Inspection on 12/05/05 for St Paul`s Residential Home

This inspection was carried out on 12th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Paul`s Residential Home 05/10/06

St Paul`s Residential Home 23/03/06

St Paul`s Residential Home 23/12/04

St Paul`s Residential Home 10/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St. Pauls Residential Home 127-129 Stroud Road Gloucester GL1 5JL Lead Inspector Sharon Hayward-Wright Unannounced 12 May 2005 11:00 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. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service St. Pauls Residential Home Address 127-129 Stroud Road Gloucester GL1 5JL 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) 505485 Mrs Mobina Sayani Mrs Mobina Sayani Care Home 14 Category(ies) of Old age (14) registration, with number of places St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 23/12/04 Brief Description of the Service: St. Paul’s Residential Home is registered to provide personal care for 14 older people.The accommodation is in a busy area of the city comprising two older style houses that have been joined and adapted for their purpose. Service users accommodation is situated on the ground and first floors in both parts of the house and is all single accommodation, though one of the rooms can provide shared accommodation for a couple if required. There are no ensuite facilities, though rooms have a hand washbasin and a commode can be provided if required. One fixed bath hoist is available in order to provide assisted bathing facilities together with alternative domestic style baths.The first floor in both parts of the house is accessible by stairs, or by a chair lift in one part of the house. A shaft lift has also been installed to provide easier access.A combined lounge and dining room is situated on the ground floor with a small adjacent lounge that is used as a smoking room. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3.5 hours, on one day in May. The Registered Manager/Provider were spoken to, as were 5 other staff members. Five service users were spoken to directly to gain their views of the care they receive and the home in general. Of these 2 service users care was looked at in detail. Care records and the management of medications were inspected, as were the records for food, training, fire and personnel records. A part tour of the home took place and the staff was observed going about their work and interacting with service users. Two requirements remain outstanding since the last inspection and the home must address these before the next inspection. What the service does well: What has improved since the last inspection? The home has made some improvements on their medication system since the last inspection but to meet the requirement in full further improvement is needed. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 6 Service users spoken with said they were happy with the activities provided by the home and they are able to choose whether they participate or not. The Registered Manager has devised a training matrix to allow easy recognition of what training staff have received or what training they need. Staff confirmed that training opportunities are available to them. The home has had all their fire equipment checked since the last inspection and has addressed a requirement issued at the last inspection for the home to undertake regular testing of their emergency lighting as directed by the local fire service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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) 1 The homes Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services provided by the home. EVIDENCE: A copy of the homes Statement of Purpose and Service Users Guide is in the main hallway allowing easy access to them by service users and visitors to the home. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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, 9 & 10 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to meet the needs of the service users. The home has made progress with regard to the arrangements for medication, however the administration process can potentially place service users at risk. Personal care is offered in such away to promote and protect service users privacy. EVIDENCE: Two service users were case tracked, as they needed more assistance with their care needs. This proved the care provided by the home was current. Six other care plans were checked, all had an assessment of need that showed evidence of reviews, comprehensive care plans again showing monthly reviews. A recommendation made was for the home to include more detail in care plans that relate to maintaining a safe environment and personal care. Records of health professional visits are maintained as well as daily records. Moving and handling assessments are in place. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 10 The home has made progress with their medication system as the cupboard has been moved away from the main entrance. However the home needs to obtain a lockable facility to transport the medication around the home when administering medication and take the MAR (medication administration record) sheets along. The homely remedy list should be updated as it was last done in 2003 and new letters should be sent to the service users GPs’. One service user’s MAR sheet had no evidence on it that a prescribed cream was being given, this must be addressed. Gaps were seen on the MAR sheets where staff had not signed or used the key to omissions. This is not an accurate record and must be addressed with staff and when the above procedure is implemented this should not happen. The date of opening on one bottle of eye drops was not clear and 1 bottle of liquid medication had no date of opening. There was no clear date of expiry on 2 opened liquid medications as one had been opened in November 2004, this must be checked to ensure that once medication is opened it is not used passed it shelf life. Records of medication received, administered and returned to the local pharmacy were seen. The Registered Manager said all staff except new staff have undertaken medication training. From observations and service users comments the staff in the home respect service users privacy and dignity. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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 & 15 Social activities are provided that meets the needs of the service users. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The Registered Manager said the home has planned activities on a Tuesday and Friday when additional staff are provided. These include 1:1 activities for service users who do not wish to take part in-group activities. On other days the staff provide activities after completing their work. Service users spoken with all said they are happy with the activities provided and 1 service user said they are able to go out independently. Outside entertainers also visit the home and this includes the ‘music and movement man’. On the day of the inspection a number of service users were looking forward to the man who plays the guitar as he was due to visit in the afternoon. Service users said visiting is open and a number of visitors were seen in the home. Positive comments were received about the food and all service users spoken with said they enjoy the food provided. The cook said they do not stick rigidly to the menus and choices are offered. Service users and the home’s food records confirmed this. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 12 The cook provided records of the safety checks that are undertaken in the kitchen. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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) No standards were assessed at this inspection. EVIDENCE: St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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) 26 The service users live in a homely environment but infection control procedures must be followed to reduce the potential risks to service users. EVIDENCE: A part tour of the home took place, no odours were present and the home was clean and tidy. A procedure has been put into place for the staff to wear aprons whilst working in the kitchen and this was observed. The Registered Manager said she has stopped visitors from entering the home through the kitchen, however 1 visitor was witnessed coming in through the kitchen. Protective clothing is provided for staff and they were observed wearing it. On one occasion a member of staff wore their tabard that they wear when assisting service users with personal care, to assist a service user to eat. The staff must either remove this tabard or cover it with protective clothing to reduce the risk of cross infection. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 15 St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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, 28, 29 & 30 The staff have a good understanding of the service users needs; and this was evident from the positive relationships, which have been formed between staff and service users. The standard of vetting and recruitment practices are not satisfactory and can potentially place service users at risk. The home provides ongoing training to ensure the staff are able to meet the needs of the service users. EVIDENCE: The duty rotas were examined as evidence of staffing levels. On the day of the inspection the home was meeting the needs of the service users. The home has 2 permanent staff that has the NVQ 2 and 1 bank care staff. Three permanent staff is undertaking the NVQ 2 training and 1 bank care staff has NVQ 3. Personnel files of 2 new staff were checked, one file did not have a reference from their last employer where they worked in a care position. There was no evidence to suggest employment gaps were explored. The second file had a reference that was not satisfactory from the staff member’s last employer, which was a care position. The home has not requested another reference from a previous care position. No risk assessment was seen documenting the issues highlighted in the reference. It is recommended that interview records be maintained. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 17 The home maintains a training matrix for easy recognition of when staff need updates and to maintain ongoing records of training. The Registered Manager is aware that new staff require training and some existing staff. The Registered Manager is aware of the Care Homes Regulation that requires new staff to have a supervisor, however no records are maintained as evidence this is happening. St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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) No standards were assessed at this inspection. EVIDENCE: St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 20 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 9 Regulation 13(2) Requirement The Registered Person must ensure that all staff adminster medication in a safe and secure manner using the MAR sheets as part of the process. Timescale of the 21/1/05 was not met. The Registered Person must ensure that records are maintained of all medication adminstered in the home. The Registered Person must ensure the expiry date of opened liquid medications is recorded to ensure no service users are put at risk by the home using medication that is out of date. The Registered Person must ensure that the staff in the home follow infection control procedures to reduce the risk of cross infection to service user. The Registered Person must obtain where applicable a reference relating to the persons last period of empolyment, which involved work with vulnerable adults of not less that 3 months duration. The Registered Person must complete a risk assessment for Timescale for action 12/7/05 2. 9 17(3i) 12/6/05 3. 9 13(2) 12/6/05 4. 26 13(3) 12/7/05 5. 29 19 & Schedule 2 30/6/05 6. 29 13(6) 15/6/05 Page 21 St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 7. 29 19 & Schedule 2 18 8. 30 the new member of staff that had an unsatisfactory reference to ensure that risks to service users are minimised. The Registered Person must obtain written satisfactory written explanations of any gaps in empolyment. The Registered Person must ensure that for any new workers the amendments to Care Home Regulations are adhered to. Timescale of 20/1/05 was not met, however the Registered Manager is aware of this requirement but needs to maintain records as evidence this is happening. 30/6/05 1/7/05 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 7 Good Practice Recommendations The home should include more detail on what staff need to do to care for service users who need personal care and for when the staff need to maintain the service users safe environment. The home should clearly write the date of opening on all liquid medications, creams, ontiments and eye drops. The home should review their homely remedy list with the service users individual GPs. The home should have a second person to check and sign any hand written entries. The home should maintain records of interviews of new staff. 2. 3. 4. 5. 9 9 9 29 St. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 Page 22 Commission for Social Care Inspection Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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. Pauls Residential Home D51_D03_31351_St Pauls_V221379_120505_stage4.doc Version 1.20 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. 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