Inspection on 20/06/05 for St Matthews

This inspection was carried out on 20th June 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 01/12/05

St Matthews 12/10/04

St Matthews 14/09/04

St Matthews 20/04/04

Similar services:

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 Hertfordshire AL3 7QG Lead Inspector Angela Dalton Unannounced 20 June 2005 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 Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Matthews Address Chequers Lane, Redbourne, Herts, AL3 7QG 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) 01582 792042 Colley Care Limited (Trading as B&M Care) Mandy Colman CRH Care Home 52 Category(ies) of DE-5, DE(E)-25, OP-27, PD-5 registration, with number of places St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one (named) lady who is currently 62 years of age. 2. The home manager must inform the CSCI when the above (named) service user leaves the home, or reaches the age of 65, whichever comes first. 3. 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. Date of last inspection 12 October 2004 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 children’s 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 I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The weather was hot and sunny on the day of inspection. This was reflected in the temperature within the home and at the end of the inspection the temperature in the home was higher than outside. Two inspectors conducted the inspection between 10.30am and 4.30pm (one inspector left at 3.15pm). The home has a great deal of work to do in order to progress and the home manager must be supported to achieve this. A number of previously made requirements remain unmet. The home manager evidently has the skills to ensure the home improves but requires the staff and senior managerial support to achieve the amount of work that has to be done. What the service does well: What has improved since the last inspection? What they could do better: St Matthews has not yet realised its potential. The environment has not been personalised by service users and the dementia unit provides no stimuli other than the courtyard. Staff vacancies exist and are covered by agency staff. The home has experienced periods of change and difficulties the home manager has made some headway in the seven months she has been in post. Senior management must recognise that the home will struggle if resources are not put in place to ensure a full staff team and the opportunities to personalise the home. It is evident that the absence of an activities co-ordinator has contributed to residents feeling bored and lethargic. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 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 I52 s50846 St Matthews v233611 200605 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 Matthews I52 s50846 St Matthews v233611 200605 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) 1,2,3,4,5,6 Service users needs are identified prior to moving into the home. EVIDENCE: A statement of purpose is available within the home and service users or their families are provided with a service users guide on admission or prior to moving into the home. A comprehensive assessment is completed to ensure that information is received enables a care plan to be written. The home does not provide intermediate care. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11 Service users are not protected by safe medication practises. Care plans do not evidence that care needs are met. EVIDENCE: Care plans have been reviewed. In spite of this information is lacking, especially in relation to managing challenging behaviour, 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 and this meets a previously made recommendation. The storage and recording of medication requires attention. Medication was being stored at 38.5 degrees Centigrade and this was far higher than the recommended limit of 25 degrees Centigrade. 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 I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 10 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) 12,13,14,15 Service users views are sought regarding mealtimes. Adequate levels of activities are not provided. EVIDENCE: The absence of an activities co-ordinator within the home has resulted in service users becoming unmotivated and lethargic. The home manager has recently ordered some in house activities to assist staff to organise events and the post of co-ordinator has been advertised. The home has links with local community projects and recently joined up with a local sixth form college, which had positive results. The home is hoping to repeat the experience due to its success. Service users with dementia would clearly benefit from appropriate activities and stimulus which is not currently available. Service users recently met with the chef over issues regarding the content of meals and the way in which items were cooked. This issue is being monitored. Service users reported that some improvement had taken place. Lunch was sampled by the inspectors and was tasty with fresh ingredients being used. However, the choice of menu may not have reflected service users requirements due to the hot weather. Drinks were available and the manager has ordered larger glasses to ensure that service users have access to more fluids where required. Service users who required assistance were offered gentle support from staff. One staff was assisting two service users at alternate times and additional staff are needed to ensure one to one attention is available. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 11 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) 16,17,18 Service users are supported in making a complaint. EVIDENCE: Service users reported that they were comfortable in raising concerns and making a complaint if necessary. The management team have a visible presence within the home and all service users felt they knew the manager and could approach her. Regular service users meetings occur where service users views are aired and recorded and subsequently acted upon. The home is currently responding to a complaint and the Commission is aware of action taken. Staff had an awareness of how to raise any concerns regarding vulnerable service users. Additional Adult Protection training is to be provided in the near future to support the training that has already been provided. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 12 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) 19,20,21,22,23,24,25,26 The home is safe but lacks identity and personality. The numbers of domestic staff are inadequate. EVIDENCE: The environment was mostly clean and odour free. However, it was evident that the home has domestic vacancies and the existing staff work hard to address immediate cleanliness issues within the home. Some areas of the home had a slight odour. This may be due to the heat in the home. The kitchenettes were not clean and the sink stained. A bar of soap was on the toilet hand basin. This must be removed to ensure infection control measures are observed especially as there are concerns about an infectious skin complaint. The temperature in the home on the day of inspection reached thirty-two degrees Centigrade. The conditions were oppressive to live and work in. Some fans were available in areas of the home but efforts to reduce the temperature proved fruitless. Despite the fact that the home has been open for nearly two years the home has not yet developed its own identity. The manager plans to address this. There are few provisions to meet the needs of St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 13 those service users with dementia although the courtyard has floral containers and a water feature. Most spend their day pacing or sitting. Staff are not proactive in ensuring that service users can sit out using garden furniture and the parasols were still in the shed. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 14 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) 27,28,29 The number of staff vacancies compromises continuity of care. EVIDENCE: The home has a high number of vacancies and the home has an ongoing recruitment process. Senior management must investigate how the home can achieve stability. The manager recognises that using agency staff on the dementia unit is far from ideal. The home will continue to struggle until a stable and cohesive staff team is achieved. A core number of staff provide some continuity but this effect is diluted by the use of agency staff. The management team within the home has undergone some changes and there are two deputy managers in post. The manager aims to ensure that a member of the management team is either on shift or on call at all times. Training is ongoing and a date specific programme is being drawn up between head office and the manager to assist staff to know when training is scheduled. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 15 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) 31,32,33,36,37,38 The health and safety of service users and staff is compromised. EVIDENCE: The manager has provided some much needed stability to this relatively new care home. She has identified the requirements of the home and senior management must ensure that she is supported in meeting the required targets. Staff and service users stated that they felt she was approachable and supportive. Supervision takes place but has been compromised by the staffing levels. Records were found to be appropriately kept. Door wedges were found to be in use in the dementia unit. This practise must cease. Windows must be risk assessed regarding the need for window restrictors as the kitchen window in the dementia unit opens to its full extent. A call pull was tied up out of reach from service users. All call bells must be accessible to service users to enable St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 16 staff assistance to be summoned. A requirement has been made to risk assess the working environment with regard to temperature. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 3 2 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 3 3 2 St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. THIS REQUIREMENT WAS MADE AT THE PREVIOUS INSPECTION. Assessed needs must be met Activities must be provided to service users The environment must reflect the needs of the service users as stated in the Statement of Purpose. The environment must assist the service users to maintain their independence, especially those with service users with dementia. 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. Infection control measures must be observed in the home. Adequate domestic staff must be Timescale for action 31/07/05 2. 3. 4. OP8 OP12 OP19 12 16(2)(n) 23(1)(a) 31/07/05 31/07/05 31/07/05 5. OP20 23(2)(a) 31/07/05 6. OP25 13(4)(c) 23(2)(p) 21/06/05 7. 8. OP26 OP26 13(3) 23(2)(d) 30/06/05 30/06/05 Page 19 St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 9. OP27 18(1)(a) 10. OP38 13 11. OP9 13(2) employed to ensure the cleanliness of the home. Consistent staff must be employed to ensure continuity of care. This is not possible whilst the home carries such a high number of vacancies. Door wedges must not be used. All call bells must be accessible to service users. Windows must be risk assessed for restrictors. Medication must reconcile - this was not possible to assess as amounts had not been recorded onto current sheets and gaps were present. Gaps must not be on regulaurly prescribed medication administration record sheets. Opening dates must be recorded. A REQUIREMENT RELATING TO MEDICATION HAS BEEN MADE PREVIOUSLY. 31/07/05 30/06/05 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. Refer to Standard OP15 Good Practice Recommendations The quality of meals should continue to be monitored and action taken where unsatisfactory. St Matthews I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts 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 I52 s50846 St Matthews v233611 200605 Stage 4.doc Version 1.30 Page 21 - 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. 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