CARE HOMES FOR OLDER PEOPLE
St Mary`s Haven Respite Unit St Marys Street Penzance Cornwall TR18 2DH Lead Inspector
Stephen Baber Unannounced Inspection 8th November 2007 09:00 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 Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Mary`s Haven Respite Unit 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 331982 01736 331982 The Presentation Sisters Denise Susan Maggs-Paulton Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 9. 30th July 2007 Date of last inspection Brief Description of the Service: St Marys Haven respite care centre is located near the town centre of Penzance, and has access to local amenities with good transport links. The facility provides accommodation and care for up to nine older people. Of the current residency, seven are permanent residents and two rooms are used to provide care on a short-term basis. St Marys Haven is an inter-denominational home working within Christian principals, and opportunities are provided for regular Christian services. Other denominations are also welcome at the home. Accommodation is provided on three floors, all of which are accessible by stairs and a lift. All the rooms are for single occupancy. The two bedrooms on the ground floor are dedicated to short term care residents who have access to bathing and toileting facilities close by. The respite care residents, share access to the dining and lounge facilities that are also located on the ground floor. Permanent residents bedrooms are located on the first and second floors of the home; all have access to nearby bathing and toileting facilities. All the rooms face the front of the building and there are some nice views of Penzance town. 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 Marys Haven is located near the town centre of Penzance. Fees range from £350 to £ 400 per week. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) have made changes to the way we inspect services. Known as Inspecting for Better Lives (IBL). We are now more proportionate when reporting our findings, and more focused on the experience of people using services. The purpose of the inspection was to ensure that resident’s needs are appropriately met, with good outcomes provided to them. We carried out the key inspection on the 8th November 2007. The inspection lasted for approximately 7:1/2 hours. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that residents’ placements in the home result in good outcomes for them. The inspection included interviews, some held privately in residents’ rooms and some in the communal area of the home, with residents and visiting relatives. Several members of staff were interviewed and there were opportunities to directly observe aspects of residents’ daily lives in the home and staff interaction with them. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the manager, senior administrator and trustees of the organisation.. The principle method of inspection was “case tracking”. This involves interviews with a select number of residents; staff caring for them and/or their representatives, and examination of records relating to their care. This provides a useful impression of how the home is working overall. At this inspection two residents files were case tracked, with particular reference to their individual and diverse needs relating to their age, culture and ethnicity, religion, gender, sexual orientation and disabilities. The current registered management arrangements at the home have finally been formalised after fourteen months without a registered manager. The manager was registered with the Commission in July 2007. What the service does well: St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 6 Prospective residents are assessed to make sure the provider is able to meet their needs, preferences and choices. The prospective resident is invited to participate in the assessment and the views of their relatives or representatives and any specialist workers involved are taken into account. Good arrangements are in place to meet residents’ health needs and health professionals regularly have contact with the residents. The doctor visited on the day of the inspection. Residents are very positive about the care and support provided and it is evident that positive and trusting relationships exist between the staff and residents. Residents also stated they were always treated with dignity and respect. Residents said they felt in control of their lives and were confident that staff positively responded to their requests and any directions they give about the care they receive. It was also evident that residents are able to make their own decisions and are treated in a dignified and respectful manner by staff. We observed relatives discussing the needs of their mother and they were very positive about the ways the staff were encouraging their mother to eat. Residents commented on the good standard of food provided which reflects the resident’s choices and preferences and promotes good health. There are no barriers to residents or visitors raising any concerns or complaints. Suitable procedures are also in place to positively deal with any issues. The environment is appropriately maintained and decorated and residents said it was comfortable and homely. A good standard of cleanliness and hygiene is maintained and residents are provided with appropriate disability equipment to assist their independence. This includes a shaft lift between the two floors. There is a communal area on the ground floor and a number of bathrooms and toilets are distributed throughout the home. These facilities are within a reasonable distance from communal areas and residents bedrooms. Residents’ bedrooms are appropriately furnished and all of the rooms have been personalised by the occupant. The manager has put in place suitable arrangements to measure and review the quality of the services and facilities provided. In addition there are reliable arrangements in place for the staff and manager to informally consult with residents and their visitors about the care and support provided. There is a very open management response to inspection and the development of the service. Comments received from residents during the inspection were; “I am at home here”. The staff are very kind and caring” I” I don’t mind paying the fee St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 7 because I receive a good service”. “You won’t find anything wrong here, it’s the best place to live and it is very comfortable.” What has improved since the last inspection? What they could do better:
In all fairness to the manager she has only been in post for four months and is committed to improving and fostering an atmosphere of respect and openness in which residents, family and friends and staff feel valued and that their opinions matter. Detailed feedback was given to the manager on the findings of the inspection and she was aware of the task ahead of her with reference to ensuring residents rights and best interests are safeguarded by the homes record keeping policies and procedures. The manager was given comprehensive feedback on the findings of the inspection. Whilst it is acknowledged that there have been improvements further work should be undertaken in the following areas: Residents care plans. The care plans should evidence that the care offered to the residents has been agreed with them. All residents or their representatives should sign the care plans to evidence their participation and agreement to the care offered. All staff should accept legal ownership of what they write by signing their full signatures in the daily records. Medication and health related activities. Two staff should witness the transcribing of medication onto the record sheets. Ongoing training should be provided for all staff who have a responsibility for administering medication. Policies and Procedures Policies and procedures should be reviewed and amended E.g. complaints procedure should have the contact details and telephone number of the Adult Social Care department who have a statutory responsibility to investigate complaints on behalf of people it commissions care for.
St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 8 Resident and Staff files. It is agreed that how files are maintained is a decision that rests with the manager. However resident and staff files could be more professionally presented to make the retrieval of information easier. Various standards and regulations inform good practice and there will be times when residents will want to access their files. Staff Supervision All staff must have regular supervision from management. This will ensure that all staff are supervised as part of the normal management process on a continuous basis. Staff Complement. Where residents have a high level of physical dependency in relation to perform the activities of daily living, staffing levels will need to reflect the needs of those residents. Management The duties of the manager are varied and many, therefore her day-to-day control of the delivery of care and how she should exercise her duties and responsibilities is pivotal to the success of the business. It is recommended that the trustees look at the many roles she plays and allow her sufficient time to provide care and management to the residents. At present if the manager is required staff have to leave the home and go across to the office, which is within the curtilege of the grounds. This situation is not always ideal for staff particularly in a crisies. 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. The summary of this inspection report can be made available in other formats on request. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 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 Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a full and detailed admission process at St Marys Respite Unit to ensure that the prospective needs of residents can be met. This whole process is thoughtfully and sensitively carried out. EVIDENCE: Care assessments records reviewed showed that the registered manager carries out a full pre-admission assessment prior to a new resident moving into the home. The care assessment records for two residents contained very clear assessments that formed the basis for the working care plans. Management and staff encourage people to visit the home prior to their admission and that their admission into the home is ‘tailored’ around their needs and wishes. There is a trial period of four weeks, which can be extended if required. This period of time allows time for the resident to settle, for consultation with the individual and for a full assessment of the individuals needs in order to ensure that the home are able to meet their needs.
St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 11 The residents I spoke with said that the manager prior to their admission assessed them and they felt involved in all its aspects. It would be good practice if all residents were encouraged to sign their care documentation to evidence their involvement and agreement. The daily records maintained within the home provide clear evidence that individual’s current and changing needs are identified and met. Clear information was in place to show the involvement of specialist services and professionals, ensuring a multi-disciplinary approach. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8,9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans; daily records have been improved on and are regularly reviewed and updated to reflect the resident’s currently changing needs and choices to ensure that the correct level of support is given. Residents health is monitored and appropriate action taken. The home seeks professional advice on health care issues and acts upon it. EVIDENCE: The manager has improved on the care planning. The new care plans inspected showed a clear understanding of the individual needs of resident’s, they contained clear guidelines for staff. In addition the care plans covered areas of identified need such as communication, social needs and emotional wellbeing, these recorded individual’s progress and any actions, which have been taken. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 13 Daily records and care planning information was in place for all of the two residents who were reviewed. The information in place recorded the individual’s preferred routines. We observed staff talking with the residents in a kind and caring manner and there appeared to good relationships established. The residents I spoke said that” they were happy with the skills and competence of the staff”. We also observed staff talking with residents, asking them their opinion, and offering choices. The care plans should evidence that the care offered to the residents has been agreed with them. All residents or their representatives should sign the care plans to evidence their participation and agreement to the care offered. All staff should accept legal ownership of what they write by signing their full signatures in the daily records. Privacy is upheld and staff support and manage resident’s personal private space in such a way that will not upset the individual. We were shown the medication administration systems in place at the home by a senior staff member. The staff member was fully conversant with their role and responsibility in this area and the importance of adhering to policies and procedures that are in place for the safe administration of medication. A review during the inspection revealed no errors. The medication was appropriately stored and was well organised. All medication records were up to date and in order. All staff handling medication should receive ongoing updating training in medication and it recommended that two members of staff should witness transcribing of medication onto the medication sheets. Care records showed evidence that residents are assisted in attending health care services and at the time of the inspection a doctor visited a resident and saw them in their own room. Residents are supported to access specialist healthcare services as required, such as hospital outpatient’s appointments. Residents we spoke with said that they are valued and respected by the staff that they couldn’t be in a better place. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and staff plan routines and activities of the home in a way, which meets the choice, and wishes of the residents with meaningful activities being arranged for those residents who wish to participate. Residents are given the opportunity to exercise some choice and control over their daily lives. The food in the home is of good quality, well presented and meets the dietary needs of the residents. The staff are experienced and meet the personal preferences of residents in the home. EVIDENCE: The management and staff support resident’s to become part of, and participate in, the local community in accordance with assessed needs and individual plans. Staff enables resident’s integration into community through knowledge and support to enable individual’s to make use of services and facilities. Documentary evidence and discussions with residents showed that
St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 15 that those living at the home are offered a variety of social, leisure and educational activities. Individuals are able to participate or not, this is dependent on the individual’s choice, age and general dependency. The residents told me that activities are regularly organised and they can choose if they wish to participate. The home has open visiting arrangements and residents can entertain their family and friends in their own room. We were told that the residents were looking forward to the Christmas activities and one lady said her husband visits her and is made to fell welcome. We shared a meal with the residents. There is attention to detail in the dining room with tables decorated with linen tablecloths and tablemats. Cold drinks and hot drinks were offered. The meal was soup, sausages two vegetable and boiled potatoes and rhubarb grumble for pudding followed with a cup of tea or coffee if so wished. The residents said the meals are very nice and they enjoyed the meal that day. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A suitable complaints and whistle blowing policy is in place and there are no barriers to residents, their representatives or staff raising any concerns. The training for all staff in Adult Protection needs to be improved to make sure residents are safeguarded. EVIDENCE: The manager or the Commission have not received any complaints since the last inspection visit. A satisfactory policy and procedure is in place to deal with any complaints and the manager is committed to dealing with any issues or concerns in a positive and efficient manner. Residents said there were no barriers to raising any concerns or complaints and they were confident that any issue would be dealt with promptly and to their satisfaction. It is recommended that the address and contact details of the Cornwall Adult Social Care department be included in the complaints procedures. The arrangements for protecting residents against any form of abuse remain in the process of development. The registered manager agreed that training and
St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 17 ongoing adult protection training is essential for all the staff. It is accepted that some staff have covered Adult Protection when they completed their N.V.Q. training. Staff spoken to showed an awareness of the policies and procedures in place to protect vulnerable adults. Recruitment practices carried out in the home protect residents from abuse, criminal records bureau and protection of vulnerable adults checks are carried out, and two written references are obtained before staff commence employment. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23,24, 25 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of furnishings and fittings in the home is good and overall a warm comfortable environment has been created ensuring residents needs individuals needs are met. EVIDENCE: St Mary’s Respite Unit is a warm and welcoming home. All rooms at the home are single occupancy and individual’s rooms were seen to contain appropriate furniture, carpets and lighting. Residents had personalised their own room with family photographs, pictures and ‘nick knacks’. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 19 The home is well maintained and has a homely feel, there is a pleasant dining room and a comfortable lounge for residents use. Residents were seen to be relaxing in these areas and referred to St Mary’s as ‘my home now’. The home is fully accessible for those with mobility difficulties and a shaft lift serves ground,first and second floor in the home. The home shows a good standard of housekeeping and no offensive odours are apparent. Good laundry facilities are provided and a resident spoken to confirmed their clothes were always well laundered and returned to them promptly in good condition. Protective clothing and hand washing facilities are provided for staff and resident’s bathrooms had paper towels and hand washing gel available The residents said to me that they are happy with the standard of accommodation and were very comfortable. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. As the needs of the residents increases sufficient numbers of appropriately trained staff should be on duty at all times to provide the care and support to meet the needs of residents. Robust recruitment, selection and vetting arrangements are in place that ensures staff have the required skills and that residents are safeguarded. Residents have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. EVIDENCE: We worked through the resident dependency levels on the day of the inspection with the senior care assistant. The residents dependency levels were assessed as medium dependency. The current staffing ratios have been calculated on the basis of additional staff at busy times of the day E.g. two hour overlap in the morning and evening. It is recommended that the staffing ratios are kept under constant review so that there are sufficient staff on duty to meet the total needs of the residents. As pointed out in the previous inspection report it was evident at the inspection that one member of staff during key times of the day does not safeguard and protect the residents. When staff have to leave the home to bring the meals from the kitchen it
St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 21 means that there is no staff to attend to any crisis that may occur or situations when the help of staff would be urgently required. Staffing ratios need to be calculated around delivering good outcomes for the residents and is not led by staff requirements. This needs to be urgently addressed. Not with standing what has been said there are clear aims and values in this home, which are individually focused and centre on the choice, rights and wishes of residents. Staff were able to clearly demonstrate this philosophy and it was evident that meaningful relationships had been forged between the staff and those living in the home. The evidence provided on staff training showed that of the nine care assistants five have successfully obtained a mixture of N.V.Q. level 2 and 3 and four mature staff have said that they do not wish to do the training. It is very important that staff are trained and competent to do their jobs. The manager is currently looking at what training she can make available for the staff. Training in fire, first aid, basic food hygiene, manual handling and infection control are essential to the smooth operation of the home and management must ensure that all staff receive ongoing training so that they are competent to do their jobs. Individual staff training profiles need to support this. St Mary’s enjoys a stable group of staff many of which have been working at the home for years. Staff who were interviewed said that they felt they were recruited fairly. Their recruitment records suggest that they were recruited on the basis of suitable checks and equal opportunities interviews that test their suitability to work with vulnerable adults in a care setting. It is recommended that staff files be better presented. Whilst the Commission do not make recommendations about how files should be kept, it is important for management that information is easily retrievable and professionally presented. Staff spoken with stated they felt supported and confirmed that the manager operated an ‘open door’ policy I.e. that is they felt able to approach her with any queries Comments made by residents during the inspection were; ‘The staff are very good and kind”, “nothing is too much trouble”’. “ My privacy and dignity is repected by the staff” “ one person said to me that they had lived in another home and did not like it there but now they are very happy in the home”. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,36 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements are in place to monitor the quality of the services and facilities provided. Ranges of measures are in place to promote safe working practices. Residents and staff benefit from the home being well managed. There is going to be clear leadership and a strong focus on the outcomes for residents in all management and development decisions. The home ensures that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team EVIDENCE: The atmosphere at the home at the time of the inspection was calm and relaxed with individuals looking clearly at ease and “at home”. The home displays a current certificate of Employer’s Liability Insurance.
St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 23 The manager has been registered with the Commission for four months. The registered manager is well supported by the trustees one of whom may visit the home daily. The Presentation Sisters have a have a high presence within the home and are involved with the day-to-day activities. The Registered Manager has the required qualification and experience; she is committed to managing the home effectively and meets its stated aims and objectives, as outlined within the homes statement of purpose. With two homes the manager has to have a sound understanding of both the needs of residents, staff and legislation relating to managing a care home. It is recommended that the roles and responsibilities played by the manager allow her sufficient time to meet the senior care staff to discuss areas of responsibilities which may include the support requirements of residents, staff training, future plans of the business. Regular staff meetings should also take place; these meetings ensure effective communication, lines of accountability, supervision for all staff and continuity of service. At present her current duties may not allow her the time to do this. In her time as the manager she has introduced new care plans that guide and inform staff. Residents said they felt in control of their lives. Comments from residents and staff in respect of the registered manager were positive, seeing her contribution to the home as valuable, supportive and a ‘good listener’. All felt they could approach her with any concerns or issues. The atmosphere at the home at the time of the inspection was calm and relaxed with individuals looking clearly at ease and ‘at home’. The home has a number of effective quality assurance and quality monitoring systems based on seeking the views of residents that are in place. These measure success in achieving the aims, objectives and statement of purpose of the home. At present the audit is undertaken at four monthly intervals. Discussion took place with the manager about this being a yearly exercise as recommended by the Commission. The yearly exercise or annual development plan could be based on planning, action and review reflecting positive outcomes for residents. The current quality audit carried out by the home is in the form of a questionnaire. Supervision for all staff must take place so that the residents know that staff are appropriately supervised. The manager said she will implement this area of her responsibility in the coming months. The manager advised that the trustees have contracted the services of a health and safety company to assist the manager to promote safe working practices and this includes a number of policies and procedures. Arrangements have also been established to positively manage risks that staff and residents may experience. The equipment and services at the home are regularly serviced and maintained and this includes the fire detection arrangements. The records in relation to fire and staff fire training were in sufficient detail and up to date. St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 24 All records seen at this inspection were appropriately and safely stored. Access was appropriately restricted St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x x 1 x 2 St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 10(1)(a) Requirement The registered person must keep under constant review residents dependency levels and if this increases employ staff in sufficient numbers to be on duty at all times to meet the health and welfare and needs of residents. The registered person must ensure that all staff are appropriately supervised as part of the management process on a continuous basis. Timescale for action 30/04/08 2 OP36 18(2) 30/04/08 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. Refer to Standard OP3 OP7 Good Practice Recommendations The registered person should encourage all prospective residents to sign their care documentation to evidence that they have agreed to the care to be offerd. The registered person should evidence that the care
DS0000008906.V354632.R01.S.doc Version 5.2 Page 27 St Mary`s Haven Respite Unit offered to the residents has been agreed with them. All residents or their representatives should sign the care plans to evidence their participation and agreement to the care offered. All staff should accept legal ownership of what they write by signing their full signatures in the daily records. 3. OP9 The registered person should ensure that two staff should witness the transcribing of medication onto the medication and that all staff who administer medication should receive ongoing medication training. The registered person should include the address and contact details of the Cornwall Adult Social Care department in their complaints procedure. The registered person should organise ongoing training for all staff in Adult Protection to safeguard all residents The registered person should be given sufficient time to develop her many roles and responsibilities and allocate her time to meet the senior care staff to discuss areas of responsibilities which may include the support requirements of residents, staff training, future plans of the business. Regular staff meetings should also take place; these meetings ensure effective communication, lines of accountability, supervision for all staff and continuity of service. 4 5 6 OP16 OP18 OP38 St Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Mary`s Haven Respite Unit DS0000008906.V354632.R01.S.doc Version 5.2 Page 29 - 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!
