Inspection on 02/03/06 for St Michael`s Care Home

This inspection was carried out on 2nd March 2006.

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 Michael`s Care Home 26/07/07

St Michael`s Care Home 15/08/06

St Michael`s Care Home 11/08/05

St Michael`s Care Home 24/11/04

St Michael`s Care Home 20/05/04

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 Michael`s Care Home Marine Parade East Clacton on Sea Essex CO15 6JW Lead Inspector Jane Greaves Unannounced Inspection 10:10 2 March 2006 nd 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 Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Michael`s Care Home Address Marine Parade East Clacton on Sea Essex CO15 6JW 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) 01255 423688 01255 423594 The Sisters of Mercy of the Union of Great Britain Mrs Patricia Elizabeth Ebsworth Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 39 persons) 11th August 2005 Date of last inspection Brief Description of the Service: St Michaels provides residential care for 39 older people. The home is situated on the sea front at Clacton on Sea and is close to local shops and amenities. The building is a large property spread over three floors. There is a religious community adjacent to the home and a Chapel that is shared by the home, Convent and the local community. There are gardens and terrace areas around the property with views over the sea. There is a small car park for visitors with ample roadside parking nearby. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place on 2nd March 2006 over 4 hours. Thirteen of the 38 National Minimum Standards were assessed at this inspection visit and all were met. The home had a new manager in post; this day was the new incumbent’s first day in charge of the home. During the course of this inspection records were scrutinised and an informal tour of the premises was undertaken. Views were gathered from residents, visiting family and friends, the management team, catering, admin and domestic staff members. There was a happy and busy atmosphere at the home on this day and the residents appeared content and relaxed. The inspector appreciated the contribution and co-operation from all involved in this inspection. What the service does well: What has improved since the last inspection? The previous inspection did not produce any requirements or recommendations. At the previous visit it was reported that plans had been agreed by the Trustees to install a ‘wet room’ with an assisted shower specifically with highly dependent residents’ needs in mind. This had been completed and the deputy manager reported that it was a very popular facility with residents. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 6 Some radiators in residents’ rooms had been fitted with specially designed thermostats to make it easier for them to maintain a comfortable room temperature independently. 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 Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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): 3 No residents moved into St. Michael’s without having a full assessment of their needs and being assured their needs would be met. EVIDENCE: The files sampled at this inspection provided evidence that the manager or deputy assessed the needs of all residents before admission to the home. The pre-admission needs assessment was comprehensive covering all aspects of individuals’ daily lives including medical history and medications, daily living needs regarding personal care, mobility and diet, together with psychological and spiritual needs. Evidence of the resident’s/family/representative involvement was present on all files sampled. During the 6 week ‘trial stay’ the pre-admission assessment was expanded with detail to form the care plan. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 and 10 The residents’ health, personal and social care needs were clearly set out in an individual plan of care. Residents felt they were treated with respect and dignity. EVIDENCE: The care plans sampled at this inspection visit were clear and comprehensive setting out in detail the actions required by care staff to support individuals and to meet the assessed needs and aspirations. There was evidence of regular care plan reviews and any changes resulting from the reviews were clearly documented for care staff to follow. Risk assessments were made for all aspects of residents’ daily life. Where actions taken to minimise the risk caused an infringement of residents’ rights this was clearly documented with evidence of the residents’ involvement with the process. A clear record of individuals’ healthcare appointments and the outcome of these were present on files. Evidence of the involvement of the residents, or their representatives, was present throughout the care plans sampled. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 10 Observation showed that care and attention was taken to show residents respect and protect their dignity in their daily life. Residents reported that care staff respected their dignity by knocking on the door before entering their bedrooms. All medical appointments took place in private. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 and 15 The lifestyle experienced at the home by residents satisfied their social, cultural, religious and recreational interests and needs and matched their expectations. Residents maintained contact with family, friends and the local community as they wished. Residents received a wholesome, balanced and appealing diet in pleasant surroundings. EVIDENCE: The routines of daily living at St Michael’s were flexible and varied to suit individuals’ expectations and capacities. A social activity programme and chatty newsletter were published monthly and distributed to all residents informing them of events in the locality as well as in the home. The deputy manager reported endeavours to encourage residents’ involvement with the selection of activities, pastimes and outings. Residents had the opportunity to attend daily Mass in the Chapel, members of the local community joined with residents. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 12 Residents were encouraged to maintain contact with family and friends. Visitors reported that they were made welcome at any time and residents had the choice of receiving them in their own rooms or in a bright cheerful parlour. Overall, residents spoken with confirmed they found the food provided at St Michael’s to be wholesome and appetising. The majority of the residents had breakfast in bed daily whilst other meals were served in the dining room. Some residents reported they were sometimes ‘rushed’ to finish their breakfast. The home employed dedicated catering staff to prepare food and wait on tables. Menus demonstrated that the residents had a choice of two main meals daily and that menus were rotated every 6 weeks. The tea menu was varied with up to five choices available including options such as soup, baked potato, pork pie, beans on toast and various sandwiches. The catering supplies held at the home at the time of this inspection were of good quality and quantity. The chef consulted with residents regarding their dietary requirements individually every 2 weeks and attended residents’ meetings. Some residents required assistance at mealtimes; this was delivered in a respectful and dignified manner. The residents had access to a daily ‘trolley shop’ where they were able to purchase personal items such as toiletries, birthday cards and sweets. The residents had decided to purchase a plasma screen television for their communal space; this had been funded by a ‘Strawberry Tea’ fund raising event undertaken last summer at the home. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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): 16 and 18 Residents, families and representatives could be confident that complaints would be listened to, taken seriously and acted upon. Residents were safeguarded from abuse. EVIDENCE: All necessary policies and procedures were in place and followed in respect of complaints. All residents spoken with were confident that if they wished to complain that they would know how. The Service User Guide and the Statement of Purpose contained a copy of the home’s complaints policy and procedures and within these were the contact details for the Commission for Social Care Inspection. The home had received one complaint since the last inspection. This was documented clearly and responded to within the appropriate time frame. This complaint was not substantiated. A staff training course in the Protection of Vulnerable Adults (PoVA) from abuse was taking place on the day of this inspection. The deputy manager reported that care staff employed at the home received this training automatically and this programme was being developed further to include catering and domestic staff members. During discussion the manager and deputy demonstrated a good awareness of PoVA procedures and gave examples of robust strategies undertaken to ensure the safety and welfare of individuals. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 14 No person was employed to work at the home until a completed enhanced Criminal Record Bureau disclosure had been received. The home enjoyed the services of a volunteer helper and had obtained a disclosure for this person. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Residents lived in a safe, well maintained environment. The home appeared clean, fresh and hygienic. EVIDENCE: The location and layout of the home was suitable for its stated purpose; it was accessible, safe and well maintained; the home met residents’ individual and collective needs in a comfortable and homely way. The residents at St Michael’s benefited from spacious well-decorated communal areas with ample seating areas to sit and chat. The home employed a building manager responsible for routine maintenance, decoration and refurbishment. Lighting and furniture throughout communal areas was domestic in character and of good quality, some carpeting and chairs had been replaced as part of the ongoing refurbishment and renewal programme of the home. The gardens were well kept, safe and attractive with gentle slopes and handrails to facilitate safe access for all residents. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 16 On the day of the inspection the home appeared clean, fresh, welcoming and friendly with no offensive odours present. There was a dedicated team of house keeping staff to maintain the home to this standard. It was reported that training in the control of infection had been provided for some staff members in the previous year. Documentary evidence was not available at the point of this inspection. Residents reported that the domestic staffing team did a good job and the home was always very nice and clean. Laundry facilities were sited away from food preparation areas. The home employed dedicated laundry staff and all residents spoken with praised the laundry service at St Michael’s. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff were trained and competent to do their jobs. EVIDENCE: All new staff undertook a comprehensive induction programme. Evidence was available to confirm that care staff had received training and refresher courses in the mandatory areas. It was reported that all staff had received infection control training however evidence of this was not available on the day. Of the 26 care staff employed at St. Michaels 11 had achieved NVQ level 3 qualifications in care and 6 had achieved NVQ level 2. The newly appointed manager is a qualified NVQ assessor/verifier and Moving and Handling Instructor. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35 St. Michael’s was run in the best interests of the residents. Residents’ financial interests were safeguarded. EVIDENCE: The home operated an effective quality assurance scheme based on gaining the views and opinions of the residents and their families/representatives. The questionnaires from the most recent survey were available for scrutiny. The residents’ comments were generally very positive and where they felt critique was necessary it was usually constructive. A summary had been made of the surveys and a plan of action made to address any areas that residents had identified for improvement. Residents’ meetings were held, the deputy manager reported a campaign to make these meetings more productive focussing on supporting the residents to be pro-active in identifying activities, pastimes and experiences they wished to enjoy. St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 19 All the residents and visitors spoken with during this inspection visit praised St. Michael’s and the care services they received there. All residents were encouraged to manage their own finances. Some personal monies for 11 individuals were held in the safe at the home. Accounting procedures for this were sound. The residents enjoyed the provision of a ‘trolley shop’ where they could purchase personal items such as toiletries, birthday cards and sweets. Where personal monies were held for in the safe for residents a receipt was issued for purchases made from the trolley shop and these were entered into the residents’ individual finance records weekly, balanced and checked by two people. Individuals’ funds were maintained separately and appropriately. Three residents’ monies were balanced with the account books and physically checked, all were found to be correct. I St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 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. Refer to Standard Good Practice Recommendations St Michael`s Care Home DS0000015327.V282720.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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