CARE HOMES FOR OLDER PEOPLE
St Joseph`s Albert Road Bognor Regis West Sussex PO21 1NJ Lead Inspector
Jennifer Wright Unannounced Inspection 8th February 2006 11:15a 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 Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 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 Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Joseph`s Address Albert Road Bognor Regis West Sussex PO21 1NJ 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) 01243 864051 Grace & Compassion Benedictines Sister Mary Breslin Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th September 2002 Brief Description of the Service: St Joseph’s is a privately owned Care Home registered to provide accommodation for up to 22 service users in the of category OP (Old Age). The establishment is a large detached house, which has been further extended to provide accommodation on three floors all of which are served by a vertical lift. All rooms are for single occupancy, are of generous proportions and have en-suite facilities. There is an area for car parking to the front and a private and well-tended garden to the rear. Housing to the rear of the property provides additional accommodation for residents’ visitors and a quiet dining room where residents can entertain their relatives and friends. An independent building (the Jubilee Room) has been erected in the garden and this is used as a venue for parties and other gatherings and any entertainment or activity being provided. It is also used to house the home’s extensive library of books, DVD’s and CD collection. There are independent catering and toilet facilities adjacent. A facility for charging wheelchair batteries is available. Situated in a quiet residential road in Bognor Regis it is approximately half a mile from the town centre and within easy walking distance from the seafront. The registered provider is the Grace and Benedictines (Organisation) and the Registered Manager is Sister Mary Breslin. St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second of a minimum of two statutory visits that an inspector must make to each care home during the course of a year. The first inspection, which was announced, was undertaken in October of last year. At this inspection the Inspector looked at standards that were not looked at during the previous inspection, or any issues or concerns raised about the home, since the last inspection. Some standards that were assessed at the previous inspection were not assessed on this occasion; the reader is advised therefore to look at the reports of both inspections for a fuller picture of the home. The Manager was present throughout the inspection. During this inspection the Inspector examined records of care being provided to the residents; as well as records of any accidents, issues, or complaints, to make sure that the residents at St. Joseph’s were being taken care of. In addition to talking to the Manager, the Inspector spoke with several staff members and residents, plus two visitors. The Inspector joined the residents for part of one of the afternoon’s activities, and talked to them, and other residents as to their views on the home. All the comments received from everyone that the Inspector spoke to were very complementary with regard to the home, the food, and the staff members. At this inspection St. Josephs was audited against the National Minimum Standards for Older Persons. All the elements in each of the standards assessed were met. The Inspector would like to thank everyone who cooperated with her on the day of this inspection. What the service does well:
The residents, who the Inspector met on the day of inspection, spoke highly of the staff members, the activities at the home, the cooking and their bedrooms. The building is maintained safely, and to a high standard. Records required by the Inspector on the day of inspection, were found to be in good order. The Inspector spoke to two visitors on the day of inspection and both said that they were extremely pleased with the standard of the home and of the care being provided. One visitor to the home told the Inspector that the person she visited was very happy at St. Joseph’s and “had a better quality of life since coming here”. A second visitor said that the person they visit is “a lot brighter” and clearly benefiting from the excellent care on offer at St. Josephs. The Inspector was told that St. Josephs does not use outside agency workers, thus ensuring that the residents always know their carers. There are numerous activities on offer at the home, which include a gardening club, film shows, constructing a model of a “thirties house”, outings, lunches, St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 6 outside entertainers, art and craft and going out for walks with a staff member, weather permitting. One resident goes out on his own in his “buggy” which is charged in the recently built “battery charger shed”. The Inspector saw many letters of appreciation from residents, relatives and visitors, which included comments such as ”she has come out of her shell and is enjoying life once again since going in the home”, “there is an excellent consistency of staff” and “walking into the home is a pleasure”. 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.
St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 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 Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 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): 4 and 6 Residents and their representatives know that St. Josephs will meet their needs. St. Josephs does not offer intermediate care. EVIDENCE: Evidence from care plans and staff training records confirmed that St. Josephs is able to meet the assessed needs of the residents accommodated there. Along with a comprehensive Statement of Purpose and Service Users Guide the Inspector was shown a video of what life is like at St. Josephs, which is made available to anyone thinking of coming into the home. The video includes comments from the Manager, staff members, residents and visitors to the home, and shows various events that have been held at the home, informing people what they might expect should they come and live at St. Josephs. The Inspector was informed that all prospective residents are assessed by a senior, trained staff member, and that specialist advice is sought where appropriate, in order that resident’s needs might be fully met. St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 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): 9 and 10 Residents feel they are treated with respect, and their right to privacy is upheld. EVIDENCE: There is a new “medicine room” at St. Josephs. The Inspector examined records of drug administration and saw that these, and all other records were maintained to a high standard. The Inspector saw that all residents electing to administer their own medication were only able to do so following a risk assessment, which involved their GP. This was recorded on the resident’s care plan, and monitored regularly. Residents spoken with on the day of inspection told the Inspector that staff members always treat them with respect. A visitor to the home confirmed this. Screens are provided where necessary, and staff members were seen to knock on resident’s bedroom door prior to entering. St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 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): 14 Residents are helped to exercise choice and control over their lives. EVIDENCE: It was evident on the day of inspection that residents are encouraged to make choices and to live their life the way they wish. Residents were seen to be able to undertake some gardening, follow their old hobbies, or learn new ones, such as using a computer. One resident told the Inspector that she was tracing her ancestry back in time, and was really enjoying how it was going. The Manager informed the Inspector that animals are as welcome at St. Josephs as people, and there was evidence of much loved pets, past and present. As well as encouraging pets in the home for the residents to befriend, the home recently had a “baby” day, where people with babies, who welcomed being fussed, over brought them into the home for the residents to hold. The Inspector was told it was a huge success. Throughout the home there was evidence in the form of photographs and videos of residents getting on with a life full of opportunities and enjoyment. St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 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): Resident’s legal rights are protected. EVIDENCE: The Inspector was informed that postal votes are obtained for residents, however, if a resident prefers transport can be arranged for them to go to the local polling booth. St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 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): 22 and 24 Residents have the specialist equipment they require to maximise their independence, and live in safe comfortable bedrooms with their own possessions around them. EVIDENCE: The Manager informed the Inspector that each resident is assessed upon entry to the home as to whether they need any type of specialist equipment, and that if they did it would be made available to them. One resident, rather than be moved from the room they have occupied for some time, has had a stair lift installed to enable them to remain where they wish to be. Where necessary grab rails, hoists, bathroom aids etc. are installed to assist the residents of St. Josephs in their daily lives. One resident’s cat was provided with a set of stairs leading from the resident’s bedroom window to allow the cat access to the outside world. Both cat and resident benefited from this arrangement. A recent addition to the home has been the installation of a wheelchair/buggy charger, allowing some residents a greater degree of freedom to come and go as they wish.
St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 13 During the course of this inspection, some of the rooms were visited to ensure that the environment was safe and comfortable for people who live there. It was noted that residents had brought personal possessions into the home, including small items of furniture, ornaments and photographs. People told the Inspector that they were very happy with their rooms. St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 14 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): These standards were not assessed on this occasion, however these standards were met at the last inspection. EVIDENCE: St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 15 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): 33, 34, 36 and 37 St. Josephs is run in the best interest of the residents. The home’s accounting and financial procedures, record keeping and policies and procedures safeguard residents. Staff members are appropriately supervised. EVIDENCE: It is apparent that the needs of the residents are uppermost at St. Josephs, and that the home ensures that resident’s rights and best interests are safeguarded at all times. The inspector saw that insurance cover is in place to meet the National Minimum Standards, and there is a business and financial plan for the home, which would be made available upon request. Residents are encouraged to manage their own affairs with the help of relatives or advocates. St. Josephs was seen to offer formal bi-monthly supervision to all care staff, which is recorded. St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 16 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 4 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 x X X X 4 X 4 X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 X 3 3 x St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Joseph`s DS0000014734.V281678.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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