CARE HOMES FOR OLDER PEOPLE
St James Court Milton Walk Doncaster South Yorkshire DN1 3QL Lead Inspector
Ms Rosemary Reid Unannounced Inspection 09:00 21 , 22 September 7 October 2005
st nd th 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.V263913.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 James Court DS0000033245.V263913.R01.S.doc Version 5.0 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 737807 Doncaster Metropolitan Borough Council Helen Booth Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places St James Court DS0000033245.V263913.R01.S.doc Version 5.0 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. 29th March 2005 Date of last inspection Brief Description of the Service: St James Court is a 24 bedded for older people, the home has two care units. One is a 12 bedded unit for older people requiring respite care the other is a 12 bedded unit for older people requiring rehabilitation in a residential setting. The home does not provide nursing care. The home is owned and operated by Doncaster Metropolitan Borough. St James is located close to the town centre. Respite care service users may stay for short periods of time e.g. overnight or longer periods depending on the why they require the respite care. Service users in the rehabilitation unit initially come on a 6-week placement offer from a hospital setting. Their needs are reviewed at the end of the 6-week placement and may be extended if necessary. The accommodation is all in single bedrooms and is on the ground floor. Necessary aids are provided as required. St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 21st September 11:30 – 3:30pm and the 7th October. 5:00pm – 6:30pm. Four staff that were on duty over the two of the three visits to the home, eight residents and were spoken with. Notices were placed in the entrance and corridor to inform residents, staff and visitors to the home that an unannounced inspection was taking place. Comment cards and prepaid envelopes were left at the home so that service users or their representatives can contact the CSCI with their views about the home, none of which has been received at the time of writing the report. The inspection focused on the requirements from the previous inspection, four residents files were case tracked along with medication, complaints, staffing rota and Adult Protection issues. The manager had recently returned to work after a long period of sickness and in her absence the deputy manager has managed the home with the support of the senior team. What the service does well: What has improved since the last inspection?
The organisation and the management of the home have taken action to comply with NMS, Care Home Regulations. New bedding and curtains for all bedrooms have been purchased and each bedroom has a chair. It has been agreed that a new carpet will be fitted from the hall to the dining room. Action has been taken in obtaining quotes for the following: installation of guards to radiators and for the further security of the building.
St James Court DS0000033245.V263913.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 James Court DS0000033245.V263913.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 James Court DS0000033245.V263913.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): 6 All residents who are referred solely for intermediate care have full assessments of their needs and are assisted to maximise their independence for their return to their own home. EVIDENCE: Prior to admission full assessments are undertaken by staff members employed at St James Court, whenever possible the assessments take place in the potential service users’ home or in hospital. The home has an Occupational Therapist and an Occupational Therapy Assistant and plus a Physiotherapist available to work with those service users assessed as needing rehabilitation. St James Court DS0000033245.V263913.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): 7, 9 The residents file and care plan system is clear and staff have received training on the care plan system however the care plans had not been reviewed on a monthly basis. Staff are working to the policies for the administration of medication, which promotes the wellbeing of residents EVIDENCE: The four residents files sampled had a pre-admission assessment and care plans and found that each service user had a current care plan based on their assessment needs. “Easy Care” documentation format is used with in the rehabilitation unit. Medication records were examined and found to be correct. St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 10 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): These standards were not assessed. EVIDENCE: St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 -18 The home has policies and procedures to protect service users from abuse. The home has a clear complaints system, which service users and relatives have used to register their grievances and/or concerns EVIDENCE: No complaints had been recorded from residents or their relatives. The organisation has a complaints procedure. Training is available and staff have received training on Adult Protection matters. All residents are issued with a contract/statement of terms and conditions to protect each resident’s legal rights. St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 12 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 - 26 Service users lived in a safe environment, which was clean pleasant and hygienic. EVIDENCE: All areas used by residents were clean and tidy without offensive odours. The home is centrally heated and there are toilets and bathrooms near to all communal areas and bedrooms. All bedrooms are single occupancy. Residents said the home was “lovely and clean” “ my room is very comfortable, it has everything I need”. Repairs had taken place and quotes had been obtained for guards to radiators and for the security of the building but no date was given for the work to commence. The manager stated that it has been agreed that a new carpet is to be fitted from the entrance hall to the dining room. St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 There were sufficient and suitably qualified experienced staff on duty that are trained in providing care for residents’ assessed needs. EVIDENCE: The staffing levels are four staff members on in the morning, three in the after noon shifts and two on night duty to ensure that service users have their care needs met. If there were an assessed need a third person would be put on the night rota. Four staff have NVQ level 2 and a further four staff are in the final stages of achieving the award. St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 14 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): These standards were mot assessed at this inspection. EVIDENCE: Action has not been taken with regard to the review and updating of the home’s policies. St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 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 Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X x St James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 16 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 OP19 Regulation Reg 23 Requirement All insecure skylights must be made bugler-proof to prevent further illegal entry into the home. The home’s policies must be reviewed and updated where necessary. Timescale for action 01/02/06 2 OP33 17 01/02/06 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 James Court DS0000033245.V263913.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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