Inspection on 11/05/05 for The Hamlets

This inspection was carried out on 11th May 2005.

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

The Hamlets 17/05/06

The Hamlets 09/11/05

The Hamlets 25/10/04

The Hamlets 29/04/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

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Alfred House Residential Care Home

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Thames House

Creative Support

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

CARE HOMES FOR OLDER PEOPLE St Michaels 93 St Michaels Church Road St Michaels in the Hamlet Liverpool L17 7BD Lead Inspector Pat Kearney Unannounced 11 May 2005 10.00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Michaels Address St Michaels Church Road St Michaels in the Hamlet Liverpool L17 7BD 0151 728 9019 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) Age Concern Liverpool CRH 12 Category(ies) of Care Home with Nursing registration, with number 12 places of places St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NA Date of last inspection 25 October 2004 St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: St Michaels is a single storey purpose built care home providing nursing care for 12 older people with functional mental ill health. The home is situated within a residential area of Aigburth South Liverpool. The property is within walking distance to shops, pubs, Sefton Park and a bus ride from Liverpool city centre and other places of local interest. The increasing frailty of the service users may prohibit independent access to these community facilities. Accommodation at St Michaels includes12 single bedrooms all fitted with wash hand basins. There is a large lounge and dining room. The dining room leads onto a patio area and large walled garden.Registered by Age Concern Liverpool over 11 years ago the establishment was “a home for life” for the then Health Authority service users. All service users admitted to the care home would have a diagnosis of functional mental illness. However the increasing age and frailty of the service users has seen the focus of care shift from predominately mental health to both mental and physical nursing care. The care practices within the home have adapted to meet the changing needs of the service users. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 10 00 hours, the acting manager was on duty. The senior manager from Age Concern Liverpool was also visiting the home and was present during the inspection. A full tour of the premises took place. The home was clean and tidy. Both staff and service users were spoken to about the service. Service users informed the inspector that the home was a happy place and staff were caring polite and courteous to them. They commented on the positive changes that had occurred since the registered manager had resigned and the deputy manager had been appointed acting manager. All relevant documentation for service users and staff were reviewed, all the homes documentation relating to residents care, and welfare and safety is in accordance with the National Minimum Standards (NMS). What the service does well: What has improved since the last inspection? A number of improvements have been made in the care home since the last inspection this includes the introduction of a service user satisfaction questionnaire which seeks service users views and makes any suggested changes to the home. Service users and staff were positive and enthusiastic about the change in management at the home and commented about the positive changes that have taken place. A budget has been allocated for service users activities A complete audit of the home has been completed by senior management and the acting manager an action plan is being developed to ensure that the home has a comprehensive and detailed maintenance programme. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 8 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 Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 9 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. The homes Statement of Purpose and Service User Guide are up to date and provides service users and/or their relatives with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: All service users in the home are provided with a statement of terms and conditions, plus a contact when they move in to the home on a permanent basis. Service users are able to visit the home several times with varying lengths of stay tailored to meet their individual needs before they decide to move in on a permanent basis. The homes senior nurses undertake a pre admission assessment on residents before they are admitted to the home, to ensure all care needs are identified. Other health care professionals known to the resident are also involved in the assessment. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7.8.9.10.11. Care plans, risk assessments, daily health records for each service user are up to date and reviewed monthly by the senior nurses in the home. This ensures that the current and changing care needs of the residents are identified. EVIDENCE: All residents in the home have an individual care plan, which is formulated on admission to the home, reviewed by the senior nurses on a monthly basis. Daily health records are documented daily for each resident, this includes any critical incidences plus any visits from GPs, specialist nurses etc. No resident in the home self medicates, all medications for residents are administered by the nurses in the home. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). Since the last inspection a review of the medication ordering system has been reviewed. All service users in the home can access their NHS entitlements. The resident’s documentation is kept secure in accordance with the Data Protection Act 1998. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15. Service users have choice and flexibility how they spend their day in the home, leisure activities are organised according to their choice and preferences. EVIDENCE: Service users are offered a choice at mealtimes, specialist diets are catered for and advice has been sought from the community dietician. Leisure activities take place at the home on an ad-hoc basis service users said they had enjoyed the recent V.E. day celebrations. Visitors are allowed in the home at any reasonable time of day, service users may entertain their visitors, in the communal lounges, or in their own bedroom. The gardens and patio area provide a setting for service users to sit with their relatives, especially in the summer months. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 12 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. The home has a comprehensive complaints procedure. The home has adopted Liverpool interagency policy and procedures for Adult Protection. EVIDENCE: There have been no internal complaints since the last inspection. The home has a robust complaints procedure, which is documented in the service users guide. The care home has up to date information on the Protection of Vulnerable adults, this information is communicated to new employees on their induction course. On the day of the inspection there was evidence that many of the staff in the home had completed training on POVA protocol. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 13 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 residents live in a homely, comfortable and well maintained home. EVIDENCE: The home is a single storey building which provides indoor and outdoor communal facilities. The care home is safe, well maintained, clean and free from offensive odours. Each service user has their own bedroom which contains individual items of personal memorabilia St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_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, 30. Age Concern Liverpool who manages the home has a robust recruitment and selection policy which ensures the safety of service users. EVIDENCE: There is always a first level Registered Mental Nurse on duty who is assisted by care staff and ancillary staff. The homes recruitment policy is robust and in accordance with the National Minimum Standards. All staff in the home has an up to date CRB/POVA enhanced certificate, so ensuring the safety of the residents. Mandatory and specialist training for all staff is ongoing in the home. Records of all training completed are to be kept in the staff personnel files. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_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, 34, 35, 36, 37, 38. The acting manager is well supported by senior staff in providing clear leadership at the home. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. Turnover of staff is low. EVIDENCE: Since the last inspection the Registered Manager has resigned The Deputy Manager has been acting as manager at the home for the past three months and will apply to become the registered manager following a six month probationary period. The Acting Manager is a Registered Mental Nurse with many years service working with the service user group at the home. Service Users and staff were St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 16 positive and enthusiastic about the changes that have been introduced by the acting manager. Service users told the inspector that they felt” the home had improved and there were more social events taking place “ The acting manager has completed with the senior manager an audit of the care home and on the day of the inspection they were in the process of producing an annual action plan. An annual service user satisfaction questionnaire has been introduced and completed with the outcomes recorded in the service users care plan. A Service User consultation questionnaire has been developed which will be completed three months following admission to the home, this will used to evaluate the admission process. The homes certificates of insurance and worthiness for machines, gas, electricity, fire equipments, lift, hoists were in date and valid. Age Concern Liverpool has introduced an annual appraisal system and a three monthly performance review completed with all staff. This is in the process of being completed by the acting manager. Staff confirmed that they have had supervision with the Acting Manager this is currently not recorded. St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 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 Standard No 16 17 18 Score 3 3 3 2 3 3 3 3 3 3 3 St Michaels F52_F02_S25185_StMichaels_Rd_V226405_110505_Stage 4.doc Version 1.30 Page 18 no 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 31 Regulation 9 Requirement A person shall not manage a care home unless he/she has the qualifications skills and experience necessary for managing a care home. Following the six month probationary period the acting manager must apply to C.S.C.I. to become the Registered Manager. Timescale for action 1.9.05 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 36 Good Practice Recommendations It is recommended that notes are recorded and kept following individual staffs supervision. 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