Inspection on 31/01/06 for St George`s Witham Nursing Home

This inspection was carried out on 31st January 2006.

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 George`s Witham Nursing Home 22/05/09

St George`s Witham Nursing Home 19/04/07

St George`s Witham Nursing Home 11/01/05

St George`s Witham Nursing Home 05/07/04

St George`s Witham Nursing Home 24/07/03

Similar services:

Sun Court Nursing Home

Park House Holiday Hotel

Grangewood

Hill Barn

Henrietta House

Pemdale

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

CARE HOMES FOR OLDER PEOPLE St George`s Witham Nursing Home 18 - 20 Avenue Road Witham Essex CM8 2DT Lead Inspector Diane Roberts Unannounced Inspection 31st January 2006 09:00 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 George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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 George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St George`s Witham Nursing Home Address 18 - 20 Avenue Road Witham Essex CM8 2DT 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) 01376 512258 01376 502790 Newton Chinneck Limited Amanda Keen Care Home 31 Category(ies) of Physical disability (31), Terminally ill (15) registration, with number of places St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 50 years and over, who require nursing care by reason of a physical disability (not to exceed 31 persons) Persons of either sex, aged 18 years and over, who require general palliative care (not to exceed 15 persons) No more than 5 persons may attend the home on a daily basis in addition to the 31 accommodated 8th August 2005 Date of last inspection Brief Description of the Service: St Georges nursing home is registered to provide nursing care to adults over the age of 50 years with a physical illness or disability. The home can also take people over the age of 18 who require palliative care. The home is situated ina quiet avenue within walking distance of Witham town centre and local facilites, including the train station. Car parking is availbale at the home. The home has a courtyard garden garden with wheelchair access and gardens to the rear. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three and a half hours and was carried out as part of the annual inspection programme for this home. The registered manager was present at the inspection. The Inspection focused upon outstanding standards not previously covered this year and the homes response to the last agenda for action. A partial tour of the premises was undertaken. Four residents and one relative and 4 staff were spoken to during the inspection. Eleven residents and three relatives completed comment cards for the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs to review its provision of staff training in relation to the specialist care the home provides for some of its residents. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 6 Regular weighing of residents needs to take place to make the assessments and monitoring more meaningful. Records need to improve in relation to monies held in safekeeping on behalf of residents but this is not a significant issue. 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 George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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 George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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): Standards not assessed at this inspection. EVIDENCE: St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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 The privacy and dignity of residents is upheld. EVIDENCE: Residents spoken to and via comment cards were happy that their privacy was respected. Relatives who commented felt that they were able to have privacy with their family at visiting time should they so wish. Residents spoken to felt that the staff team were very respectful and polite. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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): 12, 14 and 15 The residents’ lifestyle in the home generally matches their expectations. Residents’ are helped to exercise choice and control over their lives. The meal provision at the home is generally good. EVIDENCE: Residents spoken to felt that they have choice regarding how they spent their days within the routines of the homes. They confirmed that they had choice with regard to retiring to bed and rising in the morning and with mealtimes, should they so wish. Residents spoken to felt that the staff were flexible and thoughtful and worked around them and their needs as far as possible. The home employs an activity officer and records were inspected. Each resident has a care plan in place and this shows the activity offered and whether he or she has chosen to take part or not. New residents are visited to help ensure they settle in well and a new resident spoken to on the day confirmed this. Residents spoken to were generally happy with the activities offered and recognised that due to the needs of many residents’ lots of 1:1 visits are carried out in peoples rooms and group activities are limited. Records show that outside entertainers visit and that residents with sensory needs are taken into account. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 11 Residents are encouraged to retain control over their lives. Where residents are able the home supports them as far as possible. Information on local advocacy services are available around the home. Permanent residents are encouraged to bring in personal possessions on admission, the limit of is agreed with the resident. The menus at the home run over a 4-week period and tend to be changed summer and winter. Whilst there is no choice with the main daily meal, the chef reports that she knows the residents well and liaises with them about alternatives. The menus appeared varied and nutritious with some choices, mainly on deserts, being offered. The whole menu is designed so that it is suitable for diabetics. The chef prepares specialist diets where required and only purees food that needs to be soft, being very aware of textures and presentation. The home tends to provide a lot of home cooking and fresh fruit and vegetables are used on the whole. Residents spoken to on the day of the inspection were very happy with the food provided and were aware that they could have an alternative should they wish. They also confirmed that they could have a supper if they wanted during the evening, but this was rarely needed, as they felt well fed! Relatives, who commented; felt that the food was good. Out of eleven residents who commented via the comment cards, 8 stated that they only liked the food sometimes and one stated that they did not like the food. The home may wish to explore this further. The staff undertake a nutritional risk assessment for each resident and then subsequently weigh them. Records show that the weighing is inconsistent and needs to be addressed if the risk assessment is to be worthwhile. The kitchen has been awarded a gold medal by the environmental health officer for hygiene and cleanliness. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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): 16 and 18. The home has a complaints system that ensures that any concerns/complaints raised will be dealt with appropriately. The home has systems in place, which help to ensure that residents are safeguarded from abuse. EVIDENCE: The home has clear policies and procedures in place for dealing with complaints. Residents spoken to and who commented, knew who they would raise any concerns with. Since the last inspection the manager had received only one minor complaint and records show that this was dealt with appropriately and within timescales. Relatives who commented were unaware of the homes complaints procedure and the home needs to check that this is not a general issue. The inspector was able to see compliment cards received by the home, which includes comments such as ‘caring and thoughtful staff’, ‘excellent care’, ‘staff willingness’ and ‘commitment’. The home has up to date policies and procedures in place for the protection of vulnerable adults. Staff training records show that all staff have received training and update sessions are planned for this year. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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): Standards not assessed at this inspection. EVIDENCE: St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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): 27, 29 and 30. Resident’s needs are met by the current staffing levels and skill mix in the home. The home has sound recruitment systems in place. The home generally has a good training programme in place with improvements only needed in one area. EVIDENCE: Staffing rotas for a two-week period were inspected at random. Staffing levels were discussed with the manager and are felt to be appropriate for the home at the current time. The manager aims to have two qualified nursing staff on duty in the mornings and one on a late shift and at night. Care, activity and ancillary staff are also at appropriate levels. Relatives who commented felt that there were always plenty of staff on duty. Extra staff are on duty if staff are needed for escorts etc. The manager reviews levels regularly in relation to the dependency of residents, especially with the palliative care registration. Staff turnover at the home is quite stable and no agency staff are used. The home has one nursing student on placement who is supernumerary to the staff compliment. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 15 The home has comprehensive recruitment polices and procedures in place and this includes equal opportunities. Three staff files were checked at random. Records show that the home adheres to its policies and procedures and undertakes all the required checks on potential staff. Good records are maintained and updated where required and a checklist system is used. Records show that care staff are issued with the GSCC Code of Conduct for Staff and terms and conditions of employment. The home employs a training officer, shared between two homes in the company. The home has a training plan in place for all levels of staff and maintains good clear records of all the training provided. Records show that care staff are undertaking NVQ level 2 and above, in care. Records show that staff are undertaking induction to the home and standards expected when they commence employment. Both records and the 2006 plan show no records in relation to palliative care training for nursing or care staff. The home needs to review this in relation to its registration and the amount of palliative care residents cared for in the home. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 16 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): 35 Resident’s financial interests are safeguard but this could be improved. EVIDENCE: The home tends not to hold money or valuables for residents, encouraging them to do this or their relatives /representatives to be responsible. On inspection the home was holding some monies on behalf of residents, where requests had been made. Records were in place but these were limited and did not record a balance. This needs to be addressed and the homes policies and procedures updated to cover the required record keeping. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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 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 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 4 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X X St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 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 OP15 Regulation 14 and 16 Requirement The registered person must ensure that residents weight is regularly monitored and their nutritional state assessed. The registered person must ensure that nursing and care staff are appropriately trained in relation to the registration of the home – with specific regard to palliative care The registered person must maintain up to date records for each resident that has deposited money, with the home, for safekeeping. Timescale for action 14/05/06 2. OP30 18 01/06/06 3. OP35 17(2) Schedule 4 30/04/06 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 Refer to Standard OP15 OP16 Good Practice Recommendations The registered person should ensure that they obtain regular feedback from residents regarding the food. The registered person should ensure that relatives and DS0000015352.V287516.R01.S.doc Version 5.1 Page 19 St George`s Witham Nursing Home other interested parties are aware of the homes complaint procedures. St George`s Witham Nursing Home DS0000015352.V287516.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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