CARE HOMES FOR OLDER PEOPLE
St Marys Haven St Marys Street Penzance Cornwall TR18 2DH Lead Inspector
Paul Freeman Unannounced Inspection 31st January 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 Marys Haven DS0000008905.V266980.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 Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Marys Haven Address St Marys Street Penzance Cornwall TR18 2DH 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) 01736 368585 01736 331982 The Presentation Sisters Sister Francis Xavier Houlihan Care Home 26 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (26) St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users to include up to 3 adults aged over 65 with a mental illness (MD[E]) Total number of service users not to exceed a maximum of 26 Service users to include up to 26 adults of old age (OP) Service users to include up to 3 adults aged over 65 with dementia (DE[E]) 25th July 2005 Date of last inspection Brief Description of the Service: St Marys Haven is a residential care home registered to accommodate twentyseven residents over sixty-five years of age. The home is also registered to accommodate three older people who experience dementia. Sanctuary Housing Association along with the home is run by the Presentation Sisters of Penzance and the Sanctuary Housing Association owns the building. Within the grounds is another registered home for nine residents, a day centre for up to fifty older people as well as a group of terraced flats. St Marys Haven is an inter-denominational home working in a Christian atmosphere. Opportunities are provided for regular Christian services, Catholic, Anglican and Methodist Ministers may also attend to the spiritual needs of the service users. St Marys Haven is located near the town centre of Penzance and has access to local amenities with good transport links. The home is furnished and maintained to a good standard and is accessible for people who experience disabilities. A passenger lift is also provided at the home to allow easy access throughout. Communal space is situated on the ground and first floors. There are twenty one single rooms and three shared rooms and a high percentage of the bedrooms have ensuite facilities and been personalised by the occupants. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced inspection took place on 31 January 2006. The purpose of the inspection was to consider some of the key standards that include assessment and care planning, health and safety and staffing arrangements. The requirements set at the last inspection on 25 July 2005 were also considered. The registered manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also taken into account. The requirements and recommendations set at the last inspection had been worked upon and the registered manager, staff and residents fully cooperated and were very helpful throughout the inspection period. What the service does well:
Residents are able to manage their own medicines when it is safe to do so. Where residents require assistance robust arrangements are in place to store and administer medication safely. Generally the staff maintain good records and any unwanted medication is safely disposed. The staff has been appropriately trained about the administration of medication and a suitable policy and procedure to guide and direct staff is in place. Residents are very positive about the lifestyle they experience at the home and one said, “I have everything I need”. A range of activities and leisure pursuits are available at the home and the day centre that operates on the same campus. There are also no barriers to residents accessing the wider community when it is safe to do so. Resident’s stated they feel in control of their lives and are able to direct the care and support they receive. The residents commented the managers and staff were very attentive to all requests and made every effort to act on their wishes promptly. Positive arrangements are in place to deal with any concerns or complaints residents may have and to protect residents from abuse. Residents said there are no barriers to raising any issues or concerns and they are confidant these will be dealt with in an efficient and satisfactory manner. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 6 The home is maintained to a high standard and the furniture, furnishings and fitting are domestic in nature wherever possible. The layout of the home is satisfactory, generally accessible and comfortable. The home is regularly maintained and a programme of redecoration is in place. Residents said that any faults that occur are dealt with promptly and were very complementary about the standard of work and efficiency of the maintenance staff member employed at the home. Residents said they were very satisfied with the facilities provided and all were very pleased about their individual bedrooms that are also maintained to a good standard and many have been personalised by the occupant. Residents stated they were also very satisfied with the standard of hygiene and cleanliness that is maintained. Dedicated house keeping staff are employed who clearly work to high standards and maintain a positive environment that promotes residents health. Sufficient number of staff is on duty each day and night to meet the needs of residents and provide a safe place to live. Two waking staff is on duty overnight and are able to call upon a senior staff member if emergencies occur. Residents were very satisfied with the manner in which the staff undertake their duties and found staff to be responsive, reliable and efficient. Residents said they were able to direct their own care and the staff are readily available when they are required. Resident were therefore very complimentary about the care and support provided by staff and it is evident that positive and trusting relationship have been established between staff and residents. Staff is provided with a range of opportunities to undertake training and this includes courses about care, health and safety as well as NVQ training. A high percentage of the staff is trained to NVQ 2 standard and it is evident that staff has a wide range of skills and experience. The home is well run and managed and the management team actively support and advise staff on a day to day basis. The registered manager is experienced in social care and is committed to providing quality services and facilities. Residents and visitors are very positive and confident about the manner in which the home is run and commented they are regularly consulted about the services and facilities provided. Generally records at the home are well maintained and there are some good examples of record keeping. There are a number of policies and procedures in place to promote safe working practices and a safe environment for the residents and staff. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 7 What has improved since the last inspection? What they could do better:
Where a specialist worker has been consultes as part of the assessment process a suitable records should be made or obtained. Medicines that require refrigeration are securely stored in a dedicated refrigerator. However records of the fridges temperature are not maintained each day and this could adversely affect the medicines and place residents at risk. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 8 To ensure that staff training reflects the needs of staff an annual programme of training should be established. In addition individual training plans should also be in place for all staff. This will make sure that all staff has regular opportunities to further develop their skills. The vetting arrangements for new staff need to be improved in order that maximum protection can be provided to residents. 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 Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 9 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 Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 10 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. Satisfactory arrangements are in place to assess prospective residents needs to make sure they can be met at the home. The assessments would benefit from additional information from any specialist workers involved with the individual concerned. EVIDENCE: All prospective residents are assessed to make sure the home is able to meet their needs. The information collected also plays a key role in establishing a suitable care plan that reflects the persons needs, choices and preferences. Steps have been taken to provide more detail about the information to make sure a full picture is obtained about the care and support required. Prospective residents relatives or representatives are also consulted and the views are obtained of any professionals that are involved with the individual concerned. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 11 The records did not however confirm the providers access written assessment information from speaclist workers that are involved. The providers do not offer a dedicated interim care or rehabilitation service but it is evident that every reasonable step is taken to help resident to be as independent as possible. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 12 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 and 9. Each resident has a care plan that satisfactorily outlines the care and support required. This makes sure care is provided in a safe manner that reflects the individual’s preferences and choices. Robust arrangements are in place to safely store and administer medicines, which promotes residents health. EVIDENCE: Each resident has a care plan that outlines the care and support required and provides staff with information about the persons needs. A summary of the care plan is located in each resident’s bedroom and some of the residents said their record accurately outlined the services and support they require. The care plans are satisfactory for residents who are able to direct their own care and play an active role in meeting their own day to day needs. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 13 Where residents are not able to direct their own care there has been a marked improvement in the information provided. Consequently This staff are provided with appropriate guidance and direction about the care and support required which also takes account of the choices and preference of the person concerned. The care plans are regularly reviewed with the residents and staff to make sure they are up to date and the persons needs have not changed. A satisfactory record is made of the review in the residents’ records. Where appropriate the individuals care plan is also amended. Satisfactory and secure arrangements are in place to store and administer medicines safely. Residents are able to administer their own medication when it is safe to do so but where staff assist suitable records are maintained. The staff administering medication has been appropriately trained and a suitable policy and procedure to guide and direct the staff has been established. Medicines that are no longer required are safely disposed of and appropriate records are in place. Where required medicines are stored in a secure refrigerator but no records are maintained about the fridges temperature. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 14 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 and 14 Residents are able to have control over their lives and direct the care and support provided. Residents also experience a positive lifestyle that matches their expectations. EVIDENCE: Residents were very positive about the lifestyle they experiences at the home and one said, “I have everything I need”. Residents are able to participate in a range of activities and leisure pursuits at the home or in the day centre that operates from the same campus. There are also no barriers to residents accessing opportunities in the community when it is safe to do so. Residents stated they felt in control of their lives and were able to direct the care and support provided. Residents said the provider and staff were very attentive to their wishes and positively responded to any requests efficiently. Where required residents are able to have contact with advocates and there are no barriers to residents accessing their records if they wish. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 15 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. Positive arrangements are in place to protect residents and respond to any complaints or concerns. EVIDENCE: A satisfactory policy and procedure for dealing with complaints is in place and the Registered Manager or the CSCI have received no complaints following the last inspection on 25 July 2005. Each resident is provided with a copy of the complaint policy and procedure and the arrangements are satisfactorily stated in the statement of purpose and service users guide. Residents said there are no barriers to raising any issues; concerns or complaints and they are confidant that any issues will be dealt with efficiently and in a satisfactory manner. Satisfactory arrangements are also in place to protect residents from abuse and a suitable policy and procedure is in place to guide to direct staff if any concerns arise. Any allegations are reported to the appropriate authorities and where appropriate a formal investigation takes place. Suitable whistle blowing arrangements are in place for staff and this makes sure that staff can report any concerns to a third party if they feel unable to raise the matter with the providers. This provides further protection for the residents.
St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 16 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): 26. A high standard of cleanliness and hygiene is maintained at all times which promotes residents health and welfare. EVIDENCE: The home is maintained to a high standard and the furniture, furnishings and fitting are domestic in nature. The layout of the home is satisfactory, generally accessible and comfortable. The home is regularly maintained and a programme of redecoration is in place. Residents said that any faults that occur are dealt with promptly and were very complementary about the standard of work and efficiency of the maintenance staff member employed at the home. Residents said they were very satisfied with the facilities provided and all were very pleased about their individual bedrooms that are also maintained to a good standard and many have been personalised by the occupant.
St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 17 Residents stated they were also very satisfied with the standard of hygiene and cleanliness that is maintained. Dedicated house keeping staff is employed who clearly work to high standards and maintain a positive environment that promotes residents health. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 18 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, 29 and 30. Experienced and skilled staff is employed in sufficient numbers and provide high quality care that meets residents needs and offer a good quality of life. The recruitment arrangements have improved but new staff is not robustly vetted before they start work. This could place residents at risk. The care staff is appropriately trained and the training programme for 2006/7 is currently being developed. Training will further develop the service experienced by residents. Training for domestic staff could be improved to make sure that residents’ welfare is not compromised. EVIDENCE: The records show that sufficient staff is on duty each day and night to meet the needs of residents and to maintain a safe and hygienic environment. Additional staff is employed when this is required. Two waking night staff is on duty overnight and reliable on call arrangements are in place if assistance is required. Residents commented that staff promptly respond to any requests and there is no unreasonable delay when staff are called. Residents said they were very satisfied with the care and support they receive and found the staff to be reliable, flexible and responsive to any requests they made. Resident were therefore very complimentary about the care and support provided by staff and it is evident that positive and trusting relationship have been established between staff and residents.
St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 19 Residents also described the home as relaxed and cheerful and attribute these qualities principally to the staff and the manner in which they undertake their duties and responsibilities. The staff members therefore have a wide range of skills and abilities to meet the needs of residents. Staff said the home was an enjoyable place to work and a good spirit of cooperation and teamwork was in place. The records of recently appointed staff showed that steps have been taken to satisfactorily recruit, select and vet the candidates concerned. There has been an improvement in the records that are maintained but the arrangements to undertake Criminal Records Bureau and POVA checks are not satisfactory. This could potentially place residents at risk. The registered manager stated that all new staff were closely supervised and monitored until satisfactory checks have been completed. The records however did not support this. The staff group are appropriately trained and a good percentage has obtained NVQ qualifications. A rolling programme of NVQ and core skills training is in operation and one of the managers takes the lead role in coordinating training for care staff. The provider stated the training programme for 2006/7 was currently being developed and training g opportunities would be linked to staff appraisals. It was unclear who coordinates the training for the kitchen and domestic staff and one staff member commented they had not received any training in eighteen months. However a manager at the home now takes the lead responsibility for the training and induction of new staff. The staff member is also responsible for coordinating and providing manual handling training for staff. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 20 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, 37 and 38 The home is well run and managed for the best interests of residents and in a manner that actively advises, supports and directs the staff. Records at the home continue to improve but certain records keeping practices are not satisfactory. Improvements will make sure that robust arrangements are in place to protect residents. Satisfactory arrangements are in place to provide a safe environment for residents and staff EVIDENCE: The registered manager at the home is very experienced in the social care and is suitably qualified. The mangers actively support, advise and guide staff and regularly consult with residents about the services and facilities provided. The providers are taking steps to make sure that a manager has successfully completed the Registered Managers Award. In addition the homes administrator is currently undertaking business management training.
St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 21 The position of responsible individual is currently vacant but the registered manager said the providers had recently made an appointment to this position. Residents are positive about the manner in which the home is run and said this occurred in a way that made sure their best interests were the priority. During each year the providers consult with residents, staff, relatives or representatives and professionals about the services and facilities provided. This makes sure that positive quality assurance measures are in place and provides valuable information about the consumers’ view of the care and support provided. The records keeping arrangements at the home continue to improve and there are some good examples of record keeping. Satisfactory daily records are maintained on each resident that details the events that have occurred and any issues or concerns that arise. The records regarding staff and staff recruitment are not satisfactory at this time. The arrangements to manage risks have also improved and where any situation arises that could compromise the residents or staffs health or wellbeing a suitable assessment is completed and appropriate action plan developed. Therefore every reasonable step is taken to protect residents and staff. St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 22 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 4 STAFFING Standard No Score 27 4 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X X X 2 3 St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 23 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 OP29 Regulation 19 and sch 2 18(1)(a) (c) 9(2)(b)(i) Requirement Satisfactory Criminal Records Bureau and POVA checks must be completed as required by regulation. Domestic staff must be provided with appropriate training on a regular basis. The registered manager at the home must complete the registered managers award. Timescale for action 30/03/06 2 3. OP30 OP31 30/06/06 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP9 OP30 Good Practice Recommendations Records should be obtained or provided about the views and opinions of any specialist workers that are involved with prospective service users. A record of the fridge that stores medicines should be maintained daily. An annual training programme and individual staff training plans should be in place.
DS0000008905.V266980.R01.S.doc Version 5.0 Page 24 St Marys Haven St Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Marys Haven DS0000008905.V266980.R01.S.doc Version 5.0 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
