Inspection on 18/04/05 for St Teresa`s Home

This inspection was carried out on 18th April 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Teresa`s Home 06/07/09

St Teresa`s Home 02/04/07

St Teresa`s Home 05/09/05

St Teresa`s Home 13/09/04

St Teresa`s Home 26/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE ST TERESAS HOME 40/46 Roland Gardens LONDON SW7 3PW Lead Inspector Sheila Lycholit Announced 18 April 2005 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 TERESAS HOME Version 1.10 Page 3 SERVICE INFORMATION Name of service St Teresas Home Address 40/46 Roland Gardens, London SW7 3PW 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) 020 373 5820 020 7373 7330 St-teresas-home-freeserve.co.uk Sisters Hospitaller of the Sacred Heart of Jesus Sister Tomasa de la Torre Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places ST TERESAS HOME Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13 September 2004 Brief Description of the Service: St Teresas provides residential care for 25 older people. The home is located in a quiet street in South Kensington, close to shops, restaurants and other services. There are good transport links, with Gloucester Road and South Ken tube stations nearby. The building, which was originally 3 early Victorian houses, has been substantially altered to provide 25 single rooms, over 3 floors. Most of the bedrooms are of above average size, with many having an en suite bath or shower room. There are a number of communal rooms, including a coservatory, which leads out to a terrace and pleasant garden. The standard of decoration, furnishings and fittings is high. The majority of the building is accessible for wheel chair users - each floor is served by a lift and there is a ramp at the front entrance. Six of the bedrooms are not suitable for wheel-chair users, as access to the lift area is via a small number of steps, which cannot be safely ramped.The home, which is run by the Sisters Hospitallers of the Sacred Heart, has good staffing ratios with an experienced staff team. There is a chapel where Mass takes place daily. The home is open to non-Catholics. An Anglican priest visits regularly and Holy Communion is held twice weekly. ST TERESAS HOME Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on 18th April 2005 from 10.30AM until 5PM. The Manager, Sister Tomasa and the Assistant Head of Care, Ms Fatima Lopes, made themselves available throughout the day. The Inspector joined the residents for lunch and spoke with a number of residents during the visit. Comment cards were sent to residents, relatives, GPs and Care Managers prior to the inspection. Twenty four responses were received, all of which were positive about the service provided at St Teresa’s. A brief discussion was held with one relative who was visiting the home. On the day of the inspection there were 23 residents at the home. One person was in hospital. There was one vacant room, which had been allocated. What the service does well: 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 TERESAS HOME Version 1.10 Page 6 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 TERESAS HOME Version 1.10 Page 7 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) 1,2,3,4 and 5 St Teresa’s provides clear information about the service in a booklet, which is regularly updated. Contracts for residents also give details of the services provided. An assessment is carried out for all prospective residents, who are fully involved in the decision to move to the home. Assessments are sufficiently detailed to provide the basis of an initial care plan. EVIDENCE: The service user’s guide has been updated and is available in a large print format. A comprehensive assessment form is completed for self funding residents, while residents placed by local authorities have a needs assessment undertaken by the Care Manager. An initial care plan is drawn up from the assessment. Prospective residents and their families normally visit the home on a number of occasions. The Manager or Assistant Head of Care visit prospective residents at home to discuss their admission. Each new resident is allocated a particular room prior to admission, which is prepared for them by staff or by their families, with as many of their personal possessions as they wish to bring. ST TERESAS HOME Version 1.10 Page 8 A copy of the most recent inspection report is made available in the main reception room, together with other information about the service. ST TERESAS HOME Version 1.10 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) 7,8,9,10 and 11 Care plans are comprehensive, regularly up dated and shared with residents. Staff have established good professional relationships with health care colleagues, who visit the regularly. Residents are treated with respect and their rooms regarded as their own private space. Excellent care and support is given to service users who are terminally ill or are dying. EVIDENCE: Three care plans were seen. Each was well written, up to date and regularly reviewed. A computer package is used for care plans, which produces detailed plans that are easy to follow. Residents are offered a copy of their plan to keep in their room. The concerns of staff regarding one resident who was exhibiting difficult behaviour were not fully reflected in the care plan. It is recommended that ways of including these concerns be devised. Care plans show that the health needs of residents are given a high priority. Positive feedback was received from the GP practices serving the residents at St Teresa’s. The home uses the Boots measured dosage system. The Manager has requested a visit from the Boots Pharmacist who has not carried out the normal 3 monthly check. MAR sheets seen were fully completed and up to date. ST TERESAS HOME Version 1.10 Page 10 Although some residents at the home are relatively independent, others are very frail. One resident was being visited by the palliative care team. Her wish to remain at the home was being supported by the Manager and staff. ST TERESAS HOME Version 1.10 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) 12,13,14 and 15 Service users are supported to maintain their previous lifestyle as far as possible, including contact with families and interests and routines. The standard of catering is high, with a choice of menu available for each meal. EVIDENCE: Residents’ preferred times of getting up and going to bed are noted on their care plans. An organised activity takes place each day, including an art session run by a local artist. Staff accompany residents to the local shops, banks and other services or just to go for a walk. Mass is held daily in the Chapel and Holy Communion takes place twice a week. The mobile library visits monthly. The photo album in the conservatory shows staff and residents taking part in events at the home and in trips out. Nine relatives responded to the comment cards sent out prior to the inspection. Feedback on the service provided was exceptionally positive, with comments including ‘an excellent home’, ‘a very good place’, ‘a real commitment to care among the staff’. Senior staff try to be available to see relatives and to check whether there are an issues that they want to raise. The majority of residents have a direct dial telephone line to keep in touch with families and friends. Catering is provided by an external contractor, which has been employed at the home for a number of years. Residents have breakfast in their rooms and lunch and dinner in the dining room. Three courses are provided at lunch and a ST TERESAS HOME Version 1.10 Page 12 lighter, cooked meal is served in the evening. Fresh fruit and yogurts are always available as an alternative dessert. Staff serve hot drinks and a snack later in the evening. A number of residents have a fridge in their rooms in which they can keep their own food. Menus are regularly reviewed to reflect residents’ likes and dislikes. ST TERESAS HOME Version 1.10 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 Concerns and complaints are given a high priority by the Manager, who responds promptly to any issues raised. Service uses rights are protected and staff have a sound understanding of adult protection issues. EVIDENCE: The complaints procedure is clearly set out in the service user’s guide. None of the 24 residents, relatives or professional colleagues who responded had ever made or dealt with a complaint. Where issues are raised these are usually between residents and staff take steps to help negotiate a resolution. All staff receive training in adult protection, which is regularly up dated. The home has a comprehensive adult protection policy and a copy of the local multi agency policies and procedures. All policies and procedures are being reviewed and the Manager undertook to ensure that the home’s policy is cross referenced to local policies and procedures and includes contact numbers for the local adult protection enquiry co-ordinators (APECS). ST TERESAS HOME Version 1.10 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 St Teresa’s is an attractive, well maintained home, which has been well adapted to meet the needs of older people. Service users bedrooms are comfortable, spacious and reflect the individual tastes and interests of the occupants. Systems are in place to provide a safe environment. EVIDENCE: The home is furnished and decorated to a high standard. There are a number of communal areas, including a large sitting room, which has a loop induction system fitted and a pleasant conservatory. All of the bedrooms are single rooms and the majority are of well above average size. Some rooms, at the end of the building have an additional sitting area with views in two directions. As rooms become vacant, they are redecorated and new carpets fitted. Where possible vacant rooms are upgraded to provide en suite facilities. All bedrooms have a TV and telephone point. The vacant room on the ground floor was being redecorated and a bathroom installed to meet the needs of the new resident who would be moving in once the work was completed. ST TERESAS HOME Version 1.10 Page 15 In addition to the increasing number of rooms with en suite facilities, the home is well provided with bathrooms and lavatories. A variety of assisted baths are available. Radiators are protected, although one resident had chosen to remove the cover in her room. Hot water temperatures are regulated and checked monthly. The EHO visited unannounced on 13 January 2005. There were no requirements or recommendations from this visit and the ‘very good’ standards in the kitchen were noted. ST TERESAS HOME Version 1.10 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The home has good staff ratios, with sufficient staff to provide care to the most frail residents and support to other residents to retain their independence. Staff are carefully recruited and performance monitored, with any concerns promptly addressed. There is an extensive training programme, providing staff with access to accredited training. EVIDENCE: Staff rotas show that there are excellent staff ratios at all times, with sufficient time allowed for handovers, staff meetings and training. Waking night cover is provided by a separate Order, with two Sisters on waking night duty. The Manager lives in the same building and is normally on call. In her absence another Sister familiar with the home is available. Catering and domestic staff are employed via an external contractor. Two personnel records for staff recently recruited were seen. These show that all recruitment checks are made. Records show that staff receive a thorough induction to the work, which follows the TOPPS standards. Staff induction files are verified by the HR Manager, who is a NVQ Assessor. The home has an excellent record of providing staff training and development, with 7 staff undertaking NVQ2 and 4 staff undertaking NVQ3. Eighteen staff are taking part in a 20 week, accredited IT, literacy and numeracy course held on site, in which the Manager and Assistant Head of Care are also participating. The Assistant Head of Care has completed NVQ3 and is planning to start NVQ4 in the autumn. ST TERESAS HOME Version 1.10 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 St Teresa’s is a well managed home, with an experienced Manager, who provides leadership to the staff team. There is an ethos of regular review and development of the service to meet the needs of current and future residents, including seeking feedback from residents and their families. Systems are in place to support staff and to protect residents. Attention is given to sound recording, with the use of IT where possible. Health and safety is given a high priority. EVIDENCE: The Manager is a Registered Nurse, with many years experience in managing social care services. She has recently completed the Registered Manager’s Award. Staff commented on the positive support that they receive from the Manager and on her commitment to ensuring that residents receive good care. There is an annual development plan for the service, which incorporates views received from residents and families. ST TERESAS HOME Version 1.10 Page 18 The supervision records for three staff were seen. These show that supervision takes place regularly and that any issues regarding performance are discussed and action agreed. The Manager has delegated some staff supervision to the Assistant Head of Care and the Senior Carer. All policies and procedures across the Order’s homes are being reviewed. It is expected that the review will be completed by the end of the year. Record keeping is sound and up to date, with good use made of IT. Monthly visits are made on behalf of the registered provider. Copies of reports of these visits are received by the CSCI. Records show that all staff receive health and safety training, which is regularly updated. The new fire detection system has been commissioned and is working satisfactorily. An annual health and safety audit is carried out by an external contractor. In addition the HR Manager makes regular health and safety checks. Records show that equipment and systems are serviced and maintained, including fire detection and fire fighting equipment and that the water system is regularly checked and cleaned. ST TERESAS HOME Version 1.10 Page 19 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 4 4 3 4 4 3 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 4 3 3 x x 3 3 3 ST TERESAS HOME Version 1.10 Page 20 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 Regulation Requirement Timescale for action 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 18 Good Practice Recommendations The care plan for one service user who is causing concern should be reviewed to include reference to current issues and strategies. When reviewing the adult protection policy, reference to the local multi-agency policy and procedures including the contact numbers for APECs should be included. ST TERESAS HOME Version 1.10 Page 21 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26/28 Hammersmith Grove London W6 7SE 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 TERESAS HOME Version 1.10 Page 22 - 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. 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