Inspection on 02/04/07 for St Teresa`s Home

This inspection was carried out on 2nd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 05/09/05

St Teresa`s Home 18/04/05

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 Teresa`s Home 40/46 Roland Gardens London SW7 3PW Lead Inspector Sheila Lycholit Unannounced Inspection 2nd April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Teresa`s Home DS0000010849.V333890.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 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 Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Teresa`s Home Address 40/46 Roland Gardens London SW7 3PW 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) 020 7373 5820 020 7373 7330 st-teresas@hsc-uk.org 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 Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 Brief Description of the Service: St Teresas, which has been in existence for more than 75 years, provides residential care for 25 older people. The home is located 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 town houses, has been substantially altered to provide 25 single rooms, with many having an en suite bath or shower room. There are a number of communal rooms, including a conservatory that leads out onto the terrace and garden. The standard of decoration, furniture and fittings is high. Most of the building is accessible for wheel-chair users - each floor is served by a lift and the front entrance is ramped. Six of the bedrooms are not suitable for wheel-chair users, as access to the lift area is via a small number of steps that cannot be safely ramped. The home, which is run by the Sisters Hospitallers of the Sacred Heart, has good staff ratios with an experienced 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 Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 2nd April 2007 from 10.15AM until 4.30PM. The Manager was the funeral of a resident at the start of the visit but returned later. The Head of Care and later the Manager made themselves available throughout the inspection. Building works, which had been notified to CSCI, were taking place during the inspection. Twenty-two residents were at St Teresa’s, with one resident in hospital and two vacancies. The vacancies were being kept while the building works were taking place to allow residents to change rooms if necessary. The Manager and Head of Care had completed a pre-inspection questionnaire. Twelve survey forms were received from residents, fourteen from relatives and three from visiting GPs. The Inspector spoke individually with residents and with staff and had lunch with three residents. A tour of the building was undertaken with the Head of Care. What the service does well: What has improved since the last inspection? Improvements have continued to be made to the building, including the current works that, in addition to essential maintenance, will increase the number of en suite facilities, improve one of the assisted bathrooms, create new sluicing and sterilising facilities and improve access to the terrace and garden. In addition to continued NVQ and refresher training, staff have attended an accredited course on the administration of medication at Croydon College. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Many prospective residents and their relatives considering a move to St Teresa’s know the home by reputation and feel confident about the service provided. Considerable care is taken to ensure that the move to St Teresa’s is as unsettling as possible. EVIDENCE: The statement of purpose, service user’s guide, contracts and assessments were looked at during a themed inspection on 15th January 2007, when all standards were found to be met. All prospective service users and their relatives have a number of opportunities to visit the home, including an overnight stay if wished. The Manager or Head St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 9 of Care visit all service users beforehand both to assess their suitability and to discuss their needs. Rooms are allocated some time before the new service user moves in and are redecorated to their taste. Any adaptations to the en suite facilities are normally made while the room is being prepared. Relatives and carers are encouraged to make the room familiar to the resident with their furniture, pictures and other person possessions. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The comprehensive care plans are regularly updated and reviewed. Senior staff work closely with health care colleagues to ensure that residents have good access to health services. An ethos of respect for residents has been firmly established. Excellent care and support is given to residents who are terminally ill or dying. EVIDENCE: Three care plans were looked. These were detailed, regularly reviewed and drawn up with the involvement of the resident. A computer package is used for care plans and all residents are offered a copy of their plan. Plans are signed by residents or next of kin. Risk assessments are regularly updated. A key worker system has recently been introduced. During the inspection visit residents commented on the good care that they receive. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 11 Care plans and daily notes show that the health care needs of residents are given a high priority. Feedback received from the GPs currently visiting St Teresa’s was positive, confirming that ‘staff are always quick to seek advice when patients develop symptoms’ and that staff are ‘caring and sensitive to the patients’ needs – health, social and psychological’. District Nurses visit regularly and senior staff contact the local Mental Health Team when necessary. In discussion one of the residents commented on the excellent care she has received from the District Nurses. The Boots measured dosage system is used for medication, with a local pharmacy providing urgent or short-term medication. MAR sheets seen were fully completed. The Pharmacist from the local PCT visited in March and her recommendations have been implemented. All staff administering medication undertake an accredited training course at Croydon College. One member of staff, who was completing her work-book, confirmed that she was finding the course very helpful. One resident handles her own medication. A risk assessment, signed by her GP had been completed. One resident had been re-admitted to hospital a few days prior to the inspection. Sisters had visited her over the weekend and the Head of Care was in daily contact with her by phone. Other residents expressed their concern for her. St Teresa’s is committed to supporting residents to remain at the home until the end of their life, with the assistance of the District Nurses, GPs and where appropriate the palliative care team. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported to continue their interests and to maintain contact with families and friends. The standard of catering is high and steps are taken to ensure that all of the residents’ nutritional needs are met. EVIDENCE: Residents choose when to get up and go to bed and as far as practicable daily routines are organised to fit in with their preferences. On the day of the inspection the mobile library was making its monthly visit to the home. The service is used by a number of residents, one of whom commented on the helpfulness of library staff who bring books by authors that she likes. An activity takes place each morning, including an art class run by a local artist and an exercise class. Staffing levels allow staff to accompany residents on local trips to the shops and bank and for a daily walk. Mass is held daily in the chapel and Holy Communion takes place twice a week. A high level of contact is maintained with families and friends. Most residents have a direct telephone line with their own number. All of the 14 responses St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 13 from relatives were positive, with comments on both the high standard of care provided and also the welcoming atmosphere. St Teresa’s also regularly surveys relatives and visitors by means of a postal questionnaire. The catering arrangements remain the same as at previous inspections. An external contractor provides the catering, with all meals prepared on site. Residents have breakfast in their rooms and most have lunch and dinner in the pleasant dining room on the lower ground floor. An evening snack is also offered. A choice is available at all meals. If preferred, residents can have all meals in their rooms, though few choose this option. Snacks, tea and coffee and other drinks are available in the kitchenettes on each floor. A number of residents have a fridge in their room. Residents’ weight is monitored and the advice of the GP, Nutritionist and Speech and Language team sought when there are concerns. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Senior staff takes steps to elicit any concerns and complaints and to act promptly on issues raised. The Order has a comprehensive adult protection policy and procedure in which all staff receive regular training. EVIDENCE: The complaints procedure is set out in the service user’s guide. Senior staff meet with residents individually on an almost daily basis and try to elicit any concerns. The complaints record shows that there were two complaints recorded in the past 12 months. In one case the Manager had sought the advice of the local Safeguarding Adults Officer. All staff attended a protection of adults workshop in November 2006. This training is regularly run in house and a range of training materials are available. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. St Teresa’s provides an attractive and comfortable environment, with spacious single rooms that reflect residents’ individual tastes and interests. The building is maintained and decorated to a high standard. Systems are in place to provide a safe environment. EVIDENCE: St Teresa’s has been very well adapted to create a safe and comfortable home. There is a programme of regular maintenance and redecoration, including the current building works, which will further enhance the home’s facilities. Furnishings and fittings are of a high standard. There are a number of communal areas, including a large sitting room, which has a loop induction system and a conservatory that leads out onto a large terrace. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 16 All of the bedrooms are single and most of very spacious, allowing residents to bring in furniture and other possessions to create a familiar space. One resident has a small piano, which she plays daily. Some rooms have an additional sitting area, with views of Roland Gardens. There has been a policy of upgrading rooms as they become vacant, with the installation of en suite lavatories and where space permits, a bath or shower. Rooms are always decorated before a new resident moves in. Further en suites are being installed as part of the current works. In addition to en suite facilities the home has a range of bathrooms and lavatories, including assisted baths. Other specialised equipment is provided, including adjustable beds. A lift, suitable for wheel chair use, serves all floors. Hot water is maintained at a safe temperature and is checked monthly by the caretaker. One resident raised with the Inspector that the hot water in her bathroom is lukewarm in the early morning when she likes to have a shower. The Manager confirmed that there was a problem in that part of the building, although no other bedrooms were affected, which would be rectified during the current works. As at previous visits, the home was clean and fresh. Infection control procedures are followed. A new sluice room and disinfecting facilities are being installed this year. The home has a well-equipped laundry, with a designated member of staff. Residents clothes and linen look freshly laundered, pressed and in good condition. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A stable and well-trained staff team has been established. Staffing levels are above average for the sector and allow staff to provide individualised care, including supportingresidents to take part in activities both within and outside the home. A sound recruitment policy is in place. EVIDENCE: Rotas show that staffing levels are high. In addition to the care staff and Sisters, there are catering and domestic staff, a Finance Officer, Handyman and a HR Manager who oversees staffing matters for all of the Order’s homes in the UK and undertakes monitoring visits on behalf of the provider. The reception is staffed at all times during the day. The Head of Care is normally present for the early morning handover from night staff and for the afternoon handover. Photos of all staff, including the night Sisters, and their times on duty are displayed on a large board next to the main sitting room. The Manager lives in the building and is on call. In her absence another Sister who knows the home is available. All permanent care staff have completed at least NVQ2. The Sisters who provide care at night (Monday to Friday) belong to a separate Order and are Registered Nurses. The home has its own night staff at weekends St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 18 Staff files show that a sound recruitment procedure is followed, with all checks carried out. All staff undertake a probationary period, which can be extended. Records show that performance issues are raised in supervision with an agreed plan of action. The HR Manager checks the recruitment and appointment records periodically as part of the quality monitoring procedure. An induction programme in line with Skills for Care is provided for new staff. Staff induction workbooks are verified by the HR Manager who is a NVQ Assessor. All staff have access to regular training, including NVQ 3 and refresher training. The majority of care staff are enrolled on NVQ3. The home has a good selection of training materials, including books, videos and DVDs that are used for in-house training. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36, 37 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. St Teresa’s is a well-managed home with a track record of providing a high standard of care. There is an ethos of regular development and review to ensure that the service meets the needs of current and future residents. The Order, which runs a number of homes in the UK, has sound systems in place to ensure that care is provided in a safe environment. EVIDENCE: The Manager, who has recently moved back to St Teresa’s after managing another home within the Order, has completed NVQ 4 and the Registered Manager’s Award. The Head of Care has also completed the RMA and is undertaking NVQ 4. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 20 Staff are supported through daily briefings, regular staff meetings, which normally take place monthly and through supervision. Staff turnover is low and few agency staff are employed. The views of residents and relatives are regularly sought and are included in the annual report. The annual report of the Order includes information regarding budgets and certified accounts. Records of residents’ finances were not looked at during this inspection. Policies are regularly reviewed across all of the Order’s residential homes. Record keeping is of a high standard with good use made of ITC. The recording made by night staff needs to be more detailed, with times noted when care is given. Incidents and any unusual behaviour at night should also be recorded more fully. The HR Manager carries out monthly visits on behalf of the Order (Regulation 26), which include a detailed examination of different aspects of the home’s operation using a quality monitoring system. Copies of his reports are forwarded to CSCI. Health and safety is given a high priority. All staff receive health and safety training, which is regularly updated. The accident book shows that six accidents to residents occurred in the last 12 months. The accidents were recorded in detail and action taken. Records show that equipment and installations are regularly serviced and maintained. All staff undertook fire safety training in October 2006 and January 2007. The Fire Brigade visited in February 2007. The fire alarm is tested weekly at different points and regular fire drills take place. The water quality and storage is checked by an outside contractor. The Handyman cleans and disinfects showerheads monthly. A comprehensive health and safety audit is undertaken annually by an external contractor. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 4 3 4 4 4 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 4 3 4 3 X 3 3 3 St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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. 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. Refer to Standard OP37 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. St Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Teresa`s Home DS0000010849.V333890.R01.S.doc Version 5.2 Page 24 - 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!