Inspection on 12/07/05 for St Peter`s Residence

This inspection was carried out on 12th July 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 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 Residence 07/12/06

St Peter`s Residence 06/01/06

St Peter`s Residence 31/01/05

St Peter`s Residence 16/08/04

St Peter`s Residence 11/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Peters Residence 2a Meadow Road Stockwell London SW8 1QH Lead Inspector Mary Magee Announced 12 July 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 Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Peters Residence Address 2a Meadow Road, Stockwell, London, SW8 1QH 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) 0207 735 0788 Little Sisters of the Poor Sister Josephine Storey CRH Care Home 56 Category(ies) of PC Care home only registration, with number of places St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2005 Brief Description of the Service: St. Peter’s Residence is a large purpose-built residential care home for elderly people. It is located in it’s own grounds. The home is surrounded by pleasant well-maintained gardens. It is situated in a quiet residential area and within reasonable walking distance of local shops, bus routes, a tube station and a famous cricket ground. The ground floor of the home has a reception area, payphone, letter box, Chapel, parlour/guest rooms, arts & crafts room, shop, staff facilities, offices, main kitchen, main dining room, hairdressers, library, several lounges, tea/coffee bar, residents’ laundrette, linen stores and several toilets as well as a large entertainment hall. The first and second floors each have two units for 15 and 13 residents respectively, and each of the four units has its own unit manager, staff group, lounges, dining room, kitchen, bathrooms and toilets. All resident bedrooms are for single use and have ensuite facilities. All areas and rooms in the home are decorated, furnished and fitted to a high standard and there is a shaft lift for all floors. There is a sheltered housing unit for older people adjacent to the home; residents of the unit are welcomed to the dining room of the home for meals and activities.The home is one of many homes owned and managed by the Little Sisters of the Poor, which is a religious order dedicated to the care of the elderly. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out during the daytime. It lasted for over eight hours. A tour of the building was conducted; four bedrooms as well as all communal areas were viewed. A selection of personnel records relating to service users and staff were examined. Feedback and comments were received directly from twelve service users, seven relatives and three volunteers. The inspector met with the registered manager and four members of staff. What the service does well: This is a residential home for elderly people where residents receive an excellent quality of care. A competent staff team with an empathy for older people are employed. They understand the needs of service users and ensure that the lifestyle they experience at the home age meets their expectations and needs. Three of the residents said that “ staff are so kind and attentive and that nothing was too much trouble for them”. The focus on respecting the privacy and dignity of people while caring for their needs is promoted. Residents spoken to said that life at the home was exactly what older people liked and appreciated in retirement, it was calm relaxed and tranquil. The home is conducted in a manner that maximises service users’ capacity to exercise personal autonomy and choice. Staff are attentive and respond promptly to all those living at the home regardless of their ability/disability or capacity. One relative spoken to said that” staff always make time to spend with her sister”. The garden is well presented and contains plenty of suitable furniture. Service users make good use of the garden when the weather is fine. Two of them walked in the grounds with the inspector. They spoke of the enjoyment they got all the year round from “ walking in such lovely secluded grounds”. Three other service users said that “ the home offered the best services possible, staff were dedicated and committed and were always there in time of need.” Meals and mealtimes are very enjoyable for every body living there. Little extra touches that make a difference for residents are considered, such as serving iced water and ice creams regularly during hot weather. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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 Peters Residence G52-G02 S22757 St Peters Res V236550 120705 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 Peters Residence G52-G02 S22757 St Peters Res V236550 120705 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) 2 3 4 5 6 No service users are admitted without a thorough needs assessment completed first thus ensuring that care needs will be met. Prospective service users have the opportunity to test drive the home before making a decision to move there. EVIDENCE: From the written information observed on files, for three service users recently admitted to the home, it was demonstrated that individuals were only admitted following the undertaking of a full holistic assessment of need. Senior experienced members of staff had completed thorough pre- admission assessments. These were comprehensive and covered all aspects of personal and social care needs. Two service users spoken to said that they visited the home first before admission. They also told of the discussions that they had with staff about their needs and of their experiences on the visit. Service users attend the home for trial visits to gain a feel of life there. One lady recently admitted spoke of the great sense of comfort and warmth she felt when she first visited the home St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 9 and that this was what helped her make the decision to stay there permanently. Two other service users that have lived at the home for many years spoke of the high quality and consistency that they experienced. The inspector observed the assessments completed. These contained great detail and took into account individuals’ personal likes and dislikes, patterns of daily living. From this information it was possible to ascertain if the needs assessed could be met at the home. Staff individually and collectively have a good range of skills and experience and deliver an exceptional high standard of care to service users. Service users requiring less support are enabled to retain and develop independence by the provision of small kitchens in each unit to prepare light snacks and refreshments. For individuals with high support needs care is provided in a manner that is sensitive and takes into account their feelings and aspirations. The inspector spoke with twelve service users. All of these service users expressed great satisfaction at the quality of life experienced since they moved to the home. They said that people are enabled to remain as independent for as long as possible but that staff know the appropriate way to respond when they see service users losing the capacity to remain independent and respond in a discreet manner that is sensitive to individuals feelings. The home provides a physiotherapy room with a range of equipment. Physiotherapists visit the home two days per week offering therapeutic advice and exercise as well as assessing and supplying suitable equipment. Examples where this has really benefited individuals were reported. These included service users that had sustained wrist fractures and minor injuries receiving rehabilitated in the comfort of their own home and avoiding having to attend hospitals for appointments. There is a manual handling trainer available at the home on weekdays to offer training and guidance to the staff team and ensure that the correct manual handling procedures are followed. Emphasis is placed on always preserving privacy and dignity. All admissions to the home are fully planned. The home does not accept service users for intermediate care. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 10 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 The arrangements in place at the home for delivering care to service users are very good with staff kept fully informed of any changes to individual needs. The health care needs of service users are promoted and maintained. EVIDENCE: The inspector examined a total of six care plans. Care plans covered all areas of health, personal and social care needs and were drawn up with service users following the completion of holistic assessments at the home and from information received from care management assessments. Risk assessments were included with care plans and detailed all the necessary action required by staff to minimise risks in particular relating to moving and handling. Care plans and risk assessments had been regularly reviewed every month. There were also updates recorded of changes to individuals’ needs and the plans to address these changes as they arose. Risk assessments also highlighted those at risk of falls and the action to be taken by staff in reducing those identified at risk. This was an area where the St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 11 benefits of a physiotherapy service at the home were invaluable on advising of the suitability of equipment and aids to assist with walking. A number of service users using wheelchairs access the lift and the communal facilities independently. The inspector met with one of these service users. She spoke of the difference that using the wheelchair had made to her quality of life. One service user had a collision with a wheelchair user since the inspection and sustained injuries. A risk assessment was in place to determine the suitability of the service user using the wheelchair independently. It is recommended that following risk assessments consideration be given to ensuring that for those service users using wheelchairs independently, that they are instructed and advised on aspects relating to the safety of other people in the communal areas. Staff are made aware of service users and their conditions at change of shift. Reports are written on the progress of service users and then communicated directly at handover, this occurs in the morning and evening. One unit manager reported on an incident that occurred during handover and that could have been avoided. It is recommended that visual checks be made of all service users at handover period. All twelve service users spoken to said that staff at the home were professional and respected service users’ privacy and dignity. Two service users said that “people were looked after in a peaceful and delightful setting by people that really cared and that wanted to work with older people”. Service users at the home spoke of the excellent service provided by a GP. Regular weekly consultations are held with the GP. Regular annual health check ups are undertaken for all service users. Many areas of good practice were observed in the way the nutritional needs of service users were monitored. On admission all weights were recorded and thereafter were monitored every month. Care plans and the progress notes detailed changes in weight records and that the necessary action was taken to respond to these promptly. For service users with low body weights nutritional supplements were provided. Additional staff are provided from the convent to assist service users with feeding. On the care files viewed service users at risk of developing pressure sores were identified. Observations made were that essential equipment such as pressure relieving mattresses and cushions were provided to promote tissue viability. The progress records maintained of day and night time care demonstrated that service users requiring assistance with toileting were supported and changed frequently in accordance with care plans. Incontinence assessments had been St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 12 completed for service users. The inspector observed that necessary aids and equipment had been supplied to promote continence. Chiropody services are provided at the home but as the waiting time has been excessive, a number of service users are supported to visit the chiropody clinic in the locality. The home has it’s own transport which it uses to transport individuals to outside appointments. A qualified nurse checks the medication received into the home and also supplies returned to the pharmacy. A review of medication procedures had been undertaken at the home. Four MAR sheets were observed; there were no errors observed. It is recommended that photographs of service users be inserted in the medication folders. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 13 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 14 15 Service users experience a lifestyle that provides for their differing expectations and preferences and meets their social, cultural, religious and recreational interests. Mealtimes are pleasurable with excellent meals served that service users really enjoy and appreciate. EVIDENCE: The home takes into consideration the needs of all service users living at the home. In discussions with service users (twelve) the inspector found that the lifestyles they experienced met with their individual differing expectations and preferences. People’s social, cultural and occupational characteristics were taken into account. A number of service users living at the home have retired from religious life and choose to use facilities such as the library and quiet rooms and not participate in organised activities. This choice is respected. Two of these service users sitting in the garden spoke to the inspector of their experiences at the home. They said that they appreciated “the sedate and private lifestyle they now enjoyed at the home and spent long periods reading”. A chapel is located on the ground floor where mass is celebrated every day and in which many service users participate. Access is also available via a balcony on the first floor to enable less mobile service users participate in worship. A number of service users were involved in making items in the sewing room. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 14 Bazaars and fetes are held during the year where these goods are offered for sale. Three service users displayed items that they had made and the pleasure they got from being creative. The inspection day was a hot Summer day. At least twenty service users were enjoying the sunshine in the garden throughout the day. Two male service users spoken to said they were enjoying the sound of fans at the nearby cricket grounds. Service users and relatives enjoyed iced water teas and coffees that helped them to remain cool. Staff were attentive to service users outdoors and spent time in discussions and chats with individuals. Indoors in the numerous lounges consideration was given to the volume of televisions and music players; the atmosphere was tranquil with the volume adjusted to a comfortable setting. Two volunteers that run the weekly evening bingo met the inspector. They have attended the home for numerous years as volunteers to support service users with a range of activities. There is a large activities hall on the ground floor. A very varied programme of activities was viewed for previous months. Eight service users spoken to were complimentary on the excellent entertainment provided. There is a bar/coffee area on the ground floor as well as a shop. Five service users told the inspector that they” enjoy congregating in the bar and enjoying refreshments after mass on Sundays”. This they said “is a social occasion to which a large number of service users look forward to”. Kitchens are available on each unit to enable more active service users prepare light snacks and refreshments for themselves and guests. The home demonstrates an ability to meet the social care needs of all service users and take into consideration their capacities, needs and expectations. People with varying capacities, including those with cognitive impairments, received one to one support and stimulation at many periods during the day. Three relatives that had travelled some distance to visit relatives said that staff at the home welcomed them when they visited. They also reported that “staff kept them fully informed by telephone of any changes to their relatives’ conditions”. Two service users said that relatives and visitors were welcomed at the home. A receptionist is employed. The reception area is located close the main entrance to assist all visitors to the home. Following an invitation the inspector joined service users for lunch in the main dining room on the ground floor. The home places emphasis on making mealtimes as pleasurable as possible. The ambience and attention given to detail were evident with the main dining room similar to a good restaurant. The dining tables accommodating four were attractively presented with cutlery, individual napkins and cold drinks and condiments on all tables. Three service users at the table spoke of the regular options available and of the high quality of meals served at the home. Meals were attractively served and presented. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 15 For lunch there was a choice of two meals, one with meat(chicken) and a vegetarian option. A variety of fresh vegetables also accompanied the dish. The mealtime was relaxed and enjoyable for service users. All twelve service users spoken to said that the chefs were to be commended as all the meals served at the home were enjoyable. Meals in the other dining rooms were served promptly from the kitchens with no delays encountered by service users. On the first floor a number of service users were supported with eating. Interaction observed between staff and service users included good eye contact. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 16 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 18 Service user’s views are listened to and acted upon. Robust procedures are in place to protect service users from abuse. EVIDENCE: The home has a complaints procedure in operation. Records showed that three complaints were received and responded to within timescales set. None of the complaints recorded were substantiated. Discussions took place with six service users regarding how peoples’ views were acknowledged, all those spoken said that “any issues raised with unit leaders or with the management were listened to carefully and responded to”. From speaking with four members of staff the inspector found evidence that staff were knowledgeable about Adult Protection Policies and Procedures. Staff are supported and guided by experienced senior members of staff. The management follows disciplinary procedures and addresses promptly any areas of poor practice identified. A referral was made to the temporary POVA list regarding a staff member’s practice while an investigation was undertaken. The allegation was not upheld. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 17 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 20 21 22 23 24 25 26 Service users benefit from living in an environment that is safe, pleasant and well maintained. Service users personalise their bedrooms with treasured items to enable them to develop familiar and homely surroundings EVIDENCE: The inspector toured the premises, all the communal areas and four bedrooms were viewed. The layout of the premises is good. Service user accommodation is arranged over four units located on the first and second floors. Each of the four units has a separate lounge and dining room. Lounges and dining rooms were attractively decorated and contained good quality furnishings and fittings. In addition a second lounge used for smoking or for sitting quietly or privately with visitors is available on the first and second floors. Bedroms were personalised and maintained to exceptionally high standards. The registered manager informed the inspector that bedrooms are routinely decorated when vacated. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 18 All bedrooms are en-suite, there are also separate toilets available on each unit and on the ground floor. Each unit contains two bathrooms (with Malibu baths) and a wheelchair accessible shower. Corridors and communal areas displayed a range of pictures and ornaments including a water feature. Redecoration has taken place on one of the corridors on the first floor thus ensuring that presentation is retained to a high standard. The ground floor contains numerous facilities. The reception area of the home by the main entrance is attractive, inviting and peaceful, with side rooms that are used for meetings/interviews/visitors. This also has a Royal Mail post box for service users’ convenience. The ground floor also includes a chapel, the entertainments hall, tea/coffee lounge and bar and sewing rooms and shop. Externally there are ample attractive grounds that are private and include a landscaped garden with seating and a gazebo. Service users spoke of the benefits they enjoyed from the large garden. Many of the service users said they enjoyed their daily walks in peaceful surroundings. The main dining room on the ground floor is lively and used by service users that are fully mobile as well as those from the sheltered housing unit nearby. Communal areas of the home are fully accessible to service users and visitors, via wide corridors, lifts and ramps. The home employs a part time physiotherapist. It also takes advice from district nursing and other specialist professionals about disability facilities and equipment. A variety of this equipment was observed. The home provides an equipped disabilities training room on the ground floor for the physiotherapist to support and encourage service users to rehabilitate successfully. The home has been well designed with each bedroom benefiting from an abundance of natural light. Although temperatures were high on the day of inspection outside the interior of the home was well ventilated. All areas of the home seen were scrupulously clean and hygienic, and free from any odours. Visitors (seven) as well as twelve service users spoken with confirmed that this high standard is maintained at all times. The home employs a large number of domestic assistants as well as two laundry assistants, a seamstress and a full time gardener. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 19 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 30 Sufficient numbers of dedicated, trained and qualified staff that understand and meet the needs of service users are employed. Volunteers complement the staff team by assisting with and organising activities. EVIDENCE: Staff retention levels are good thus ensuring continuity and consistency to the care delivered. Rotas were viewed. These demonstrated that the home has one Unit Manager and two care assistants on duty for each shift. The unit managers are qualified nursing sisters and work over the seven-day period. Rotas demonstrated that staffing levels are increased to three care assistants on the Unit with the most dependent service users. In addition there are Sisters living in the convent who support service users at meal times and that are available at other times as necessary, for example on call at night/available for 24 hour sitting with service users at the end of life. Because the Sisters are available on-call at night, the home has two waking staff on night duty. Records of current service users showed that these levels were adequate currently. Two of the unit managers spoken to reported that night time staffing levels were constantly reviewed to reflect the numbers and needs of service users. Pre inspection questionnaires included recorded dates of Crimnal Records of Enhanced Disclosure for all care staff and that members of staff do not commence employment until full and satisfactory information has been sought first. Personnel records were not examined at the inspection. A number of volunteers support staff with arts and crafts and entertainment. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 20 Three of the regular volunteers met with the inspector. They were enthusiastic about their contribution to enhancing life for those living there and helped organise regular weekly events. Some also assisted with serving snacks and beverages. They commented favourably on the calibre of the staff team. A local school has involved placing pupils that have been carefully vetted and selected for work placements. The teacher in charge of the project met with the inspector to discuss the project and the vetting process used. Evidence was available that service users are in safe hands at all times due to the skills and experience of the staff team. Of the thirty six care staff employed four of these are qualified nurses. Twelve care staff have acquired NVQ level 2 in care, five of the other care staff are currently undertaking NVQ Level 2 in care. From discussions with five service users feedback received was that staff were kind and knew how to look after people. Four service users singled out the nursing sisters on the units for particular praise. They said that “ the sisters lead the staff team by good example which gave service users a great sense of stability and security”. A training coordinator is employed to develop and coordinate training of the staff team. Copies of two staff development programmes were viewed. These recorded that individual development plans were in place and that staff were trained and developed according to their needs and to the needs of the service users. A manual-handling trainer is also employed to ensure that staff are knowledgeable and know how to transfer service users safely. One of the unit managers said that her advice is also sought on additional concerns raised regarding manual handling for individuals. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 21 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 32 37 38 Service users receive a high quality of care from a team that have good leadership and direction. Good practice throughout the home promotes and safeguards the health, safety and welfare of service users. EVIDENCE: The registered manager has been in post for a number of years. She is an experienced professional and gives clear direction and leadership. Service users, their visitors and staff made positive comments about the staff team. They gave examples of good communication and staff were clear of what was expected of them. One area commented on favourably by several service users as well as their visitors was that the care delivered was reliable and consistent. Records of regular one to one supervision were viewed. Three members of staff confirmed with the inspector that they were supervised and supported. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 22 Inspection of records indicated that regularly tests to fire fighting equipment were carried out as well as regular fire drills. This was also confirmed by the three staff spoken to. Records held for maintenance of the premises demonstrated that essential equipment is regularly services, these included emergency lighting, the lift, hoists, bathing equipment wheelchairs and central heating. Insurance cover was in place. Record keeping is good at the home both for service users and for the home. The registered manager resides at the convent located next to the home and is present daily. Regulation 26 visits are completed every month. It is stated as a requirement that copies of these reports be forwarded to CSCI every month. Records were viewed of accidents and incident reports. The home experiences a low number of accidents. Not all of these notifications in accordance with Regulation 37 of care home regulations have been forwarded to CSCI and are detailed as the subject of a requirement in the report. The completed pre inspection questionnaire demonstrated that policies and procedures were in place for the home. Discussions with three members of staff concluded that staff were familiar with the policies and procedures of the home. Staff also confirmed that a staff handbook had been issued to staff that contained a summary of these. St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 23 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 4 4 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x 3 x 3 2 3 St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 24 no 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 37 Regulation 37 Requirement The registered person must ensure that written notification is given to CSCI of all notifiable incidents The registered person must ensure that copies of the Regulation 26 visit reports are forwarded every month to CSCI Timescale for action 31st August 2005 31st august 2005 2. 37 26(4) c 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. 2. 3. Refer to Standard 9 7 9 Good Practice Recommendations The registered person should ensure that further safety measures are in place for independent wheelchair users using the communal facilities The registred person should ensure that visual checks for all service users are conducted at change of shift The registered person should ensure that photographs of service users are inserted in the medication folder St Peters Residence G52-G02 S22757 St Peters Res V236550 120705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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