CARE HOMES FOR OLDER PEOPLE
St Marthas Residential Home 17 Thornhill Park Sunderland SR2 7LA Lead Inspector
Mr Clifford Renwick Announced Inspection 8th February 2006 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 Marthas Residential Home DS0000015725.V271918.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 Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Marthas Residential Home Address 17 Thornhill Park Sunderland SR2 7LA 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) 0191 565 6443 0191 510 8810 Ms Gwendoline Swalwell Care Home 24 Category(ies) of Dementia (8), Mental disorder, excluding registration, with number learning disability or dementia (4), Old age, not of places falling within any other category (24) St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: The home provides care to older people over the age of 65 years some of who may have dementia or mental health needs. It provides personal care only and any health needs are dealt with by the Community Nursing Services. It is not registered to provide care for people with a physical disability. The home also provides a day care service in a separate designated area of the home, a domiciliary care agency as well as a meals at home service none of which impinge upon the care home. The house is Victorian in construction and three storeys high with most of the bedrooms being on the upper floors. The house is semi detached and extensions over the years have been added. There is a large garden and paved terrace area to the front of the home with an arrangement of seating that can be used by the residents and their visitors. The home is sited in a quiet tree lined street, which has a number of other residential and educational facilities in close vicinity. It is only a short walk into the City Centre where there are a range of services and shops. St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was carried out as part of the statutory twice-yearly inspection process. Prior to the inspection a questionnaire was issued to the owner and this was returned to the commission with updated information about the service. In addition to his comment cards were made available to residents and their relatives in order that they could offer a view on the service. A total of 16 comment cards were returned. Selected areas of the premises were viewed which included all communal areas and several bedrooms. A range of records were examined which included residents care records as well as records that related to health and safety and staff employed in the home. Discussion took place staff and also with residents and lunch was taken with residents in the dining room. Time was also spent observing staff practices. It was established in discussion that the people who live in this home prefer to be known as residents and this term of reference is used throughout the report. The judgements made are based on the evidence available at the time of the inspection. What the service does well:
Good use continues to be made of accessing community facilities such as the shops and local community clubs. Residents are encouraged to pursue their chosen religion and arrangements are in place to support this. A number of residents have been supported by staff to go on pilgrimage to Lourdes in France and this has taken place two years in succession. This year will be the third year that residents will have the opportunity to take part in this. This is a successful event and this year the home have featured in the Diocese magazine as well as having had photographs published on the Diocese website. St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 6 There is a nice atmosphere in the home and the building is clean and tidy and furnished to a good standard. The activities coordinator ensures that a range of appropriate activities is available for the residents. A number of comments were made by residents and their relatives in the comment cards, some of which are reflected below. “Complaint made about the laundry and the situation is under review”. “I am very happy here, the staff are all my friends and I feel safe here”. “My mam has been in the home two years and I have never had reason to complain”. “It puts my mind at rest knowing my mam is well cared for”. “Staff are very welcoming making you feel comfortable at all times”. Discussions held with residents confirmed that they are satisfied with the services provided in the home. What has improved since the last inspection?
A training plan is now in place, which demonstrates what training staff will be receiving over the next 12 months. In order to reward staff the owner has introduced an employee of the month scheme, which has financial benefits for the employee. Care plans, appropriate health care charts, assessment tools and review forms have continued to be developed and implemented and overall the records systems are showing signs of positive improvement. A new staff handbook that contains the homes policies and procedures has been developed and a copy is to be made available to all staff. Three bedrooms have been refurbished and fitted with good quality furnishings. St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 7 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 Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 8 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 Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 9 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): 1, 2, 3, 6 A range of information is available which enables prospective residents to make a fully informed choice about where they would like to live. Good assessment information is available about residents, which confirms that the home can meet their needs and this helps staff to design care plans. The owner confirmed that each resident is issued with a copy of his or her terms and conditions of residence however these were not available for examination. This home does not provide intermediate care. EVIDENCE: A Statement of purpose and service user guide is in place and is accompanied with a brochure of the home. This is available to give out to anyone who makes an enquiry about the home. The documents contain information about the services provided in the home. Examination of case files for the three most recent admissions to the home confirmed that both the home and the placing authority had completed assessments in order to ensure that their needs could be met in the home. A copy of the standard contract, which sets out the terms and conditions of residence, was seen.
St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 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, 10 Staff at the home successfully supports residents with their social, health and personal care needs in a way, which treats them with respect and promotes their rights and privacy. However this is not always recorded in detail in the care plan. EVIDENCE: Care plans are in place for individual residents and a case tracking exercise focused on three residents. The care plan is introduced following admission and information from the assessment tool is used to focus on what are seen as immediate needs. These are reviewed monthly then amended if required. Care plans are continuing to be developed in a more structured way and now include additional information such as fluid balance charts where appropriate. In addition to this the care plans confirmed that advice is sought from health professionals if required. One resident who is totally dependent on staff for all aspects of care is receiving this. However the detail of the work carried out by staff is not recorded in the care plan.
St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 11 The care plans examined identified residents personal choices and likes and dislikes and this was positive The care plans also confirmed how a resident was able to maintain contact in the community and visit their club on a weekly basis. As a way of supporting a resident with their independence the home have provided the resident with a fridge in their room for storing drinks and items of food. Observations confirmed That staff are respectful towards residents and any intimate care tasks were carried out in the privacy of the resident’s own bedrooms. St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 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): 13, 14, 15 Residents are offered the opportunity of participating in a range of leisure and social activities enabling them to lead active and fulfilled lives. Friends and families are encouraged and involved too. The meals provided offer a good balanced diet and contribute to the promotion of healthy eating and service users are involved in menu planning. EVIDENCE: Several of the residents go out to an “over 60’s” club and this is supported by staff. An activities coordinator is involved in arranging a number of activities for the residents many of which include craftwork and making items for the home. Recent events in the home have been themed Italian nights when Italian food was served. And a forthcoming event is a cowboy night later in the month. Some residents spoke of an outing that was planned for later in the week when they would be going to a local school to see a musical, the Gondoliers. An event that they said they were looking forward to. There are no restrictions on visiting times and families can visit whenever they wish.
St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 13 Lunch was taken with a group of residents and this was an enjoyable experience. The meal was nicely presented, sufficient in quantity and very tasty. Following discussion with staff after the meal arrangements were put in place for menus to be displayed on each table in order that residents could be informed of what was available. Discussion with residents confirmed that they enjoyed the meals and they stated that mealtimes were always unhurried and relaxed. St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 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 The home has a satisfactory complaints system. Complaints are handled appropriately and the outcomes used to improve the service. EVIDENCE: Discussion held with the owner confirmed that there had been one complaint and this had been dealt with. The records to confirm this were not available for examination. However a relative survey card received prior to the inspection confirmed that they had made a complaint and this had been dealt with satisfactorily. St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 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, 26 Improvements have been made to the building, which ensures that resident’s needs are met. However the exterior of the building needs to be fully decorated and remedial work carried out to the cement work. The building is clean, warm, homely and attractive offering residents a pleasant environment in which to live. EVIDENCE: A number of bedrooms were seen on various floors throughout the building. Rooms are well furnished with a mixture of resident’s own personal items and good quality furnishings supplied by the home. There were no noticeable hazards and all areas viewed were clean. A good standard of housekeeping was evident throughout the home. Some interior changes have been made in the last 12 months as part of a variation to the registration of the home. There are some outstanding works that need to be addressed to the exterior of the premises. This was discussed with the owner and becomes a requirement of this inspection.
St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29, 30 The deployment and number of staff on all shifts ensures that at all times service users are supported by an experienced group of staff. Staff recruitment practice and record keeping in respect of new staff employed in the home, is robust and offers sufficient information to ensure that residents are protected. EVIDENCE: A copy of the annual training plan confirmed that a range of training courses have been organised for staff for the next 12 months. The training plan also includes specialist training in dementia care. Copies of staffing rotas confirmed that sufficient staff were on duty to meet the needs of the residents. Appropriate documentation in respect of staff recruitment is obtained and kept in the home. Staff morale in the home is good and a the owner has now introduced an employee of the month scheme which has an advantage in that staff who achieve this are awarded £50.00 of Debenham’s vouchers. St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 17 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): 35, 38 Appropriate records are in place to ensure that any monies held on behalf of the residents are dealt with appropriately. A well-managed staff team promotes the health and safety of the service users. EVIDENCE: The home handle small amounts of money on behalf of residents and records that record any transactions carried out on their behalf are kept. These are satisfactory and include receipts for any purchases made on behalf of residents. Records of accidents are kept and these include action taken by staff but not the outcome. Examination of the fire logbook confirmed that appropriate fire drills and fire instruction is carried out with staff. Staff sign a record sheet when they have received fire instruction.
St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Requirement A copy of the terms and conditions of residence must be issued to each resident. A copy of this document must also be kept on each residents file. Residents care plans must continue to be developed as advised within this report. Mealtime practices must be reviewed as discussed during the inspection. The exterior of the premises must be decorated and all remedial works as discussed during the inspection must be addressed. Timescale for action 31/05/06 2. OP7 14 31/08/06 3. 4. OP15 OP19 16 23 30/06/06 31/05/06 St Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 20 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 Marthas Residential Home DS0000015725.V271918.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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