Inspection on 27/09/05 for St Omer

This inspection was carried out on 27th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Omer 27/07/06

St Omer 16/02/06

St Omer 18/02/05

St Omer 12/10/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE St Omer Greenway Road Chelston Torquay TQ2 6JE Lead Inspector Mark Sharman Announced 27 and 28th September 2005 th 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 Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Omer Address Greenway Road, Chelston, Torquay, Devon, TQ2 6JE 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) 01803 605336 01803 690733 info@st-omer.org Ian Day Joanna Petrina Day Barbara Harris Care Home 24 Category(ies) of Old age - not falling within any other category registration, with number (24) of places St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One service user (named elsewhere) who is within the category DE(E) may be accommodated. Date of last inspection 18/2/05 Brief Description of the Service: St Omer is a large detached Victorian house in a quiet residential area, registered to provide care to people aged 65 or over. The communal rooms are spacious and comfortable, comprising a dining room, lounge and sun lounge. All but two of the bedrooms are single rooms, and the majority have en suite toilet facilities. There are good views of the bay from many of the home’s windows. The front door is accessed up a few steps, but there are other entrances providing level access into the home. The home is equipped with stairlifts and other disability aids, including two assisted bathrooms and a large shower room. There is a sun terrace and large, attractive gardens and parking for several cars. An extension to the home is now nearing completion, which includes a shaft passenger lift and four additional bedrooms with en suite facilities. The new lift will greatly improve access between the ground floor and first floor for residents with reduced mobility. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection over two mornings, lasting a total of about eight hours. A pre-inspection questionnaire was received before the inspection, completed by the home owners in a well organised and thorough way. Also received were some completed comment cards, four from residents and four from relatives of residents. Eight of the residents, five of the staff and one visitor were consulted during the inspection, and a sample of the home’s records was inspected. All of the communal areas and some of the bedrooms were seen, and the extension in progress was also seen. (The home’s web address is www.st-omer.org.) What the service does well: What has improved since the last inspection? A requirement was made at the last inspection for the covering of any radiators which are accessible to the residents because of a risk of burns, and St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 6 some further progress has been made with this work. It has not yet been completed but the owners have planned the work in conjunction with the current building extension, and the remaining radiators will be covered in the next few weeks. The extension has now provided four new smart en suite bedrooms, all with attractive views, and the bedrooms below are also being refurbished. New armchairs have been bought for the main lounge, which has made it more comfortable for the residents. 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 Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Standard 6 is inapplicable. An assessment of the needs of any prospective resident is always made before her/his admission to the home in order to ensure the suitability of the home for that person. EVIDENCE: A sample of residents’ files was inspected and all contained a completed copy of the home’s pre-admission assessment form. The registered manager said that she visits any prospective resident at their own home or in hospital to carry out an assessment of their needs. All prospective residents are invited to the home for a day’s visit, which was confirmed by residents consulted. In cases where a resident is publicly funded a Care Management assessment is requested from the local authority prior to admission (some of these have been seen previously). St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9. The standard of care planning is commendable, and the residents’ health care and social care needs are being well met. There is a very good medication system. EVIDENCE: A sample of residents’ files was inspected and the care plans were comprehensive and well organised. Each one included a manual handling assessment, pressure area assessment, nutrition assessment and a general risk assessment. They had been signed by the individual resident in question (showing her/his involvement in the process), and had all been reviewed at least monthly. Additionally there was a distinct night care plan for each person showing her/his care needs at night and preferred routine. All residents are registered with a general practitioner, and residents consulted were satisfied that they receive medical attention when necessary. In fact a general practitioner and a district nurse attended the home during the inspection. One of the residents said that she had also been seen at the home recently by her dentist and optician. Residents’ files include a pressure area assessment and a nutrition assessment, and pressure area equipment is obtained when required (some of this equipment was seen in use). Residents St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 10 are encouraged to take gentle exercise and a seated exercise session is one of the regular activities. There is a detailed medication policy and procedures, which staff who administer medication are required to read. Competent residents may selfmedicate if they wish, and one does. The Boots monitored dosage system of medication is used, and Boots training is arranged annually for the appropriate staff. The last Boots pharmacist’s report (11/7/05) was inspected and was satisfactory. Medication review forms are maintained in residents’ files. It is commendable that the home’s manager has instituted a monthly audit of the medication procedures to check that they are followed correctly by staff, and these audit records were seen. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 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 and 14. There is a suitable range of activities and entertainment on offer, and residents decide for themselves whether to participate and are able to follow their preferred routines. EVIDENCE: All of the residents consulted felt that an adequate range of activities is provided and confirmed that they did not feel under pressure to participate if they did not wish to. The programme of regularly occurring activities was displayed on the notice board, including an exercise session, bingo, games, word games/quiz, a “pamper” afternoon (e.g. manicure), fortnightly communion and monthly worship with music. Residents confirmed that occasional professional musical entertainment takes place and that occasional trips out are arranged. There were to be two trips to Living Coasts in Torquay in the few days following the inspection. A part-time person is employed to offer one-to-one time with any residents interested, and this person also runs a shop for residents one day per week. Residents said that their visitors are made welcome, and it is the home’s written policy that visits can be made at any reasonable time. One visitor consulted during the inspection said that she visits the home nearly every day. She was very satisfied with the care given to her relative. Those residents able to manage their own financial affairs do so, and many are helped by relatives. Several have an attorney under the Power of Attorney process. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 12 St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 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 standard(s) 16 and 18. Residents are confident that any complaint they might have would be taken seriously, and the arrangements to ensure that they are protected from abuse are of a high standard. EVIDENCE: All of the residents who were asked said that they were sure that the manager and the home owners would do their best to resolve any complaint. In fact no complaint was expressed during the inspection. There is a satisfactory complaint procedure, which is included in the residents’ guide and explained to new residents. A complaints book is kept, and this was inspected. No complaint has been made to the Commission for Social Care Inspection since the last inspection. The home has an appropriate policy and procedure in respect of adult protection. In addition there is a policy on physical restraint, and a policy in respect of gifts from service users to staff and service users’ wills. The home’s own training manager provides abuse training to staff, and staff on duty confirmed that they had received this training. An allegation (unfounded) of abuse some time ago was investigated by Mr Day in a commendably thorough and professional way. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 14 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 and 26. The home provides an attractive and comfortable environment, and is being continuously improved. All parts seen were clean and tidy (apart, of course, from the extension in progress!). EVIDENCE: The home is in a quiet, attractive location with good views from many of the windows. There is level access to the terrace outside, and the gardens were attractive and well kept. Some of the bedrooms in the extension have been completed and work is in progress to install the new shaft lift. The ground floor bedrooms beneath the new extension have been fitted with new windows and doors, giving direct access on to the terrace. Inevitably the building work has caused some disruption, but it is hoped this will be completed in early November. All parts of the home which were seen were clean and tidy. Residents consulted were complimentary about the domestic staff and said that their bedrooms are kept clean. There are written infection control procedures. A new laundry room has been built, and the laundry equipment is of high specification. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 15 St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 16 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, 29 and 30. Staffing arrangements are satisfactory and staff morale is high, resulting in a well motivated staff group. A good percentage of the staff are appropriately qualified and there is a very good training programme in place. EVIDENCE: The residents consulted all said that the staff are kind and competent, and they felt staffing levels are adequate. For example they said that call bells are normally answered promptly. There have been difficulties recently due to three carers having been away on maternity leave. This has resulted in frequent use of agency staff, but the home’s manager said that the agency staff used are those who have become familiar with the home and the residents. Indeed one of the staff on duty was employed by the agency but said she now knew the home well. Three staff files were inspected and the recruitment practice demonstrated was satisfactory. All contained written references and two contained Criminal Records Bureau disclosures. In the third case there was a delay in receiving the disclosure but a Pova First check had been received. Staff consulted said that there are ample opportunities for training. The home has a qualified training manager (part-time) who co-ordinates a training programme for the care staff, and training records for the last year or so were seen. Mandatory training for each carer includes fire safety, food hygiene, manual handling, first aid, medication, and abuse training. In addition she has now instituted a training package on the typical experiences of ageing, which will prove very useful for work with St Omer’s residents. Staff have completed a feedback form in respect of this training course. Each new carer has St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 17 induction training which meets national standards, and is then offered the opportunity to work towards an NVQ qualification. Over half of the care staff have achieved NVQ level 2 or above. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 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 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, 33, 35 and 38. The home is managed in a competent, professional way with a view to continuous improvement of the services provided. Residents’ financial interests are satisfactorily safeguarded. The arrangements for ensuring their health and safety are generally satisfactory, although some work remains to be completed over the next few weeks. EVIDENCE: The residents consulted were very complimentary about the home owners (Mr and Mrs Day) and the registered manager. The manager has had many years experience of working with this client group and is currently undertaking NVQ level 4 in management and care. Mr Day has developed a structured quality management system which incorporates audits at weekly, monthly, quarterly and annual intervals. The current annual development plan which was seen is focussed on the building extension and associated works. There are regular St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 19 meetings with residents, regular staff meetings (separate for night staff) and regular management meetings, and minutes of these meetings are kept (a sample was seen). Residents may control their own finances, which some do, but for many this is done by relatives or an attorney (via the Power of Attorney process). Some residents’ personal money is administered by the home, and a sample of these records (including receipts) was inspected. In most respects the Standard in relation to health and safety matters is complied with. Fire safety training and first aid training is provided to care staff. Risk assessments have been carried out in respect of first floor windows, which may pose a risk to residents, and several of the window frames are fitted with blocks to restrict the opening. One remaining shortcoming from the Standard is that not all of the radiators accessible to residents have been covered yet, but Mr Day said that this work is planned for completion by November 4th. The radiator covers have been bought and were seen during the inspection. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 4 3 x 4 x 3 x x 2 St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 21 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 25 Regulation 13 Requirement Pipework and radiators accessible to service users must be guarded or have low temperature surfaces. (Previous timescale of 31/7/05 not met). Timescale for action 30/11/05 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 38 Good Practice Recommendations The home owners should consult the Environmental Health Department of Torbay Council for advice in relation to the restriction of upstairs window openings. St Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, TQ13 7UP 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 Omer D54-D07 S45297 St Omer V237738 270905 Stage 4.doc Version 1.40 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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