Inspection on 18/01/06 for St Peter`s Court Nursing Home

This inspection was carried out on 18th 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 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 Peter`s Court Nursing Home 07/08/07

St Peter`s Court Nursing Home 04/09/06

St Peter`s Court Nursing Home 01/06/05

St Peter`s Court Nursing Home 16/11/04

St Peter`s Court Nursing Home 05/05/04

St Peter`s Court Nursing Home 26/01/04

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

CARE HOMES FOR OLDER PEOPLE St Peter`s Court Nursing Home Spital Road Maldon Essex CM9 6LF Lead Inspector Lysette Butler Unannounced Inspection 08:30 18 January to 13 February 2006 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Peter`s Court Nursing Home Address Spital Road Maldon Essex CM9 6LF 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) 01621 840466 01621 840801 manager.stpeterscourt@careuk.com www.CareUK.com Care UK Community Partnerships Limited Mrs Penelope Irene Heap Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24) of places St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 60 years and over, who require nursing care by reason of dementia (not to exceed 24 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 24 persons) The total number of residents accommodated must not exceed 24 persons 1st June 2005 Date of last inspection Brief Description of the Service: St Peters Court is a care home with nursing for 24 Older People with Dementia. A multidisciplinary team that includes Registered Mental Nurses, Care Assistants, and other professionals allied to medicine, deliver care that enables the residents to live safely and securely. The care environment consists of a purpose built bungalow style accommodation, situated in the grounds of St Peters Hospital in Maldon, Essex. There are eight single and eight double rooms. All resident rooms are on the ground floor, with staff areas only on the upper floor. St Peters Court is part of Care UK Community Partnerships Limited. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took six hours on one day during January 2005. The inspector following the inspection also received six relative survey forms. Relatives and staff alike were happy with the home and the care offered. Twenty of the thirty-eight National Minimum Standards were inspected during this visit. It was found that many of the standards had been met or partially met. All the National Minimum Standards were assessed at the two statutory inspections for the year 2005/6. Information on any standards not assessed at this unannounced inspection can be found in the report dated 1st June 2005. The overall care and well being of the residents was very good; staff and visitors were welcoming and happy to speak to the inspector. Due to the level of cognitive impairment experienced by the residents in this home the inspector was not able determine their personal views on the home. During this visit the inspector spoke to three relatives/visitors; ten staff members including the administrator; housekeeping staff; the laundry person; the cook; the maintenance man; Registered Nurses and care assistants. The registered manager and acting manager were not available at the time of this inspection. What the service does well: What has improved since the last inspection? Extra housekeeping staff have been employed which has made a significant improvement in the level of malodours and general cleanliness of the home. Thermostats have been fitted to all resident sinks to ensure that water is delivered at a n appropriate temperature and to prevent accidental scalding. St Peter`s Court Nursing Home DS0000015361.V278728.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 Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 The admission criteria and supporting information are clear, ensuring those prospective residents and their relatives have a good understanding of what the home can offer. EVIDENCE: All residents at this home are admitted from the Drake House assessment centre, which is a National Health Service provision. All beds are block purchased by the National Health Service. The statement of purpose and service users guides have both been reviewed and updated as required within the last twelve months. All mandatory elements are dealt with in the two documents. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Transferring to the new internal computerised care planning system has improved the quality of the resident care plans, making them more up to date and relevant to both staff and residents. EVIDENCE: Care UK has committed to a new computerised care planning system, which is being used exclusively in this home. The system is a secured system with various levels of data protection incorporated. In the opinion of one of the nurses spoken to during this visit the quality and quantity of information put into the system by staff has greatly improved from the old written care plans. The information is also much easier to read and staff cannot forget to sign and date the entries as this is automatically done as part of their signing on procedure each time they access the plans. A complete list of whom and when the plans have been accessed are possible with this system. Three care records were reviewed during this visit, showing a great improvement in there content and usage. Regular reviews are facilitated so that nothing is forgotten, as the item shows yellow on the screen until it is up dated. Information that might be needed in a hurry, such as terminal care and funeral arrangements, are kept in a separate loose-leaf folder, one resident to a page. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 & 15 The staff make an effort to improve the daily life of residents in this home and cater for their needs regardless of their level of cognitive impairment. EVIDENCE: The community contact with this home remains good. The staff of the home were involved with last years local carnival and won first prize, in their category, for their float. Residents of the home helped make decorations for the float and some were taken to see the parade. A scrapbook of photographs of the event was put together for the residents to see. The staff try to involve the residents in all activities they undertake. All residents have the option to vote and take control over their lives; however due to the severe cognitive impairment experienced by this group of residents this is not always possible. The menus are varied and the cook tries to offer a wide range of foodstuffs to stimulate the residents’ food intake. The cook endeavours to give residents what they ask for, but often they have forgotten their request by the time it is served the next day. Therefore the cook watches very carefully, with the help of the care staff to see what the residents appear to really enjoy and what foods are left uneaten. There is a two-month menu cycle, which is changed every four months, but changes to the menu are made as necessary if required. At the time of this inspection she had just written to all the residents relatives to ask if their relatives have any particular likes or dislikes. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 The handling of complaints and protection issues in this home is good ensuring a generally safe environment for the residents. EVIDENCE: The complaints policies & procedures in this home are part of the Care UK systems, with their own reporting system. There had been no complaints either directly to the home or to the local office of the Commission for Social Care Inspection, since the last inspection. The home make every effort to protect the legal rights of the residents and all staff spoken to demonstrated a good understanding of the problems related to these particular residents. There have been no Protection of Vulnerable Adults complaints regarding this home since the last inspection. All staff training in the subject is up to date and all staff has been supplied with a copy of the Essex social services PoVA booklet. The administrator and acting manager are very good at keeping the commission informed of all incidents in the home. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25 & 26 This home is suitable for purpose but is in need of major refurbishment. The staff work hard to make it a homely, odour free environment, which they are now generally managing to do. EVIDENCE: There had been no change to the fabric of the building since the last inspection. All areas of the home were toured during this visit. Redecoration of the home is always on going with the maintenance person carrying out the decoration, to a good standard, in between his other duties. However the home is still in need of a ‘major facelift’ to cover all the decoration problems present. All regular checks were undertaken and the maintenance person was very organised in his way of working. The gardens were well tended and safe for the residents should they wish to venture outside the home. The acting manager had recently taken advice regarding colours and signage to be used in the home. A lot of the suggestions were going to be implemented as the maintenance person decorated. Since the last inspection all sinks had been fitted with appropriate thermostats that were set between 39oC and 44oC. The temperatures were all checked on a weekly basis and all remained with in the set limits. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 13 There had been a dramatic reduction in the malodours experienced by this home. There had been an increase in the number of housekeeping hours available at this home and they were using new products to clean and air the home, which the housekeeping staff were very happy with. The two housekeeping staff spoken to at the time of this inspection were enthusiastic about the new products and felt that they were treated as valued members of the team. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 There is a good multidisciplinary staff team in this home that work together for the benefit of the residents. EVIDENCE: New housekeeping staff have been taken on since the last inspection, which has made a difference to the cleanliness and odours in the home as referred to above. The care staff hours remain good and appropriate for this group of residents. Very little agency staff are utilised, duties are either covered by bank staff, or by the permanent staff undertaking overtime. At the time of this inspection there was one registered nurse post empty. All personnel information is now held on the computerised ‘Saturn’ system, (as highlighted above with regard to care planning.) Four staff files were reviewed during this visit. All contained the required elements and were easy to review. Paper copies of references, Criminal Records Bureau declarations and letters were still kept in separate files that were checked at the same time as the ‘Saturn’ information. Information on ‘Saturn’ was password protected and was not accessible to all staff. Different grades of staff have different levels of access to the system to protect confidentiality. New criminal records bureau declarations were seen and signed off by the inspector. Staff training was also on the ‘Saturn’ system, which allows quick checking of what updating individual staff members training needs. A list of upcoming training sessions was available throughout the home and staff were happy with the level of training they could undertake. Induction programmes were being double checked by the acting manager following completion. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35, 37 & 38 The management and administration team at this home is strong and supportive to all the staff ensuring that residents are well cared for. EVIDENCE: Monthly health & safety audits are carried out throughout the home in line with Care UK polices. Other quality assurance audits and surveys are regularly carried out to ensure the safety and comfort of the residents and visitors to the home. A summary of feedback from users of the service has been submitted to the Commission for Social Care Inspection and is kept on file of the local office of the commission. The home appeared to be financially viable and staff reported that they were not kept short of anything that was required to enable them to care for the residents. Insurance certificates on view in the entrance lobby were valid until September 2006. Three residents monies were checked and all were correct. The documentation, records and receipts are now kept on the ‘Saturn’ system, (for details see St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 16 previous standards above.) No residents were looking after their own finances and the home does not act as appointee for any of the residents. Record keeping throughout the home is good. Paperwork is kept in secure filing cabinets in locked rooms and the protection and back up arrangements on the ‘Saturn’ system are good. (See previous comments for detail.) All health & safety and servicing certificates checked were correct and up-todate. Regulation 37’s and RIDDOR assessments are sent to the appropriate authorities as needed and copies are kept on the ‘Saturn’ system. Following this inspection Care UK notified the Commission for Social Care Inspection that the present registered manager for the home has taken a job elsewhere in the organisation and Lisa Scott the deputy manager has been promoted to manager. She is in the process of submitting an application for registration by the Commission for Social Care Inspection. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 17 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 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X x X X 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 X 3 3 St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP22 Good Practice Recommendations The proprietors should consider a full occupational therapy assessment of the home. St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Peter`s Court Nursing Home DS0000015361.V278728.R01.S.doc Version 5.1 Page 20 - 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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