Inspection on 06/03/07 for St Davids Residential Care Home

This inspection was carried out on 6th March 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 11/12/07

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 Hilda Stephenson Key Unannounced 6th March 2007 09:30 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.V332543.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.V332543.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 (5), 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.V332543.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 five (5) 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 23rd November 2005 Brief Description of the Service: St Davids 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 DS0000027444.V332543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the home was conducted as an unannounced key inspection during the day on 6th March 2007. The evidence was taken by speaking to seven residents, two staff, the manager and by examining care records, staff files and the certificates and records required by regulation. The home is a small adequately managed residential home and was found to be clean and tidy with the residents carrying on with their own daily routine. The key minimum standards that were checked during this visit resulted in the home being issued with three requirements and one recommendation. What the service does well: What has improved since the last inspection? The home had no outstanding requirements from the previous inspection. Several areas of the home have been redecorated. The dining room is clean, tidy and has had a new flooring laid. Four bedrooms have been redecorated with residents advising on the colour scheme. The library on the lower ground floor has also been redecorated making the room more inviting for residents to sit and read. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Davids Residential Care Home DS0000027444.V332543.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.V332543.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given information prior to admission, are invited to visit and an assessment is completed by the manager to ensure the home can meet their needs. EVIDENCE: The manager visits all residents to assess their personal needs and the written assessment is included with the care records containing resident’s personal daily requirements. 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 social worker 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.V332543.R01.S.doc Version 5.2 Page 9 The home has had no further admissions since the previous inspection, so the manager explained the admission process. The evidence was gained by reading the records of the last resident who had been admitted into the home for a short stay. Two further residents were spoken to regarding their initial admission to the home and both stated the Manager had visited them beforehand. Assessment details were kept within their care plans. St Davids Residential Care Home DS0000027444.V332543.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved when the care plan is written and reviewed. The home organises other professionals to visit residents, when appropriate. Residents are protected with safe procedures with administering their medication. EVIDENCE: Each resident has a basic care plan that is reviewed at regular intervals. Two care plans were read and found to contain the current care needs and last review of two residents chosen at random to follow through case tracking. The manager confirmed that the majority of residents continue to be included when the reviews are undertaken. 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 worker system is in place and each resident is allocated a member of staff who will help with personal shopping, writing letters or general care to ensure that all aspects of care are catered for. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 11 One resident had necessary equipment to enable her to continue and improve her independence. A small life story of the resident was included within the care records, where family had assisted with the initial recording to help staff to prompt memories and conversation. Staff discuss changes on a regular basis. Daily records are used during staff handover to maintain continuity of care. MAR (Medication administration records) sheets of both residents were checked plus 4 random MAR sheets, all were completed satisfactorily. The deputy and senior staff completes the ordering, administering and returning of medication. Controlled drug records were also checked. The local PCT Pharmacist had recently audited the medication of all residents, no out of date medication was in stock. All staff had received recent medication training, seen in staff training files. The medication was observed during the lunch time period being distributed satisfactorily by the senior staff in charge. Residents spoken with stated ‘that they felt the staff were very respectful in their manner and they were treated with dignity’. Observation during the site visit and past inspections provided evidence that residents were treated with respect by all the staff on duty. St Davids Residential Care Home DS0000027444.V332543.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities are well organised to include both group and individual interests including the two main mealtimes as a sociable event. EVIDENCE: The staff organise a selection of social activities during the week depending on the residents’ wishes. A small number of residents continue to go out for daily walks, while others rely on help from the staff. Several of the residents do not have any relatives or visitors and staff tends to spend more time with these residents. Some residents confirmed that they continue to go out and do their own shopping with their family, or that staff can prearrange to take them out. The residents who do not wish to take part in organised activities have their wishes respected. Visitors are welcomed into the home by friendly polite staff. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 13 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. The dining room has recently been refurbished. 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. The home has a water cooler in the dining room for residents and visitors to help themselves. The manager organises snacks and drinks for those who have smaller appetites and caters for residents who are celebrating a birthday or special anniversary. All residents confirmed that meals and the amount of food was excellent and could not be improved. The resident’s likes and dislikes and nutritional needs were recorded and kept in the kitchen and individual care plans. The kitchen was clean and tidy. The home requires a relief cook and currently staff that have previously cooked are filling in, although this does not affect the care staff numbers. All staff hold the food hygiene certificate. St Davids Residential Care Home DS0000027444.V332543.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): 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 policy in place and procedures to protect vulnerable adults. EVIDENCE: The manager confirmed that complaints were recorded and dealt with immediately, either by herself or her deputy. A complaints policy is in place and a copy is kept in the front hall. The manager explained the adult protection procedure. Senior 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 8 out of 15 residents. No complaints were received during this visit. Staff records of two staff were seen and showed evidence that adult protection had been included in their induction and ongoing NVQ training. St Davids Residential Care Home DS0000027444.V332543.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): Quality in this outcome area is adequate. 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 although some improvements are required to be completed. EVIDENCE: The home has comfortable furnishings and residents’ bedrooms contained personal possessions to maintain individuality. 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 St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 16 information that is given on admission. Access to the upstairs is by a shaft lift, which is in good working order. 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. The carpet is worn in places and needs to be replaced. Several bedroom windows also require replacing to allow residents to have a clear outside view, in rooms 1,2,8,9 & 14. The carpet in room 15 also requires replacing. A spot check was carried out on both bathrooms. They were both clean although both contained the same bathing chair. It was recommended that the manager consider changing one of these chairs to accommodate the frailer residents into the bath to ensure staff maintain the privacy and dignity of those residents who require assistance. Residents confirmed that the manager had asked their opinion of the colour scheme for the lounge, which is to be redecorated. This is good practice. St Davids Residential Care Home DS0000027444.V332543.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are cared for by well-trained polite friendly staff. However, the home is required to increase the numbers of staff. 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 night. The manager or senior carer is on call to support the staff. Two care staff and one senior is on duty during the weekend when the manager is off duty. Unfortunately, the home has recently lost 4 members of staff and preparations have begun to replace these posts. Current staff are working extra hours to maintain adequate numbers. A replacement for the laundry staff has been recruited. The most recently recruited member of staff’s records were seen and found to be satisfactory, ensuring the manager employs staff in an appropriate manner, following the recruitment procedure. Other staff files through case tracking were also seen and the manager had the required checks such as CRB and employment records to ensure that residents are protected. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 18 The manager uses the Croners induction training package taking 13 weeks for new staff to complete. The manager invites professionals into the home to complete training such as fire, moving and handling, food hygiene, first aid, dementia awareness, and infection control, these were the latest courses that have been completed by the staff. By using this type of training the manager invites care staff from other care homes to join in with the training and should be commended for networking with other homes. Currently five staff are undertaking the recommended NVQ training. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements are meeting the needs of residents although improvement is required to the premises. EVIDENCE: The manager has attended all compulsory training and has achieved the City & Guilds Advanced Management, including adapting supervision within the care home. The manager continues to audit the services at the home gaining evidence from questionnaires to residents and visitors. Regular residents meetings to discuss future changes within the home have carried on throughout the year. The manager holds personal spending money for one resident and these records were checked. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 20 The required environmental checks such as fire records, lift, water and equipment were seen and have been satisfactorily maintained. The registration certificate and insurance are displayed in the main hallway. The home ensures that residents are cared for within a safe environment in St David’s with adequate risks being assessed beforehand to enable them to live as they wish. The proprietor visits the home to provide ongoing support to residents, staff and the manager. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 21 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 3 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 2 X X X X X X 2 STAFFING Standard No Score 27 2 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 3 X 2 St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 22 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. 2. 3. Standard OP19 OP19 OP19 Regulation 23 23 23 Requirement The windows require replacing in rooms 1, 2, 8, 9, & 14. The lounge carpet requires replacing. The carpet n room 15 requires replacing Timescale for action 06/06/07 06/04/07 06/06/07 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 OP8 Good Practice Recommendations One of the bath chair hoists should be replaced to allow frailer residents more privacy and dignity when having an assisted bath. St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Davids Residential Care Home DS0000027444.V332543.R01.S.doc Version 5.2 Page 24 - 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. 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