Inspection on 19/12/06 for St Elizabeths

This inspection was carried out on 19th December 2006.

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 Elizabeths 23/05/07

St Elizabeths 07/03/06

St Elizabeths 21/12/05

St Elizabeths 03/03/05

St Elizabeths 04/10/04

St Elizabeths 04/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE St Elizabeths 115 Swift Road Woolston Southampton Hampshire SO19 9ER Lead Inspector Michael Gough Unannounced Inspection 19th December 2006 10:30 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 Elizabeths DS0000011646.V324160.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 Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Elizabeths Address 115 Swift Road Woolston Southampton Hampshire SO19 9ER 023 8042 1212 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) stelizrch@aol.com Mr Andrew Watt Mrs Barbara Watt Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15) of places St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: St. Elizabeth’s is a family run business and is owned by Barbara and Andrew Watt. The home is registered to provide care and accommodation to 15 service users over the age of 65 years and those who have a diagnosis of dementia. St. Elizabeth’s is a large detached property with gardens accessible to all service users living at the home. The home is located close to the centre of Woolston and a short car or bus ride to Southampton city centre. Fees at the home range from £327 to £425 per week and service users are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at St Elizabeth’s Residential Care Home and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out on the 7 March 2006. The inspection took into account the homes pre inspection questionnaire; and comment cards received from 8 service users. The inspector also had the opportunity to speak with 2 care managers from social services prior to the site visit to the home. An unannounced site visit to the home took place on the 19 December 2006. During the site visit the inspector had the opportunity to tour the home, read and inspect records and also observe the interaction between staff and service users. It was also possible to gain the views of people living at the home and the inspector had the opportunity to speak with 7 service users, 2 members of staff and the homes manager, who assisted the inspector throughout the visit. The home is registered to provide support for 15 service users but at the time of the inspection there were only 14 service users living at the home. What the service does well: What has improved since the last inspection? Since the last inspection Service users have been offered a copy of the home’s terms and conditions if they would like one and a copy is also held in the office at the home. Supervision for staff has been improved and all staff now receiving supervision at least 6 times per year in line with the National Minimum Standards. One of the rooms at the home has been re-decorated and a new carpet has been laid. St Elizabeths DS0000011646.V324160.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 Elizabeths DS0000011646.V324160.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 Elizabeths DS0000011646.V324160.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): 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about where they wish to live and each service user has a written contract. No service users move into the home without having their needs assessed. EVIDENCE: All service users and relatives are issued with a copy of the homes terms and conditions and this is dealt with during the assessment process. Needs assessments were looked at for 3 service users and these were comprehensive documents. Potential new service users are invited to the home to look around and the needs assessment then takes place in the home whenever possible, this enables the assessment to be undertaken in the surrounding where they will be living. Service users spoken to confirmed that they were able to visit and look around before moving permanently to the home and information received from care managers also said that the assessment process was thorough. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of service users are set out in an individual plan of care and the health care needs of service users are met. The storage and administration of medication was satisfactory and service users are protected by the homes policies and procedures. Service users at the home are treated with dignity and respect and their right to privacy is upheld. EVIDENCE: Care plans were seen for 3 service users and these gave clear information to staff on what support was required and also how this support should be given. Care plans were kept secure in the office at the home and information in each care plan was simple and easy to follow. All care plans had clear information on service users abilities, problems and needs, aim of care and how care should be delivered There was also information on the time of getting up and going to bed. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 10 Daily recording was carried out at the end of each shift and provided clear information on service users well being during the day and night. Service users at the home are registered with 5 different GP’s, although the majority are with the same surgery, however service users may keep their own GP if they wish. A local surgery provides a district nurse service and other health care services are also provided through this service. A visiting optician provides eye care and the home has a visiting chiropodist who calls once every six weeks. The home has a policy and procedure for administering medication and the home uses a monitored dose system from a local chemist. Medication is delivered to the home weekly by the pharmacy and this is recorded. The homes medication cabinet was looked at by the inspector and a sample of stock was checked against records and found to be correct. Controlled drugs were stored appropriately and clear records are kept. Service users spoken to were very positive about the care received at the home, and comment cards received by the inspector were also positive. All service users said that staff were very caring, helpful, and friendly and stated that they were always treated with dignity and respect. Comments such as “everyone is so kind” “I couldn’t ask for anything better” and “they are all so good” were made to the inspector. Observations confirmed that service users and staff get on well together and staff were observed interacting with service users and were seen to treat service users with dignity and respect and staff knocked on service users doors before entering and used service users preferred form of address when talking to service users. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 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. 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. Service users are supported to exercise choice and control over their lives. The home provides a range of activities and this provided stimulation for service users. The religious and recreational interests of service users at the home are provided for. Service users are able to maintain contact with family and friends and visitors are welcome at any time and service users benefit from the homes visiting policy. Service users are provided with a wholesome and balanced diet in pleasant surroundings at times convenient to them. EVIDENCE: Activities at the home include bingo, games, musical movement, video’s, hand massage, reminisance sessions, memory games and in the summer months trips out are organised and there are also visiting entertainers. Some of the comment cards received from service users said that more activities would be welcome, however service users spoken to on the day of the visit stated that there was always something going on and they enjoyed the activities at the home. On the day before the inspection service users said that they had a singer entertaining them at the home and that there was a carol service organised for the evening of the visit. The manager stated that a local vicar St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 12 visits the home once per month and that service users could choose to attend if they wish. Service users interests are documented in care plans and there are no restrictions on bathing, getting up or going to bed. The home has a visiting policy and there are no restrictions on visitors and the visitor’s book at the home showed that there are regular visitors to the home. Service users spoken to were able to confirm that they are able to make informed choices on what they wished to do and were able to control their own lives. The inspector was informed that service users were consulted regularly and that staff at the home respected their views and that if they wanted anything all they had to do was ask. A number of service users had bought some of their own possessions into the home and rooms had been personalised. All service users spoken to were happy with the food provided by the home and stated that the food was plentiful and good. The home operates a four week rolling menu and service users are offered a choice at meal times and are able to eat their meals in the dining room, their own rooms or elsewhere if they prefer. On the day of the visit lunch was Liver and Bacon casserole and service users spoken to said that it was delicious. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 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. 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. There is a simple, clear and accessible complaints procedure, which includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures protect service users from any form of abuse. EVIDENCE: There have been no complaints made to the home since the last inspection and service users spoken to were aware that the home had a complaints procedure and stated that they would address any complaint they may have to a staff member or the manager. The home has a policy and procedure for dealing with any complaints and this contained all of the required information and gave details of how to contact the CSCI. A copy of the complaints procedure was on display on a notice board in the home. Staff members spoken to were also aware of the complaints procedure. Staff at the home have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to know what to do should they suspect any form of abuse or poor practice had taken place. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 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. 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. Service users live in a safe and well-maintained environment and have access to comfortable indoor and outdoor facilities. The home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: A tour of the building was undertaken and the home was clean throughout with no unpleasant odours. Furniture in the home was in a satisfactory state of repair, communal areas were well lit and service users spoken to were happy with the facilities available. Service users have access to safe and comfortable indoor and outdoor communal facilities and service users were seen to be using both of the communal lounge’s in the home and also the conservatory. Routine maintenance is carried out and the home is decorated on a needs led basis. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 15 The laundry at the home has a domestic washing machine that can wash clothing at suitable temperatures and also a tumble drier. Staff at the home carry out laundry duties and suitable protective clothing is provided for staff, any soiled laundry is brought down in separate bags so that it is clearly identified. The home has infection control policies and procedures and all staff at the home have received training with regard to infection control to help prevent the spread of infection. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 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 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 has mix of staff that has a range of skills and there were sufficient numbers of staff on duty to meet the needs of service users. Staff morale was good and service users benefit from a staff team that has had sufficient training to meet the needs of service users and they are competent and qualified. The homes recruitment policy and practice supports and protects service users. EVIDENCE: Staff morale was good and there was a good rapport between service users and staff. On the day of the visit there was 1 senior carer and 3 care staff on duty and the homes staffing rota showed that sufficient staff were on duty to meet the needs of the current service users. The home employs 15 care staff and of these, 7 members of staff have completed NVQ2 and there are currently 2 just about to start NVQ2 training. The home also employs a cleaner who is employed from 0900 – 1300 3 days per week. Recruitment records were inspected for 2 members of staff and records inspected contained all the required information, including CRB checks and POVA checks where appropriate. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 17 Staff training records showed that staff has completed regular training and those staff members spoken to said that they are informed of any training course in advance and that they receive regular training. Staff were confident that they could meet the needs of service users. The home has an induction booklet provided by a training organisation, which covers care practice and principles of care. There is also an in house induction procedure to cover procedures within the home. St Elizabeths DS0000011646.V324160.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by a manager who is responsible and of good character and the views of service users as to how well the home is performing is taken into consideration. Service users are safeguarded by the accounting procedures in the home and individual service users finances are protected. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The homes manager has been running the home for 8 years and is also one of the registered providers and she has considerable experience of managing a care home. Care managers spoken with were happy with the way the home is managed and felt that it meets its aims and objectives. St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 19 The home does not have regular staff meetings, however the manager and her deputy meet staff, service users and families on a regular basis to obtain their views on how the home is performing. At present the home is developing its quality assurance system and is planning to give out questionnaires to gain the views of service users and other interested parties. Service users relatives mainly handle the financial affairs of service users, however the home does keep some personal money. This money is kept individually and clear records are kept along with receipts. The balances of 2 service users were checked and found to be in order. The home had a visit from a health and safety officer on 16 October 2006 and the inspector saw the report, which stated that no problems with health and safety were identified as a result of the visit. The Fire logbook was inspected and all required testing had been carried out. Certificates for the testing of the stair lift was in date as were certificates for hoists and call systems. The homes fixed electrical wiring was inspected in October 2003 and private electrical equipment was in date for test. St Elizabeths DS0000011646.V324160.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 3 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 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 X X 3 St Elizabeths DS0000011646.V324160.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Elizabeths DS0000011646.V324160.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Elizabeths DS0000011646.V324160.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!