Inspection on 20/05/08 for St James Court

This inspection was carried out on 20th May 2008.

CSCI found this care home to be providing an Good service.

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 James Court 04/06/07

St James Court 04/03/06

St James Court 21/08/05

St James Court 29/03/05

St James Court 07/10/04

St James Court 23/03/04

Similar services:

Snydale Care Home

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Larchfield Manor

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The Grove Waltham

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St James Court Milton Walk Doncaster South Yorkshire DN1 3QL Lead Inspector Christine Rolt Key Unannounced Inspection 20th May 2008 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 James Court DS0000033245.V363830.R01.S.doc Version 5.2 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 James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St James Court Address Milton Walk Doncaster South Yorkshire DN1 3QL 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) 01302 363696 01302 738114 NONE NONE Doncaster Metropolitan Borough Council Mrs Claire Louise Thompson Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To admit a service user under the age of 65 years of age One specific service user under the age of 65, named on variation dated 1st November 2004, may reside at the home. 4th June 2007 Date of last inspection Brief Description of the Service: St James Court is a 24-bedded care home for older people owned and operated by Doncaster Metropolitan Borough. The home is located close to the town centre. It comprises two care units, one for older people requiring respite care the other for older people requiring rehabilitation following a period of illness or incapacitation. The home does not provide nursing care. The private accommodation provided is all in single bedrooms and is on the ground floor. There are two lounges and two dining areas as well as kitchens for people using the service and their families and visitors to use. Necessary aids are provided to enable people to maintain and improve their independence. Information about the service is available in the form of a brochure and people are told about this service by social workers or hospital workers. A copy of the most recent inspection report is available in the home. Charges made for the respite services are dependent on a financial assessment. Fees range from £0 to £342.87 per week dependent on financial assessment. People using the service for rehabilitation are funded through the Primary Care Trust. Additional charges are made for private chiropody £15 to £18 and hairdressing from £6.50 upwards. The registered manager supplied this information during the site visit on 20th May 2008. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 10:00 am to 5:15 pm pm. The registered manager completed an Annual Quality Assurance Assessment (AQAA) before the site visit. This document gave the manager the opportunity to say what the home did well, what had improved and what they were working on to improve. Various aspects of the service were then checked during the site visit. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with the manager. The majority of people living at the home were seen throughout the day, and four were asked for their opinions of various aspects of the home and the care received. Two visitors and a district nurse were also asked for their opinions. Their opinions and comments are included in this report. The care provided for two people was checked against their records to determine if their individual needs were being met. Two members of staff were interviewed. Questionnaires were sent to 10 people who had spent time in this home, seven relatives and three health and social care professionals. However, none were available in time for their comments to be included in this report. The inspector wishes to thank people in the home, their visitors, the district nurse, staff, and the registered manager for their assistance and co-operation. What the service does well: People were encouraged to maintain their independence and this was observed throughout the site visit. The home was clean and tidy and there were no offensive odours. People thought the staff were friendly and kind and that they provided a good service. The meals were considered to be really good with sufficient choice, variety and quantity. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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 James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using this service had full assessments of their needs and were provided with the means to maximise their independence for their return to their own home. EVIDENCE: Records showed that people coming into this home for rehabilitation or respite were assessed and their needs were recorded. Assessments were checked and updated each time a person came for respite care. The manager was advised to include more information on people’s preferences e.g. whether they preferred a bath or shower and the frequency. The home’s ethos was for people to keep the skills they had and encourage independence, particularly where people were attending for rehabilitation. This was seen throughout the day and also noted in records e.g. self-administration of medication. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were treated with respect. Medication recording procedures were met. Care and health needs were met but care planning could improve. EVIDENCE: People living in the home looked well cared for, clean and appropriately dressed. They said they were happy living in the home. Staff were observed treating people with respect and kindness, and interactions were good. Two care plans were checked in detail. Daily records provided some information of how people had been throughout the day but did not always specifically show that a person’s individual needs had been met. Person centred care (covering physical, health, social and emotional needs) was discussed with the manager who said that she was already looking into this. Files contained risk assessments. Information of visits by health care professionals was included in files. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 10 Accidents were recorded and the manager showed that she had introduced an Accident Analysis Sheet that monitored any patterns to falls. This is good practice. The manager was also advised to introduce 72 hour monitoring sheets. These forms record the close monitoring of people who’ve had accidents or falls where no injuries are apparent at the time of falls and ensures that injuries are quickly noted. The medication system showed a marked improvement from the previous inspection. The manager said that she carried out random checks of medication as part of the quality assurance programme. Medication was stored securely and the medication trolley was clean and tidy. The medication for three people was checked. Each medication was signed and dated on receipt and quantities were recorded. All entries were handwritten and the manager was strongly advised to have handwritten entries countersigned to ensure that the correct information was copied. Instructions for use should also be copied and included on Medication Administration Record (MAR) sheets. There were no gaps in the Medication Administration Record sheets. Medication that needed to be kept cool was kept in the medication refrigerator. The temperature was recorded daily and this showed that the temperature was within the prescribed limits. Controlled drugs were stored in a controlled drugs cupboard. The controlled drug register was checked. Medication was recorded properly with two signatures and a diminishing total. People were encouraged to maintain their independence and administered their own medication within a risk management framework. Keys were provided for lockable facilities to enable them to do this. People said that they received the care and support they needed and were treated with respect and dignity. Visitors confirmed this. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were satisfied with their lifestyles at the home. EVIDENCE: There are no restrictions on times for visiting and people saw their visitors in their own rooms or in one of the communal rooms. Staff encouraged people to do what they wanted and people confirmed that they followed their own routines. One person said that she liked the music they played because it was old songs and she liked to sing along to them. Two people were playing dominoes in one of the communal lounges, several people were chatting with other people in the home. One person said that bingo was sometimes organised and a trip had been organised for the following day but she had chosen not to go on it. The manager confirmed that they had trips out about once a fortnight. Other people said that they could go out and the manager said that staff escorted people into the town centre, which was only a short walk from the home. The manager also added that people were St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 12 encouraged to keep to their routines therefore if they attended the day centre, then they were encouraged to continue with this. All meals were displayed on a menu board to inform people of the meals on offer. Meals were well presented and looked appetising. People were extremely pleased with the meals on offer and all comments were very positive. “Very good – good choice and if there’s nothing you like on the menu they will ask if they can bring you something else” “Really good” “You’d never go hungry here – they don’t know what small helpings are.” On two mornings per week the occupational therapists organised a ‘breakfast club’ where small groups of people used the kitchen to prepare their own breakfast. This promoted independence. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People felt they were listened to and protected. EVIDENCE: The complaints procedure was displayed and copies were given to each person when they were admitted. The complaints book was checked. There were three complaints that the manager had dealt with. There were also cards and letters of thanks from people who had used the service and their relatives. All staff have received training in Adult Protection in 2005 and all new employees received this training as part of their induction. The manager intended for all staff to have refresher training in safeguarding procedures. The South Yorkshire safeguarding procedures manual was available in the home. Three staff were asked about adult protection and all were clear of what this meant and their responsibilities. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a comfortable, clean and pleasant environment, but safety could improve. EVIDENCE: All parts of the home were clean and tidy. There were no offensive odours. Aids and adaptations were available throughout the home. Furniture was in good condition. None of the radiators were cool touch or were fitted with guards. The manager said that she had tried to get something done about the radiators but did not have the authority. She had updated the environmental risk St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 15 assessments and rearranged furniture to try to reduce the risks. There is a constant turnover of people going to the home for respite and rehabilitation and where people are likely to be on their own e.g. bedrooms and possibly lavatories, there is a higher risk associated with unguarded radiators. At the time of this site visit, the radiators were not in use because of the warm weather. After the site visit, the inspector contacted Doncaster Corporate Health and Safety who arranged for a Safety Advisor to visit the home. He advised that the home identify the radiators that pose a potential hazard to people coming into the home and that these radiators must be made safe. Advice was given on how this could be achieved e.g. cool wall radiators, radiator covers. He also left contact details to have the radiator temperatures checked. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are cared for by a well trained and dedicated staff team but improvements could be made to recruitment procedures. EVIDENCE: There were sufficient staff on duty to meet the needs of people at the home on the day of the site visit. Staff said that they considered there were sufficient staff but they were sometimes short staffed during holidays or sickness. Staff recruitment documents were kept centrally in the Human Resources Department. The manager was asked to make available the files for two of the most recently employed staff. When these two files were checked, the Criminal Records Bureau (CRB) disclosures were dated 2002 and 2004 respectively. When the manager rang the Human Resources Department to determine whether more up to date CRB disclosures with Protection of Vulnerable Adults (POVA) disclosure information were available, she was informed that because both members of staff had continual employment with the local authorities then no new documentation was needed. Therefore neither employee had been checked on POVA because they were employed before POVA commenced. The manager was told that the local authority St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 17 would be aware of any referrals to POVA, as they would be the ones making the referral. However, this does not take account of staff working, without the local authority’s knowledge, for any private organisation. Therefore, as a sign of good practice it is strongly recommended that new CRB and POVA disclosures be obtained every few years and particularly where people change jobs within the organisation. All staff had induction training that met the ‘Skills for Care’ standard. More than 50 of care staff had the National Vocational Qualification in care at Level 2 or above. Two staff were interviewed and asked if they had received any skills training. Both said that they had but that it was several years ago. The manager was advised to look at training to enhance staff skills and promote awareness e.g. sensory awareness, continence care, tissue viability, and diabetes. Staff received supervision and annual performance appraisals. People were full of praise for the staff. “Very good – and friendly” “Very kind” “Very nice” “Excellent” Comments were, St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager promotes the welfare of people at the home, and it is run in their best interest. EVIDENCE: Since the last inspection, a new registered manager was in post. Staff said they felt the manager was proactive and ensured that everything was done to promote the best interests of people coming into the home. The manager had achieved the Registered Managers Award. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 19 The home had a quality assurance system that included audits of systems and records within the home and safety checks of the environment (but see also Environment). Residents’ meetings commenced four months ago and residents said they were aware of the most recent one and some had participated. The manager said the relatives were also invited to participate if they were visiting people in the home. As part of the discharge planning, people were asked to complete a questionnaire about their experience of being in the home. The manager informed the CSCI of any incidents that affected people living in the home and the responsible person carried out visits to the home and produced reports as required in regulations 37 and 26 respectively of the Care Home Regulations. The majority of people in the home looked after their own money and lockable facilities were provided. Money that was held by the home on people’s behalf was stored securely. Two people’s money was checked against their records. Cash tallied with the records and numbered receipts were available for purchases made on their behalf. Records were available to verify that weekly checks of fire safety systems were carried out. Fire drills were held regularly to ensure that staff knew what to do. Certificates were available to verify that systems and equipment within the home had been serviced and maintained within the required timescales. Mandatory health and safety training (i.e. moving and handling, basic food hygiene, emergency first aid, infection control and fire awareness) was ongoing and a staff training matrix was available with dates of the most recent training. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 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 X X 3 X X 3 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 21 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 2 Standard OP7 OP25 Regulation 15 13 Requirement Daily records must verify that people’s individual needs have been met. Radiators must be made safe in accordance with Health and Safety advice given by the Safety Advisor Timescale for action 17/06/08 12/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP3 OP8 OP9 Good Practice Recommendations Including people’s preferences on their assessments would ensure that their wishes were considered. Implementing 72-hour accident monitoring sheets would ensure that injuries would be highlighted quickly where no injury was apparent at the time of a fall. It is strongly advised that handwritten entries on Medication Administration Records (MAR) are checked and signed by a second person to verify that all the relevant information has been copied and is correct. As a sign of good practice it is strongly recommended that Criminal Record Bureau and Protection of Vulnerable DS0000033245.V363830.R01.S.doc Version 5.2 Page 22 4 OP29 St James Court 5 OP30 Adults checks are carried out at regular intervals and particularly where people change jobs within the organisation. Skills training would enhance staff knowledge of people’s needs. St James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 James Court DS0000033245.V363830.R01.S.doc Version 5.2 Page 24 - 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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