Inspection on 01/11/05 for St Stephens Care Home

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Stephens Care Home 17/04/07

St Stephens Care Home 28/06/05

St Stephens Care Home 25/01/05

St Stephens Care Home 13/07/04

St Stephens Care Home 03/03/04

St Stephens Care Home 07/10/03

St Stephens Care Home 30/09/02

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

CARE HOMES FOR OLDER PEOPLE St Stephens Care Home London Road Elworth Sandbach Cheshire CW11 4TG Lead Inspector Denis Coffey Unannounced Inspection 1st November 2005 09:00 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 Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 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 Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Stephens Care Home Address London Road Elworth Sandbach Cheshire CW11 4TG 01270 759565 01270 753425 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) Community Integrated Care Sharon Timms Care Home 40 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (21) of places St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 40 service users to include: * up to 21 service users in the category of OP (Old age not falling within any other category) * up to 19 service users in the category of DE(E) (dementia over the age of 65 years) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The registered provider must provide staff to meet the dependency needs of the residen at all times and shall comply with any guidelines which may be issued through the Commission for Social Care Inspection. 28/06/05 2. 3. Date of last inspection Brief Description of the Service: St. Stephen’s is a single storey purpose built home consisting of two wings for the provision of nursing care for elderly people. Saxon Wing is registered to care for nineteen people with dementia, and Penda Wing for twenty-one people that are elderly and infirm. Bedroom accommodation comprises of 40 single bedrooms. There are no ensuite facilities provided but bedrooms; lounge/dining rooms are close to the bathrooms and toilets. Communal space is adequate for the number of people accommodated. The home is situated in the village of Elworth approximately 1½ miles from Sandbach and 3 miles from Middlewich. In accordance with regulations there are trained nurses on duty at all times. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a five-hour period and included a tour of the premises, an inspection of care and medicine records, and speaking with residents and their visitors. Those residents and visitors spoken with were positive in their comments about the home in general, the care provided and the support given by the staff. Two requirements were identified at this inspection. These were in relation to care plans and the standard of décor on the corridors on Saxon Unit. Recommendations have been made for proper signs to be provided for the bedroom doors on Panda Unit and for a falls/trips risk assessment to be carried out on the premises. What the service does well: What has improved since the last inspection? What they could do better: St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 6 Care plans are in place for each resident that identify the care they receive in relation to problems/needs identified. These could be improved by ensuring that the care plans are amended when a change in the residents’ condition occurs. The provision of appropriate door signs for the bedroom doors on Saxon Unit would improve the dignity issues of residents occupying those rooms. The majority of accidents sustained by residents are attributed to falls/trips, and it has been recommended that a risk assessment of the premises be carried out to ascertain if there are any particular areas of the home that account for these accidents. 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 Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 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 Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 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&3 Information is available for residents to enable them to know that their needs can be met. EVIDENCE: The company owning the home has produced a handbook detailing general information on what services the home provides, e.g. the care and support philosophy, arrangements for managing finances, and the staff code of conduct. The home also has its own brochure providing specific information on the facilities provided. The home’s statement of purpose has been reviewed and updated. Evidence was seen of prospective residents’ being assessed by a trained nurse prior to taking up residency at the home. St. Stephen’s does not provide intermediate care so standard 6 is not applicable. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 9 St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 & 11 The care needs of the residents are identified in their individual care records, but these do not accurately reflect in all instances the care required when there has been a change in the residents condition. Medicines are well managed providing a safe system for ensuring that residents receive their medicines as prescribed. EVIDENCE: The care records of four residents were examined at this inspection. These contained plans of care for the perceived needs of the residents along with nutritional and skin integrity assessments. Evidence was seen of the care plans being evaluated on a monthly basis. However, one of the care records examined did not contain a care plan for communication, and the resident’s oral hygiene needs had not been identified. One of the residents was now being nursed in bed as their condition had deteriorated. A plan of care had been devised identifying the care the resident needed whilst being nursed in bed. The daily records for the resident stated that they were not accepting diet or fluids, but there were no interventions identified as to how this problem was being addressed, and the care plan for nutrition was in need of updating St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 11 as it states the resident has their meals at the dining table, and that a liquidised diet was required. All of the residents are registered with a general practitioner, and records were seen of treatment being given by chiropodists, dentists and referral to a dietician where appropriate. Residents spoken with said that their care needs were fully met, and that the staff were friendly and attentive. Medicines were stored securely and the medicine administration record sheets of the residents were correctly filled in. A random sample of medicines were chosen for stock reconciliation and these were found to be correct. The residents’ care records examined had a section in them that identified the residents’ wishes following death, and the home has a policy on care of the dying that includes supporting the family. See Requirement 1 St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 12 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): 12, 13 & 14 Activities are provided for residents to take part in to keep them active and stimulated. Residents and their family’s views are sought to enable them to make choices in how the home is run. EVIDENCE: The home employs a full time activities co-ordinator who was on holiday at the time of inspection. In her absence the care staff were providing social and leisure activities for the residents. A Christmas Fair has been organised to take place at the home in late November the proceeds from which will be paid into the residents’ amenities fund. This fund has paid for a piano for the home, and bedding plants, and will provide a Christmas present for each of the residents. External entertainers visit the home throughout the year, and residents have recently had an evening out to Blackpool. Some residents go for a coffee morning each week at a local church. A Christmas party has been arranged for the residents on the 17th December 2005. At the time of this inspection three sets of visitors were spoken with, all of whom were positive in their comments about the staff and the care they deliver. Residents spoken with were equally positive about the home and the care they receive. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 13 A relatives and residents meeting takes place monthly with a record made of the topics discussed, e.g. organising a quiz night, general activities, and any concerns anyone might have. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 14 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 There is information available to residents, and visitors to the home on how to make complaints and how these will be dealt with. EVIDENCE: A copy of the home’s complaints procedure is contained in the service users’ guide, and in the company’s brochure. The procedure identifies who to complain to, and how this will be dealt with. The address and telephone number of the Commission is also included. There have been no recorded complaints received at the home since the last inspection. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 15 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, 20, 21, 24 & 26 The home provides a comfortable and clean environment for the residents to live in. Whilst the standard of décor was in general well maintained, there were areas where this needed to be attended to, to improve the environment. EVIDENCE: The home employs a maintenance person for an average of 18.75 hours per week. There is also a contract with a company that provides twenty-four hour cover in case of emergencies. The main corridors on both units are in need of redecoration as the paintwork on the walls was marked, and on the doors and skirting boards, chipped. The manager said that redecoration of this area on Panda Unit has been agreed. Each unit has a lounge and separate dining facilities. Additional seating areas are provided in alcoves that have easy chairs supplied. There is in addition to these lounges a large central lounge that is used for functions, and a further lounge sited at the back of the home is used as an activities room. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 16 There are a total of twelve toilets, four baths and two showers provided at the home. All of the baths are adapted for use with residents who have difficulty in using a domestic style bath, and on the day of inspection an engineer was in the home replacing one of the baths with a new one. Wash hand basins are provided in all of the bedrooms. An extensive redecoration programme was carried out at the home in 2003. At that time a decision was to be made whether bedroom doors would be numbered or have the residents names on them. On Saxon Unit a frame has been placed on the wall beside each bedroom door with a photograph of the resident occupying the room, their name and room number, placed in the frame. However, the doors on Panda Unit have pieces of paper attached to the doors with the residents name on them. All parts of the home were visited at this inspection and found to be clean, tidy and free from unpleasant smells. A macerator machine is provided on both units for the disintegration and flushing away of disposable incontinence aids, e.g. bedpans and urinals. See Requirement 2 See Recommendation 1 St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 17 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, 28, 29 & 30 Recruitment procedures are thorough ensuring that the residents are protected from any possible harm. Training is provided to enable staff to develop and maintain their skills in the delivery of care. EVIDENCE: An examination of the staffing rotas showed that there are three trained nurses and seven care assistants on duty in the morning, two trained nurses and four care assistants on duty in the afternoon, and two trained nurses and three care assistants at night. All trained nurses are required to maintain their registration with the Nursing and Midwifery Council every three years, and evidence was seen of this registration being maintained by the nurses employed at the home. The personnel files of three staff were examined at this inspection. All of these contained two satisfactory references, completed application forms, proof of identity, and occupational health forms stating that the person was fit to work. Two of the files contained evidence that a satisfactory Criminal Records Bureau (CRB) disclosure had been obtained. A protection of vulnerable adults check had been made for the person whose CRB disclosure was outstanding, and the manager was aware that this person must be supervised when delivering personal care to the residents’. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 18 Eleven out of a total of twenty-six care assistants have completed the NVQ level 2 in care, and one carer was awaiting confirmation that they had successfully completed this training course. Three other care assistants were currently undertaking training leading to this award. Two of the trained nurses employed at the home are NVQ assessors, and another trained nurse is attending training to gain the assessors award. All of the domestic staff employed at the home have successfully completed the NVQ level 1 in cleaning and support services, and all barring one have gone on to complete the level 2 in this category. The company has its own training department that facilitates staff training, and training sessions in foot care, continence, wound care and coaching and appraisal skills have been booked to take place before the end of December 2005. The manager and deputy manager were attending a two-day dementia awareness course following this inspection. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 19 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): 31, 33 & 38 The health and safety of the residents and staff is well promoted. This could be improved for the residents by an assessment of the premises in relation to falls/trips to ascertain if any part of the home is a particular risk hazard in relation to these types of accidents. EVIDENCE: The home manager has been registered with the Commission as the registered home manager since the last inspection, and has recently completed an NVQ level 4 in management. Records were seen of a representative of the company making monthly unannounced inspections of the home where they commented on the premises, looked at the complaints record, and spoke with staff, residents and their relatives. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 20 The accident records of the residents showed that the majority of accidents occurring in the past three months were attributed to falls/trips. A recommendation was made at the last inspection that a falls/trips risk assessment be carried out of the premises, but this has not been done. Fire drills were recorded as taking place since the last inspection in August and September. Not all of the staff employed at the home have received fire safety training this year, but the manager said that this would be completed before the end of December by the two staff at the home who have been appointed as fire safety instructors. Records were seen of the fire alarm system being tested weekly, and of the emergency lights being tested monthly. Adapted baths and hoists used in the moving and handling of residents’ are due for servicing by an engineer in December 2005. The cold water system at the home was disinfected in August 2005 and a certificate of satisfaction was issued. Thermostatic valves are fitted to the hot water system to prevent scalding, and when tested, the temperature of hot water supplied to the baths was found to be within acceptable limits. See Recommendation 2 St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15 Timescale for action Care plans must be in place that 15/12/05 address all of the identified needs/problems of the residents accommodated at the home. The plans must also be amended to reflect the changing needs of the residents. Redecoration of the walls, doors 10/01/06 and skirting boards on the corridors of Saxon Unit is required. Requirement 2 OP19 23 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 Refer to Standard OP24 OP38 Good Practice Recommendations Appropriate identification signs should be supplied to the bedroom doors of the residents on Panda Unit. A risk assessment of the premises should be carried out in relation to falls/trips hazards. This recommendation was identified at the last inspection. St Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Stephens Care Home DS0000018741.V254621.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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