure that staff receive regular recorded supervision sessions. Arrangements must be in place to ensure that appropriate fire testing is in place to protect residents and staff from harm. Timescale for action 29/02/08 29/02/08 3. OP38 23(4)(c) (v) 31/12/07 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 OP31 Good Practice Recommendations The home would benefit from an up to date computer system to improve management processes. St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI St Davids Residential Care Home DS0000027444.V356476.R01.S.doc Version 5.2 Page 23 - 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!