Inspection on 30/09/05 for St Gregory`s House

This inspection was carried out on 30th September 2005.

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 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 Gregory`s House 03/05/06

St Gregory`s House 02/03/06

St Gregory`s House 29/03/05

St Gregory`s House 04/10/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Gregory`s House Preston Patrick Kendal Cumbria LA7 7NY Lead Inspector Jane Strawbridge Unannounced Inspection 30 September 2005 1.50 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 Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Gregory`s House Address Preston Patrick Kendal Cumbria LA7 7NY 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) 015395 67543 St Gregory`s House Ltd Mrs Tracey Diane Bindloss Care Home 29 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (29) of places St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 29 service users to include: up to 29 service users in the category of OP (Old age, not falling within any other category) up to 16 service users in the category of DE(E) (Dementia over 65 years of age) may be accommodated within the overall number of registered places. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 29/03/2005 2. Date of last inspection Brief Description of the Service: The home is a large detached three storey Victorian house, which was formerly the local vicarage. It is situated in beautiful open countryside on the edge of Preston Patrick, a small village between Kendal and Kirkby Lonsdale. Modern extensions have been added to provide bedrooms, communal living spaces and an office. An extension is currently being built to provide a new dining room for the residents. The house has a passenger lift to provide easy access to all floors including the basement, and there are assisted bathing facilities. The home has its own attractive grounds with seating areas and car parking. Additional land adjoining the property has been purchased to create extra car parking spaces and a secure garden. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took place during an afternoon. Ms Tracey Bindloss the home’s registered manager, and Mr Carl Weatherill, a director were present throughout the inspection. The inspector spent some time talking with the residents either in small groups or individually, with their visitors and with the staff on duty. The inspector looked around the home and saw records relating to the care of the residents and the day to day running of the home. What the service does well: What has improved since the last inspection? Work has been completed to provide lockable storage space in each bedroom in response to a requirement made at the last inspection. The shared bedroom on the ground floor has been refurbished and new furniture has been purchased to make the living space brighter and more welcoming and homely. There has been further liaison with the local pharmacist regarding the labelling of medicines for residents and they now have a system that works well and ensures that medication is administered safely. A system to audit the extent and cause of falls in the home has identified where and when falls are most likely to happen. As a result extra assistance at night has been given to residents most at risk and the number of falls has decreased. Staffing hours have increased for housekeeping and office administration so that care staff are able to spend more time with the residents. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Gregory`s House DS0000022702.V249710.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): 1, 3, 5 The home uses an admission procedure that means a proper assessment takes place before people move into the home. This practice together with the information given to prospective residents ensures that care needs can be met. EVIDENCE: The manager or head of care visit prospective residents to assess their needs and to see if the home is suitable for them. They obtain as much relevant information as possible from the person and their family and carers. In return they provide information about the home to help each party to make an informed decision about moving in. The home has an informative statement of purpose for residents and visitors. Anyone considering moving into the home is given the opportunity to stay over night or make a short visit to help them to decide whether or not they would like to move in. St Gregory`s House DS0000022702.V249710.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): 8, 9, 10 Residents’ health care needs are identified, recorded and met in a way that respects their dignity and privacy. Routine safe practices ensure the residents are protected from harm. EVIDENCE: Each resident’s health care needs were recorded and the community nurse visits the home twice weekly. The manager said that these nurses strengthened the team. The home has a good working relationship with the local doctors and other health care professionals who visited on request. Residents were taken to keep hospital out patient appointments and to see their chiropodist, dentist or optician. Regular audits within the home and monitoring by the local pharmacist ensure that there are safe procedures for the storage, handling and administration of medication. All staff with a responsibility for administering medication had completed the appropriate training. Members of staff on duty were seen to behave in a professional manner showing respect and courtesy for each of the residents. Residents confirmed this by saying “the staff help me when I need it and are very kind to me” and St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 10 “ I would rather be in my own home but couldn’t manage alone so I have no regrets about moving here.” St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Visitors are welcome and the social activities are well organised. These work together to provide interest and stimulation for the residents. Meals are balanced and nutritious to offer a healthy variety of food that meets the residents’ tastes and choices. EVIDENCE: St Gregory’s House has an open door policy where visitors are welcome at any time. Residents can see their visitors in private in their room or in communal spaces away from the main lounges. Currently the residents are physically fitter and more able bodies than previously so different activities have been organised to take this into account. Home visits and outings were encouraged for residents to maintain social contact with families and friends. The home had managed to secure places at a day centre so that residents were able to take advantage of creative and stimulating activities in a different setting. Some residents’ were now unaccompanied by staff on their planned outings and risk assessments were in place to cover these. The home has an in house programme of activities and each afternoon there is an extra member of staff on duty so that they can spend time with residents and, if they wish to do so, they can help them to take part in an activity that interests them. New ideas for activity sessions are encouraged and staff St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 12 members discuss and plan these in supervision sessions. Three outside entertainers visit the home each month. The home has welcomed a new cook following the retirement of the previous post holder. New menus have been developed incorporating suggestions from a residents’ survey. A new rolling programme of four weekly menus has been organised. The residents have approved the menus and they said “I like the food, it’s good and if you don’t like something there’s always an alternative” and “ I look forward to the meals.” A new extension is currently being built to provide a new and more spacious dining room. Residents said they were looking forward to using it. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 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 Residents in this home are confident that any concerns they may have are taken seriously and dealt with. The home has a procedure to protect people from harm. EVIDENCE: All residents and visitors spoken to said that they knew who to contact if they had a concern or complaint. They said that they expected any concern to be taken seriously and acted upon. They also said they did not have anything to complain about. Staff had been given training on how to respond to any suspicion or allegation of abuse. This subject is covered in the staff induction programme as well as during specific training sessions and in staff supervision. The home has its own policies and procedures in place together with Cumbria’s Adult Protection Policy for staff to refer to if needed. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 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): 22, 23, 24, 25, 26 Recent investment in a refurbishment and redecoration programme has improved the standards of some accommodation for residents. EVIDENCE: The home has adequate specialist equipment in place to assist the less mobile residents to move around as independently as possible. There are handrails fitted where necessary in corridors and stairways and overhead hoists in bedrooms where appropriate. A bedroom on the ground floor that is shared by two residents has been transformed through refurbishment to create a more comfortable and pleasant living space. All residents are encouraged to bring some of their own treasured possessions with them to make their rooms more homely. As mentioned earlier there is a new dining room under construction. On completion the living conditions for residents will improve because it will be more spacious and cooler in the summer than the current dining room in the conservatory. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 15 The home was clean and tidy and residents said that the housekeeping staff worked hard to maintain high standards and “this is how it always looks.” St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 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, 29, 30 The procedures for staff recruitment are sound and offer protection for people living and working in the home. The numbers of staff on duty during the day and night are sufficient to meet the needs of the residents. EVIDENCE: This home benefits from a low turnover of staff and the current staff team is well established. However the home does follow the necessary procedures and checks whenever new staff members are recruited to protect its residents from harm. The manager uses comprehensive system to audit and identify staff training needs. The training plan shows that training sessions on all of the mandatory subjects and 14 other topics is planned for every month of the year except August and December. This commitment to in-house training and NVQ qualifications ensures that staff are suitably qualified and have the necessary skills to do their job well. Staff members who were on duty were observed working competently with residents and colleagues. Residents confirmed that they were happy with the way in which staff provided personal care for them. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 17 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, 36, 38 The registered manager provides adequate direction, guidance and leadership for the staff so that residents are given consistent quality care. There are procedures and practices in place to ensure the health and safety and wellbeing of the residents, staff and visitors. EVIDENCE: The registered manager and the head of care are appropriately qualified and experienced senior managers in residential care. Areas of responsibility and accountability were clearly defined. Staff had been given training to protect themselves and residents from harm. This training included moving and handling, infection control, fire training, food hygiene and first aid. Records showed that risk assessments had been undertaken to identify potential and actual hazards and actions taken to ensure the health and safety of everyone living, working and visiting the home. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 18 The fire alarm and equipment tests had been carried out within the appropriate time scales and the entries into the fire logbook had been recorded correctly Staff members are supervised “on the job” and at handover sessions between the shifts. Matters were addressed as necessary to ensure safe and appropriate working practices. In addition some care staff are given formal supervision at least six times per year although records showed that there were staff members who had not been supervised as frequently. The manager should ensure that all care staff are given the same advantages to be gained from formal supervision sessions. . St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 19 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 X 3 St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action 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 OP3636 Good Practice Recommendations The registered manager should ensure that all staff receive supervision at least six times per year. St Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Gregory`s House DS0000022702.V249710.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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