Inspection on 23/05/07 for St Elizabeths

This inspection was carried out on 23rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 19/12/06

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 Christine Walsh Unannounced Inspection 09:30 23rd May 2007 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.V335911.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.V335911.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.V335911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 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 residents 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.V335911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit formed part of the key inspection process and was carried over one day by Mrs C Walsh, regulatory inspector. The manager completed an Annual Quality Assurance Assessment (AQAA) document, which was returned to the Commission for Social Care Inspection prior to the visit to the home. In addition “Have Your Say” resident and relatives comment cards were sent of which twenty-five were received in total. The information obtained to inform this report was based on viewing people who use the service and staff records, speaking with the residents, visitors and staff and observing care and support practices. A tour of the home took place and documents pertaining to health and safety were viewed. What the service does well: The home provides a warm, friendly and homely environment for the people who use the service to live in, with an emphasis on ensuring they can meet their needs by undertaking a thorough assessment and working closely with them, their families and health care professional to make sure they are settled, reassured and happy. The home puts the needs of the people who use the service first respecting their individual rights, individuality, wishes and preferences and making sure all their health and welfare needs are considered at all times. A member if staff said: “This is their home and we adapt the way we work to meet what they want and need and not what we want” A resident said; “The staff are very kind and helpful”. A relative said: “I feel the care service is above average, they treat the residents as individuals, they have fun and try to make the home as home like as possible” St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 6 Residents and relatives are provided with information about the home and there is regular and clear communication between all concerned with the health and wellbeing of the residents. A relative said: “I have no reason to complain but if I felt I had to I know I could discuss it with any of the staff and the manager and they would listen” Another said: “I am always kept informed of mums wellbeing” A staff member said: “I have only been working in the home a couple of weeks but I think the care here is very good and the way the staff communicate with each other is excellent” The home provides a clean, homely and comfortable environment where the majority of the residents have their own bedrooms and can bring small items of own furniture and personal belongings if they wish. The home provides sufficient numbers of skilled and competent staff ensuring the staff receive regular training which is specific to the needs of the residents such as dementia and Parkinson’s and health and safety such as food hygiene, first aid and moving and handling. A staff member said: “We are encouraged and supported to do an national vocational qualification (NVQ) and the manager will often test our knowledge unexpectedly by asking us questions such as fire procedures”. The home is managed by an experienced and dedicated manager who recognises the importance of ensuring the home is working to a high standard and is providing quality care, who works along side her staff, provides regular and informal support to them and ensures by using robust recruitment procedures they appoint the right calibre of staff. A staff member said: “We have a good manager and deputy manager that we can talk to, and they also work with us as a team”. The manager is energetic and keen to improve the quality of care it provides and is keen to take on new ideas and ways of doing things to achieve this. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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.V335911.R01.S.doc Version 5.2 Page 8 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.V335911.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does well to undertake a thorough assessment process to ensure it can meet prospective residents needs. The home does not provide intermediate care. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated that the manager and deputy manager carry out the assessment, invite prospective residents to the home where the assessment takes place (where possible) and provide them and their relatives with a copy of the homes terms and conditions and all the information they need to make an informed choice. This was tested at the time of the visit by viewing three newly admitted residents assessment documents, speaking with the residents and the managers. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 10 Comments made by people who use the service: “I visited the home before I moved in, my daughters looked at forty homes before helping me to choose this one” “I made several visit to homes in the area and was impressed with the standard at “St Elizabeth’s”. A relative said: “We were very happy with the information provided to us and we were very impressed with the home, mum seemed to like it straight away”. A member of staff said: “It is very important to make sure we can meet residents needs but also make sure we have the right resident who will gel with the other residents”. Information gathered from the residents, relatives, staff and manager demonstrates the home undertakes a robust and thorough assessment procedure. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does well to ensure the people who use the service have their needs met and a consistent approach to their care by a clear care planning and risk assessment process, however the recording of risk assessments requires further attention detail. The home does well to ensure the people who use the service receive their medication as prescribed by trained staff but must ensure there is evidence to demonstrate changes to medications have been agreed by a prescribing health care professional. The home does well to respect the people who use the service individual rights, privacy and dignity, and choices. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated that health, personal and social care needs of the service users are written in individual St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 12 care plans. This is to ensure that their needs are met. Care plans are reviewed monthly. This was tested at the time of the visit by viewing four residents care plans, including newly admitted residents, speaking with residents, a relative, staff and the manager and viewing comment cards received from residents and relatives. The care plans were found to provide clear instruction on the individual residents strengths area of need and how the resident must be supported, a member of staff spoke of how the care plans and regular discussions with the manager and other staff provide continuity of care for the residents. There is evidence that care plans are reviewed monthly by a keyworker (a nominated member of staff responsible for the care of a nominated resident or residents). This is done where possible with the resident. The manager spoke of how she is a keyworker for some residents as this provides her with an opportunity to monitor day to day the resident’s wellbeing and staff performance. All three received residents “have your say” comment cards indicated they always receive the care and support they need: A resident said: “ The staff at St Elizabeth’s are always willing to help and support me”. A relative said: “The care service always ensures that my mum is dressed nicely, with jewellery on and her hair done”. In addition to care plans the home undertakes a risk assessment of the mobility needs of each resident identifying where the residents needs assistance and how the risk of potential falls can be eliminated. The accident book presented evidence of a resident having repeated falls, the source was identified and there are now procedures in place to protect the residents from falling. The manager gave other examples of how they minimise individual risks such as the risk from wandering at night and how they have reduced the associated risks to this. Thus information was provided in detail however the manager must ensure these are clearly detailed in the residents personal notes and ensure moving and handling risk assessments are fully completed. The manager said that the home has very good contacts with health care professionals including GP’s, district nurses, and psychiatric teams which includes the memory team. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 13 The manager said all the residents living in the home are currently in good health and none are receiving support from the district nurse. However those who are elderly frail have pressure-relieving equipment to prevent sores occurring. A relative said: “Recently my mother had a chest infection, the care service checked my mothers history with me and called the doctor in three to ensure she was checked out thoroughly and given the right medication”. A resident spoken with at the time of the visit said she hadn’t needed the doctor since arriving in the home but felt certain the home would make sure she got the help needed if she became unwell. The home supports all residents with their medications and staff that have undergone a seven-week training programme and deemed competent by the manager does this before administering medication. Records were found to be in order and there are good systems for storage, administration, recording and receipt and disposal of medications. The manager said she is visited twice a year by the pharmacist who undertakes a thorough audit of the homes medication supplies and storage. However the manager must seek advice from the pharmacist on the shelf life of topical creams and lotions once they are open and ensure changes to medications over the phone are witnessed and recorded by two people. A relative said: “The home always makes sure the residents get their medications and the care staff give out the medication individually” The home demonstrates that it understands the importance of respecting the resident’s rights, dignity, privacy and choice. The staff were observed interacting with the residents in a respectful and polite manner. In a resident’s care plan it talked of supporting them to make a choice of what to wear and a member of staff spoke of the importance of respecting and preserving the residents privacy and dignity, giving positive examples of how she does this. A resident said: “We are always given the choice of what we would like to eat and the staff are always very polite”. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 14 However the manager must consider the rights verses the duty of care when placing someone on a healthy eating plan without their written consent. The manager said that the residents was aware that the staff were monitoring their weight and advising then to eat healthily but there was no evidence that the manager had obtained their written consent. This was discussed at length and the manager agreed that she would speak with the resident and seek written consent. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 15 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,and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does well to provide and support the people who use the service to engage in a range of activites, maintain contact with family and friends, access the local community, exercise choice over their daily lives and enjoy wholesome and nutritious meals. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated we provide a range of activities to help provide stimulation. Service users are given the choice as to whether they take part and staff support them when required. Service users maintain co0ntact with families and visitors are welcome at anytime. We provide a nutritional diet and cater for special diets and any dislikes. This was tested at the time of the visit by viewing residents personal plans, observing interactions and activities between residents and staff, viewing the menu plan and chatting with residents, the manager and staff. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 16 The home does provide a range of activities and these are laid out in an activity book which is offered to the residents to make a choice of what they would like to do, but in the main activites are done on an individual basis taking into account the residents hobbies and interests prior to entering the service. The home obtains a record of what the resident’s interest and occupation were before entering the home and encourages these activities in part to continue in the home such as knitting, sewing and floristry. A lengthy discussion took place with the manager regarding how previous occupations of the residents could be incorporated as an activity. At the time of the visit the staff were observed spending quality time with residents talking with them reading newspapers to them and playing cards, in the afternoon some residents assisted planting up flower tubs for the garden. The manager said that the home supports a resident who speaks an alternative language and enjoys conversing with her husband in that language when he visits the home. The resident’s diverse needs are being respected and the staff spoke of the importance of providing stimulating activities to keep the body and mind active. The manager said that visitors are always made very welcome and are encouraged to visit as often as they like. A relative: “My sister and I take turns in visiting mum everyday and we are always made to feel welcome and offered drinks on arrival”. The relative was asked if she felt she was proved with enough privacy when meeting her mother and said we can go to “mums room if we want” Another relative said: “I am always kept up to date and informed of mums well being”. This was observed at the time of the visit when the manager took a phone call and up dated a relative on the wellbeing of one of the residents. The manager said that the home respects the individuality and diverse needs of each residents this was evident in individual daily individual routines which describes what time resident chooses to get up, whether they like to have breakfast in bed describing how they like their drinks and how many they before getting up, what they like to do during the day and what time they like to go to bed. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 17 A resident said: “I do not feel pressured to do anything I don’t want to do, the staff are very kind and helpful”. The residents enjoy a range of wholesome and nutritious foods and the menu is displayed daily, the main meal of the day is eaten at lunchtime and there is a choice of hot and cold savoury snacks at teatime. The residents were observed enjoying their lunch in a congenial setting where tables were laid with linen tables cloths and napkins. The home caters for special diets and staff will support residents where required. If there is concern regarding the resident’s health this is closely monitored and the GP is involved. The manager is aware of the concerns regarding nutrition in the elderly and especially those with dementia. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 18 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 and 18 This judgement has been made using available evidence including a visit to this service. The home does well to provide the people who use the service and their relatives with confidence that their complaints will be listened to and acted upon and protect them from potential risk of harm. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated: We have a simple clear accessible complaints procedure, this includes timescales for the process and any complaints to be logged and responded to appropriately. We have a policy and procedure to protect service users from abuse. This was tested by speaking with the residents, staff, a relative, the manager and viewing “have your say” comment cards. The manager said she had not received a complaint in the nine years that she has been running and managing the home and therefore hadn’t had to record a complaint although the home has a complaints log. The staff spoke of the importance of dealing with complaints efficiently before they became unmanageable and the importance of letting the manager know. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 19 A statement made by a member of staff in a comment card said: I would firstly inform the manager, if the manager did not act upon the complaint in a suitable manner I would then inform the inspector for this home” Three residents comment cards indicated that they know how to make a complaint but a large number of the comment cards received from relatives said they weren’t sure. A resident said: I have only been here a short while, but I haven’t felt the need to complain, the girls are very good”. A relative said: “I am very happy with the service provided here” The manager is advised to address the concern that a large number of relatives did not know how to make a complaint. It was discussed how this could be achieved and the manager agreed to resend a copy of the complaints procedure to every relative. The manager said that all of her staff receives annual training on abuse and dementia care, which includes types of abuse and what they must do if they witness an abusive act taking place. The manager also said that at coffee breaks she regularly tests the knowledge of her staff by painting different scenarios of abuse asking them to respond. This was later confirmed by staff who appeared to have a very good understanding of what constituted abuse and how it should be dealt with. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 20 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): 19,21,23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does well to provide the people who use the service with a well maintained, homely, comfortable and hygienically clean environment. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated: We ensure the home is clean and free from offensive odours and we ensure the service users live in a safe and well-maintained environment. This was tested by touring the building, speaking with residents and staff and viewing comment cards received from residents and relatives. The service provides a warm, homely and welcoming environment for the residents to live. It is pleasantly decorated throughout with good quality furniture and furnishings. There are several small lounges one which doubles as a dining room and a conservatory which one residents said she liked to use St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 21 all the time, there is separate fully equipped kitchen and utility room and two bathrooms one of which is not currently used. The home has a small but pleasantly tendered enclosed garden, a patio area allows residents to sit out in the warmer weather, resident was very keen to get into the garden as she was a land army girl and worked on a farm during the war. Bedrooms are nicely decorated and furnished and personal belongings reflect the individuality and personality of the resident all single rooms have en suite facilities. The home is spotlessly clean and has a cleaner in three times a week. Two senior members of staff have recently undertaken an in depth infection control training course and plan to disseminate their knowledge to other carers via a questionnaire and one to one feedback. The staff wear protective clothing and the home has a clinical waste contract for soiled waste. A resident said: “St Elizabeth’s is always clean and fresh and of the highest standard, my bedclothes are always clean and fresh and my laundry is always first class and put away in my bedroom nicely”. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 22 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are supported by competent and qualified staff, who receive regular, updated and specific training to meet their individual and the home does well to protect them by using robust recruitment procedures. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated: We have a mix of staff who have a range of skills, we ensure there are sufficient numbers of staff on duty to the service users needs and staff are given sufficient training so they are competent and qualified to meet the service users needs. This was tested by observing day to day staff activity, viewing the duty rota, training records and staff recruitment records, speaking with resident relatives, staff and viewing comment cards. In total the home has seventeen staff a cleaner three times a week. The home covers any absences with their own staff. The manager spoke of the importance of the continuity of care and said she had only used one agency member of staff in eight years. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 23 Staff were observed going about their day in an unhurried and relaxed way, spending quality time with the residents during the day and residents appeared settled and relaxed. The staff are prompt to answer buzzers and are visible, frequently visiting all areas of the home to check the residents are okay. Staff with whom the inspector met with said they enjoyed coming to work as the home felt like home from home and everyone gets on well with one another. A member of staff said: “There’s time for a laugh and joke and the care of the residents is carried out in the way that they wish” A relative said: “I feel the care service is above the average, they treat residents as individuals, they know all their personalities, they have fun and try to make it as home like as possible for them”. The manager encourages and supports her staff to undertake a National Vocational Qualification (NVQ) and provided evidence that the majority of her staff have either undertaken an NVQ level 2 or 3, the manager spoke how she is encouraging her deputy manager to undertake a NVQ 4 as she is a very good deputy manager and in time will make a very good registered manager. The manager uses the “Skills for Care” induction programme when inducting new staff into the home. The record of one carer’s induction record was viewed and found incomplete despite working in the home over three months. The induction must be completed with in a specific timescale stated by “Skills for Care”. The manager confirmed that she will complete the induction within the next couple of days of the inspection taking place. The manager undertakes a robust recruitment procedure and said she is very particular to who she employs as they have to be of a certain calibre that will work well with the residents and staff. The records of the last a appointed member of staff were viewed and found to hold all the necessary documents and there evidence of criminal record bureau (CRB) and protection of vulnerable adult (POVA) checks being undertaken. The member of staff was later spoken with and confirmed that she had attended an interview and provided all the necessary checks prior to starting. There was evidence in records that the manager provides sufficient training for staff including mandatory training such as moving and handling, first aid, food hygiene and specific service lead training such as understanding abuse and St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 24 dementia care, Parkinson’s, stoma care and medication administration. The manager also stated how she will provide other training if there it is identified that the staff require it to support a specific need of a resident such as insulin dependent diabetic. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 25 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a manager who is fit to be in charge, who considers the best interest and views of the people who use the service and ensures their financial interests are safeguarded. In the main the people who use the service have their health and welfare protected but areas of improvement in fire safety are required. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated: Management ensures that the views of the service users are taken into consideration, service users are safeguarded by the accounting procedures in the home and St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 26 individual services users finances are protected. The health, safety and welfare of the service users and staff are promoted and protected. This was tested by observing and speaking with the manager during the course of the day, viewing the quality audit system and health and safety records, touring the building and speaking with residents, a relative and staff. The manager demonstrates that she is professional and puts the needs of the residents and her staff first. She is visible and accessible and works alongside her staff to ensure they are providing quality care. Both residents and staff speak of the manager highly, how kind she is and supportive. The manager admits that she prefers to be hands on and is a keyworker to some residents as she likes to keep in touch with what’s going on but she is aware that this is at the detriment of some of the administration work she is required to do. The manager must consider sharing her time between both areas of management and administration. A member of staff said: “We have good communication here between the managers and staff, not only are the residents best interests taken on board and dealt with promptly so are the staff’s. It is a very good working environment just like home”. Another said: “We have a good manager and senior manager that we can talk to; they also work with us as a team. Sty Elizabeth’s is like a second home for me and I am glad to be working here. The residents always come first”. The home has as a quality-auditing tool in the form of a questionnaire for residents, relatives, staff and other stakeholders that will seek their views on the quality of the service, but the manager has yet to implement this system. The manager is advised to do this, as this will assist her when planning improvements to the service. Staff confirmed that they have regular meetings with the manager and good communication takes place at all handover shifts. A member if staff said: “The left hand knows what the right hand is doing all the time” Another said: “I enjoy working here because you get to spend quality time with the residents” St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 27 The home does not have responsibility for resident’s financial affairs such as benefits and pensions but will take responsibility for holding small amount of personal monies for safekeeping. There is lockable storage for those who wish to hold their own personal monies and safe financial auditing systems in place for those who don’t. In the main the manager provides a safe environment for the residents to live, where all serviceable utilities and equipment such as gas, electric and the stair lift are regularly serviced, however the lack of checks on hot water outlets and systems and fire protection places the residents at potential risk. The manager must ensure hot water temperatures are checked as legislated, make safe the unused bathroom and she must ensure there is written evidence that her staff have received suffient training in fire safety. The manager must also complete the fire risk assessments as required by Fire Safety Legislation implemented in October 2006. The manager agreed to address the areas of concern without delay. St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 28 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 3 3 X X 3 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 2 X 3 X X 1 St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)(a) (b)(c) Requirement The people who use the service must be safeguarded from potential risk of harm by the process of individual recorded risk assessments. The people who use the service must be protected from the potential risk of harm from fire by fully trained staff. This training must be recorded. 3 OP38 13(4)(a) (b)(c) The people who use the service must be fully safeguarded against the risk of scolding from hot water outlets. 30/06/07 Timescale for action 30/06/07 2 OP38 13(4)(a) (b)(c) 23(4) 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 30 St Elizabeths DS0000011646.V335911.R01.S.doc Version 5.2 Page 31 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.V335911.R01.S.doc Version 5.2 Page 32 - 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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