Inspection on 21/12/05 for St Elizabeths

This inspection was carried out on 21st December 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 Elizabeths 23/05/07

St Elizabeths 19/12/06

St Elizabeths 07/03/06

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 Chris Johnson Unannounced Inspection 11:00 21 December 2005 st 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.V252063.R01.S.doc Version 5.0 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.V252063.R01.S.doc Version 5.0 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) stelixrch@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.V252063.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2005 Brief Description of the Service: St Elizabeth’s is owned and managed by Mrs Barbara Watt. The home is registered to provide care and accommodation to 15 service users over the age of 65 years and for 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 close to the centre of Woolston and a short car or bus ride to Southampton city centre. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day on the 21st December 2005. The registered manager assisted the inspector throughout the inspection. Written and verbal feedback was supplied to the manager at the end of the visit. The findings of this report are based on a number of different sources of evidence including; a pre inspection questionnaire completed by the manager prior to the inspection, comment cards from residents and relatives, a tour of the premises that included looking at residents’ bedrooms, communal areas and observation of care practices. Staff and care records were inspected. A group discussion was held with several residents other residents were spoken with individually. What the service does well: What has improved since the last inspection? What they could do better: There were not any aspects identified for improvement at this inspection. The home continues to maintain standards and provide a good service. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 6 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. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 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.V252063.R01.S.doc Version 5.0 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 the following standard(s): 3,4 and 5 The home operates a thorough admission and assessment procedure ensuring that they can meet peoples’ needs prior to them moving in. EVIDENCE: As part of the admission process to the home all prospective residents are assessed to determine whether the home can meet their needs. As part of this procedure prospective residents and or their representative have the opportunity to visit the home, look at the type of accommodation on offer and find out about day-to-day life in the home. The benefits of assessing residents in the home as opposed to elsewhere are that their needs in relation to the physical environment of the home and everyday care needs can be more accurately assessed. Residents spoken with confirmed that they had been given this opportunity and that this assisted them in making their choice of home. It was recommended that the manager obtain care management assessments wherever appropriate to further assist with the assessment process. All residents spoken with said that they considered that their needs were being met and that they received the appropriate level of support. Evidence recorded in residents care plans and individual files would support this. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10 Support with personal and health care is good and care is offered in such a way as to promote residents’ privacy, dignity and independence. EVIDENCE: Each resident has an individual plan of care. These provide detailed information, with clear and specific guidance as to the level of assistance that residents require with their personal care needs. The information recorded in the care plans addressed service user’s abilities with regard to personal care and would suggest that service users’ independence is promoted. In discussion with residents their description of their personal care needs matched with the details recorded in the care plans and residents reported that they considered that their personal care needs were being met. All care plans looked at had been reviewed regularly and in addition to these each file contained a brief overview of the person’s care needs and their preferred daily routine to enable staff to make quick reference to. Also included on file are ‘life histories’, giving details of significant events in residents lives, work history, memories and likes and dislikes. This was evidence of good practice. Residents are fully supported with their healthcare needs. All residents are registered with a local GP. A podiatrist visits the home and residents are registered with dentists and opticians have access to District Nurses as St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 10 required. Residents told the inspector that they had access to a range of healthcare support as and when necessary and written documentation supported this. One person commented,” You just need to tell the staff and they organise it for you”. Residents also confirmed that they were happy with the way that their medication was managed and that they received them regularly and at the correct time of the day. Medication is safely and appropriately managed in line with written procedures. Stock records were checked against administration records for several residents and all were found to be correct. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 Residents are supported and encouraged to pursue their own interests and are able to keep in contact with family and friends. EVIDENCE: Several of the comment cards completed by residents prior to the inspection suggested that they did not consider there to be always enough activities. However all residents spoken with during the inspection said that they were happy with the level of organised activities and there was plenty of evidence to demonstrate that a range of activities are organised and provided. Residents described a range of interests and leisure pursuits that they were able to pursue and this was substantiated through observation and information recorded in files. On the evening of the inspection the manager and staff had organised a karaoke evening and several staff were attending this in the own time. Service users confirmed that they were free whether or not to take part in an activity and how to spend their day. All residents spoken with or whom completed a comment card confirmed that they were free to receive visitors as and when they pleased. This was substantiated from inspection of the visitor’s book whereby a written record of all visitors to the home is maintained. Several visitors were in attendance during the inspection. There were not any reported restrictions on visiting times. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 12 There was a relaxed and fun atmosphere within the home and staff and service users appeared to be relaxed in each other’s company. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Satisfactory systems are in place for service users to address any concerns or complaints that they may have. EVIDENCE: There had not been any complaints made about the home since the last inspection. A complaints procedure is displayed within the home informing residents of their right to complain and how they can go about this. All residents spoken with or whom completed a questionnaire reported that they knew who they could speak to if they were unhappy with anything. Relatives and visitors reported that they had never had to make a complaint and most of them were aware of the complaints procedure. Residents spoken with said that they would discuss any concerns with either the manager or deputy manager that they were confident that it would be dealt with. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,25 and 26 The home provides a friendly, welcoming and homely environment to live in. EVIDENCE: The home was clean and well kept throughout and is homely in appearance. Repair and redecoration are carried out as needed. All residents spoken with were in agreement that it was a clean and comfortable home to live in. Policies and procedures were in place for the control of infection, including the safe handling and disposal of clinical waste, which is dealt with by an outside contractor. The home has a separate laundry room, which is situated away from the kitchen and food preparation area. Staff were observed to follow infection control procedures such as, using gloves and aprons and ample supplies of these were available. Adequate adaptations and equipment are available to meet the needs of the current service users. These include a stair lift to enable residents to access all floors, and ramps are in place where needed. Call bells were fitted in all bedrooms seen. Residents reported that staff responded to call bells promptly. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 15 One person commented, “They leave whatever they are doing and come straight away”. Evidence recorded in residents care plans would support this. There are two lounges in the home, one of which is a lounge diner. In addition to this there is a large conservatory coming off from the main lounge and a well-maintained back garden. Residents appeared to be relaxed and at home in their surroundings and were observed to be able to use all communal parts of the home or spend time in their own rooms as they pleased. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 29 Staffing levels are maintained and care is delivered by a caring and responsive team. The home’s recruitment procedures provide protection to residents. EVIDENCE: On the day of the inspection the staff team consisted of, three care staff and a cleaner. The home has a well-planned rota and provides a sufficient level of staffing to meet the needs of the current residents. Staff retention is good and a number of members of staff have worked at the home for several years. This helps to provide stability and consistency to residents. Additional staff provide evening and nighttime cover and on-call arrangements are also in place to deal with emergencies. A bank worker is also employed to cover holidays and sickness. All residents spoken with or whom completed a questionnaire responded that they felt safe in the home and that the staff were very friendly and attentive to their needs. Residents were observed to be relaxed and at ease with the care staff. The files of two members of staff recruited since the last inspection demonstrated that the manager continues to carry out thorough and robust checks before employing staff to safeguard the residents. Criminal Records Bureau certificates, and checks against the Protection of Vulnerable Adults list had been obtained, as had all necessary references and evidence that they had been through a thorough recruitment procedure. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,37 and 38 The home is well and safely managed. EVIDENCE: The manager has managed the home for several years and works closely alongside the staff team. A deputy manager is also employed to oversee the running of the home in the manager’s absence. This clearly works well and provides staff and residents with access to a senior staff member at most times throughout the day. Residents expressed their confidence in the management and said that they were approachable and accessible. The manager maintains high standards and the home continues to be well and safely managed. All necessary records were in place, well maintained and securely stored. There were not any concerns as a result of this inspection as to the health safety or welfare of service users. Regular testing of the fire alarms had taken St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 18 place and service contracts were available to demonstrate that the home’s fire fighting and detection equipment is regularly serviced. Certificates were available to show that the stair lift, portable electrical appliances and the gas system had all been regularly inspected and maintained. St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 3 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 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 X 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 3 St Elizabeths DS0000011646.V252063.R01.S.doc Version 5.0 Page 20 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. 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.V252063.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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