CARE HOMES FOR OLDER PEOPLE
St Georges Abbey Hey Lane Gorton Manchester M18 8RB Lead Inspector
Sarah Oldham Unannounced Inspection 28th February 2006 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 Georges DS0000021580.V285103.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 Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Georges Address Abbey Hey Lane Gorton Manchester M18 8RB 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) 0161 220 8885 0161 220 8885 Mr Haile Kidane Ms Margaret Beech Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: St Georges is a privately owned residential care home providing accommodation for up to 10 people aged 60 and above. The home is situated in the Gorton area of Manchester close to public transport links into Manchester City Centre and Hyde. The home is a three-storey property previously used as a rectory. The accommodation is provided in one double bedroom and eight single bedrooms located on two floors. Access to the first floor is via a passenger lift and a central staircase. The third floor provides office space and a staff sleep-in room. None of the bedrooms have en-suite facilities. All bedrooms have a washbasin and vanity mirror. Accessible toilet and bathroom facilities are provided on the ground and first floors close to the living accommodation. There is a lounge on the ground floor with a separate dining room. A kitchen and laundry are also located on the ground floor. St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a 3-hour period on the 28 February 2006. During the inspection time was spent talking to four residents, the manager and two members of staff. This was to find out what it was like to live at the home. Time was also spent looking at the home’s records, resident’s files, care plans and other documents. During this inspection only a selection of the National Minimum Standards were assessed and in order to get a full picture of what it is like to live at this home this report should be read with the previous and any future reports. What the service does well: What has improved since the last inspection?
Training requirements made at the previous inspection with regards the protection of vulnerable adults had been addressed by the home manager. All staff had received training by way of a training video and training by the manager.
St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 6 A fridge has been purchased for the storage of medication that requires being stored in a fridge. The complaints policy had been amended to include the contact number of the Commission for Social Care Inspection (CSCI). A copy of the complaints procedure was maintained and was with the visitor’s book by the front door along with other key policies of the home including the protection of vulnerable adults. 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 Georges DS0000021580.V285103.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 Georges DS0000021580.V285103.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): None of these standards were inspected on this occasion. EVIDENCE: St Georges DS0000021580.V285103.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): 7, 9, 10 & 11 The home provided a homely environment for the residents who live there with some activities available. Residents were able to exercise choice and control over their lives and were able to maintain contact with family and friends. EVIDENCE: The care plans examined during the inspection were clearly recorded and identified the needs of the residents. One care plan viewed required up dating to ensure that the residents changing needs were appropriately recorded. This manager had already identified this as part of her audit of the care files and discussed it with the key worker. A number of residents spoken to said that staff treated them with respect and dignity and that when being given personal care, their dignity was maintained. The residents said they were not made to feel uncomfortable when staff assisted them to have a bath. One resident said that initially she had been concerned about how she would be treated by staff but this was prior to moving into the home. The resident said that she had been made to feel “welcomed into the home and every one was very friendly and helpful”. The resident said that they felt that the move to the home had been a positive one.
St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 10 Following the previous inspection the storage of medication had been reviewed and the medication trolley was used solely for the storage of medication. A fridge had been purchased for the storage of medication that required these storage facilities. The fridge was not lockable and therefore medication stored in this fridge was accessible to anyone. The manager said that wherever possible residents would be supported and their needs met by the home for as long as possible. This was discussed with the resident and their family. St Georges DS0000021580.V285103.R01.S.doc Version 5.1 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): None of these standards were inspected on this occasion. EVIDENCE: St Georges DS0000021580.V285103.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 & 18 The home had appropriate policies and procedures in place to ensure that the residents at the home were safeguarded from abuse. EVIDENCE: The complaint policy had been amended and now included a time frame that the home responded to complaints within. A copy of the complaint procedure was kept in a folder by the main entrance to enable all visitors to have access to it. Staff had received training with regards the protection of vulnerable adults. This training had been undertaken by the manager and staff and were aware of the policies and procedures to follow. Copies of training certificates were maintained. Staff spoken to were able to demonstrate a good knowledge of the issues surrounding the protection of vulnerable adults. St Georges DS0000021580.V285103.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): 19, 20 & 26 The premises are safe, however, some areas of the homes flooring and décor needed to be renewed and replaced. EVIDENCE: The location and layout of the home was suitable for its stated purpose. At the time of inspection the home appeared to be clean, tidy and free from unpleasant odours. The manager said that there were plans to renew the homes carpeting in the hallway and a programme of redecoration was planned. The area that required to be decorated as a matter of priority was the dining area. The manager said that this had already had been agreed and would be done. A number of resident’s rooms were seen to have the appropriate furnishings and fittings and were personalised. Residents spoken to said that they had been involved in choosing the décor of their bedrooms. One resident said that their room was “ always warm and comfortable with enough room for all her personal things”.
St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 14 Residents’ bedrooms had been fitted with a privacy lock suited to their capabilities and accessible to staff in emergencies. Residents were provided with a key on request unless a risk assessment suggested otherwise. All rooms had a lockable storage space for medication, money or valuables. At the previous inspection the owner of the home had identified plans to extend the building. The Commission for Social Care Inspection had not received an application to vary the homes conditions of registration in respect of the planned works. St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 15 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 & 30 The numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated. EVIDENCE: Staff undertook various training courses in relation to Health and Safety, Moving and Handling, Basic First Aid, Fire Safety and the Protection of Vulnerable Adults. All but one of the staff members had achieved NVQ Level II and three staff were undertaking NVQ Level III. A number of staff files were inspected and found to contain the appropriate information required to ensure that recruitment and selection of staff supported the health and well being of the residents. St Georges DS0000021580.V285103.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): 31, 32 & 33 The management of the home created an open and inclusive atmosphere resulting in practices that promotes and safeguards the health, safety and welfare of the residents living there. EVIDENCE: The manager had undertaken the Registered Managers Award and had received notification that she had been successful in achieving this. The manager had undertaken training with staff to ensure that the service that the home provided met the resident’s needs. Staff spoke to felt that the manager was approachable and managed the home well. Residents said that the manager was approachable and listened to any suggestions or requests that they had and acted upon these if it was appropriate to do so. The manager was observed talking with residents and it was apparent that the residents felt comfortable talking to her.
St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 17 The home had not yet developed an effective Quality Assurance monitoring system and the previous requirement for this to be developed is reiterated in this report. The Commission for Social Care Inspection had not received any regulation 26 reports from the homeowner. This requirement was made at the previous inspection and is reiterated in this report. St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 18 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 3 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X X St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 19 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 OP9 Regulation 13 Requirement The fridge purchased for the storage of medication must be fitted with a lock to enable the fridge to be secured when not in use. Flooring in the dining room must be deep cleaned to remove staining The furnishings and décor to the dining room must be renewed/replaced. The owner must submit records of Regulation 26 visits made to the home on a monthly basis. Carpeting to the hallway, stairs and landing must be replaced. Planned renewal programme for the replacement of the remaining carpets in the home must be put in place with details of timescales submitted to CSCI Timescale for action 30/05/06 2 3 4 5 OP19 OP19 OP19 OP19 13 16 26 16 30/06/06 30/10/06 30/04/06 30/07/06 St Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 20 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 Georges DS0000021580.V285103.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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