Inspection on 22/05/07 for St Matthews

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Matthews 04/10/06

St Matthews 06/06/06

St Matthews 01/12/05

St Matthews 20/06/05

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 Herts AL3 7QG Lead Inspector Hazel Wynn Unannounced Inspection 22nd May 2007 08:50 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.V340606.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 Matthews DS0000050846.V340606.R01.S.doc Version 5.2 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 stmatthews@bmcarehomes.co.uk www.bmcare.co.uk Colley Care Limited (Trading as B & M Care) Miss Emma Louise Pead 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.V340606.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate one (named) lady who is currently under 65 years of age. The home manager must inform the CSCI 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. 4th October 2006 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. The remaining 25 places are on the first floor and are offered to residents with dementia. There is ample storage space and a room has been assigned 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 large enclosed garden and this enables residents to utilize the grounds safely. A number of rooms have a patio area outside and it is hoped in time that residents will personalize this area. Closed circuit television cameras are discreetly positioned over the main entrances to the home. The home is adjacent to a childrens nursery and therefore benefits from additional security measures. Copies of the statement of purpose, service user guide and the most recent report on the home published by the Commission were all clearly on display in the reception area. The fee range at the time of this report was £600 - £650 per week. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted with the deputy manager and staff on duty. Time was spent talking with the people who live at St Matthews and examining records. A tour of the home was carried out. This report has been written from the information already known to the Commission and a visit to the service. Where information has remained the same this has been carried forward into this report. What the service does well: What has improved since the last inspection? What they could do better: Once the alterations to the premises have been completed, the service provider should consider a programme of re-decoration. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 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.V340606.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential service users and their supporters can be assured that they will be provided with sufficient information to ensure that the home will be suitable to meet their needs. EVIDENCE: Copies of the statement of purpose, service user guide and the most recent report on the home published by the Commission were all clearly on display in the reception area. All care plans examined contained evidence that the management team ensure that the needs of potential service users can be met before a place is offered and emergency admissions are resisted for that reason. Care plans included a full assessment of needs (which also appeared to be reviewed on a regular basis). St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 9 During the course of this site visit, a family of a potential service user was meeting with senior staff. The information provided to them was factual and realistic. A trial visit and, if required, a trial stay can be arranged subject to places being available. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 10 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): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff adopt an appropriate and individualised style of supporting service users with their personal and health care needs, which means that service users can be confident that they will be treated with respect. EVIDENCE: A number of care plans were examined on both floors. All those examined contained details of current needs and a clear instruction on how those needs were to be met. There was also evidence of service user involvement in some of the care plans examined. Care plans are routinely reviewed each month or earlier if care needs change. Staff were knowledgeable about individual service user’s needs, wishes and foibles. Medication storage and records were examined and administration was observed. The practice was good. Currently, no service users administer their own prescribed medication. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 11 Service users confirmed that staff respected their privacy and this was borne out by the practice seen during the site visit. Interactions between all staff and service users was friendly but was also respectful. All service users appeared to be well groomed. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to exercise choice and control in their daily lives. The service meets recreational, social and religious needs and the meals provided are said to be commendable by service users. EVIDENCE: The site visit was planned to coincide with the breakfast period, (which begins at 08:30). Service users were offered a choice of breakfast and some elected for two of the choices. It was also noted that individuals decide where they will take breakfast and some preferred it in their own bedrooms. In the ground floor dining room, breakfast was a relaxed and social occasion. Staff offer drinks throughout the day and it was noted that water in water jugs was routinely changed. A number of service users made positive comments about the quality and quantity of the food provided. An activity coordinator has been in post for five weeks and has already had a beneficial impact on the service users. There was evidence that she has encouraged some ‘room dwellers’ to socialise, and staff reported that one service user had been to church on Sunday for first time. It was not possible to St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 13 interview the activity coordinator as she had made arrangements to take some service users out to a garden centre on the morning that this site visit took place. The deputy manager confirmed that visiting ministers provided for the religious needs of individual and that visitors are welcome at any reasonable time of the day or evening. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 14 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): 16, 17 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have received appropriate training to equip them with the skills to safeguard service users. Service users are protected from harm and their concerns are both taken seriously and also acted upon. EVIDENCE: The manager has established a reputation for dealing with complaints in an open and even-handed manner. Staff take concerns seriously and act upon them, which, in turn, reduces the need for formal complaints to be made. All staff spoken to were aware of the complaint process and all had received training in safeguarding adults from abuse. A poster provided by the County Council on adult protection was on display in the office and there were policies and procedures available to guide staff in protecting service users from abuse as well as providing guidance on finances, valuables and gifts. Service users are encouraged to participate in elections if they wish and one service user spoken to said that arrangements had been made for him to have a postal vote. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 15 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): 19, 20, 21, 22, 23, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is suitable to meet the varied needs of the service users who, in turn, can follow a comfortable and safe lifestyle. EVIDENCE: The premises were purpose-build and were being maintained to a high standard of cleanliness. The overall decorative standards are acceptable, especially in view of the proposed changes to the building. (One wing was virtually empty and a new dining room was being constructed on the first floor. This was in anticipation of the service provider’s proposed changes in the way the service will be delivered, outlined in ‘Management and Administration’ below). A handyman was being recruited but the B&M Maintenance team are working on site and could be used in the interim. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 16 Externally, there are well-maintained and secure grounds that are available for the exclusive use of service users. One service user remarked that she tried to walk around the garden every day. Personal possessions were in evidence in every service users’ bedroom entered and the home generally has a ‘comfortable’ feel to it. Staff confirmed that they have sufficient equipment available to enable them to assist service users where necessary. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent and are deployed in sufficient numbers to ensure that service users are cared for safely at all times. EVIDENCE: During the site visit, it was noted that there were appropriate numbers of staff deployed and they were working in a pleasant, confident and diligent way. The staff attitude was supportive towards the service users (and one another). For example, on first floor, a member of care staff elected to update care plans with service users present. This was done in a way that did not compromise confidentiality, but maintained a staff presence in the lounge. A visiting District Nurse commented, “The girls here are excellent. This is one of the best homes I visit”. Since the last inspection, there has been an increased in the numbers of permanent staff. The housekeeper was from an agency, but her work was to a very high standard. An examination of the staff files for recently recruited staff confirmed good recruitment practices. Training is a priority and in addition to ‘mandatory’ training, examples of training included six care staff undertaking a distance learning course on dementia care and the Deputy Manager who is completing a foundation degree in care management. Care staff have completed one-day dementia awareness training. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 18 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): 31, 32, 33, 35, 36, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is managed in a proactive way and is operated in the best interests of the service users. It is designed to promote the health and welfare of everyone at the home. EVIDENCE: Service users and staff alike had positive things to say about how the home is being managed. It was also noteworthy that service users who had been resident since the home opened were able to make favourable comparisons on how life has continued to improve at St Matthews. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 19 Staff confirmed that they receive adequate supervision and that they feel supported in their work. There was clearly a strong team spirit amongst the staff on duty during this site visit. Records available demonstrated that the health and safety of service users and staff is ensured and observation of staff showed that safe practices are followed. Staff do not handle personal money and there are policies and procedures covering valuables and gifts. A quality assurance system is in operation and this includes a satisfaction survey of service users and their supporters. The philosophy of how the service provides care has been radically reviewed and the service provider now intends to offer a wider range of services to people whose care will range from low needs to fairly advanced stages of dementia. Changes are being made to the environment to support this and staff are receiving appropriate training. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 20 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 3 X 3 3 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 21 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. Standard Regulation 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 Refer to Standard OP19 Good Practice Recommendations Once the alterations to the premises have been completed, the service provider should consider a programme of re-decoration. St Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Matthews DS0000050846.V340606.R01.S.doc Version 5.2 Page 23 - 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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