Inspection on 05/09/05 for St Teresa`s Home

This inspection was carried out on 5th September 2005.

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 02/04/07

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 TERESAS HOME 40/46 Roland Gardens LONDON SW7 3PW Lead Inspector Sheila Lycholit Unannounced 5 September 2005 11:00 AM 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 G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 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 7373 5820 020 7373 7330 st-teresas-home-freeserve.co.uk Sisters Hospitallers 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 G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 April 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 TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit took place from 11AM until 4.30PM on Monday 5th September 2005. The Manager, Sister Tomasa, was on duty and made herself available throughout the day. Discussion also took place with the Assistant Head of Care. Five residents were spoken with during the visit, including the 3 people admitted since the last inspection in April. There were no vacancies at St Teresa’s. There were 24 residents present, with one person on holiday. A tour of the building took place. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 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 G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 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) 3 and 4 An assessment is carried out for all prospective residents, who are fully involved in the decision to move to the home. EVIDENCE: Each of the 4 residents’ files seen contained an assessment, from which an initial care plan had been drawn up. The home has it’s own format for assessments for self-funding residents or the local authority needs assessment is used. Discussion and records show that all of the recently admitted residents, together with their families, were involved in the decision to move to St Teresa’s. Each of the most recently admitted residents who were able to express an opinion, were very positive about the home. St Teresa’s does not provide intermediate care. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 8 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 and 10 Care plans are comprehensive, regularly updated and shared with residents. Residents comment on the kindness and courtesy of staff. EVIDENCE: The 4 care plans seen were detailed, up to date and had been regularly reviewed. Care plans, using a computer package, are agreed with residents, who are offered a copy of their plan. Care plans show that the health needs of residents are regularly assessed and referrals made to health colleagues. The GPs and District Nurses visit regularly and good support is offered by the Mental Health Team. Staff were observed to treat residents with courtesy and respect. Residents’ rooms are regarded as their own private space. Keys are offered to all residents and a number lock their room when they go out. One resident was regularly locking her door from the inside. As she would not always answer staff who knocked, this was causing concern. In discussion with the Manager it was agreed that if the resident could not be persuaded to cease leaving the key in the lock, an alternative lock that could be over-ridden would need to be fitted. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 9 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 and 13 Residents, many of whom have lived locally, are supported to maintain their previous interests and routines. Excellent contact is maintained with relatives and friends. EVIDENCE: On the day of the inspection a number of residents were in the main sitting room with a member of staff who was conducting a exercise session. Other residents were attending Mass in the chapel or were in their rooms. One resident had gone on a holiday arranged by her Care Manager and St Teresa’s. An organised activity takes place each day. The good staff ratios at St Teresa’s allow residents to pursue individual interests and to be accompanied to the local shops and other services. The mobile library visits monthly. One resident, who at a previous inspection expressed her interest in having the opportunity to take part in an outing further afield, said that no trips out had been arranged, though she had been out and about in the local area. In discussion the Manager said that she would ensure that at least one outing was arranged before the end of the summer. The home has a volunteer driver and the use of a mini-bus. Daily notes and the visitors’ book show that relatives and friends visit regularly and that staff keep relatives up to date with regular phone calls. Most residents have a telephone with their own direct line in their room. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 10 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 Concerns and complaints are given a high priority by the Manager, who responds promptly to any issues raised. EVIDENCE: The complaints procedure is clearly set out in the service user’s guide. Issues occasionally arise between residents, which staff take steps to resolve. One complaint was received anonymously by CSCI since the last inspection, which the Inspector looked into. The complaint was not substantiated. The home has a comprehensive adult protection policy and staff receive regular training. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 11 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 The building is well maintained and decorated and furnished to a high standard. Residents’ bedrooms are spacious and reflect their individual tastes and interests. Systems are in place to maintain a safe environment. EVIDENCE: All parts of the building seen at this unannounced visit were clean, tidy and well maintained. The 3 rooms that became vacant this year have been redecorated, with one having a new en suite bathroom installed. The existing en suite in one of the other vacant rooms has been made more accessible. Bedrooms are individually furnished with most residents bringing a number of pieces of their own furniture and other possessions. Photos and pictures are well displayed, often with the help of family members. Eight of the bedrooms have en suite bath or shower rooms. The home is well provided with a range of additional bathrooms and lavatories. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 12 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 Staff ratios are good, allowing staff time to provide individual care and support. Staff are carefully recruited and performance monitored. Staff have access to an extensive training programme, including accredited training. EVIDENCE: On the day of the unannounced inspection the home was well staffed, with the Manager, Assistant Head of Care, 2 members of the Order and 3 care staff on duty. Rotas allow time for handovers, recording, staff meetings and training. One new member of staff had been recruited since the last inspection. Records showed that satisfactory references, CRB, POVA and other checks had been received. Six staff are undertaking NVQ2 training. A new member of staff is continuing with her NVQ3 training. Health and safety training is on going. All care staff and senior staff had recently completed a workshop in pastoral care held at the home. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 13 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, 32,33,34,35 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 the Manager seeks to continually improve the service. Systems are in place to support staff and to protect residents. Health and safety is given a high priority. EVIDENCE: The Registered Manager is an experienced Manager and Registered Nurse, who recently completed the Registered Manager’s Award. In her absence, an experienced Sister who knows the home and the Assistant Head of Care are available. An annual report is available, together with a development plan for the home, which is regularly reviewed. Monthly visits are made on behalf of the Order, with reports of the visit sent to CSCI. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 14 The majority of residents manage their own financial affairs, some with the support of family members. Two residents have their affairs managed by the Court of Protection. Personal allowances are handled for the above residents and 3 others whose families are not able to visit regularly. Records seen show all transactions are recorded and receipts kept. A Health and Safety audit by an external contractor was carried out in July. A detailed report is available. The Manager was taking steps to address the action recommended in the report, none of which was urgent. ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 x 15 x 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 x x 4 3 3 3 3 x x 3 ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 16 NO 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. Refer to Standard Good Practice Recommendations ST TERESAS HOME G60-G09 S10849 ST TERESAS UIV245813 050905 STAGE 4.doc Version 1.40 Page 17 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. 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