CARE HOMES FOR OLDER PEOPLE
St Helens Care Home 6 Manor Road St Helens Auckland Bishop Auckland DL14 9DL Lead Inspector
Belinda Parker Unannounced 25 April 2005 09:30 am
th 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 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 Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service St Helens Care Home Address 6 Manor Roadm St Helens Auckland, Bishop Auckland, County Durham. DL14 9DL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01388 606 093 01388 607 962 Southern Cross Healthcare Services Ltd Care Home 48 Category(ies) of MD Mental Disorder - 19, DE (E) Dementia over registration, with number 65 - 29, DE Dementia - 5, PD Physical Disability of places - 5, A Alcohol Depend past present - 5 St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th October 2004 Brief Description of the Service: St Helens is a forty-eight bedded home that provides 24hr care for people with mental health needs mainly dementia.The home is situated in St Helen’s West Auckland near Bishop Auckland.The accommodation is purpose built for the needs of the service users. The home consists of two units, upstairs is nursing and residential for older people with mental health needs and downstairs the “Lister Unit “ provides nursing input for nineteen younger people with enduring mental health problems. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on the 25/4/05 and the 27/4/05 over 7 hours. During the inspection time was spent talking to service users and staff. We looked around the building and a number of records were examined. The home has had a change in management since the last inspection. The new manager is currently going through the process of registration with the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection?
Since the last inspection a new manager has been appointed. Comments from service users and staff spoken to during the inspection were complimentary of the managers style and approachability. POVA training (Protection of Vulnerable Adults) has been completed for all staff, which provides staff with the knowledge to deal with an incident of abuse if it occurs, and to protect service users who live there.
St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 standard(s) 4 and 5 There is a clear and comprehensive system of admission in place to ensure that the home has the capacity to meet the needs of prospective service users. Service users and their relatives are given time to make a decision on whether the prospective person wishes to move in to the home. EVIDENCE: The staff member in charge was able to demonstrate the home’s capacity to meet the assessed needs of individuals admitted to the home. Training records examined showed that staff working in the home collectively had the skills to deliver the services and care which the home offers. Individual service user’s care plans contained a record of input from other health care professionals. The staff member in charge said prospective service users and their representatives are invited to visit and spend time in the home with other service users’ and staff before they make a decision to stay. One service user spoken to said he felt strange when he moved in but the staff soon made him feel settled.
St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 standard(s) 7, 8, and 9 The systems in place for care planning, maintaining the health of service users and administration of medication are good ensuring involvement and protection of service users living in the home. EVIDENCE: Four service users’ care plans examined showed that they were generated from a comprehensive pre-admission assessment. Each plan set out in detail the action which needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the individual service user were met. The manager and key workers audit and evaluate individual users’ care plans on a monthly basis involving the service user in the process. Records examined in the care plans showed that service users’ health needs are maintained and the manager ensures the service users’ have access to health care services to meet assessed needs. An audit of the system in place for administration and safe keeping of medication was found to be in keeping with the home’s policy and procedures.
St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 10 Receipt and disposal of controlled drugs in the home are recorded in the Controlled drugs registered and stored in an appropriate locked facility. Service users care plans contained an assessment as to the ability of the service user to self medicate. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 standard(s) EVIDENCE: This standard section was not assessed at this inspection. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 standard(s) 18 The manager and staff have a good understanding of the POVA process, which ensures the protection of service users living in the home. EVIDENCE: Records examined showed that since the last inspection all staff working in the home had attended training on POVA (Protection of Vulnerable Adults). Staff spoken to during the inspection were able to demonstrate that they had a good understanding of POVA and said they would report any incidents of abuse to protect service users. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 standard(s) 19 and 22 The home had the necessary disability equipment in place to meet the collective needs of the service users. A thorough review process in place to meet the physical changing needs of individual service users. The general standard of décor and some furnishings and carpets were poor giving the appearance of a drab and dull environment for the service users who live in the home. EVIDENCE: On touring the home we observed that generally the standard of décor in the home was poor and in some areas furniture, furnishings and carpets were worn and stained. The manager said a new senior management structure is in place within the company and they are aware of internal enviromental issues that need to be addressed. Care plans examined showed evidence that prior to admission a full assessment of service users needs had been carried out by persons trained to do so, to ensure the home had the capacity to meet their individual needs. The company employs an Occupational Therapist who is available to review
St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 14 service users with the manager where there is a change in physical need to ensure the right equipment is obtained to meet their individual needs. A range of disability equipment was observed to be available in the home to meet the collective needs of the service users. Records showed this equipment was regularly serviced for the health and safety of service users of service users. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 Staffing levels reflected the collective and specialist needs of service users living in the home. Thorough recruitment procedures were followed for the protection of service users. The management have a positive approach to staff development to ensure a good standard of service delivery to the people who live in the home. EVIDENCE: Duty rotas examined showed that staff where employed in adequate numbers with the correct skill mix to meet the collective needs of the service users. Staff spoken to during the inspection were able to demonstrate their role of responsibility. Records showed that care staff are continuing to work towards achieving NVQ2 in care, with some care staff having achieved NVQ2 progressing to the next level. Care staff spoken to said they were positive towards developing their skills and knowledge to enable them to deliver a good standard of care to service users. The home has a thorough recruitment and induction process in place to ensure the protection of service users. Records examined contained evidence to show that appropriate Criminal Records Bureau checks had been carried out on all staff prior to appointment. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36, 37 and 38 The home is managed by an experienced person with the appropriate qualifications who ensures the home is run in the best interests of the service users. Service users financial interests are protected by sound financial and accounting procedures. The health and safety and welfare of service users and staff are promoted and protected by robust policies and procedures. EVIDENCE: Since the last inspection a new manager has been appointed, who has the experience and required skills to manage the service and ensure the protection of service users. The manager is currently going through the process of registration with CSCI. The home has a quality assurance and monitoring system in place with evidence of system audit done on a monthly basis to ensure the home is run in the best interests of the service users.
St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 17 Service users are safeguarded by sound financial systems being in place for the effective and efficient running of the business and for money held on behalf of service users in the home. A copy of the current business plan is available in the foyer for service user and visitors information. A system of formal supervision for all staff is in place, which covers all aspects of practice, philosophy of care and career development. Staff spoken to said this was a beneficial exercise to enable them to enhance their professional role and knowledge base to enable them to deliver a good care service to the people who lived in the home. Records for the protection of service users examined were current and up to date with reference to care planning and review, recruitment, health and safety, financial, medication and policies/ procedures. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 1 x x 3 x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x 3 3 3 3 3 3 St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 19 Are there any outstanding requirements from the last inspection? 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 19 Regulation 23 Requirement The registered person must ensure the internal environment is redecorated and furniture and furnishings that are worn are renewed Timescale for action 1/1/06 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. Refer to Standard 31 Good Practice Recommendations The manager should achieve the Registered Managers Award in this current year. St Helens Care Home B54 S749 St Helens V223044 250405 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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