Inspection on 22/05/06 for St Georges Park Care Centre

This inspection was carried out on 22nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Georges Park Care Centre 02/10/08

St Georges Park Care Centre 05/10/07

St Georges Park Care Centre 30/11/06

St Georges Park Care Centre 02/02/06

St Georges Park Care Centre 26/10/05

St Georges Park Care Centre 04/07/05

St Georges Park Care Centre 19/10/04

St Georges Park Care Centre 24/05/04

St Georges Park Care Centre 24/02/04

St Georges Park Care Centre 03/04/03

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

CARE HOMES FOR OLDER PEOPLE St Georges Park Care Centre School Street St Georges Telford Shropshire TF2 9LL Lead Inspector Keith Salmon Key Unannounced Inspection 22th May 2006 10:00 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 Georges Park Care Centre DS0000022275.V290303.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 Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Georges Park Care Centre Address School Street St Georges Telford Shropshire TF2 9LL 01952 616300 01952 616345 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) Southern Cross Healthcare Care Home 71 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (33), Physical disability (6) of places St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 71 Nursing beds which may include a maximum of 10 residential beds, including 32 older people with dementia on the ground floor and up to 6 residents with a physical disability on the first floor. 2nd February 2006 Date of last inspection Brief Description of the Service: St Georges Park is a Care Home located in St Georges, Telford, and registered to provide personal care, with nursing, for up to 71 older people, some of whom may suffer from dementia. The Home comprises two Units, Rydal on the lower floor which can accommodate a maximum of 31 older people who have dementia, and Derwent situated on the first floor, which can accommodate a maximum of 40 older people requiring general nursing care. All bedrooms are single occupancy and with the exception of one room all have en-suite toilet facilities. The Home is owned by Southern Cross Health Care and the Manager is Debbie Baron. Weekly fees range from £357 to £520. St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection commenced at 10.00am, lasted 5.5 hours and concluded at 3.30pm. Present was Debbie Baron, who was appointed Manager at the beginning of 2006 and is currently in the process of applying to the CSCI to be formally approved as ‘Registered Manager’. Being the first Inspection of 2006/07 it centred on ‘Requirements’ cited at the previous Inspection, held in February 2006, plus all ‘Key’ National Minimum Standards. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas, staff files, plus a range of other documents/records reflecting the general operation of the Home. The Inspector also held 1:1 discussions with the Manager, 10 Residents, 4 Visitors, and several members of Staff. What the service does well: The Home provides a clean and comfortable environment, where day-to-day focus is centred on the needs of Residents. General observation, review of records, and discussions with Residents/Relatives/Visitors and Staff demonstrated efforts continue to be made to promote positive outcomes for people with complex, and challenging, physical and mental care needs. At the time of this Inspection the individual bedrooms seen were clean, comfortable and personalised. The Home offers a good choice of menu and provides a comprehensive range of activities appropriate to the capabilities and interests of the Residents. Comments made by Residents and Relatives included, “…My relative is very happy and well cared for”, “…The Staff are always friendly and kind to us”, “…I really enjoy the ‘sing-along’ sessions”, “…The meetings we (Residents and Relatives/Visitors) have with the Manager and Staff are very good, and they take notice of what we say.” St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 6 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. St Georges Park Care Centre DS0000022275.V290303.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 Park Care Centre DS0000022275.V290303.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): 1 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available which should enable prospective Residents (or their ‘agents’) to reach an informed decision about entering the Home. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: The Home’s Statement of Purpose and Service User Guide have been revised so as to be in line with the corporate models utilised by the Home’s new Owners, Southern Cross Health Care. ‘Case Tracking’ involving the review of 6 Residents’ Care Plans/Files, i.e. those relating to the two most recently admitted Residents, plus four selected at random, demonstrated all potential Residents have their care needs assessed by the Registered Manager prior to taking up residence. St Georges Park Care Centre DS0000022275.V290303.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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An overall judgement as to the efficacy of the model of Care Plan utilised could not be made, as the Home is in the process of changing to the corporate model employed by Southern Cross Health Care. The care provided by the Home is effective in meeting the Residents’ assessed care needs, and is delivered considerately and effectively. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: As a component part of ‘Case Tracking’, 6 Residents’ Care Plans/Files were reviewed and discussions held with the respective Residents. In the majority of Residents’ Care Plans the Home is still utilising the design introduced by the previous owners, which is disorganised and in many ways lacks necessary detail. However, at the time of this Inspection 17 out of 69 Care Plans were observed to be using the newly introduced ‘Southern Cross’ Model. Those examined, St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 10 e.g. all recent admissions, showed the model to be much more comprehensive and informative. The transfer of information from ‘old’ to ‘new’ Care Plans is being undertaken by the relevant ‘Key Worker’, overseen by the Manager or specific ‘Unit Manager’, with the whole process expected to be completed by the end of August 2006. A ‘Requirement’ of this Inspection will be all Care Plans are to be in the form of the ‘new’ model by the end of August 2006. At the previous Inspection two ‘Requirements’ were cited under the Standard covering the management/administration of medicines. These being:− Any eye ointment / drop medication is to be clearly labelled stating the date opened − A full stock audit to be undertaken for all medication at the Home, and procedures implemented to ensure that unnecessary ordering of stock is prevented A thorough inspection of the medicine storage provision and medicine administration records showed these ‘Requirements’ to be fully met. The Home’s practices now meet the guidelines of the Royal Pharmaceutical Society. St Georges Park Care Centre DS0000022275.V290303.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure opportunities are provided, which are consistent with Residents’ capabilities. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: The Home has a full and varied programme of activities, which are planned and organised jointly by Residents and Staff under the leadership of an ‘Activities Co-ordinator’ employed for 30 hours per week, normally attending the Home between 11.00am and 6.00pm. Minutes of Residents’ Meetings, together with comments made by Residents and Relatives/Visitors, provided evidence of their input in determining the range and nature of activities. It is commendable that Residents’ Meetings are to be held during the afternoons, in addition to the evening, as is the current arrangement, to facilitate attendance by interested parties. It was very evident that the open St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 12 and inclusive approach of the new Manager is greatly appreciated by Residents and their Relatives/Visitors. Of particular note, and also to be commended, is the effort being made to engage the involvement in activities of Residents with dementia. Evidence was seen of active links with local clergy, for example Residents being escorted to the local Church of England Church by Staff members or members of the Church. Activities include local trips out with Relatives and/or Staff, regular visits to local garden centres, involvement in national commemorative events, traditional games, including cards, dominoes, and bingo, a ‘fitness club’ involving ‘musical movement’, and visiting entertainers/sing-alongs (this includes provision of an ‘in-house produced’ large-print songbook. Recently the Home has held a chocolate party and a car boot sale in the Home’s gardens. Residents informed the Inspector the range, quality and choice of food provided was very good and the Home caters for those Residents who have individual preferences/dislikes. St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse. EVIDENCE: Complaints Procedure details are included in the Service User Guide and are displayed prominently for the benefit of visitors. There are policies and procedures in place intended to provide protection for vulnerable people. These fully meet the requirements of this Standard and staff training files confirm the topic is covered both at induction and through on-going staff training. St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides a generally safe environment with communal rooms, and many bedrooms, benefiting from a recently commenced redecoration and refurbishment activity and replacement of armchairs. The gardens are easily accessible at all times of year. General cleanliness throughout the Home is good. EVIDENCE: At the previous Inspection three ‘Requirements’ were cited under Standards covering ‘Environment’ - these related to:− The replacement of broken and worn armchairs − The refurbishment of kitchenettes − The introduction of a written programme (and record) for routine maintenance, decoration and renewal of the fabric of the premises St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 15 The Home has also made good progress in addressing ‘Requirements relating to the refurbishment of the kitchenettes and replacement of broken/worn furniture. At the time of the Inspection work was almost complete on the refurbishment of the second kitchenette with the first having been completed. Some corridors have been redecorated, and the Inspector observed new brass effect nameplates for Residents’ Doors, with availability from the supplier on a ‘next-day’ basis. There remains a need to establish a written programme for redecoration, refurbishment and replacement, which includes firm target dates for completion of such works. It is accepted the introduction of such a plan has been delayed as the new Owners, and new Manager, have spent time addressing areas in immediate need of attention. An example of this is seen in the policy of redecoration of bedrooms as they have become vacant and in other work already completed including repainting of corridors. St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 16 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty and skill-mix were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home to provide training for Care Staff is good and in accordance with individual Staff Members’ learning needs. EVIDENCE: A ‘Requirement’ cited at the previous Inspection was the staffing ratio, as agreed, must be maintained at all times. The current staffing rota, and those from the immediately preceding weeks, were examined and demonstrated the ‘Requirement’ had been met. A review of employment files for 5 members of Staff, i.e. those relating to the 2 most recently appointed, plus 3 selected at random, provided evidence the Management of the Home has fully addressed these ‘Requirements’. Staff Personal Files are now fully compliant with the Standard and Schedule 2 of the Regulations. A review of ‘Training’ records evidenced Staff are subject to a thorough and relevant orientation/induction programme, a comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘simple infection control’, followed by access to NVQ Training. Evidence was also observed St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 17 confirming particular attention is being afforded to the training needs of Staff providing care to Residents with dementia. This involves input from a Doctor employed directly by ‘Southern Cross’ as a ‘Dementia Care’ Consultant. Minutes were also seen of a ‘Dementia Care Team Meeting’, which is held on a regular basis and involves representation from Staff of all designations. Noteworthy output from this Meeting includes the decision to embark on a programme which will assist Residents with dementia in orientation to their own bedrooms, i.e. Residents’ bedroom doors will be painted in bright primary colours, of individual choice where possible, complete with door knockers, letter boxes and name-plates. Other plans will see the introduction of ‘reminiscence aids’, ‘tactile boards’, further development of activities and menus/food preparation specific to the needs of the client group, and the development of practices to help reduce ‘transitional shock’, experienced by many Residents at the time of admission to the Home. St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 18 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): 31,32,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is well managed by Debbie Baron who, although having been in post for less than six months has actively, and effectively, addressed issues previously unattended. Operationally, the Home now appears well organised with the central purpose being ‘the best interests of Residents’ with an ambience that is warm, friendly and inclusive. Lines of accountability are clearly defined and observed. The views of Residents and other interested parties are sought by the Home and acted upon. Service Users are safeguarded by the financial procedures operated in the Home. All Staff are subject to effective support with regular supervision, and appeared involved and happy in their work. Health and Safety Policies/Procedures/Practices were satisfactory. St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 19 EVIDENCE: Observation by the Inspector, together with comments from Residents, Visitors and Staff suggest the Home is currently being well managed with clear signs of improvement in many areas of care provision from those found at previous inspections. Support for the Manager is evidenced by regular attendance at the Home by the Area Manager, representing Southern Cross Health Care, and monthly submission to CSCI of Regulation 26 Visits. Records reviewed demonstrated cash, held by the Home on behalf of Service Users, is being managed appropriately, e.g. there are full records of transactions, including receipts and two signatures where necessary. Quality assurance work, including questionnaires to Residents and regular meetings with Residents, Relatives/Visitors has continued. Results of these questionnaires, and notes of monthly meetings, were seen and found to be relevant with suggestions being implemented where possible. COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken, and appropriately documented. Records are maintained for hot water supply to baths, and water temperatures tested during the Inspection were satisfactory. COSHH data sheets were up-to-date. St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 20 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15 –(1) Requirement The process of transferring all Care Plan data from the ‘old’ care plan model to the ‘new’ one must be completed without undue delay. A programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. A copy must be forwarded to CSCI (Shrewsbury) by the due date for action. Timescale for action 31/08/06 2. OP19 23 – (2) (b)(c)(d) 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Georges Park Care Centre DS0000022275.V290303.R01.S.doc Version 5.1 Page 23 - 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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