Inspection on 22/06/05 for St Stephens Residential Home

This inspection was carried out on 22nd June 2005.

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 Stephens Residential Home 07/08/06

St Stephens Residential Home 05/10/05

St Stephens Residential Home 03/11/04

St Stephens Residential Home 30/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE ST STEPHENS St Stephens Terrace Droitwich Road Worcester WR3 7HU Lead Inspector Andrew Spearing-Brown Unannounced 22 June 2005 9:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service St Stephens Residential Home Address St Stephens Terrace Droitwich Road Worcester WR3 7Hu 01905 29224 01905 26574 sstephens@festivalhousing.org Partnership Care Services 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) Mrs Susan Finbow CRH 51 Dementia - over 65 Old age Physical disability - over 65 Category(ies) of DE(E) registration, with number OP of places PD(E) ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: There are no other conditions of registration other than those refered to on the previous page of this report. Date of last inspection 3rd November 2004 Brief Description of the Service: St Stephens is registered to provide accommodation and care for 51 older people who may also have needs relating to physical disabilities and/or a dementia illness. A specialist dementia service is not provided. However care can be offered to people who have mild to moderate dementia care needs. The home is situated on the outskirts of Worcester city, close to local amenities. The building was upgraded and refurbished in 1999. It is a large three-storey building with a shaft lift to enable easy access between floors. There are 43 single bedrooms, 21 of which have en-suite facilities, and 4 double bedrooms, all of which have en-suite facilities. All bedrooms meet or exceed the National Minimum Standards (Older People) for usable space. There is a wide choice of communal lounges and dining areas and all rooms are well fitted and furnished. St Stephens has an attractive level central garden. The home is owned by Partnership Care Services who is referred to in this report as the registered provider.Mrs Susan Finbow who is referred to in this report as the registered manager manages the home. The registered provider’s representative, Mrs Julie Ledington, oversees the management of the home. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by an inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The visit lasted just over six hours. The last inspection took place during November 2004. The main focus of this inspection was therefore to assess the progress made in relation to the requirements from the previous inspection. On the day of this inspection the registered manager and her deputy were both on duty, but were involved in staff appraisals throughout the morning. Other senior staff, one carer and three residents were consulted. Many areas of the home were seen including some bedrooms and all communal rooms. The care records of a small sample of residents were seen. Other documents seen included medication records, complaints, fire records and some policies and procedures. What the service does well: Residents consulted were very positive about the meals provided within the home. The grounds, especially the centrally patio area, continue to be well maintained and attractive. All areas of the home were clean and tidy, residents’ comments were positive about the cleanliness of St Stephens. All residents’ bedrooms that were seen were personalised. Communal lounges are well furnished and comfortable. St Stephens has a stable core group of staff; many have worked within the home for a number of years. Staffing levels are maintained, using agency staff when necessary. Residents were complementary about the staff’s caring attitude. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were assessed in any detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at St Stephens. EVIDENCE: ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 No progress has been made on improving care records held on computer to ensure that the health care needs of residents are followed up and met. Safeguards in the systems for recording the administration of medication are poor. These shortfalls have a potential to place residents at risk. EVIDENCE: Residents care plans are held on computer. Terminals are available within the office and the ‘treatment room’. Paper copies of care plans can be generated and were available although these were not the most up to date version. As part of this inspection a small number of care plans and daily notes were viewed on one of the computers. The available headings on the care plan include those as listed under standard 3.3 of the National Minimum Standards – Older People. However not all headings were used in relation to each resident. The information upon the care plans themselves remains scant in detail and fails to effectively specify the care activities and the interventions required by care staff to meet individual needs. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 10 The terminology used on the diary notes was not always appropriate ‘ bell happy’ and ‘ on the bell all night’ were noted. Information included within the diary notes was not always followed up, in one incidence it was stated that a social worker was going to request a GP visit to a resident. No visit had taken place and no action to chase up a visit had taken place despite evidence that the perceived ‘problem’ was continuing. Another entry made reference of a ‘skin tear’ but no further reference was evident in relation to action taken or that the injury had healed satisfactorily. A request by a resident to increase the level of assistance offered in the morning was noted in the diary notes. No care plan was in place regarding any level of personal care. The CSCI recently received a notification under Regulation 37 regarding an incident whereby a resident was choking. The care plan entitled eating and drinking made no reference to this and therefore no details or risk assessment as to how any reoccurrence was to be avoided. The care plan of one resident stated ‘wears a hearing aid often now.’ While having a look around the home the hearing aid was found on top of the bedside cabinet while the resident was in the lounge. No explanation as to why the hearing aid was not in place was recorded. The goal under the heading ‘Communication’ stated ‘ to ensure XX gets all the know!’. Nutritional screening of residents does not take place at the time of admission and periodically thereafter. No risk assessments to identify residents who could be susceptible to pressure sores were in place. As part of this inspection the current month’s Medication Administration Record (MAR) sheets were examined. Serious concerns were noted which required an immediate requirement notice to be issued. Controlled medication was not signed or accounted for, antibiotic medication was signed for incorrectly and gaps where nobody had signed for medication were noted on the MAR sheets. Other MAR sheets evidenced that staff signed either prior to medication administration or collectively afterwards as some sheets were signed as given and then altered to show that the resident was not within the home. No temperatures readings had been taken for three weeks regarding the medication ‘fridge, as the thermometer was broken ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals in the home meet the needs of residents offering choice and variety. EVIDENCE: As part of this inspection the opportunity to take lunch with service users was taken. The main meal was lamb chops, potatoes, cauliflower and mixed vegetables. Some residents had a ham salad. The salads well presented. The meat for the hot meal was served plated with residents helping themselves to vegetables from serving dishes. Staff members were observed to be assisting service users discreetly; no resident required help feeding. All residents consulted were very complementary regarding the quality and quantity of food available. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 12 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) None of the standards in this section were assessed in any detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at St Stephens. EVIDENCE: ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 13 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, 22, 23, 24 ,25 and 26 Recent investment to improve the appearance of corridors and communal areas has improved an environment, which was already a comfortable and pleasing place to reside. EVIDENCE: The gardens, especially the back garden, are very well maintained; suitable shaded seating is provided. All residents consulted as well as many others with whom a brief discussion was held agreed with the above sentiment. Communal facilities seen were spacious, varied, comfortable and attractive. Residents infrequently use the lounge on the top floor. A small smokers’ lounge is provided; smoking is not permitted within individual bedrooms. Lounges on the ground floor and corridors have been decorated since the last inspection. The washing machines within the laundry are suitable for the needs of residents. They both have a sluice facility. It is believed that the machines meet the Water Supply (Water Fittings) Regulations 1999. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 14 Communal bathing and toilet facilities within the home possessed liquid soap in line with infection control policies provided by Herefordshire and Worcestershire Health Authority. The previous inspection report noted St Stephens to be both clean and tidy; this was also noted during this visit. Residents consulted stated that they felt the standard of cleanliness to be good. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 15 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 Staff on duty were sufficient in number to safeguard residents. EVIDENCE: St Stephens has a staffing assignment consisting of a registered manager, a deputy manager, assistant managers and a team of day and night care assistants. There is also a team of domestic staff as well as catering staff. Sufficient numbers of staff were on duty on the morning of this inspection, this level of staff consisted of both staff employed by the home as well as agency staff. Concern was however voiced regarding the lack of ‘quality’ time to spend with residents Three wakeful care assistants cover the nights with a member of the senior team on call sleeping in within the home. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 16 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) 35 and 38 Shortfalls in the routine testing and checking of fire safety equipment could potentially place residents at risk. EVIDENCE: A box was in the reception area for residents and their representatives to deposit their response to a questionnaire. The balance of a small random sample of residents’ money held in safekeeping was checked and found to be correct. Two members of the senior team have recently undertaken training for home managers from Hereford and Worcester Combined Fire Authority. All staff have received recent fire training consisting of a simulation of a fire in the kitchen, however some staff have not received full fire awareness training for a considerable period of time. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 17 Shortfalls were identified within the fire logbook. The weekly testing of the fire alarm was unsatisfactory. Further deficiencies were noted in relation to the visual checking of detectors and the test of the emergency lighting. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x 3 x x 2 ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 5 (1) (b) Requirement The registered manager must ensure that each service user is provided with a statement of terms and conditions. (This standard was not assessed as part of the inspection carried out on 22nd June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection) . The registered manager must ensure that an identified care need generates a care plan. Timescale for action 30/11/04 2. 7 15 (1) immediate and on going 3. 7 15 The registered manager must ensure that the service user’s care plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of need are met. (Previous timescale of 30/11/04 not met). immediate and on going ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 20 4. 7 15 (2) (a) The registered person must ensure that care plans are reviewed on a monthly basis or more frequently to reflect the changing care needs of service users. (Previous timescale of 30/11/04 not met). immediate and on going 5. 8 13 (1) (b) The registered manager must ensure that necessary follow up action is taken and recorded in relation to service users welfare and needs. (Previous timescale of 30/11/04 not met). immediate and on going 6. 8 17 (1) (a) Schedule 3 (o) The registered manager must ensure that service users’ care plans contain information regarding nutritional care needs. The registered manager must ensure that risk assessments in relation to pressure care prevention are carried out. The registered manager must ensure that medication administration records are completed adequately and at the time of administration. (Previous timescale of immediate and on going not met). immediate and on going immediate and on going 7. 8 15 (2) (b) 17 (1) (a) Schedule 3 (p) 13 (2) 8. 9 immediate and on going 9. 9 13 (3) The registered manager must ensure that when a variable dosages is prescribed the actual dose given is recorded. immediate and on going ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 21 10. 9 13 (3) The registered manager must ensure that a new thermometer is obtained and that the recording of the fridge temperatures recommences. immediate and on going 11. 19 23 (2) (b) The registered provider must 30/11/05 ensure that all areas of the home are well maintained and in good and sound order. (Part met) 12. 17 (2) Schedule 4 (9) 35 The registered manager must audit the records of all items deposited by service users for safekeeping to ensure all items are suitably recorded as held. (This standard was not assessed as part of the inspection carried out on 22nd June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 30/11/04 13. 17 (2) Schedule 4 (9) 35 The registered manager must review present policy, procedure and current practice in relation to the payment of service users moneys to a third party. (This standard was not assessed as part of the inspection carried out on 22nd June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 30/11/04 ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 22 14. 17 (2) Schedule 4 (9) 35 The registered provider must develop suitable policies and procedures in relation to items held in safe keeping which are unclaimed by the rightful owner (This standard was not assessed as part of the inspection carried out on 22nd June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 31/12/04 15. 17 (2) Schedule 4 (16) 37 The registered manager must review present policy, procedure in relation to missing persons. (This standard was not assessed as part of the inspection carried out on 22nd June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 30/11/04 16. 23 (4) 38 The registered manager must ensure that all staff receive approprate and up to date fire training. The registered manager must ensure that the fire log is maintained and that the required weekly and monthly tests are carried out as required. 31/08/05 17. 23 (4) 38 immediate and on going ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 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 7 7 8 3. 4. Good Practice Recommendations More detail should be included in care plans regarding the service user’s wishes in relation to cultural and religious requirements. The registered manager should have a further review of the present system in place for the recording of care notes, care plans and other care related documentation. ST STEPHENS E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 24 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7HU 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 E52 S18676 St Stephens V221778 220605.doc Version 1.20 Page 25 - 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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