Inspection on 25/10/05 for St George`s Court Care Centre

This inspection was carried out on 25th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St George`s Court Care Centre 01/09/08

St George`s Court Care Centre 14/02/07

St George`s Court Care Centre 10/04/06

St George`s Court Care Centre 27/01/05

St George`s Court Care Centre 22/06/04

St George`s Court Care Centre 06/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Coronation Street (15) Cambridge Cambridgeshire CB2 1HJ Lead Inspector Nicky Hone Unannounced Inspection 25th October 2005 08:20 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 Coronation Street (15) DS0000015238.V254842.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. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coronation Street (15) Address Cambridge Cambridgeshire CB2 1HJ 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) 01223 712135 01223 712138 Excelcare Holdings Caroline Elizabeth Rae Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named female under the age of 65 with a physical disability Date of last inspection 2nd August 2005 Brief Description of the Service: Purpose-built in the late 1970s, 15 Coronation Street is in a residential area close to the centre of the city of Cambridge. There is a range of local shops, churches, pubs, restaurants, banks and a post office within a few minutes walk; the city centre is a short bus ride away; and the main-line station with direct links to London and the North is in walking distance. The home is built on three storeys with a passenger lift accessing the upper floors, and is divided into self-contained units, each with its own lounge, dining/kitchen, bathrooms and toilets. There is a main kitchen and laundry, and a courtyard garden. A three-storey extension has been built to replace a single storey part of the original building. The new building has been inspected since the inspection in August 2005 and some of the bedrooms are now in use while parts of the existing building are being refurbished. The building work has inevitably caused some disruption for service users, but staff and contractors have worked together to ensure this has been kept to a minimum. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection of this service in the 2005/6 inspection year. An unannounced inspection was carried out on 2nd and 12th August 2005. The reader should note that not all the National Minimum Standards were assessed at this inspection: to gain a complete overview of the service provided by 15 Coronation Street this inspection report should be read in conjunction with previous reports. During this inspection, a tour of the building was made and time was spent talking to service users and the manager, as well as checking records. What the service does well: What has improved since the last inspection? What they could do better: Residents are not always offered a choice of meals and financial records for one service user were not adequate to ensure the person’s financial interests are safeguarded. There was a smell of stale urine in some areas of the existing home, although this should be remedied when this part of the home has new carpets and flooring laid. There have been occasions when the home has been short of staff, and some records were not being maintained as required. The fire alarm system had not been tested as required and chemicals were not being stored securely: an immediate requirement notice was left at the home regarding these issues. Coronation Street (15) DS0000015238.V254842.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. Coronation Street (15) DS0000015238.V254842.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 Coronation Street (15) DS0000015238.V254842.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): None EVIDENCE: None of these standards were assessed at this inspection. Standards 1, 3 and 5 were assessed at the last inspection and were met. Coronation Street (15) DS0000015238.V254842.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): 10 Induction, training and monitoring of staff ensures that residents’ privacy and dignity are upheld. EVIDENCE: On the day of the inspection staff were observed to knock on doors before entering and personal care issues were dealt with sensitively. Staff were seen to treat residents with respect. One resident spoken to said the staff are wonderful. The manager said that issues of privacy, dignity and respect are dealt with during induction of new staff and are part of the ethos of the home. Standards 7, 8, and 9 were assessed at the last inspection and were met. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 10 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): 15 Catering arrangements are not reliable enough to ensure that residents always have a choice of meals. EVIDENCE: On the day of the inspection the chef had telephoned in sick. The menu had been changed to accommodate this and a ‘cook/chill’ meal was being prepared: there was no choice of main course for lunch, which the manager said is usually offered. One resident said the food is good. The main kitchen was reasonably clean, with fridges and store cupboards adequately stocked. No record of food provided is kept. Additional kitchen staff might be required when the home’s expansion is complete and the number of residents is more than double the number being catered for at present. The manager said that there will probably be an additional chef and kitchen assistant when residents from the home that is closing for refurbishment move to 15 Coronation Street. Standards 12, 13 and 14 were assessed at the last inspection and were met. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 11 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): None EVIDENCE: These standards were not assessed at this inspection. Standards 16 and 18 were assessed at the last inspection and were met. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 12 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, 24 and 26 The standard of the environment at this home is generally good providing residents with a comfortable and attractive place to live. EVIDENCE: Parts of the new extension are now in use and offer residents light, airy and spacious accommodation. One resident said she is very pleased with her new bedroom, which has an ensuite shower. Water temperatures are checked regularly. Tests carried out on 26/09/05 were seen: the temperature of the hot water in two of the bathrooms was recorded as being high but was then re-calibrated to the correct temperature. The new areas of the home were very clean and smelled fresh. There was a smell of stale urine in two areas of the original part of the home. The manager said the carpets are shampooed regularly and will be replaced when those areas of the home are refurbished. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 13 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 There are not always sufficient staff on duty to adequately meet the needs of the residents. EVIDENCE: On the day of the inspection there were 8 staff on duty. This included a trained nurse and 2 staff who were working under supervision as they were newly employed. Staff rotas showed that there have been days when there have been fewer staff on duty. One resident said sometimes the home is short of staff, and one said s/he had been unable to have a shower the previous evening because there was a shortage of staff. The manager reported that recent recruitment has gone well and several new staff are starting work at the home. Some of the staff from the home that is closing will be coming to work at 15 Coronation Street. Standards 29 and 30 were assessed at the last inspection and were met. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 14 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, 33, 35 and 38 The home’s record-keeping and health and safety measures are not robust enough to ensure that residents are protected. EVIDENCE: Mrs Caroline Rae is the registered manager. She is a qualified nurse and has managed the home for two years. The manager said that the quality assurance system in the home includes questionnaires being sent to residents and relatives every six months asking their views on the service, and regular meetings being held with residents and with relatives. The manager has an open door policy so that people can approach her at any time, and she holds a ‘surgery’ on one evening a week so that people not able to visit during the day know that she will be able to speak to them. Results of the questionnaires were not seen. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 15 All except one resident deal with their own financial affairs, or have a representative to do this for them, so no money is held in the home on behalf of the residents. One resident’s money is held in a bank account by the company: the manager cashes a cheque when this resident requests money. The records seen relating to this were not adequate to show that this person’s financial interests are being safeguarded. The majority of records required by the regulations are being maintained. However, there is no record in sufficient detail of food provided; and reports of visits by the provider were available in the home but a copy is not being sent to the CSCI. Residents’ daily notes were in a pile on a table in the corner of the dining room. It was a requirement following the last inspection that these records must be stored securely. The inspector has taken into account the disruption to the staff and the environment caused by the move into the new part of the building, and has carried this requirement forward, however, any future breach will result in the CSCI considering legal action. Tests of the fire alarm system are not being carried out weekly as required. In the period from 28/11/04 (47 weeks) there were only 13 entries in the fire log: 10 of these were tests and 3 were a record of the alarm going off for other reasons, for example, when toast was burnt. An immediate requirement notice was left with the manager regarding this. The emergency lighting system was tested each month as required up to 27/07/05, then a test on 01/09/05 and none since then. Two cupboards containing chemicals for cleaning, which should be locked at all times, had the keys in the locks, and one of the doors was open. There was a large number of bottles of cleaning fluids in this cupboard. Safe storage of chemicals was a requirement following the last inspection: this has not been met and maintained. Again, the inspector has taken into account the disruption to the staff and the environment caused by the move into the new part of the building, and has issued a further immediate requirement: any future breach will result in the CSCI considering legal action. Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X X 3 X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X 2 2 Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 OP26 Regulation 16(2)(k) Requirement All parts of the home must be kept odour-free. This requirement is carried forward from the inspection on 02/08/05. The registered person must ensure at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This requirement is carried forward from the inspection on 02/08/05. Records must be available to show that residents’ financial interests are protected. Service users records must be kept securely. This requirement is carried forward from the inspection on 02/08/05. Timescale for action 30/11/05 2 OP27 18(1)(a) 25/10/05 3 OP35 17 & schedule 4(9) 17(1)(b) 30/11/05 4 OP37 25/10/05 Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 18 5 6 OP37 OP38 17(2) & sch (4)(13) 13(4)(a) A record of food provided must be maintained Chemicals must be stored securely. An immediate requirement notice was left at the home regarding this. An immediate requirement notice was left at the home following the inspection on 02/08/05 regarding this. Fire alarm tests must be carried out weekly as required by the fire authority. An immediate requirement notice was left at the home regarding this. 30/11/05 25/10/05 7 OP38 23(4)(c) 25/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations Residents should be offered a choice of meals Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Coronation Street (15) DS0000015238.V254842.R01.S.doc Version 5.0 Page 20 - 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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