Inspection on 02/03/06 for St Teresa`s Home for the Elderly

This inspection was carried out on 2nd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 for the Elderly 09/10/07

St Teresa`s Home for the Elderly 31/10/06

St Teresa`s Home for the Elderly 11/07/05

St Teresa`s Home for the Elderly 23/02/05

St Teresa`s Home for the Elderly 09/07/04

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 for the Elderly 12 Lansdowne Road Wimbledon London SW20 8AN Lead Inspector Jon Fry Unannounced Inspection 2nd March 2006 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 for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 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 for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Teresa`s Home for the Elderly Address 12 Lansdowne Road Wimbledon London SW20 8AN 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 8879 7366 020 8879 1070 The Congregation of the Sisters of St Ann Mrs Loyola Maria Goodsell Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11 July 2005 Brief Description of the Service: St Teresa’s Home for the Elderly provides nursing and residential care for up to 28 residents. Accommodation is provided over three floors that are served by a passenger lift. The home is operated by the Congregation of the Sisters of St Anne and is situated in a residential area of Wimbledon. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 2nd March 2006. The inspection took place over six hours. The inspector spoke with ten residents, the manager and one member of staff. A number of records were examined, as well as a tour of the communal areas of the home. What the service does well: What has improved since the last inspection? What they could do better: The home must make sure that staff always keep accurate records for the administration of medication. All medication must be administered as prescribed. There are opportunities to develop the information contained within the care plans for individual residents. The frequency of supervision for care staff needs to be improved. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 6 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 Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 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 for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Resident’s benefit from their needs being appropriately assessed before admission. EVIDENCE: There is an appropriate procedure to make sure that the individual needs of a resident are assessed before they move into the home. Assessments were in place for two residents whose care plans were examined and these had been improved since the last inspection took place in July 2005. Comments from residents were very positive regarding the care provided and included ‘very good’, ‘excellent’ and ‘they take good care of me’. Compliment letters were displayed in the home and included recent comments from relatives thanking the home for ‘the wonderful care of our mother’. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 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 the following standard(s): 7, 9 and 11. Care plans have been updated and are subject to a monthly review process. There are further opportunities to develop the individual care plans to be more person centred and to better reflect care needs and their individual life, experiences and preferences. Overall there are good systems in place for the administration of medication to residents. Minor improvements were however seen to be required during this inspection visit. EVIDENCE: Care plans were looked at for two residents. Both documents were fully completed and had been reviewed on a monthly basis. Improvements were noted from the July 2005 inspection in the completion of the individual plans and, in particular, the daily recording of care. The reviews of assessments for areas such as risk of falls or of developing pressure sores had also improved. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 10 Good information around individual wishes for death and dying was also recorded within the care plans seen. The home must however make sure that the information recorded is consistent throughout the care plan. Instances were seen where information recorded around residents individual care needs differed within the different sections of the plan. There are opportunities to further improve the care plans by looking at how they could be more ‘person centred’ and better reflect the individual’s own preferences and life experiences. It may also benefit care staff to discuss care planning around sexuality to make sure that good information is recorded as required. Medication administration records were generally well maintained but further improvement is required to fully ensure the safe administration of medicines to residents. One instance was found where a medication was not being administered at the time prescribed to one resident. This was due to a mistake in the completion of the administration record in use at the home. It is strongly recommended that the home should complete an individual risk assessment where residents are self-medicating. The assessments should state the storage arrangements as well as the checks to make sure that residents have taken their medication as prescribed. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 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 the following standard(s): 14 and 15. The dietary needs of residents are very well catered for. Residents are able to exercise choice in their daily lives. EVIDENCE: The majority of residents spoke extremely positively about the food provided at the home. One resident said that the food was ‘very good” and another said ‘good food and good attention’. Other comments included ‘excellent’, ‘we get a choice’ and ‘no complaints’. All residents reported that they get asked for their meal choices on a daily basis. The sweet trolley seen on the day of inspection was very well presented and offered a number of inviting dessert choices to residents. Residents are able to look after their own financial affairs for as long as they wish. The home holds smaller amounts of money for individuals when required and full records are kept of any deposits or withdrawals. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 16. Appropriate procedures are in place for the management of complaints. EVIDENCE: An appropriate complaints procedure was seen to be displayed in the entrance hallway of the home and includes the contact details for the CSCI. A record of complaints is maintained. The manager reported that no complaints have been made about the service since the last inspection. The CSCI has not received any complaints about the service in the same period. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19, 24 and 26. Residents enjoy a comfortable and homely living environment. The premises are well maintained and kept to a good standard of cleanliness. EVIDENCE: The home is situated in a pleasant residential area of Wimbledon. The communal lounge and dining areas provide a very comfortable and wellmaintained living environment for residents. Bedrooms are individualised to individual preferences. Residents are able to bring personal items, including furniture, with them on admission and are able to have a private telephone line should they wish. Individual residents spoken to were satisfied with their accommodation. Comments from residents included ‘nice’, ‘I have a lovely view’ and ‘fine’. The home was clean and tidy on the day of inspection. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. The home has sufficient staff on duty to meet the needs of the residents. Residents feel that staff provide good care. Residents are protected by the home’s recruitment practices. A satisfactory programme of training is in place at the home. This ensures the competency of care staff working at the home. EVIDENCE: Residents gave very positive comments on the staff. The care staff were described as ‘very good’, ‘polite’, ‘great’ and “very kind’. One resident stated that staff ‘take good care of me’. All residents spoken to said that they felt there were enough staff on duty to meet their needs. One member of staff spoken to said that they felt there were sufficient numbers of staff for each shift and said that the staff ‘work as a team’. The home carries out appropriate checks including Criminal Records Bureau (CRB) checks on staff before they start work in the home. This process helps to ensure the protection of residents. Recruitment records examined for two members of care staff were well maintained and included application forms and identity documents. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 15 There is a rolling programme of training for care staff provided by an external facilitator. An induction pack is given to new staff members that are mapped to current national standards. It is recommended that the home start to review this document to reflect the newer ‘common induction standards’ that must be used from September 2006. The home should also look at providing dementia training for all care staff. This will make sure that any changes in the needs of individual residents can be met by the service. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 38. There is a commitment to seeking residents’ views about the home. A system for individual staff supervision is in place. The home needs to increase the frequency of these sessions for staff. The Health and Safety of residents is protected by regular checks being carried out within the home. Further action is required regarding regular checks of First Aid boxes and making sure that a risk assessment for Legionella is in place. EVIDENCE: The home completed its own quality survey in January 2005. It is recommended that this exercise now be repeated and a development plan put in place for the home. The manager reported that a residents meeting is held every six months and this frequency suited the residents living at the home. It St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 17 is recommended that residents be asked if this arrangement continues to be satisfactory at each meeting. Procedures are in place to safeguard resident’s finances. The home holds money for a small number of residents and keeps full records of any deposits or withdrawals. Care staff currently have supervision with their line manager that helps them to develop their own practice. This provision must be reviewed to make sure that each individual staff member receives this at least six times per year. This will further support the delivery of quality care by the staff member to the residents. Regular recorded checks are carried out to the building, furnishings and equipment to ensure the Health and Safety of residents and visitors to the home. The home must make sure that records are kept for monthly checks of First Aid boxes. A risk assessment of the premise for Legionella also needs to be carried out. St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 18 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 2 X 2 St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 (1) (2) Requirement The Registered Persons must ensure that consistent information is recorded throughout all sections of the care plan. The Registered Persons must ensure that all items of medication are administered as prescribed. The administration record must accurately reflect the information as contained on the prescription label. 3. OP36 18 (2) The Registered Persons must ensure that all care staff have supervision with their line manager at least six times annually with full records kept. The Registered Persons must ensure that: monthly checks are undertaken of the contents of First Aid boxes with full records kept. a risk assessment of the premises is carried out with St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 20 Timescale for action 01/07/06 2. OP9 13 (2) 01/04/06 01/07/06 4 OP38 13 (4) 01/07/06 regard to Legionella. 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 OP7 Good Practice Recommendations It is recommended that the systems for care planning be developed to make sure that good quality ‘person centred’ information is recorded. The care plans should better reflect the person – their preferences and life experiences. It is recommended that individual risk assessments be put in place for all residents who self-medicate. These should fully stipulate all storage and monitoring arrangements. Further provision of dementia training for care staff should be considered. It is recommended that the home start to review the induction materials for care staff to reflect the new national ‘common induction’ standards. It is recommended that the home conduct a quality assurance survey at least annually. This should include consultation with residents, their representatives and other stakeholders. The home should make sure that residents are regularly consulted about the frequency of their meetings. 2. 3. 4. 5. OP9 OP30 OP30 OP33 6. OP33 St Teresa`s Home for the Elderly DS0000019128.V285942.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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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