CARE HOMES FOR OLDER PEOPLE
St Marys Haven Respite Unit St Marys Street Penzance Cornwall TR18 2DH Lead Inspector
Paul Freeman Unannounced 21 June 2005 10.00 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 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 Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service St Marys Haven Respite Unit Address St Marys Street Penzance Cornwall TR18 2DH Telephone number Fax number Email 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 331982 01736 331982 The Presentation Sisters Sister Francis Xavier Houlihan Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Service users to include up to 9 adults of old age (OP) for respite care Date of last inspection 8 November 2004 Brief Description of the Service: St Mary’s Haven respite care centre provides accommodation and care for up to nine older people. Of the current residency, seven are permanent residents and two rooms provide care on a short-term basis. There is a designated area for respite care, the bedrooms are on the ground floor, with access to bathing and toileting facilities close by. However the respite care service users share the dining and lounge facilities and can access the multi faith chapel located on the site as well as day care facilities. The respite care beds are booked a long way in advance due to the popularity and demand of this service. Accommodation is provided on three floors, all of which are accessible by stairs and a lift. All the rooms are for single occupancy. Permanent residents occupy the first and second floor of the home, all have access to nearby bathing and toileting facilities. All the rooms face the front of the building and therefore there are some nice views of Penzance town. The home has a garden, which service users can access.The Presentation Sisters of Penzance are responsible for the management of the home. Within the grounds is a registered Residential care home caring for twenty-six residents. A day centre, which caters for fifty people and a group of terraced flats. St Mary’s Haven is an interdenominational 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 Mary’s Haven is located near the town centre of Penzance.
St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over six hours. The Inspector looked over the building and at a number of records and documents. Five of the residents, three of the staff, one relative, the provider and registered manager were spoken to. The Inspector found the requirements and recommendations set at the last inspection had been worked upon. What the service does well:
Satisfactory arrangements are in place to assess the needs of prospective residents. This makes sure the care home is able to provide the care and support required by the person. The prospective resident is included in the process and their relatives or representatives are also consulted. The assessments will also take account of the views of professional that are in contact with the person. Prospective residents are able to visit the home to help them decide if it is a suitable setting. Each residents has a care plan that is regularly reviewed to make sure their needs and choices are accommodated. Residents commented they were very satisfied about the way in which their health needs are met. Reliable arrangements are also in place to store and administer prescribed medication. Residents are able to manage their own medicines when it is safe to do so. The visiting arrangements are flexible and the managers and staff of the home positively welcomes visitors. A varied and nutritionally balance menu is provided that reflects the residents preferences and choices. Refreshments are also readily available. Residents describe the food as homely and said they are satisfied with quality and choice provided. Reliable arrangements are in place to deal with any concerns or complaints. Residents and relatives commented that any issues of concern are dealt with efficiently, positively and in a satisfactory manner. Residents also commented they had confidence about raising any issues with the management or staff at the home. Sufficient numbers of staff are on duty each day and night to meet the needs of the residents. Where necessary additional staff is on duty to make sure that the required standard of care is not compromised. Residents commented they were very positive about the manner in which the staff undertook their duties and the standard of care provided. Residents said that staff were flexible and treated them with dignity and respect. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 6 The home is well managed and organised in an open and positive manner. The environment is well maintenance and satisfactory steps have been taken to provide a safe environment for residents and staff. 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 Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 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 standard(s) 3 and 5 Satisfactory arrangements are in place to assess prospective residents to make sure the home is able to meet the person’s needs. Flexible arrangements are in place for prospective residents to visit the home. This helps the person to make an informed decision about the facilities and services available. EVIDENCE: Residents that had recently begun to use the service commented they had been assessed and provided with the opportunity to talk about the care they required before they stayed at the home. The assessment documentation confirmed a satisfactory assessment had been completed that also took account of the views of other professionals in contact with the resident. The residents said they had opportunities to visit the home before the stay commenced. This helped them to make sure they were satisfied with the services and facilities available. Relatives commented they had been properly consulted during the assessment process and had been invited to visit the home during this stage of events. Residents said the staff had positively welcomed them whenever they have visited the home.
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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 standard(s) 7, 8, and 9 The care planning arrangements are satisfactory and the plans are regularly reviewed. This makes sure that up to date information about the services and facilities required are provided. Reliable arrangements are in place to meet residents’ health needs and to administer prescribed medicines. EVIDENCE: Each resident has a care plan that satisfactorily states the care and support required to meet the person’s needs. Residents commented they were very satisfied with the care provided and described the support they receive as “wonderful, kind staff and flexible arrangements”. Residents play a lead role in deciding the contents of the care plan to make sure their needs, preferences and choices are accommodated. The care plans are regularly reviewed with the residents to make sure they are up to date. Some of the reviews did not occur by the date stated on the records. The staff commented they are regularly consulted about the needs of the residents and their views are taken account of as part of the review arrangements. Residents said they are very satisfied about the way in which their health needs are met. Residents are also confidant that health services are accessed
St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 11 promptly and efficiently when required. The records at the home evidence this occurs. Reliable arrangements have been established for the storage and administration of medication and the staff responsible for this task has completed suitable training. Residents are able to administer their own medication when it is safe to do so. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 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 standard(s) 13 and 15 The visiting arrangements are positive and residents decide where they meet with visitors. The meals at the home provide a varied and nutritionally balanced diet that reflects the residents’ preferences and choices. Refreshments are also readily available to residents. EVIDENCE: Residents commented that positive arrangements were in place for visitors to the home. The residents were confidant that visitors are warmly welcomed and the residents decide where to meet with their visitors. Visitors said they were always well received and complimented the management and staff at the home about the high standard of communication that occurs. A suitable policy and procedure about the visiting arrangements has been established. The residents said they were very satisfied with the standard of food and meals provided. A varied menu is in place and residents are provided with a choice each mealtime. Some of the residents were unclear about the arrangements for making choices each day but were confidant they would receive a meal they enjoyed. The residents describe the meals as homely and home cakes are provided each day. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 and 18 Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: No complaints have been received by the home or the Commission following the last inspection visit. Satisfactory arrangements have been put in place to deal with any concerns or complaints that are outlined in the homes policy ands procedure. Residents and visitors commented they were confidant that any concerns or issues raised are dealt with promptly and in a satisfactory manner. They also said were no difficulties in raising any concerns or issues with the management or staff at the home. Satisfactory arrangements are also in place to protect residents from abuse and any allegations will dealt with formally. A satisfactory policy and procedure is in place to make sure that every reasonable step is taken to protect residents. A suitable whistle blowing policy and procedure is in place for staff. This gives staff the opportunity to raise any concerns about abuse and provides a further protection measure for residents. The home also keeps a compliments file where there are many votes of thanks from residents or their relatives. The comments include “reassuring in such good hands”, “great kindness”, “excellent care” and “thank you for being so nice”. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 0 The standards were not assessed. EVIDENCE: The Inspector noted no concerns regarding the environment or the facilities provided. The home presents as well maintained with a good standard of cleanliness and hygiene. Residents said they were very satisfied with the facilities provided. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Satisfactory arrangements are in place to recruit, select and vet new staff and offers protection to the people living at the home. The deployment and number of staff are on duty are sufficient to meet the needs of residents. EVIDENCE: Sufficient numbers of staff are on duty each day and night to meet the needs of residents. Additional staff is employed throughout the day at peak hours to make sure that care is provided at the time residents require. Extra staff will also be on duty if this is required to meet the needs of residents. Residents commented they found the staff to be helpful, flexible, efficient and reliable. This means that request for assistance are dealt with promptly and residents are able to direct the care and support they receive. The home have a relatively stable staff group who are experienced and a positive mix of skills is provided. Residents commented that staff treat them in a dignified manner that respect their privacy and rights. The recruitment, selection and vetting arrangements for new staff have improved since the last inspection and are now satisfactory. Appropriate records are maintained by the home which evidence that robust recruitment and selection arrangements are in place. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The home is well managed in an open manner to make sure that residents’ needs are choices are met. Satisfactory arrangements are in place to maintain a safe environment for residents and staff. Further attention needs to be given to the arrangements to minimise individual risks to residents. EVIDENCE: Residents, visitors and staff commented that the home is managed in an open and positive manner. It is evident the managers are approachable and committed to meeting the needs, preference and choices of the people in residence. The staff said they were well supported and advice and guidance was always readily available. The registered manager has considerable experience of care provision and regularly undertakes training to update her knowledge. Satisfactory arrangements are in place to provide a safe environment for residents and staff. Residents commented that the environment was clean and hygienic and maintained to a good standard. Satisfactory arrangements are in
St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 17 place to minimise any potential risks to the staff and residents’ health and welfare throughout the home. The assessment and management of additional risks individual residents experience need to be improved further. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 2 St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 19 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 Regulation NONE 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. 1. 2. 3. Refer to Standard 7 15 38 Good Practice Recommendations Reviews should be completed by the date set. Service Users should be aware of the arrangement in place for them to choose the meals they want. The risk assessments and management arrangements for service users should record the assesmnet undertaken and any action required by the staff. St Marys Haven Respite Unit D52-D04 S8906 St Marys Haven Respite Unit V215878 210605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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
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