Inspection on 06/02/07 for St Peter`s House

This inspection was carried out on 6th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Peter`s House 18/12/08

St Peter`s House 01/03/06

St Peter`s House 05/09/05

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE St Peter`s Cottage Nursing Home 29 Out Risbygate Bury St Edmunds Suffolk IP33 3RJ Lead Inspector Jane Offord Key Unannounced Inspection 6th February 2007 09:30 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 DS0000064425.V329723.R01.S.doc Version 5.2 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. DS0000064425.V329723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peter`s Cottage Nursing Home Address 29 Out Risbygate Bury St Edmunds Suffolk IP33 3RJ 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) 01284 706603 01284 706811 County Care Homes Limited Post Vacant Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places DS0000064425.V329723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: St Peters Cottage is a privately owned care home with nursing, and is registered to accommodate up to 15 Older People. The home is situated on a main road out of Bury St Edmunds, opposite the West Suffolk College. It is within a residential area close to facilities, such as shops and churches. The building, which is set in its own grounds with ample car parking, has an enclosed garden and patio area at the rear. The accommodation is partly in a converted domestic dwelling and partly in a purpose built extension. All rooms are on the ground floor and are single, five with en-suite facilities. St Peters recently changed ownership, and the new owners, County Care Homes Ltd, plan to extend the premises. There are two lounges and a dining room. There is access to the garden from all bedrooms and communal rooms. The fees for the home range between £575.00 and £650.00 per week and depend on the size and location of the accommodation. DS0000064425.V329723.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place between 9.30 and 15.00 on a weekday. This report has been compiled using information available and evidence found on the day. The acting manager was present for the inspection and the owner was on site for part of the time inspecting some new building work that is being done to extend the home. During the day a tour of the home was undertaken with the nurse in charge but all areas were visited again later in the day. Part of the medication administration round at lunchtime was observed and a number of staff and residents spoken with. Various files, maintenance records and policies were inspected and care practice was observed. The home was clean and warm on the day of inspection and residents looked comfortable and relaxed in the homely environment. Medication administration was safe and the lunchtime meal looked appetising. A resident spoken with said they had enjoyed their meal. A number of residents were going out with the activities co-ordinator and a member of staff to have lunch at a local public house. Interactions between staff and residents were cheerful and friendly. What the service does well: What has improved since the last inspection? Corridors and fire exits were clear of obstructions and hazards on the day of inspection. Controlled drugs were correctly stored and recorded. DS0000064425.V329723.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000064425.V329723.R01.S.doc Version 5.2 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 DS0000064425.V329723.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is adequate. People who use this service cannot be assured that they will have a preadmission assessment of need undertaken. The home does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has not had a vacancy recently and the latest person admitted to the home arrived in the middle of 2006 before the registered manager left their post. Two residents files were seen. One contained a pre-admission assessment that was incompletely filled out and not signed or dated. The other file had no documentary evidence that a pre-admission assessment had been undertaken. The acting manager said they were aware this needed addressing particularly in view of the fact that the home was to increase the number of residents they supported when the new building was complete. DS0000064425.V329723.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. People who use this service can expect to have a care plan in place to help staff meet their needs, be protected by medication administration practice and be treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents’ files and care plans were seen and showed evidence that health needs were identified and addressed. Information on past medical history, medication, known allergies and health professionals involved with the resident such as GP, physiotherapist, speech therapist, community dietician and chiropodist were recorded. An assessment of need covered communication, pain, skin integrity, mobility, personal hygiene, continence and nutrition. In addition there were details of orientation, moods, religious persuasion, sleep pattern and social needs. Each file had risk assessments for moving and handling, falls, skin integrity and nutrition. One file had a body map to show areas of broken skin and both contained weight records. DS0000064425.V329723.R01.S.doc Version 5.2 Page 10 The care plans seen were individualised and there was evidence of regular reviews. Interventions included wound management, dysphagia and dysphasia, management of a feed directly into the stomach (PEG feed) and pressure area care. The daily records seen were full and gave details of moods of the resident as well as physical care given. One said, ‘in a very good mood today, laughing and watching television’. When a resident refused care it was recorded so one entry said, ‘refused to visit the hairdressers today’. The medication policy was seen and covered ordering, storing, administering and disposing of medicines. Part of the medication administration round at lunchtime was followed and the medication administration records (MAR sheets) were seen. Practice on the day was safe and the nurse said the home had recently changed to a monitored dosage system (MDS) and the pharmacist had been to instruct staff about the new system. The MAR sheets were correctly completed including the amount of medication given when a prescription gave a choice of dose i.e. one tablet or two. There was written permission from a GP for the tablets of one resident to be crushed before administration. Each MAR sheet had an identification photograph of the resident with it. The controlled drugs (CD) register and stock were checked and tallied. Staff were observed knocking on doors before entering rooms and offering residents choice about where they wanted to be and what they wished to do. Residents spoken with said staff were always willing to help and that nothing was too much trouble. DS0000064425.V329723.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. People who use this service can expect to be encouraged to maintain contact with family and friends, be offered meaningful pastimes and receive a wellbalanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ files seen both had contact details of the next of kin and the relationship to the resident. One had some life history work so family connections were detailed. During the day a number of visitors came and went seeing residents in the lounge or their own room. The home employs an activities co-ordinator who usually visits once a week but was in the home on the day of inspection to help a group of residents who were going to have lunch at a local public house. Wheel chair friendly transport had been arranged and the group left in good spirits looking forward to the outing. One carer went with them to assist as required. The coordinator said this outing was a monthly occurrence. DS0000064425.V329723.R01.S.doc Version 5.2 Page 12 The home provides a number of newspapers and magazines for the residents and one record about activities stated, ‘read the newspaper to the resident and discussed the news’. Another entry said, ‘we had a chat about Daniel O’Donnell’. The menus were seen and showed that a cooked breakfast is available each day if the residents choose that. There are always two options for the main course at lunch and a hot snack and sandwiches available for teatime. Hot and cold drinks are available at any time. The lunch on the day of inspection was corned beef hash with fresh vegetables followed by trifle. One resident spoken with said the meal was, ‘very nice’. The kitchen was visited and was clean and tidy. There was evidence of a daily cleaning schedule that was signed as tasks were completed. Records showed that the refrigerators and freezers were all functioning within safe limits for food storage. Left over food that was stored was covered, labelled and dated. The kitchen assistant said there was a delivery of dry stores every two weeks and fresh fruit and vegetables twice a week or more frequently if requested. DS0000064425.V329723.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. People who use this service can expect to have any concerns taken seriously but they cannot be assured that the home has an abuse policy that reflects the county guidelines or that staff have received recent abuse training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy was seen and meets the standard set out in the National Minimum Standards (NMS) offering an investigation and response within a timescale. Neither CSCI nor the home has received a complaint about the service since before the last inspection. The complaints/compliments log was seen and contained a number of cards and letters expressing satisfaction with the service. One said, ‘your kindness, patience, courtesy and caring for our relative, from the yummy food to the nursing care, were hugely appreciated’. The home’s abuse policy was seen and did not reflect the guidelines issued by the Vulnerable Adult Protection Committee of Suffolk or cross-reference to them. Staff spoken with said they had not had updates on protection of vulnerable adults (POVA) training but were clear that they would report any suspicions to a senior member of staff. Documentary evidence of the original POVA training was not seen. The home has a whistle blowing policy to protect staff who make such a report. DS0000064425.V329723.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, 26. Quality in this outcome area is adequate. People who use this service can expect to live in pleasant personalised bedrooms with attractive communal rooms available for use but they cannot be assured that the water supply to some bathrooms is safe or adequate or that health and safety regulations are respected in the laundry. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection the home only had eleven residents as five bedrooms had been closed due to re-development. One resident had been moved to a room previously used as a staff room. The room had been attractively decorated and was light and airy. The acting manager said future plans included moving all the residents into the new building when it was completed to allow redecoration of the existing building prior to admitting new residents. The present residents would be given the choice of which room they wished. DS0000064425.V329723.R01.S.doc Version 5.2 Page 15 On the day of inspection the home was clean and tidy. Individual rooms were personalised with photographs, pictures and ornaments and all benefited from a French door access to the garden that gave a lot of natural light. During the building work the garden is not to be used because there are building materials stored outside and scaffolding on parts of the building. The communal rooms were pleasant and the furnishings in keeping with the style of the house and suitable for the client group. The hot water supply to hand washbasins was checked and found that in two in bathrooms the supply was inadequate or dried up completely after a few seconds. The bathroom next to the building project had no lighting as it had been disconnected at the same time as the electricity had been disconnected for the building project. The laundry was visited and was clean and tidy with the exception of some products covered by the control of substances hazardous to health (COSHH) regulations that had not been secured. In the laundry the water to the hand washbasin ran at 52 degrees centigrade, which is above the recommended temperature of around 43 degrees centigrade and would make correct hand washing procedures to prevent cross infection difficult. DS0000064425.V329723.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. People who use this service can expect to be supported by adequate numbers of suitably trained staff but cannot be assured that evidence that they are correctly recruited will be available for inspection or that all training is regularly updated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that throughout the twenty-four hours there was always a trained nurse on duty supported during the morning by three carers, in the afternoon by two carers and one carer at night. In addition there was a cleaner daily, a cook and kitchen assistant, an activities coordinator one day a week and a maintenance person two days a week. Staff and residents spoken with said there were enough staff to meet the needs of the residents. Staff were able to spend time with residents chatting and call bells were answered promptly. Records showed that some staff had attended an update training day in May 2006 that had included moving and handling, fire awareness, food hygiene and health and safety. There was also evidence of further moving and handling training taking place in November 2006. Neither day had included protection of vulnerable adults (POVA) training or infection control. DS0000064425.V329723.R01.S.doc Version 5.2 Page 17 Staff spoken with said they had not had POVA training recently. One kitchen assistant said they had not had any food hygiene training since commencing at the home several months earlier although they had had some at their previous post. The acting manager does not have access to staff files and there is no system in place for an inspector to access them for inspection purposes. The owners did not have the correct keys with them on the day of inspection but said there were files available on the computer. The files on the computer were inadequate for inspection purposes so evidence that correct recruitment procedures had been followed was not available. DS0000064425.V329723.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is adequate. People who use this service can expect to have their financial interests safeguarded but cannot be assured that they will have formal consultation about the service they receive, that all health and safety policies are promoted or that the person in charge is a registered manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager left the service in September 2006. An acting manager who has worked in the home as a registered nurse for a number of years has filled the post temporarily. They have just commenced the registered managers award study. The acting manager is unaware of the steps being taken to recruit a permanent manager. DS0000064425.V329723.R01.S.doc Version 5.2 Page 19 Documentary evidence of quality assurance consultation was not available on the day of inspection and the acting manager said that there had been no residents’ or staff meetings held since the last manager left. Residents’ personal monies are held in the safe in the office and the shift leader has access to the key. The system was explained and it was clear there was an audit trail with receipts kept and entries for each transaction. Two wallets were checked at random and their contents tallied with the records. Evidence was seen that a gas safety check had been carried out in May 2006 and the fire extinguishers had been inspected in May 2006 as well. There were records of weekly checks on hoists, wheelchairs, bath chairs and water temperatures. As noted earlier in the report not all water temperatures were within safe limits and not all COSHH products were secured. DS0000064425.V329723.R01.S.doc Version 5.2 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 DS0000064425.V329723.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes. 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 OP3 Regulation 14 (1) Requirement The registered persons must ensure a pre-admission assessment of need is undertaken for each prospective resident and retain documentary evidence of it. The registered persons must update the home’s POVA policy to reflect the guidance given by the Vulnerable Adult Protection Committee of Suffolk and crossreference to it. The registered persons must ensure all staff receive updated POVA training. The registered persons must ensure that the hot water supply is delivered around the recommended safe temperature of 43 degrees centigrade. The registered persons must ensure that the hot water supply to the hand washbasins is constant and have adequate force to enable good hand washing practice. The registered persons must ensure adequate lighting is provided in all bathrooms. DS0000064425.V329723.R01.S.doc Timescale for action 06/02/07 2. OP18 13 (6) 31/03/07 3. 4. OP18 OP25 13 (6) 23 (2) (j) 13 (3) 13 (4) (c) 23 (2) (j) 31/05/07 06/02/07 5. OP25 06/02/07 6. OP25 23 (2) (p) 06/02/07 Version 5.2 Page 22 7. OP29 19 (1) Sch 2 17 (3) (b) 8. OP30 18 (1) (c) (i) 9. OP31 8 (1) (a) 10. OP33 16 (2) (m) (n) 24 (1) (a) (b) 13 (4) (a) (c) 11. OP38 The registered persons must ensure that all records required under regulation to be available at inspection are accessible to representatives of CSCI including evidence of the recruitment checks made. The registered persons must ensure there is evidence available that training updates for POVA and infection control have taken place for staff. The registered persons must take steps to recruit and appoint an individual to fill the post of registered manager. The registered persons must establish a quality assurance system that allows the residents the opportunity to express their opinions about the service they receive. The registered persons must ensure that the COSHH regulations are enforced in the home. 28/02/07 31/05/07 31/05/07 30/04/07 06/02/07 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 DS0000064425.V329723.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000064425.V329723.R01.S.doc Version 5.2 Page 24 - 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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