CARE HOME ADULTS 18-65
St Teresas Cheshire Home Long Rock Penzance Cornwall TR20 9BJ Lead Inspector
Paul Freeman Unannounced Inspection 7th November 2005 10:00 St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 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.V260278.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 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.V260278.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Teresas Cheshire Home Address Long Rock Penzance Cornwall TR20 9BJ 01736 710336 01736 710549 teresas@swest.leonard-cheshire.org.uk 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) Leonard Cheshire Mrs Christine Proctor Care Home 27 Category(ies) of Physical disability (27) registration, with number of places St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 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 16th May 2005 Date of last inspection Brief Description of the Service: The care home is situated on the outskirts of Marazion and overlooks St Michaels Mount and the 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 service users have personalised and furnished their own rooms. St. Teresas provides four distinct self-contained units two of nine residents, one of four and one for five. 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 the Social Services Department for short-term care. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The planned unannounced inspection took place over two days on the 7 November 2005 and 8 November 2005 and lasted for around nine hours. The Inspector looked over the building and at a number of records and documents. The Registered Manager, ten of the residents and seven of the staff from all the units were spoken to. The Inspector found the requirements and recommendations set at the last inspection had been acted upon. No Immediate requirements were set at the inspection. What the service does well:
Each resident is issued with a contact. The contract is either issued by the care home providers where residents fund their own care or the Agency providing the funding. Where funding is provided by a third party the care home also issue terms and conditions of residency that details the arrangements at the home that are not covered in the third parties contract. Residents are positive about the manner in which the staff undertake their duties and provide the care and support required. Wherever possible residents are encouraged to direct their care and have control over their lives. Where this is not possible the staff at the home closely consult and seek guidance from the persons representative. In addition staff at the home regularly consult with residents to make sure the care and support provided reflects the individuals choice and preference. There are flexible visiting arrangements at the home and the staff actively support residents to maintain links and relationships with family and friends. Residents said that visitors are always positively welcomed by the staff and commented that staff always made every effort to make sue the visit was a positive experience for all concerned. Residents are also able to participate in a range of activities, hobbies and interests of their choice at the care home and in the local community. Wherever possible staff actively supports the residents when this is required. Residents commented they were pleased with the arrangements in place. A main kitchen located at the home which provides the main meals for residents in three of the units. The residents are regularly consulted about the menu and residents said they were satisfied with the quality, quantity and variety of the food provided. The kitchen also caters for special diets and residents are able to choose the meals they have.
St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 6 A recent Environmental Health Officers inspection concluded that good hygiene practises were adopted in the main kitchen. In each of the three units there is a kitchen/diner where snacks and refreshments can also be provided. The residents on the fourth unit have chosen to prepare all of their own meals and are satisfied with this arrangement. The staff that undertakes catering duties have all been appropriately trained. Residents’ health needs are well met and a qualified nurse is on duty at all times. Residents said they were confident that medical assistance was accessed promptly and efficiently whenever it is required. It is also evident that good multi disciplinary work takes place on a regular basis. The Providers deals with any concerns or complaints the residents raise positively and efficiently. Residents said there no barriers to raising any concerns or complaint they have with the staff or Providers and were confidant that any matters are dealt with in a satisfactory manner. Suitable arrangements are 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 also have their own dedicated communal space and there are other communal areas throughout the building that residents can utilise. Within each unit there is a sitting room and separate dining area and each bedroom is furnished and equip according to the occupants needs, preferences and choices. Many of the bedrooms have ensuite 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 speaclist assessment to determine the equipment or adaptations they require to met their needs and promote their independence. The home is maintained to a good standard of hygiene and cleanliness and the environment well maintained and decorated. The residents said they were very satisfied with the facilities provided and the manner in which the home is maintained. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 7 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 employed each day and night to meet the needs of the residents. Residents are very positive about the manner in which staff provide care and meet their needs. The staff said they are well supported and advice, guidance and assistance is readily available whenever it is required. A qualified nurse is on duty at all times and reliable arrangements are in place for staff to obtain out of hours assistance. The home is well run, managed and organised by the Registered Manager who is a qualified nurse and has considerable experience of care provision. Residents and staff expressed confidence in the manner in which the home is run. The daily records about residents continue to improve but in some units further work is recommended in this area. Suitable policies and procedures have been established to provide a safe environment for residents’ and staff. Equipment and services provided at the home are regularly maintained and serviced and satisfactory fire precaution and fire safety measures are in place. There are no reported concerns about the financial viability of the care home and a suitable Insurance policy is in place. What has improved since the last inspection?
In three of the units there has continued to be an improvement in developing the care planning arrangements. In each unit residents care plans clearly detail the persons needs and provide staff with good information about the best ways to provide the care and support required. The plans promote the residents independence and wherever possible encourage the person to direct their own care and have control over their lives. The care plans are regularly reviewed with the resident or their representative to make sure they accurately reflect the services and facilities needed to meet the persons needs, preferences and choices. The arrangements for the storage and administration of medication are satisfactory and residents are able to administer their own medicines when it is safe to do so. Appropriate records are maintained where the staff assists in the administration of medication and a suitable policy and procedure is in place. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 8 In some of the units the arrangements for maintaining daily records for residents have improve and they now detail the events that have occurred, any incidents or concerns and any action taken by the staff. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 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.V260278.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 All residents are issued with a contact that details the terms and condition of residency at the home. EVIDENCE: Each resident is provided with a contract about the terms and conditions of residency at the home. Where a resident funds their own care the contract is issued by the Providers. If a third party provides funding a contract is issued by the funding agency to the resident and Provider. In addition the Providers also issue terms and conditions of residency that outline the arrangements at the home that are not covered in the contract. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. The care planning arrangements in three of the units provide staff with the information and guidance required to meet the needs of individual residents. In one unit more detailed direction is required to make sure that effective arrangements are in place. Further attention needs to be given to the arrangements to manage risks that may occur to residents and staff in order that their health and wellbeing are not compromised. EVIDENCE: Of the four units three have made positive steps to improve and develop the care planning arrangements. It was particularly noticeable that one of the units has made significant improvements. The care plans provide good information to guide and direct the staff to provide the care and support required to meet each individual residents needs. The care plans are written in a manner that also promotes accessibility for the staff. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 12 The staff said they found the plans to be accurate and positive in providing the information and guidance required to provide a good standard of care. The plans are also written in a manner that promote the residents independence and encourages the person concerned to be able to direct their own care wherever this is possible. The documentary evidence also confirms the care plans are reviewed with the residents or their representative on a regular basis. Where necessary the plans are then adjusted to make sure that residents changing needs are accounted for. In the other unit each residents also has a care plan that summarises needs but in certain instances does not provide sufficient guidance or direction for the staff. It is evident that staff at this unit encourage and promote residents to direct their care and have control over their lives. Regular reviews also are undertaken but the records of the review need to be more detailed in order to capture the contents of the review and any decisions or agreements that have been reached about the care and support required by the individual. Residents in all of the units were positive about the care and support provided. They said they found the staff to undertake their duties efficiently and in a respectful manner that promoted their independence, choice and dignity. The arrangements to make sure residents and staff are not placed in a position of unreasonable risk to their health and safety has improved. The four units are at different stages in implementing the policy and procedure that has been adopted by the providers. The arrangements are designed to make sure that every reasonable step is taken to identify and manage risks in a positive manner. Further improvement is required to make sure that no one is placed in a position of risk. Attention to assisting residents with their mobility and taking positive action following an accident or incident experienced by the resident is also required. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 15 and 17. A good range of opportunities is accessible to residents that promote stimulation and personal development. Flexible visiting arrangements are also in place and residents have control over where visits occur. The meals at the home are good offering both choice and variety and catering for special dietary needs. The kitchen facilities require improvement to address certain elements that do not meet the required standards. EVIDENCE: In each unit residents are able to participate in a range of activities, leisure pursuits and hobbies at the care home and in the local and wider community. Wherever possible staff support is provided where this is required or alternatively assistance is given by a responsible or suitably qualified person from outside the home. The residents are able to have control over how they spend their time and the pursuits reflect each individual’s choice and preference. The pursuits and pastimes also provide each resident with opportunities for personal development. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 14 The activities chosen by the residents are detailed in each individuals care plan. On certain units more detailed and comprehensive information should be provided. Residents said they were very pleased with the arrangements and the support and assistance provided by the staff. In certain units residents commented they would like to further expand the opportunities and is recommended the providers take account of residents wishes at future reviews. Positive arrangements are in place for residents to maintain links and relationships with family and friends at the care home and outside. The provider’s policy and procedure clearly indicates there are flexible arrangements in place. Residents are also able to have control over who they meet with and where any meetings take place. The staff at the home will support a resident if they elect not to meet with a visitor. Residents said they were very satisfied with the arrangements in place. They commented that visitors are always welcomed at the home and staff made efforts to make sure the contact was a positive experience for all concerned. The main kitchen at the home supplies the meals at the home for three units. In addition each of the units is provided with a kitchen/dinning area where snacks and refreshments can be made. The other units cater for their own meals in the kitchen diner that is situated within the unit. Residents said they were satisfied with quality, quantity and menu that is provided. A choice of meals is offered each day and residents are able to make specific requests about the meal they want. The staff also accommodate special diets and residents are regularly consulted about the menu available. The kitchen staff are appropriately trained and adequate health and safety measures are in place. The Environmental Health Officer inspected the facilities in July 2005 and commented that good hygiene practices had been adopted. The facilities are looking tired and in need of refurbishment and the layout of the kitchen could be improved to assist the staff in meeting the standards required. The Environmental Health Officer also recommended that ventilation in the kitchen be improved, the layout considered and that certain repairs or “deficits” are undertaken. The Registered Manager said that plans were being formulated to address the areas of concern. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 15 In the unit that is self catering the residents said they were satisfied with the arrangements and the menu that is provided. In this unit residents are also regularly consulted about the menu provided. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Staff have a good understanding of residents needs and residents choice and preference is accommodated in the manner that personal support is provided. Residents’ health needs are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at the home is managed in a satisfactory manner that promotes good health. EVIDENCE: Residents said they were satisfied with the manner in which the staff at home met their needs. The residents commented they found the staff to be flexible, approachable and efficient in their work. On the whole each individuals care plans provides information about the care and support required and gives the staff direction about the most appropriate way to meet needs. Residents are regularly consulted about the care provided and steps are taken to make sure that each person’s choice and preference are accommodated. It is evident that staff have a good understanding of the residents needs and that positive relationships have been formed between the staff and residents at the home. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 17 Positive arrangements are also in place to meet residents’ health needs. Residents said they were confidant that medial assistance is accessed appropriately and efficiently when required. A qualified nurse is on duty at all times at the home and two experienced nurses who have management responsibilities take a lead role in supporting and coordinating the health care needs of the residents. The records confirm that General Practitioners and other health professions regularly visit the home and that good multi disciplinary working takes place on a regular basis. The home has improved the arrangements in place for the administration and storage of medication. Where it is safe to do so residents are able to administer their own medicines. Staff at the home are suitably trained and medicines are kept in secure facilities. The records regarding medicines are maintained to the required standard and satisfactory arrangements have been established to dispose of unwanted medication. A Pharmacy agreement is in place and therefore staff have access to specialist advice and guidance if required. The Providers have introduced the MDS system for prescribed medicines but there are occasion the Pharmacy are not recording the exact prescribed medicine and dosage on the records they provide. It is recommended the Register Manager address this situation to make sure that residents are not inadvertently placed at risk. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Arrangements for responding to residents concerns or complaints and to protect residents from abuse are positive. EVIDENCE: No complaints have been received by the Provider or the CSCI following the last inspection on 16 May 2005. A suitable 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. A satisfactory policy and procedure is in place to protect residents and any concerns or allegations about abuse are reported to the Social Services Department or other statutory bodies for investigation. In addition a suitable whistle blowing policy and procedure has 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.V260278.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. The standard of the environment within the home is high and provides residents with an attractive and homely place to live. EVIDENCE: The care home is a detached single storey facility that is maintained to a high standard. Wherever possible the fixtures and fittings and the 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. There are accessible gardens around the care home and ample car parking facilities at the entrance to the home. 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 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. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 20 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 ensuite 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 speaclist assessment to determine the equipment or adaptations they require to met their needs and promote their independence. 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 good standard of cleanliness throughout the home. A regular programme of maintenance, replacement and redecoration is provided. Transport is also available to residents at a reasonable charge and all the drivers are trained to the MIDAS standard, which has promoted a professional service. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 36. 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. Satisfactory arrangements are also in place to supervise and provide guidance and assistance to staff when required. EVIDENCE: Each unit has a core group of staff and the numbers of staff on duty are determined by the needs of the residents. There are no issues about the staffing levels at the home. A registered nurse is on duty at all times and a reliable out of hours on call arrangement is in place if any emergency assistance is required. Every unit has a manager who coordinates the care provided and named nurses assist the unit manager with their duties. Qualified nurses are duty at all times. Residents are very complimentary and positive about the way that staff undertake their duties. The staff group have considerable experience, skills and abilities about providing care. It is clearly evident that staff build and maintain positive relationships with residents and have a good understanding of residents support needs.
St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 22 It is also evident that the domestic and kitchen staff have the appropriate skills and abilities to provide a good service and the maintenance staff have recently been increased to ensure that all requirements are dealt with promptly and efficiently. The staff at the home said they were well supported by the managers and informal advice and guidance was readily available when this was 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. St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 41, 42 and 43. The home is well run and managed for the benefit of the residents and appropriate arrangements are in place to provide residents with a safe and healthy environment. EVIDENCE: It is evident the home is well run and well managed. The Registered Manager is a qualified nurse and has considerable experience of care provision. The Registered Manager is appropriately qualified and is working towards 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 recommendation set at the last inspection in respect of residents’ records was considered. In certain units it was evident that the daily records have improved and record the events that have occurred, any concerns that have St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 24 arisen and the action taken by the staff. Other units the improvement was less tangible and is recommended that further improvements occur. 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 regularly serviced and maintained and appropriate fire precaution and fire safety measures are in place. Residents and staff said they were confidant that every reasonable effort was made to provide a healthy and safe environment. 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.V260278.R01.S.doc Version 5.0 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 x Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 x 13 x 14 x 15 4 16 x 17 Standard No 31 32 33 34 35 36 Score X 3 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
St Teresas Cheshire Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 4 X X X 3 3 3 DS0000008937.V260278.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement Care plans must provide sufficient information to satisfactorily guide, inform and direct the staff. Detailed risk assessment must to be completed whenever a situation potentially compromises an individuals health and well being. The kitchen area, facilities and food storage areas must be improved to meet the required standard. Timescale for action 30/03/06 2. YA9 13 30/01/06 3. YA17 16(2)(g) 30/09/06 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 YA12 YA12 Good Practice Recommendations The records about the activity programme chosen by services should be more detailed to reflect the current provision and include all the choices made. The activities, hobbies and leisure interests should be further explored with service users at their next review.
DS0000008937.V260278.R01.S.doc Version 5.0 Page 27 St Teresas Cheshire Home 3. 4. YA20 YA41 The MAR sheet for prescribed medicines should accurately state the dosage and frequency the medicine is administered. The daily records maintained for each service user should detail the events, incidence or concerns that have arisen, any action taken and the outcome of that action St Teresas Cheshire Home DS0000008937.V260278.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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