Inspection on 01/12/05 for St Matthews

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Matthews 22/05/07

St Matthews 04/10/06

St Matthews 06/06/06

St Matthews 20/06/05

St Matthews 12/10/04

St Matthews 14/09/04

St Matthews 20/04/04

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Matthews Chequers Lane Redbourne Herts AL3 7QG Lead Inspector Angela Dalton Unannounced Inspection 1st December 2005 10:20 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 Matthews DS0000050846.V267375.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 Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Matthews Address Chequers Lane Redbourne Herts AL3 7QG 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) 01582 792042 Colley Care Limited (Trading as B & M Care) Mandy Colman Care Home 52 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (25), Old age, not falling within any other of places category (27), Physical disability (5) St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate one (named) lady who is currently 62 years of age. The home manager must inform the NCSC when the above (named) service user leaves the home, or reaches the age of 65, whichever come first. This variation applies only to this (named) lady and ceases to be in force when she leaves the home, or reaches the age of 65, whichever comes first. 20th June 2005 Date of last inspection Brief Description of the Service: St Matthews was opened in 2003. It caters for the needs of 52 older people 27 beds are dedicated to personal care on the ground floor, whilst the remaining 25 cater for service users with dementia on the first floor. The home has plenty of storage space and has assigned a room specifically for therapies and another for hairdressing. The laundry, kitchen and staff room are situated on the lower ground floor. Throughout the home there are facilities for visitors to prepare refreshments. The home has a vast enclosed garden and enables service users to utilize the grounds safely. Closed Circuit Television is in situ and is discreetly positioned over the main entrances to the home. The home is adjacent to a childrens nursery and therefore benefits from additional security measures. A number of rooms have a patio area outside and it is hoped in time that service users will personalize this area. The home employs a gardener to support this process taking place. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two Inspectors between 10.20am and 1.50pm. The focus of the inspection was to follow up issues identified issues from a previous inspection in June 2005 and an additional visit in September 2005. The manager was on annual leave so Inspectors liaised with the Area Manager who previously managed the home. Some of the previously made requirements have been met but others remain in place. A full inspection was conducted in June so not all standards have been revisited on this occasion. What the service does well: What has improved since the last inspection? What they could do better: The quality of meals is still an issue in the home and service users confirmed that they had discussed this with the manager but little has changed. Infection control continues to be compromised by the presence of bar soap in the bathrooms. Communal areas of the home are being used to store wheelchairs and other items. This makes the home look untidy and one exit was observed to be blocked. Cleanliness of the home has improved but further developments are required. The home was overly warm during the inspection and fans that had been purchased to circulate the air during the summer (following a requirement) were still in use. Medication continues to require attention as errors are clearly occurring. Agency staff are in use and a permanent staff team continues to evade the home and has done since opening. The home needs a period of stability and to develop its identity, as it appears it has not had the opportunity to do this. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 6 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 Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not inspected on this occasion. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Service users are not protected by safe medication practises. Although care staff seem to be meeting needs, care plans do not evidence that care needs are met. EVIDENCE: Care plans have been reviewed. In spite of this information requires expansion, especially in relation to managing challenging behaviour and meeting nutritional and pressure care requirements. Individual needs have been identified as part of the assessment process but has not progressed onto a care plan. Staff evidently had knowledge of individual needs and were managing them but there was no documentation to support this. Individual wishes after death are recorded in care plans. An Enforcement Notice has not been served in light of a new manager being in post. Some work has commenced regarding care plans but their improvement must be a priority. Although service users spoke highly of staff, one member of agency staff was seen to leave a service user with their breakfast tray in a difficult position to eat from and did not interact with them. The medication system again requires attention. There were gaps on the Medication Administration Record Sheets which does not reflect that medication had been given. Opening dates were not recorded on the majority of medication bottles and boxes. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 10 Medication totals did not balance and a high number of tablets (22 Paracetamol) were unable to be accounted for. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 11 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): 12,13,14,15 The appointment of an Activity Co-ordinator has had a positive effect on daily life in the home. Meals are of a poor quality and alternatives are not always available. EVIDENCE: An Activities Co-ordinator has been appointed and positive interaction was observed. The appointment is a positive step in the development of the home. The dementia unit appeared a livelier environment and service users throughout the home have structure to the day. An advent calendar was available on the ground floor for each service user to open in turn. Some further developments are required in order to identify that there is a specialist dementia provision. The home has links with Help the Aged and Age Concern as one service user may require additional support in the future. The home has identified this need. Both Inspectors sampled lunch. It was beef stew, mashed potato, carrots and broccoli. The stew was very dark and looked overcooked in the serving tray. Although the meat was tender the gravy was incredibly salty. Service users comments were ‘This is disgusting, it cannot be eaten.’ ‘Can you help us get this sorted out? It’s really awful.’ Service users said they had made the manager aware but there had been no improvement. Staff confirmed that meals regularly came back only partially eaten or refused. One Inspector St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 12 overheard a staff member ring down to the kitchen to request an alternative and it was reported that the chef was rude and hung up on them. When the Inspector visited the kitchen they observed the chef to take a ‘phonecall again requesting an alternative and they were curt and offhand. One service user has an intolerance to white flour and an alternative is purchased. They reported that as they required their meat to be pureed white flour pastry had been pureed aswell causing them to be unwell. Service users did not have access to salt and pepper. One service user who had breakfast in their room was served bread without the option of butter and no condiments to accompany their bacon and egg which was served on a cold plate. At lunchtime additional gravy was served on plates without consulting the service user. Mealtimes form the focus for service users and an opportunity to socialise. Action must be taken to ensure the quality of meals is improved. Service users reported that the quality of meals varied according to the staff in the kitchen. Menus were on display but they were incorrect. An alternative should be offered. The alternative offered by staff was scrambled egg, poached egg or omelette. Service users do not currently get a real alternative to the meal served. A requirement was made at the previous inspection regarding meals. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: Not inspected on this occasion St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 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 the following standard(s): 22,25,26 Storage space is not appropriately used. Parts of the home are unclean. EVIDENCE: Parts of the home were untidy and could have been cleaner. Agency domestic staff are being employed. This is an area that the home has struggled with for sometime. Beds were not made at lunchtime. Bathrooms were unclean and some individual bedrooms were untidy and unclean. Bars of soap were in bathrooms around the home suggesting that more than one service user uses them. Better infection control must be observed. An external exit was blocked with wheelchairs and other mobility aids. Alcoves were accommodating walking frames, wheelchairs and plastic bags despite the home having adequate storage. There are few provisions to meet the needs of those service users with dementia and although improvements are being made some further developments are needed. The home remains hot and fans were circulating the air. Trailing wires may pose a risk to service users and must be risk assessed. Records of temperatures throughout the home must be kept and appropriate action taken to ensure comfortable living and working conditions. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 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 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): EVIDENCE: Not inspected on this occasion. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 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 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): EVIDENCE: Not inspected on this occasion. St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X x X X 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 12(1)(b) Requirement Care plans must state how identified needs will be met e.g. with regard to meeting nutritional needs, challenging behaviour, falls and pressure care. As the manager is working towards improving care plans an Enforcement Notice will not be served on this occasion. Further expansion is still required relating to individual service users needs. Assessed needs must be met. Once identified there must be evidence to show how they are to be met, managed and monitored. A safe medication system must be implemented. Medication must reconcile with records kept on the Medication Administration Record sheets (MAR). Gaps must not be on regularly prescribed medication administration record sheets. Opening dates must be recorded. REQUIREMENTS RELATING TO MEDICATION HAVE BEEN MADE PREVIOUSLY. An Enforcement Notice will be DS0000050846.V267375.R01.S.doc Timescale for action 31/12/05 2. OP8 12 31/12/05 3. OP9 13(2) 31/07/05 St Matthews Version 5.0 Page 19 served at the next inspection if this requirement is not met. 4. OP14OP10 12(4)(a) Service users’ dignity must be observed regarding staff interaction and individual requirements e.g. offering lunch condiments An audit must be conducted on the quality, nutritional content and amount of food that is served to service users. A record of food served and alternatives offered on the menu must be recorded. THIS REQUIREMENT WAS MADE AT THE PREVIOUS VISIT. Action must be taken regarding Service Users’ dissatisfaction. The environment must reflect the needs of the service users as stated in the Statement of Purpose. THIS REQUIREMENT HAS BEEN PARTIALLY MET BUT FURTHER DEVELOPMENTS MUST BE MADE. The temperature of the home must be comfortable to work and live in. A strategy to ensure a comfortable temperature must be devised, implemented and a copy sent to the Commission. A risk assessment must be completed. Temperature records must be kept throughout the home. THIS REQUIREMNT HAS BEEN MADE PREVIOUSLY. Infection control measures must be observed in the home. THIS REQUIREMENT REMAINS UNMET The home must be kept clean. Consistent staff must be employed to ensure continuity of care. (This is not possible whilst the home carries such a high number of vacancies). 31/12/05 5. OP15 16(2)(i) 31/12/05 6. OP19 23(1)(a) 31/01/06 7. OP25 13(4)(c)& 23(2)(p) 31/12/05 8. 9. 10. OP26 OP26 OP27 13(3) 23(2)(d) 18(1)(a) 31/12/05 31/12/05 31/07/05 St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Matthews DS0000050846.V267375.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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