Inspection on 24/10/05 for St Faith`s Nursing Home

This inspection was carried out on 24th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Faith`s Nursing Home 31/07/06

St Faith`s Nursing Home 20/03/06

St Faith`s Nursing Home 01/03/05

St Faith`s Nursing Home 23/09/04

St Faith`s Nursing Home 12/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Faith`s Nursing Home Malvern Road Cheltenham Glos GL50 2NR Lead Inspector Mr Adam Parker Unannounced Inspection 24th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Faith`s Nursing Home DS0000016584.V259542.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 Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Faith`s Nursing Home Address Malvern Road Cheltenham Glos GL50 2NR 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) 01242 240240 01242 224353 Cheltenham Old People`s Housing Society Limited (The Lilian Faithfull Homes) Mrs Patricia Anne McCluskey Care Home 69 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (69) of places St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Service User under 65 Years. Date of last inspection 1st March 2005 Brief Description of the Service: St Faith’s Nursing Home is a large attractive property, which has been extended and refurbished to provide comfortable accommodation for 69 elderly service users who require nursing care. The home is owned and managed by a charitable organisation and is one of the Lilian Faithfull Homes. It is situated in a residential area, close to the centre of Cheltenham and to local amenities. Service users are accommodated in two wings of the Home. Twenty-seven Residents are cared for in the Fairhaven Wing, which compromises three Floors and two mezzanine levels. Northcroft wing accommodates forty-two residents on three floors. All of the service users have the benefit of a number of accessible sitting rooms and dining areas throughout the building. There is also a well-equipped multi sensory room where aromatherapy and reflexology treatments may be given. The Home has a day care facility to care for people with Dementia. The service users have the benefit of a landscaped garden, which is easily accessible. St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and a half hours on one day in October 2005 with two inspectors. The Registered Manager was present throughout the inspection and three registered nurses and three care staff were spoken to. Care records and the facilities to meet health needs were looked at as well as medication and arrangements for privacy and dignity. A tour of the premises took place and arrangements for staff training and recruitment was examined. A tracking exercise was undertaken in relation to accidents and the home’s arrangements for maintaining safe working practices and maintaining essential services in the home were looked at. Several service users were spoken to and care observed where residents were unable to communicate with the inspector. What the service does well: What has improved since the last inspection? There have been improvements in medication storage arrangements and administration records. The home has an intention to work towards the new common induction standards. St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 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. St Faith`s Nursing Home DS0000016584.V259542.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 Faith`s Nursing Home DS0000016584.V259542.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 The home’s assessment procedure ensures that all service users are admitted to the home on the basis of a full assessment of their needs, ensuring that they can receive the care that they require. EVIDENCE: All care records seen included an assessment of the service user’s needs prior to admission or on admission. The assessment was based on general information and on the activities of daily living in order to ascertain that service user’s needs can be met. Service users may also receive an assessment from a mental health advisor if required. A care plan drawn up for each resident based on the assessed needs. St Faith`s Nursing Home DS0000016584.V259542.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 & 10 Generally service users needs are set out in individual care plans to enable health and personal care needs to be met. Care is offered in such a way as to promote the privacy and dignity of service users. Generally medication administration, recording and storage procedures ensure that service users are protected although issues were raised about covert medication administration. EVIDENCE: Of those care plans seen where the service user had been assessed as requiring bedsides and bumpers, there was not any reference to this in the care plan actions. For elimination core care plan there was no reference to pads being used for the service user in the care plan actions but in the evaluation a referral was made to the use of pads. The inspector generally picked this information up by reading the evaluation of the care plan or the St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 10 daily record. When it is an assessed need it should be clearly stated in the care plan actions, so that all staff know to do this. In the main most of the care plans seen were reviewed and updated monthly although it was not done so well on Fairhaven. Those seen reflected the care needs of the service users seen. Three recommendations relating to medication were followed up from the last inspection. Medication storage temperatures are now being recorded although it was noted that the medication fridge in Fairhaven was iced up and in need of defrosting. All bottles of liquid medication were being dated on opening although some attention needs to be given to stock rotation. Hand written entries in medication charts were being initialled and dated with only one exception. Medication for some service users was being disguised in food and drink or being crushed. In one case this had been detailed on an individual care plan. The Inspectors were unhappy with this and felt it raised legal and Pharmaceutical issues with a variety of implications for the home and staff. This was discussed with the registered manager and one of the registered nurses they told the inspectors that the Pharmacist had told them this was acceptable and they had discussed it with GP and got consent. They were only giving medication that was essential to the resident’s health (there were several in the home that they did this for because they would not take their medication). The Inspectors require that written authorisation must be available at the home from the GP and Pharmacist and if this was not forthcoming insist that all medication is given in liquid form. Care observed by the inspector was given appropriately and respectfully and maintained the residents dignity. Staff were observed feeding service users and this was done well with them sitting talking to the service user and feeding them slowly and appropriately. Pureed diets were excellently presented; all parts of the meal were pureed separately and served on the plate in scoops of potato, vegetables and meat. Carers were undertaking tasks diligently, respectfully and compassionately. During tasks they were talking and engaging with the individuals during all interactions. They were all carrying out the day’s duties in a calm unhurried manner. St Faith`s Nursing Home DS0000016584.V259542.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): No standards assessed in this section EVIDENCE: St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 12 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): No standards assessed in this section. EVIDENCE: St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 13 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 & 26 The standard of the environment in this home is excellent providing service users with an attractive and clean place to live. EVIDENCE: The environment of the home was clean tidy and well maintained. The home benefits from the attention of a team of maintenance workers. Gardens to the side of the home are accessible, attractive and well maintained. There were no unpleasant odours detected in the home. St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 14 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): 29 & 30 Since the last inspection the standard of vetting and recruitment has declined. The required checks are not being carried out and leaving service users potentially at risk. The home has an intention to work towards the new common induction standards to ensure that staff are trained and competent to do their jobs. EVIDENCE: A number of recruitment files were examined and it was found that robust recruitment practices had not been applied. There were several examples where staff had been recruited without all of the required checks being undertaken. Some staff had been employed before Criminal Records Bureau checks had been received or a preliminary check had made against the protection of vulnerable adults list although this was usual practice. Newly recruited staff had been supervised in their work. Some staff had been recruited who had criminal convictions the decision for this was reported to have been made by the Registered Manager and the Chief Executive Officer. No written risk assessment had been recorded. The home had retained copies of Criminal Records Bureau disclosures after they should have been destroyed. The home should look at their obligations in terms of data protection. The Commission can assist in terms of inspection of these documents before destruction. Following a requirement made at the last inspection the home now has an intention to work towards the new common induction standards for staff training. St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 15 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): 36, 38 The frequency of the staff supervision arrangements may be insufficient to ensure clear consistent guidelines in the care of service users. The home has good training provision and practices in the area of health and safety to ensure that service users live and staff work in a safe environment. The home has however failed to report to the Commission, certain incidents affecting service users. St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 16 EVIDENCE: The issue of staff supervision was looked at. Staff supervision sessions have been carried out on a one to one basis and have been recorded. In addition staff meetings take place and minutes are kept of these. The home will need to find a way of demonstrating that six supervision sessions per year are held with each member of care staff. The home provides training for staff in safe working practices as part of induction and on-going training is provided in fire safety, people handling, first aid, infection control and health and safety. Heating and electrical systems and appliances had been appropriately serviced. Hot water outlets accessible to service users are controlled by appropriate valves and checks had been made and a record of temperatures kept. The home has sought the advice of a specialist consultant regarding the risks of Legionella and take action to reduce risks. The home also keeps a record of accidents and incidents and these are subject to a monthly audit. The Manager audits the accidents monthly and they are reviewed in terms of Resident name/location/ minor or major injury / time of day. A bar chart is produced representing the monthly accident statistics per two-hour period over the 24-hour day. However it was noted that two accidents where service users received hospital treatment had not been reported to the Commission. Since the inspection a number of reports have been received. St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 17 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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 4 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 2 St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 18 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 15 (2) (c) Requirement The registered person must ensure that where there is additional action implemented that is not documented on the pre-printed core care plan this must be added. The registered person must ensure that where bed rails and bumpers are used this is stated in the care plan actions on the core care plans. The registered person must ensure that where continence aids are used or continence routines are implemented the type and size of pads used and the toileting routine is recorded in the care plan actions on the core care plans. The registered person must ensure that service users assessments are kept under review. The registered person must ensure that written authorisation is obtained from the pharmacist or general practitioner as appropriate, for the covert administration of medication. DS0000016584.V259542.R01.S.doc Timescale for action 31/01/06 2 OP7 15 (1) 31/01/06 3 OP7 15 (1) 31/01/06 4 OP7 14 (2) (a) 7 (b) 12 (1) (b) 31/01/06 5 OP9 31/01/06 St Faith`s Nursing Home Version 5.0 Page 19 6 OP29 19 (1) (b) Sch 2 7 OP29 19(1)(a) & 13(4) (c) 8 OP38 37(1)(a) to (g)(2) The registered person must not employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1 to 9 of Schedule 2. The registered person must ensure that the employment of persons with criminal convictions is based on a recorded risk assessment with due regard to the protection of service users. The registered person must ensure that notice is given to the Commission without delay of the occurrence of events listed in (a) to (g) of regulation 37. 31/01/06 31/01/06 30/11/05 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 2 3 4 Refer to Standard OP7 OP9 OP29 OP36 Good Practice Recommendations Care plans should be reviewed on a monthly basis. Stock rotation of medication should be checked on a regular basis. The home should review its practice of storing criminal records bureau disclosures with regard to the requirement for inspection by the Commission. The home should demonstrate that care staff receive six supervision sessions per year. St Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Faith`s Nursing Home DS0000016584.V259542.R01.S.doc Version 5.0 Page 21 - 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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