Inspection on 11/01/06 for St Oggs

This inspection was carried out on 11th January 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Oggs 25/03/09

St Oggs 05/09/06

St Oggs 29/06/05

St Oggs 14/03/05

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 St Oggs 14 Front Street Morton Lincs DN21 3AA Lead Inspector Sue Hayward Unannounced Inspection 11th January 2006 09:30 St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 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 Oggs DS0000061668.V277417.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 Adults 18-65. 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 Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Oggs Address 14 Front Street Morton Lincs DN21 3AA 01427 617173 01427 617173 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) Prime Life Ltd Mr Scott Edwards Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2005 Brief Description of the Service: The home is a detached adapted property providing care and accommodation for up to twenty residents with mental health needs. There is also a bungalow within the grounds, which can accommodate two residents. The home is situated in a residential area of Morton, once a village and now a suburb of the town of Gainsborough. There is a Church opposite the home and local shops and a post office are located on the corner of the road. Gainsborough town can be reached by using a bus service, which passes the corner of the road. The home has a minibus, which also provides residents with transport for example to appointments, trips out and to attend day care services. This is shared with another home within the same group. The home was extensively refurbished when the current organisation took it over. There are three lounges, a games room and dining room. These are on the ground floor. Bedrooms are on both floors. The home does not have a lift. The front garden has flowerbeds, paved areas and seats. There is a driveway leading to the rear of the property, which has a decked patio/seating area and car parking. The home is part of Prime Life Limited. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second required by law for April 2005 – March 2006 and took place over 5 ½ hours. One inspector carried it out. The main method of inspection used was “case tracking”. This involves selecting a sample, on this occasion two residents and tracking the care and support they receive through checking records, discussion with both residents and a staff member on duty. It also included some discussions with three other residents and a health professional that visited during the inspection. A partial tour of the premises and a sample of regulatory records and policies and procedures were also checked. As the manager was not present at the time of the inspection a telephone discussion was held on the following day to clarify some information. What the service does well: What has improved since the last inspection? Since the last inspection there has been some changes to house meetings that are held, which residents and staff attend. They are now being held on a fortnightly basis and a newsletter is produced which everyone can refer to as a reminder of what was discussed. There is an ongoing redecoration programme and some bedrooms have been repainted. Staff encourage residents to be involved with this is they wish. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 6 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 Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 There are satisfactory procedures in place for the introduction and assessment of people to the service, which ensures that residents needs are met and their independence is promoted. EVIDENCE: The homes statement of purpose and service users guide, which gives information about the home, is on display. A resident’s comments and records checked in relation to the admission procedure indicated that this had been a planned process. It had included meetings and visits to discuss the service that the home offers and to assess the needs of the resident. The resident confirmed that she had been able to have a trial visit and had discussions with the manager. Residents’ comments and records demonstrated that they are involved in the development of their care plans. Information was also available on a resident’s file that indicated information had been given about independent advocacy services. Comments from residents indicated that they were satisfied with the care received for example “ I feel more settled here than where I was before”. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Residents are actively consulted and involved in the planning of their care and have opportunities to influence the running of the home. Risk assessments undertaken are not fully documented in some instances to demonstrate that all aspects of residents’ health and safety have been considered. EVIDENCE: Both files checked contained a plan of care and residents spoken to were aware of them and had signed to denote their agreement to them. There was information available to demonstrate that care plans are reviewed on a monthly basis. A key worker system is in place. This gives staff specific responsibilities for specific residents. A resident commented that she had individual time with her key worker and felt able to talk about any concerns or problems she may have. Staff spoken to had a good knowledge of the needs of residents. Care plans had been developed from assessments, which also included other professionals and were detailed. They included documented individual risk assessments for some matters but not for others. For example a risk assessment was not in place for a resident who goes into the community St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 10 independently. It is however acknowledged that risk assessments are in the process of being reviewed. Comments from residents indicated that they felt able to make their own decisions and were supported by staff to be as independent as possible. There are regular house meetings held where residents are able to raise any issues and discuss the running of the home. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16 and 17 Residents’ independence and privacy is promoted and visitors are made welcome at the home. Residents receive well-balanced meals that take into account individual preferences and dietary requirements. EVIDENCE: Discussion with residents indicated that their independence is promoted. For example a comment made was that staff support residents to prepare their own meals and to work towards achieving their own identified goals. Comments were also made which indicated that staff respected residents’ privacy and rights and staff were observed and gave examples of how these values are implemented in the home. The organisation has a policy about promoting contact with families and friends and about sexuality and relationships. Residents’ comments confirmed that they are able to have visitors when they wish and that they are made welcome. Risk assessments are completed where they have been identified about relationships. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 12 A visiting professional confirmed she is made to feel welcome and in her opinion the atmosphere in the home was friendly. Residents’ comments indicated that their rights and privacy were respected in the home, for example residents have keys to their bedrooms. Residents’ comments about the meals provided were good. They indicated that they were supported to shop and prepare their own meals if they wished and are consulted about the types of meals offered. Care records indicated that nutritional assessments are completed. The organisation has policies and procedures relating to food safety and nutrition and satisfactory records are kept in relation to the meals provided. The main dining room has been refurbished in the style of a ‘Euro-Café, with a bistro style layout. There is also a smaller kitchen where residents can prepare their own snacks, meals and drinks. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The systems in place in relation to medication help to ensure residents safety. EVIDENCE: There are satisfactory policies and procedures and systems in place relating to medication, which include residents being responsible for their own medication if assessed as able to do so. The storage arrangements and records kept were satisfactory. A pharmacist visits the home periodically and checks the systems in place. The last visit occurred on 27/09/05. A staff member gave a satisfactory account of the medicine administration procedure and also confirmed the process that is followed to assess residents to administer their own medication, which is done over a period of time. Training is provided by the organisation to ensure that staff have the necessary skills to administer medication. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 There are satisfactory procedures in place in relation to the handling of complaints and adult protection matters, which help to ensure residents are protected. Staff will benefit from training that is planned to ensure that they are fully aware of adult protection procedures. EVIDENCE: There is a satisfactory complaints procedure in place and residents’ comments indicated that they were aware of how to raise any issues if they had any. Notices about how to raise concerns were on display in the home. Minutes seen of house meetings demonstrated that residents are reminded of their rights to raise concerns and of the involvement of advocacy services. A visiting professional commented that communication was good between herself and the home. The record of complaints kept demonstrated that the home had received one complaint since the last inspection. This had been responded to appropriately. There is an adult protection and “no secrets” policy in place. A staff member spoken to knew the procedure for reporting such matters should they occurred. The home has notified one adult protection issue to Social Services since the last inspection. Records and discussion demonstrated that further training for staff has been planned in relation to adult protection procedures. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 15 Comments from residents indicated that they were aware of who was in charge, how to raise any concerns and felt able to do so either at house meetings or with staff on an individual basis and felt safe in the home. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home provides a comfortable and clean environment. EVIDENCE: Those areas of the home seen included the kitchen, dining room and lounges and two residents bedrooms. The home was clean, tidy and comfortably furnished. Interim action has been taken to address the requirement from the last inspection in relation to the dining room radiators posing a risk to residents’ health and safety from hot surfaces by switching them off. A risk assessment has been completed for this a copy of which was provided to the CSCI on 13/01/06. It indicates that action is to be taken to cover or move radiators that are deemed to be a significant risk by February 2006. Individual and risk assessments of the environment have been completed however some need further attention to demonstrate how decisions have been reached and what is in place to reduce them. (See comments made at standard 9). Fire risk assessments are in place and a Health and Safety Audit of the home was undertaken on 15/11/05. Records kept demonstrated that weekly tests of the fire alarm system are done. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 17 Residents are encouraged to maintain the cleanliness of their own bedrooms either independently or with assistance from staff where required and confirmed that they are able to arrange their bedrooms to their own personal taste. Comments from residents were their rooms were comfortable and their privacy is respected. A visiting professional also confirmed that the home is clean and tidy and residents independence is promoted. Policies and procedures are in place relating to infection control matters. An Environmental Health Officer visited the home on 23/02/05 and conducted a kitchen inspection. His comments indicated it was a “well organised kitchen”. Cleaning rotas are in place and records checked of a staff member indicated that she had had basic food hygiene training. A staff member confirmed that equipment is provided such as gloves and aprons to ensure good hygiene practices. She also confirmed that her training had included health and safety matters such as First Aid, Fire training and fire drill. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34 The home is staffed to ensure residents’ needs are met however the recruitment process in operation does not fully protect residents. EVIDENCE: Comments from residents were positive about their relationships with staff. They indicated staff were approachable and attentive and they received the support and help they needed. A visiting professional confirmed that the staff had provided “tremendous support” to a resident by accompanying her to hospital visits on a daily basis. She also said that staff were always available to speak to if needed. On the day of the visit there were two care staff on duty and a cleaner. Due to unforeseen sickness there was not a cook on duty at the time of the inspection therefore a staff member prepared the lunchtime meal. Additional staffing is provided for some hours for specific residents for one to one support. Comments from staff indicated that staffing levels were sufficient to meet the needs of current residents. Records demonstrated that the organisation has an on-going training programme for staff, which includes statutory matters such as fire training and training that is more specific to residents needs. Some staff have achieved National Vocational Qualification Awards. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 19 Records of the recruitment procedure checked of a staff member who had been employed since the last inspection did not demonstrate that a satisfactory Criminals Record Bureau check had been obtained prior to the staff member commencing employment in the home, although has been obtained since. This has the potential to put residents at risk. This issue was raised at the time of the last inspection and remains outstanding. Records also demonstrated that in this instance only one written reference had been obtained. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Residents’ health and safety is promoted through staff training and the record keeping systems in place. EVIDENCE: Those areas of the home seen on the day of the visit were well maintained as were the sample of records seen. These included tests of the fire alarm system and fire risk assessments. Systems are in place to promote health and welfare matters for example cleaning rotas are kept in relation to the kitchen areas The organisation conducts health and safety audits of the environment. Records demonstrated that the last audit took place on 15/11/05. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 21 Discussion with staff and records checked demonstrated that there is a training programme relating to health and safety matters, such as fire training and infection control and there are also policies and procedures in place. Residents spoken to were aware that they could approach the manager and felt that they could raise any issues and would be listened to. Comments included that they felt safe at the home. St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X X X X 3 X St Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 23 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 YA24 Regulation 13(4) Requirement Timescale for action 28/02/06 2. YA34 19(1) The registered persons must ensure risk assessments are documented relating to any activities that have the potential to pose risks to residents such as accessing the community independently. The registered persons must not 28/02/06 employ staff to work in the home unless a satisfactory CRB or POVAFirst check, pending a satisfactory CRB check has been received by the employer. Timescale of 31/07/05 not met. 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 Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Oggs DS0000061668.V277417.R01.S.doc Version 5.1 Page 25 - 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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