Inspection on 04/06/07 for St James Court

This inspection was carried out on 4th June 2007.

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 James Court 20/05/08

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

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St James Court Milton Walk Doncaster South Yorkshire DN1 3QL Lead Inspector Ros Sanderson Key Unannounced Inspection 10:30 4th June 2007 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.V315229.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.V315229.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 NONE NONE 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.V315229.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 March 2006 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 of 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. The maximum charges made are £375 per week. This information was supplied on the 4th June 2007. Additional charges made for chiropody, hairdressing and personal newspapers. People using the service for rehabilitation are funded through the Primary Care Trust. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on a pre inspection questionnaire Comment cards returned from 5 service users, 4 staff, and 1 healthcare professional. A visit to the home carried out by one inspector. A site visit was carried out and lasted for four and a half hours. Six service users, one visitor and five staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. Observation of care practices in the home were observed, where appropriate. This helped the inspector to gain an insight of what life is like at St James Court for the people that live there. The manager, her staff and administrator assisted the inspectors during the day. The manager and her deputy were given feedback from the inspection at the end of the day. What the service does well: What has improved since the last inspection? St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 6 There were no requirements or recommendations made at the last inspection. The home continues to provide a valuable and valued service to people living in this area. 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.V315229.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.V315229.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use the service experience excellent quality outcomes in this area. All people using this service have full assessments of their needs and are provided with the means to maximise their independence for their return to their own home. We have made this judgement using a range of evidence, including a visit to the service. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 9 EVIDENCE: Before people are admitted to the home staff undertake a full assessment of their care and social needs. Whenever possible the assessments take place in the potential service user’s home or in hospital. People who use the services for respite care are charged according to their financial assessment. Respite care service users may stay for short periods ranging from overnight stays to longer periods depending on their needs. 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. People have access to an occupational therapist and a physiotherapist to assist their rehabilitation. Equipment is also provided such as walking bars and steps to practice on and regain independence. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 10 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 and 10. People who use the service experience adequate quality outcomes in this area. People receive care in a way that promotes privacy, dignity and respect. Medication procedures however have the potential to place people at risk of harm. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The care records of four people were looked at and all had comprehensive care plans in place. These plans gave good and clear information to staff about how the assessed needs of people are to be met. People commented, ‘The care cannot be faulted’ and ‘From the moment I came through the door the staff have gone out of their way to help me regain my independence.’ St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 11 Medications were checked and the people admitted to the rehabilitation unit receive their prescribed medication safely. People who are admitted for respite care, however, bring in their own individual systems for use. In some cases it is not always clear what medication has been prescribed, yet staff take responsibility for the administration of these drugs. Medication administration records are completed on admission but the entry reads, ‘Nomad’ rather than each individual drug. Staff are not aware of what drugs they are administering and if a drug was required to be omitted or stopped they would not know which tablet this related to. The manager stated that in some cases people brought medication in unlabelled bottles. One person had brought the inner part of a Nomad in and there was no record of the drugs contained within this. The manager stated she was aware of what was in the container and the list of drugs was found later in the day. These practices have the potential to place people at risk. Advice has been sought from the Commission for Social Care Inspection pharmacist and they advised that this is poor practice and that a new prescription should be requested when it is difficult to identify what drugs people are taking and if they are presented in a container other than what they were prescribed in. The original tablets could be returned to the person. In addition to this staff should sign for individual drugs and not for drugs entered on the MAR sheet as ‘Nomad’. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 12 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 and 15. People who use the service experience excellent quality outcomes in this area. People are satisfied with their lifestyles at the home. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There are no restrictions on times for visiting and people can see their visitors in private either in their own rooms or a quiet area in the home. Staff encourage people to do what they want such as discussion with each other, play dominoes, read newspapers and watch their favourite television programmes. If people wish to receive communion then arrangements are made for clergy to visit the home or for the person to attend church. Recently a greenhouse had been purchased and many people had enjoyed growing plants. Some people had said they would like more to do on an evening, however, it is clear that what is arranged is focused on promoting independence. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 13 People said that they enjoyed themselves and did not feel pressured to take part in activities. One commented, ‘People who will are encouraged to take part, but some prefer to spend time alone’ The food on the day looked nutritious and well balanced. People commented that they enjoyed the food. One said, I have never had a meal here that I didn’t enjoy’. Another comment received was, ‘The meals are nutritious, tasty and imaginative’. There is a ‘breakfast club’ where small groups of people use the kitchen to prepare their own breakfast. Again this is aimed at promoting independence. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 14 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 and 18. People who use the service experience good quality outcomes in this area. People feel they are listened to and protected. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The organisation has a complaints procedure that is displayed at the home and given to each person when they are admitted. There have been no complaints received since the last inspection, however, there were many cards and letters of thanks from service users and relatives. All staff have received training on Adult Protection matters. The local authority policy is available in the home. Staff spoken with are clear about their responsibilities. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 15 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 and 26. People who use the service experience adequate quality outcomes in this area. People live in a comfortable and pleasant environment, however one element within the home may place some people at risk. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: All bedrooms are for single occupancy. One person commented the home was ‘spotless, clean and fresh’. Another said, ‘My relatives have experienced care homes and have commented how fresh and clean the home is’ St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 16 The home is centrally heated and there are toilets and bathrooms near to all communal areas and bedrooms. All areas used by service users were clean and tidy without offensive odours. Aids and adaptations around the home encourage people to improve and maintain their independence. Radiators in the home are not guarded and the manager was unable to find the risk assessment. This has been provided since the inspection but was dated 2005 with no evidence of review. At the time of the inspection the radiators were not in use due to the hot weather. The risk assessment states that as clients only visit for short periods then having radiators guarded would give them a false sense of security and place them more at risk when they return home to unguarded radiators. People are admitted to the home for respite and rehabilitation. People may be in a frailer condition during their stay and are not familiar with their surroundings. The risk assessment must be reviewed and these points considered. The risk assessment must also look at the bedrooms where the beds are close to the unguarded radiators and so posing a greater risk to people. Once reviewed, control measures identified to reduce the risk must be put in place before the radiators are used again. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 17 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 and 30. People who use the service experience good quality outcomes in this area. People are cared for by a well trained and dedicated staff team. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The rotas provided showed that there is sufficient staff on duty at anytime to meet the needs of people at the home. All staff have an induction to the home that meets the ‘Skills for Care’ requirements. 50 of care staff have a qualification in care at NVQ level 2 or above. All staff receive the training they need to ensure people are cared for safely. Staff are regularly supervised and receive annual performance appraisals. People at the home appreciate the kindness and caring they receive from staff. One person commented, ‘Other carers should be sent here to learn the true meaning of care’. Another said, ‘I cannot fault the care’ St James Court DS0000033245.V315229.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 at least once during a 12 month period. 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. The manager promotes the welfare of people at the home, to ensure they remain safe the requirements in the report must be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Mrs Helen Booth is the manager and has managed the home since it opened as a respite and rehabilitation unit. Staff said they feel supported and valued by her and the senior team. St James Court DS0000033245.V315229.R01.S.doc Version 5.2 Page 19 Quality assurance systems in the home ensure that there is continual selfmonitoring of the services provided. Feedback from people using this service is actively sought and any issues acted upon. The line manager for the home undertakes monthly monitoring visits and the record is sent to the CSCI. People are encouraged to look after their own financial matters. If the manager was asked to look after any personal money then clear and accurate records are kept of transactions along with receipts. Health & Safety certificates were checked. The PAT testing certificate of electrical equipment was not available. The manager has confirmed that a request has been made for this. The risk assessments referred to earlier need to be reviewed and updated. They must then be kept under review. This will ensure peoples continued safety. St James Court DS0000033245.V315229.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 4 X X 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 2 St James Court DS0000033245.V315229.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 Standard OP9 Regulation 13(2) Requirement Timescale for action 15/06/07 2. OP9 13(2) 3. OP38 13(4(c)) Medication must only be dispensed from containers that are clearly labelled with the drugs name and the instructions for its’ administration. This will ensure that people receive the correct medication at the correct time and dosage. Staff must sign for individual 15/06/07 drugs on the Medication Administration Record and not for a group of drugs. This will mean that each individual drug is signed for and any discrepancies or omissions will be accounted for. The risk assessment for the 03/07/07 unguarded radiators must be revisited and take into account the fact that people may be admitted needing more care than is usual for them and do not know the environment well. In addition the risk assessment must address those bedrooms where the beds are close to the unguarded radiators. Once reviewed control measures must be implemented to reduce any identified risk. DS0000033245.V315229.R01.S.doc Version 5.2 St James Court Page 22 This will ensure that people are not at risk from burns from high surface temperature radiators 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.V315229.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 James Court DS0000033245.V315229.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. 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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