Inspection on 07/06/05 for St Dominics Residential Home

This inspection was carried out on 7th 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 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 Dominics Residential Home 10/05/07

St Dominics Residential Home 19/12/05

St Dominics Residential Home 15/02/05

St Dominics Residential Home 31/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Dominics Residential Home London Road Kelvedon Colchester Essex C05 9AN Lead Inspector Kay Mehrtens Final Unannounced 07 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 Dominics Residential Home Version 1.10 Page 3 SERVICE INFORMATION Name of service St Dominics Residential Home Address London Road, Kelvedon, Colchester, Essex C05 9AN 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) 01376 570359 01376 573668 St Dominics Residential Home Limited Miss Sheila Perkins Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places St Dominics Residential Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 15th February 2005 Brief Description of the Service: St Dominic’s is a home that accommodates service users, of both sexes, over the age of 65 years. The home comprises of two storeys with lift access. The home is registered for 29 service users but currently accommodates 28 in single rooms, 11 of which have en-suite facilities. The home has large wellmaintained gardens with a summerhouse, water features and patio areas. There is a large, heated conservatory that offers more than adequate communal space for residents. The home is close to the local facilities in Kelvedon and accessible by train and other forms of transport. St Dominics Residential Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 7th June 2005, lasting 6.5 hours. The inspection process included: discussions with the manager, four care staff, assistant cook; two housekeepers; fifteen residents ; six relatives/visitors and a visiting district nurse. Some of the premises were inspected, including the grounds. Samples of records and residents care plans were inspected. The inspector had the opportunity to spend a considerable amount of time in the company of the residents and their comments are reflected in the report. This inspection covered seventeen standards, three of which exceeded the standard by demonstrating commendable practice and actions. The home was clean and well maintained. The staff were caring and much respected by the residents. The manager approached the inspection in a positive and cooperative manner that was focused on achieving best practice to meet the needs of the residents. The inspector was advised that there has been no change in the weekly fees since the inspection in August 2004. They remain at £431 to £496 per week, with additional charges for hairdressing and personal items. What the service does well: What has improved since the last inspection? The home has received a Gold Award for Food Hygiene following a recent inspection by the Environmental Health Officer. The manager and staff have actively sought additional health care input and advice from specialist practitioners in response to identified specialist needs of some residents. St Dominics Residential 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 Dominics Residential 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 Dominics Residential 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 and 3. Standard 6 is not applicable. The home offers support and care to residents, including an identified number with dementia, and ensures that residents’ needs are met though the home is not registered for dementia care. EVIDENCE: The home has cared for some residents over a considerable period of time, to the point where their mental health has deteriorated and their care needs have changed. The home is not currently registered to care for residents suffering with dementia. The manager has worked well with the families of these residents and listened to issues raised by the staff and other residents in the home. She is aware of the need to ensure that adequate risk assessments, staff training and behaviour management strategies are in place if these residents are to continue to be accommodated at the home. The manager was informed of the need to apply for a variation of the condition of registration if the home is to continue caring for these residents. She was aware of the need for continual assessment and monitoring of the needs and behaviours of these residents and for all staff to receive training. Staff had already undertaken some training, with regard to dementia care. St Dominics Residential Home Version 1.10 Page 9 The home has a good admission procedure that includes visits to the home by prospective residents and their families. There is a format for assessments that covers the required areas. This is completed with residents and/or their families. Residents were aware of the process though not too sure what was in “a care plan”. They were aware of spending time with staff talking about their past and why they came into the home. They were clear that the staff knew about their needs and how to met them. The home does not offer intermediate care. St Dominics Residential Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. The general and specialist health care needs of residents were extremely well met. The manager and staff are caring and positive in their contact with residents. EVIDENCE: Three care files were sampled. The inspector spoke to the residents and families (that were available) regarding the care files sampled. As previously mentioned, the residents were not sure what a care plan was but did recall meetings and discussions with staff and their families. The care plans addressed all aspects of care and identified target areas for more structured input such as mobility, behaviour management. Relevant risk assessments and management strategies were in place. The daily records reflected residents’ comments, activities and health care requirements. All the information gathered, on new a resident, is collated by the manager and staff to develop care plans and appropriate interventions. Care plans are regularly reviewed. The manager undertakes additional, as well as annual reviews, with the residents, their families and other agencies as required. Copies of the review minutes are provided for residents. Those seen at the inspection, addressed issues raised by the resident, their families and the home. St Dominics Residential Home Version 1.10 Page 11 There was detailed information regarding medical interventions, outcomes of hospital visits and advice sought from relevant health care professionals. The manager and staff act as positive advocates for their residents to ensure that the required assessments and interventions are provided. The inspector had the opportunity to meet a visiting district nurse who was extremely complimentary regarding the care provided and the referrals made to her team. She felt that she had a good relationship with the care staff and that they listened to and acted upon the advice provided. The same level of input was actively sought for residents with mental health difficulties. The manager was aware of the need to seek appropriate advice and input from specialist professionals to ensure that that the needs of these residents were met. the care notes indicated that careful monitoring and discussion with specialist agencies had taken place and led to an improvement in the health and care provided. The home provides additional staff to accompany residents to all medical appointments. The senior staff have been trained with regard to the administration of medication. The medication round was observed and the member of staff followed the correct procedures. They were very gentle and respectful whilst administering medication, especially to those residents that were frail and confused. The medication administration records were well organised and managed. Residents were pleased to sit and chat with the inspector. They were very open and positive in their comments. They informed the inspector that the staff are very respectful and always ensure that their privacy is respected, in the bedrooms and when they have visitors. The inspector observed very good practice, during the inspection, with regard to ensuring residents’ dignity. One example was the approach of care staff whilst hoisting a resident. They were observed speak to the resident throughout the process, reassuring them, making the whole process less worrying and maintaining the residents’ dignity. The resident told the inspector that they the process very reassuring and respectful. St Dominics Residential Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The home is very welcoming of visitors and privacy is respected. Catering arrangements are good. Residents enjoy a social and pleasant time during mealtimes. EVIDENCE: The home is currently without its activity worker, due to illness. The residents clearly miss this worker and were very complimentary of the activities they had provided. They told the inspector that another member of staff was organising activities and events in the home and doing a good job, though they did find the mornings a bit boring. The home is well staffed and staff did state that they have more time to sit and chat or do other activities, including cards, crosswords, puzzles and papers during the afternoon. The residents agreed with the staffs’ comments. There is a monthly programme of events displayed in the communal areas of the home. It included church services and weekly entertainment. The inspector had the opportunity to meet several visitors. They stated that they can visit whenever they wish and are always made welcome and invited to eat or have a cup of tea. They were very complimentary about the manager and staff, finding them always polite and respectful towards themselves and the residents. Residents also informed the inspector that they have lots of visitors and are supported by the staff if they need help to write or use the St Dominics Residential Home Version 1.10 Page 13 telephone. The home has a smoking room and a separate large quiet room for residents to use when they have visitors, if they wish to. The very large conservatory area also provides sufficient space for private conversations and visits. The home had just recently been awarded a Gold Award for Food Hygiene by their visiting environmental health officer. This is an improvement on last year when they were awarded silver. The catering staff are to be commended upon their high standards. Residents were very complimentary regarding the food. Some even said that there was too much provided and too much choice! Some residents invited the inspector to lunch and the meal was well presented and very tasty. The staff serve the food and asked each resident what they wanted to eat, including vegetables. The mealtime was relaxed and sociable. The staff and manager ate with the residents and those residents that required assistance were dealt with a discreet and respectful manner. St Dominics Residential Home Version 1.10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents felt able to voice any issues with the manager. There are good procedures in place that ensure residents safety. EVIDENCE: The home has a complaints procedure that is available for residents. There have been no complaints since the last inspection. Residents meetings are held regularly. The residents informed the inspector that they felt able to voice any concerns and issues at these meetings and with the manager. They felt that their opinions were listened to and generally acted upon. They said that “some little things are not always acted on” but they did not feel that these were complaints just occasional grumbles about other residents. They certainly did not feel unable to voice their opinions. The manager was very aware of the need to check the Protection of Vulnerable Adults (POVA) register with regard to staff employment. Staff have received training in the protection of vulnerable adults. They are aware of and have access to the policies and procedures with regard to POVA referrals, if required. St Dominics Residential Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The standard of the environment is excellent and exceeds the standard. The home provides the residents with a safe, comfortable and pleasant environment. EVIDENCE: The home is decorated, furnished and fitted to a very high standard. The residents enjoy the use of the large conservatory. The other communal rooms offer them the choice of where to entertain guests as well as provided them with a quiet, solitary space, if needed. The home also provides the residents with a separate smoking room. The gardens are large and extremely well maintained. They provide the residents with different sitting areas. There is ample sturdy garden furniture and a summerhouse for the residents to access. The residents and their visitors were using these facilities during the inspection, as it was a lovely sunny day. The residents were very complimentary regarding the garden and the home. They were particularly chatty about the “elephant water feature” as it brings them pleasure, as well as the local nursery children that visit it regularly to watch it spurt water. The residents get a great deal of pleasure from contact with the children, as well as the garden. St Dominics Residential Home Version 1.10 Page 16 The home is clean and free from any offensive odour. The housekeeping staff do a really good job in ensuring the home is well presented and spotless. This was much appreciated by the residents and their families. All of the residents spoken to commented positively regarding the laundry service in the home and the high standard of cleanliness. St Dominics Residential Home Version 1.10 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 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 and 29 Staffing levels are continuously reviewed to ensure that they meet the needs of the residents. Staff are recruited after a thorough recruitment process. EVIDENCE: The staffing levels on the day of the inspection were one senior plus four staff for the morning. The afternoon shift was one senior plus three staff but this is to increase to four in order to meet the needs of the more dependant residents, recently admitted to the home. There are three staff on during the night. The home does not have any “sleep-in” staff. The staffing levels are constantly reviewed by the manager to ensure that they meet the needs of the current group of residents. This has recently led to an increase for the afternoon shift. The manager stated that she is well supported by the provider in her requests for increased staffing. Escorts are provided to accompany residents on health appointments. The residents spoke very highly of the staff. They felt that they worked very hard but were there for them when needed. They went on to comment that the staff were caring and respectful. Throughout the inspection, the staff were observed to interact with the residents in a gentle, respectful and pleasant manner. The residents and staff clearly enjoyed each other’s company. The home does have a stable staff group. The manager was involved in interviewing some new staff during the inspection. The staff files were well organised. All required checks were undertaken prior to staff working in the home. St Dominics Residential Home Version 1.10 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 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 and 37 The manager is well supported by the owner and staff in providing a well managed home that ensures good care for the residents. EVIDENCE: The residents and relatives were complimentary regarding the manager. They stated that they found her to be approachable and a good listener. The residents told the inspector that the owner and manager were well known to them and the manager often joined them for a chat. The manager’s comments, actions and records indicate that she acts as a positive advocate for the residents, especially with regard to their health care needs. She has built a committed and skilled staff team. Staff spoken to were positive regarding the support offered by the manager and senior staff in the home. Records examined included the staff rota; residents’ register; daily records; visitor record and nutrition records. All contained the required information and St Dominics Residential Home Version 1.10 Page 19 were well organised. Residents were involved in the gathering of information for their records, which are securely held. St Dominics Residential Home Version 1.10 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. 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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 3 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 3 x x x x 3 x St Dominics Residential Home Version 1.10 Page 21 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 1 Regulation 4 Requirement The registered person must make an application for a variation in conditions of registration with regard to the identified residents with dementia. Timescale for action 08.07.05 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 Good Practice Recommendations St Dominics Residential Home Version 1.10 Page 22 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex C01 1RJ 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 Dominics Residential Home Version 1.10 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. 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