CARE HOME ADULTS 18-65
St Teresas Cheshire Home Long Rock Penzance Cornwall TR20 9BJ Lead Inspector
Paul Freeman Unannounced Inspection 11th July 2007 10:00 St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 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 Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Teresas Cheshire Home Address Long Rock Penzance Cornwall TR20 9BJ 01736 710336 01736 710549 chris.proctor@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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) Mrs Christine Proctor Care Home 27 Category(ies) of Physical disability (27) registration, with number of places St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up 27 adults with a physical disability (PD), 15 of whom may have nursing needs 17th July 2006 Date of last inspection Brief Description of the Service: The care home is situated on the outskirts of Marazion and overlooks St Michaels Mount bay on one side. The town of Penzance is within easy reach and therefore there is a wide range of amenities available. St. Teresas provides a home for up to 27 younger adults who experience disabilities and are registered to provide nursing and residential care. The Home comprises of a new purpose built setting that was opened in 2000 and an established building that has acted as a care home for many years. The two settings are interconnected. Internally the accommodation is maintained to a high standard and residents have personalised and furnished their own rooms. St. Teresas is organised on the basis of three self-contained units of nine residents. Each unit has dedicated staff allocated and a Care Coordinator to facilitate efficient and smooth functioning. Each service user is allocated a key worker who takes a key role in ensuring the individuals needs are met in a manner that is acceptable to the individual concerned. Qualified nursing staff are on duty 24 hours a day to meet the nursing needs of residents. Currently twenty-five people are accommodated on a long-term basis and two beds purchased by Cornwall County Councils Department of Adult Social Care for short-term care. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced key inspection took place over two days on the 11 July 2007 by two Inspectors Paul Freeman and Diana Penrose. The purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the last inspection on 17 July 2006 and to inspect the key standards. Therefore some of the key standards that were considered include assessment and care planning, health and safety and staff recruitment. The environment, records and documents were also considered. The manager, residents and staff were consulted about the services and facilities provided. Prior to the inspection the providers had also sent to the Commission written information about the services and facilities provided. What the service does well:
Each prospective resident is assessed to make sure the providers are able to meet their needs, preferences and choices. The prospective resident has the opportunity to be fully involved in the assessment process and their relatives or representatives are also consulted. The views of any professionals that are in contact with the prospective resident are also taken into account. This means the providers have a clear picture of the care and support required and the information provided forms the basis of the care plan. Residents said they had felt in control of the assessment arrangements and had been positively welcomed and supported when they move to the home. Residents are also able to participate in a range of social, educational and recreational opportunities at the care home and in the local community. Staff also support residents to participate in activities when it is possible. Residents said the meals at the home were good and reflect their individual needs, tastes and choices. A varied and nutritional menu is offered and residents are provided with a choice at each mealtime. Residents said they had confidence in the staff and the manner in which their health needs are met. The care and support arrangements at the home are reliable and residents said the staff are flexible, efficient and responsive to their needs and requests. Residents are also able to administer their own prescribed medicines when it is safe. The qualified staff also administers medicines where assistance is required and the staff concerned have all been appropriately trained.
St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 6 Medication is stored in secure facilities and suitable disposal arrangements are in place for medication that is no longer required. The Providers deals with any concerns or complaints that are raised positively and efficiently. Residents said there no barriers to raising any concerns or complaints they have with the staff or managers and were confidant that any matters are dealt with in a satisfactory manner. Suitable arrangements are also in place to protect residents from abuse. Any concerns or allegations are reported to the statutory authorities for investigation. The environment and facilities in the home are of a high standard and provide a homely and comfortable setting for residents. The accommodation is provided in a single storey building that has accessible gardens and car parking facilities. Each of the units has their own dedicated communal space and there are other communal areas throughout the building that residents can use. Many of the bedrooms have en-suite facilities and communal toilets and bathroom facilities are also distributed throughout the home. A wide range of disability equipment is evident at the home and this includes hoists, specialist baths and mobility equipment. Where required each resident has a specialist assessment to determine the equipment or adaptations they require to meet their needs and promote independence. The home is maintained to a good standard of hygiene and cleanliness and the environment is well maintained and decorated. The staff group are enthusiastic, skilled and well trained and have a good understanding of residents needs. It is evident that positive relationships have been formed between the staff and residents. Sufficient numbers of staff are also employed each day and night to meet the needs of the residents. Residents are very positive about the manner in which staff provide the care and support required to meet their needs. Good arrangements are in place to recruit staff that make sure the new staff have the appropriate skills and abilities. Each new member of staff also completes an induction programme so they have a clear understanding of the residents’ needs and the standard of care and support required. Staff are also well trained and provided with regular opportunities to update and improve their knowledge and skills. Experienced managers manage the services and facilities in the best interests of residents. Residents and staff expressed confidence in the manner in which the home is run.
St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 7 Satisfactory arrangements are in place to regularly review the services and facilities. The arrangements include regular consultations with residents, staff and visitors and monthly visits by staff that are not directly employed at the care home. The feed back from the consultations is positive and indicates that residents value the care, support and facilities provided. A range of measures is in place to promote safe working practises at the home and satisfactory steps are taken to safeguard residents, staff and visitors. There are no concerns about financial viability and a suitable insurance policy is in place. What has improved since the last inspection? What they could do better:
St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 8 The providers need to review their policy and procedures about the provision of “cot sides” and protectors. The current arrangements rely upon the resident’s agreement but do not appear to take account of the individual’s abilities to take reasoned decisions about their own safety and well being. The providers also need to establish better arrangements for residents to manage and use the “social hours” they are allocated. Currently residents are unclear about the social hours they can access. Residents also requested that arrangements are improved in order they can spontaneously access community facilities. The shared space next to the kitchen requires improvement to make sure it mirrors the accommodation provided throughout the rest of the environment. This will also enhance the living experience of the residents in that area. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standard considered was 2. Quality in this outcome area is good. Each prospective resident is assessed to make sure the providers have a clear understanding of their needs and are confidant they can provide care and support required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers undertake an assessment on each prospective resident to make sure they are able to meet the needs of the person concerned. The prospective resident is fully involved in the assessment process in order that their needs, preferences and choices can be fully taken into account. Residents said they had felt in control of the assessment process and had also been provided with appropriate information about the services and facilities provided. Relatives and representatives of the prospective residents are also invited to contribute to the assessment. The providers also take account of the views and assessments of any professionals that are involved with the prospective resident at that time.
St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 11 Prospective residents are also able to visit the care home and the visiting arrangements are flexible. Residents said they been positively welcomed and helped to settle when they first moved to the home. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 6, 7 and 9. Quality in this outcome area is good. The providers have improved the care planning arrangements and there are some good examples of care planning. The plans provide staff with clear information and guidance about the care and support required. The plans are regularly reviewed but in certain instances the records of the review are incomplete. Residents are able to have control of their lives and make decisions. Where appropriate suitable support advice and guidance is provided. Risks around the home or experienced by individual residents are managed in a satisfactory manner to protect and safeguard residents. This judgement has been made using available evidence including a visit to this service. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 13 EVIDENCE: Each resident has a care plan that is developed from the assessments, which have been completed by the providers. The care plans detail the care and support required and provide staff with the information, guidance and direction about services and facilities needed. The providers and staff have continued to improve and develop the quality of the information provided in care plans. The care plans now meet the national minimum standards but the providers should not be complacent given there continue to be occasions when the quality of the information could be improved. It is also evident that one unit is below the standard of the other two and it is expected the quality will continue to improve at future inspections. There also continues to be occasions when a resident’s social recreational and leisure interests are not fully represented. This also needs improvement. Residents said the care and support provided was of a good standard and they were generally satisfied about the contents of their care plans. Residents stated they were able to direct the care and support they received and clearly felt in control of their daily lives. Residents also commented they had confidence in the staff who they found to be reliable, efficient and responsive to their needs. The evidence indicates that care plans are regularly reviewed and residents confirmed they are regularly consulted about the care and support provided. Records are made of each review but there are still occasions when the records do not detail any conclusions that have been reached or any additional action required. More detailed records will make sure that staff have a full picture of the residents needs. It is clear that residents are able to make decisions about their lives and how they spend their time. The care plans confirm that residents are encouraged to maintain their independence as far as possible and are provided with appropriate support to make decisions when required. There are also no barriers to residents accessing independent advocates if they wish. The providers have also continued to develop and improve the arrangements to assess and manage risks around the care home and in respect of individual residents. A satisfactory assessment of the environment has been undertaken and where necessary guidance has been provide in order to promote a safe setting. The providers have also established a regular arrangement to review the environment risk assessments. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 14 Where any situation arises that could potentially compromise the health and safety of a resident an individual risk assessment is completed and a suitable management plan is put in place where necessary. This is designed to protect the residents and staff. The directions given to staff were generally sufficiently detailed or written in a clear manner. However there continues to be occasions where more detailed directions and information are required. The providers must therefore ensure the minimum standards are maintained at all times. One of the risk assessments was in regard to “cot sides” for a resident. The assessment identified that “cot sides” and protectors were required. However the residents had declined the protectors and this had not been provided. The providers need to review this situation in regard to the resident’s capacity and the organisation policy and procedures in this situation. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 15 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 12, 13, 15, 16 and 17. Quality in this outcome area is good. The daily living arrangements at the home are flexible and residents are able to determine their patterns of daily life. Good arrangements are also in place to support residents to maintain personal relationships at the care home and in the community. Residents are able to participate in a range of social and educational opportunities that are based upon their interests and choices. A balanced and nutritional diet is provided that meets with residents’ choice and preference. The kitchen facilities have been improved to make sure they comply with the required standards. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 16 Daily routines at the care home are flexible and residents are able to determine how they spend their time. There are also no restrictions to residents maintaining links with family or friends and this occurs at the care home and in the local community. Where visitors come to the care home the residents are also able to decide where they meet. Residents said that all visitors received a positive welcome. Residents are also able to decide upon how they spend their leisure time and this includes participation in educational opportunities. Residents’ interests are initially identified in their assessments but the information recorded in care plans could be more detailed, directive and comprehensive. Some of the residents said they would like spontaneity in accessing the resources they need to participate in community opportunities. In addition there are allocations of “social hours for individual residents. Although the hours can be used flexibly there appear to be no reliable arrangements to coordinate or record the hours available. In addition many of the residents were unclear how many hours they had been allocated. The staff at the home will also accompany residents to participate in community activities but this can only occur in a planned manner within the resources available. Residents also have access to adapted transport, which they can use, for a nominal fee. The drivers’ have all been appropriately trained and the vehicles are kept in good working order. Residents stated they were very satisfied about the meals at the care home and a varied nutritional menu is in place that reflects the residents’ choice. Residents are provided with a choice at each mealtime and special diets are also catered for. The kitchen and food store have recently been refurbished and this has significantly improved the working conditions for the staff. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 18, 19 and 20. Quality in this outcome area is good. Good arrangements are in place to provide personal support and meet resident’s health needs. Medicines are held in secure facilities and safely administered to promote residents’ health and well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said they were very satisfied with the care and support they receive from the staff. It is evident that positive and trusting relationships have been established between the staff and residents. Residents also said the staff were flexible, reliable and responsive to needs where required. The residents also stated they are treated in a respectful and dignified manner at all times. Residents’ health needs are also well met and medical services are promptly accessed when required. A qualified nurse is also on duty each day and night and other health professionals are in regular contact with residents.
St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 18 Where required the providers also assist residents to participate in physiotherapy and a specialist worker is employed on a part time basis. Residents said they had confidence in the manner their health needs are met and there were no barriers to raising any issues or concerns with the staff or managers of the home. Residents are also able to administer their own prescribed medicines when it is safe. Qualified staff also administers prescribed medicines where the residents requires assistance. The staff involved in administration of medication have all been appropriately trained and the providers have established a policy and procedure to guide, direct and inform the staff. The records are generally good and confirm that medicines are being administered according to the prescription. Suitable arrangements are also in place to dispose of unwanted medicines and medicines are stored securely. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 22 and 23. Quality in this outcome area is good. Good arrangements are in place to positively deal with any concerns or complaints and to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A suitable complaints policy and procedure is in place and residents are provided with a copy. Residents’ comments showed that people feel very comfortable about discussing any issues of concern with the managers or staff. Four complaints have been made over the last year and were partially substantiated. All the complaints were dealt with efficiently and to the satisfaction of the complainant. A satisfactory policy and procedure is also in place to protect residents and any concerns or allegations about abuse are reported to the statutory authorities for investigation. In addition a suitable whistle blowing policy and procedure have been established. This enables staff to report concerns to a third party if they do not feel in a position to report the matter to the providers. This provides residents with further protection.
St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 24, 28 and 30. Quality in this outcome area is good. The standard of the environment is high and a regular programme of redecoration and furniture and equipment replacement occurs. This provides residents with an attractive and homely place to live. The shared space next to the kitchen requires refurbishment so that it mirrors the excellent standards throughout. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care home is a detached single storey facility that is maintained to a high standard. Wherever possible the fixtures and fittings and furniture are domestic in nature and therefore a homely atmosphere is provided. Residents describe the home as comfortable and had no significant concerns about their safety.
St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 21 There are accessible gardens around the care home and ample car parking facilities at the entrance to the home. One of the residents has also been instrumental in developing a sensory garden. Each unit is decorated in the preferred manner of the people who reside there and it is evident that residents have personalised their own bedrooms. Each of the units also has its own communal space that comprises of a sitting room, dinning area and kitchen. In addition there are other communal rooms at the home that residents are able to utilise if they wish. Residents’ bedrooms are also furnished to a high standard and the resident is able to choose their own colour scheme. If they wish they can provide their own furniture, furnishings and fittings. In addition the rooms are set up to enable the occupant to maximise their independence. Many of the bedrooms have en-suite facilities and there are also a number of shared bathroom and toilet facilities distributed throughout the care home. A wide range of disability equipment is evident at the home and this includes hoists, specialist baths and mobility equipment. Where required each resident has a specialist assessment to determine the equipment or adaptations they require to met their needs and promote their independence. One of the areas of communal space in the original building is sited next to the kitchen. Originally this was the care homes dinning room and essentially has not been improved or refurbished for many years other than redecoration. This area now required improvement and refurbishment. This will further improve and develop the communal facilities and services for the residents that reside in that area. The home is clean and a good standard of hygiene is maintained on a daily basis. Residents said they were very satisfied with the facilities and equipment provided and the standard of cleanliness throughout the home. A regular programme of maintenance, replacement and redecoration is placed and the providers also employ maintenance staff. Residents said the maintenance arrangements were efficient and responsive to any repairs required. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 32, 34 and 35. Quality in this outcome area is good. The staff have a good understanding of the residents support needs and positive relationships have been formed between the staff and residents. The work force is enthusiastic and employed in sufficient numbers to meet the needs of residents. Robust arrangements are also in place to recruit, select and vet new staff and all new recruits complete an induction programme. Satisfactory arrangements are also in place to supervise and provide guidance and assistance to staff when required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each unit has a core group of staff and the numbers of staff on duty are determined by the needs of the residents. A registered nurse is on duty at all times and a reliable out of hours on call arrangement is in place for any emergencies that arise. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 23 Each unit has a manager who coordinates the care provided and named nurses assist the unit managers with their duties and responsibilities. Residents are very positive about the manner in which the staff undertake their duties and provide the care and support required. It is clearly evident the staff build and maintain positive relationships with residents and have a good understanding of residents support needs. It is also evident the kitchen and maintenance staff have the appropriate skills and abilities and provide a good service. The staff at the home said they were well supported by the managers and informal advice and guidance was readily available when required. In each unit the managers have established regular opportunities for staff to be formally supervised about their work and each staff member has an annual appraisal. Robust arrangements are in place to recruit, select and vet new staff and all staff newly appointed completes an induction programme. A suitable programme of training is also in place for all staff and each staff member has an individual training programme for the year ahead. The training centres on the core skills required and professional qualifications. Many of the care staff are trained to NVQ 2 and NVQ 3 standard. Regular training assists staff to develop their skills and knowledge and has a positive impact on the quality of the care and support provided. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 37, 39, 41 and 42. Quality in this outcome area is good. Suitably experienced and qualified managers manage the service in the best interests of residents. Suitable arrangements are also in place to regularly review with residents and stakeholders the quality of the service and facilities provided. Records at the home have continued to improve and generally are now satisfactory. The providers must be diligent in making sure all the records required by regulation are in place. A wide range of safe working practises are in place to make sure the environment is safe and that residents are safeguarded. This judgement has been made using available evidence including a visit to this service. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 25 EVIDENCE: It is evident the home is well run and well managed. The registered manager is a qualified nurse, has considerable experience of care provision and holds the Registered Managers Award. Staff and residents were positive about the manner in which the home is run and organised and commented they found the registered manager to be approachable and responsive to any concerns or suggestions they raise. The providers have established a range of methods to review the quality of the services and facilities provided each year. The arrangements include consulting with residents and staff, monthly reviews of the facilities and regular visits by staff who are not directly employed at the care home. This includes the monthly regulation 26 visits undertaken at the home. The indications are that residents and staff are very satisfied with the services and facilities provided. It is also clear that any suggestions or recommendations to improve the services or facilities are carefully considered by the providers and acted upon wherever possible. The record keeping arrangements at the home have continued to improve and generally now met the standard required. However the providers must not become complacent and need to take steps to make sure comprehensive records are in place at all times. Suitable policies and procedures are in place to promote safe working practises and provide a safe environment for residents and staff. The equipment and services at the home are also regularly serviced and maintained. Residents and staff said they were confidant that every reasonable effort was made to provide a healthy and safe environment. The fire safety and prevention arrangements have been improved and develop and the staff regularly are provided with fire training. The providers will also assist residents to manage their personal allowances when no third party is available. Where assistance is provided good records is in place that detail each transaction and the balance remaining. These records are also regularly reviewed and monitored. There are no concerns regarding the financial viability of the home and an appropriate Insurance Policy is in place. The registration and Insurance certificates are publicly displayed in the reception area. St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 27 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 YA13 Regulation Requirement Timescale for action 30/09/07 16(2)(m-n) Reliable arrangements must be in place for residents to plan and access community based activities. 23(2)(a)(e) The shared space next to the kitchen must be improved and refurbished. 2. YA28 30/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations The registered provider should review the policy and procedure regarding the provision of “cot sides and protectors” so that robust arrangements are in place that safeguard residents. Arrangements should be in place for services users to spontaneously access community facilities whenever possible. 2. YA13 St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Teresas Cheshire Home DS0000008937.V341984.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
