Inspection on 17/05/05 for St Theresa`s

This inspection was carried out on 17th May 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 Theresa`s 08/12/09

St Theresa`s 11/12/06

St Theresa`s 17/11/05

St Theresa`s 21/10/04

St Theresa`s 24/05/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE St Theresas St Therese Close Callington Cornwall PL17 7QF Lead Inspector Philippa Cutting Announced 17 May 2005 9:30 a.m. 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 Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Theresas Address St Therese Close Callington Cornwall PL17 7QF 01579 383488 01579 383488 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) The Aldington Group Limited Ms Vivienne Mary Milden Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Physical disability (15) Terminally ill (3) St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21 October 2004 Brief Description of the Service: St Theresa’s is part of the Aldington group of homes (responsible individual Michael Freeland). It is a purpose built care home with nursing where accommodation is provided on one level throughout. It is situated in a cul de sac in a quiet residential area of Callington. It provides care and accommodation for up to 45 people in need of care by reason of old age, physical disability or terminal illness. The accommodation is mainly in single rooms although two double rooms are available for people choosing to share. Approximately half the rooms have en suite facilities.The communal areas are situated centrally within the home where service users can see what is going on, or overlooking the garden which itself has been planned for visual effect and easy access, including wheelchairs. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9.30am & 5.15pm and concentrated on health & personal care, daily life and activities and the staffs’ comments on the care and procedures in the home. The views of service users and visitors were sought. These were positive but the report will reflect that the dependency levels in the home have risen considerably. 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. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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 standard(s) 1,4,5 St Theresa’s is selected as a positive choice by & on behalf of service users. EVIDENCE: The home’s statement of purpose remains unchanged and relevant. A service user guide was seen in bedrooms. The current service user group is highly dependent. The home supplements the care it provides with other agencies as needed; for example the speech & language therapist visited the home to assess a service user on the day of the inspection. Relatives of service users were spoken to and asked why they had selected St Theresa’s, as the majority of people living there are too poorly to have made a visit or nominated the home themselves. They said it was convenient for them to visit, they had heard of its reputation, it had been recommended. People said that they were satisfied with their choice St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 9 People admitted for short stay care under a NHS initiative said they had found the care helpful in aiding their recovery. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 The physical needs of service users are well managed in a demanding setting of high dependency. EVIDENCE: Each service user has an individual care plan drawn up detailing his/her needs and the care required to meet these. They are reviewed monthly or more often if needed. Relatives are asked to read and sign care plans to show their acknowledgement and understanding of their relative’s care. Relatives who wish, are encouraged to be actively involved in their spouse’s (or other relation’s) care. The home has a good record in care, maintaining tissue viability and the prevention of bed sores etc. It has a wide range of equipment to assist this. Relatives of frail service users confirmed that they felt the care provided was good and other more able/vocal service users agreed. The opinion was voiced to the inspector that the level of care was good but the needs of service users had increased significantly over the last six months so that some relatives, acting as observers, felt that this had been at the expense of activities and social stimulation. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 11 The involvement of other professionals is recorded where it is sought. Medication is well managed with regular audits being undertaken to monitor the procedures. The inspector noted that during the time she was in the home there were service users who, once seated, did not have the opportunity to change their position. Some were confined due to medical apparatus attached to them; others had their meal brought to them as they were unable to go to the dining room. The registered manager said that a lot of service users usually went back to their rooms for bed rest after lunch but that day people had stayed in the sitting room to listen to the entertainment. Cushions and other prophylactic equipment were provided for these people to assist with their comfort but a change of position must be generally more beneficial. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Service users’ interests are promoted but their increasing frailty is making this more difficult to sustain. EVIDENCE: The home employs an activities coordinator but her job has become more difficult as people’s frailty has increased. Realistically she can offer one:one contact with service users rather than group activities. However regular musical sessions with music and songs appropriate to the service users’ age are arranged which most people seemed to enjoy. Service users who have particular talents or interest, such as painting or piano playing etc, are encouraged to pursue these. People can choose whether or not to participate in any activities which includes religious services. There were frequent visitors throughout the day. Some visit more than one person having got to know others over a period of time. The meals were reported as being very good but it was observed that due to the increasing number of people needing help with their food, meal times were an increasingly time consuming activity, especially as the carers try to make it a pleasurable part of the day. The inspector was told that because of the time it took to help service users get up and have breakfast, some people had not long finished this when it was lunch time. Three service users who St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 13 were more able but chose to stay in their rooms, commented that they had no complaints about the care they received but they would appreciate a little more ‘quality time’. This was discussed with the registered manager & registered person. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a complaints procedure designed to safeguard service users and address any issues that are raised. The registered manager does not hesitate to use it when necessary. EVIDENCE: The home has received two complaints in recent months. These have been addressed by the home and resolved with the complainant. The Commission for Social Care Inspection was kept informed of the process. The registered manager and some senior staff are due to attend a course relating to the protection of vulnerable adults (POVA) to complement the home’s present policies and procedures. Carers said, when asked, that they would not condone malpractice by any other member of staff and if they became aware of it would approach the trained staff. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 Service users are provided with a clean and comfortable environment. The changing requirements of care since the home was built means that the passages in the wings are narrow so that some equipment has to be manoeuvred carefully. EVIDENCE: The majority of rooms (43 single, two doubles) are for single occupation with en suites in 17 singles and the two doubles. A new bathroom and a shower room have been fitted and some further work is planned to enlarge storage and treatment areas. Service users’ rooms were seen to be clean and tidy. Most contained people’s own possessions and small items of furniture/memorabilia etc. With the exception of four, all these rooms have natural ventilation but some windows (the tip tilt variety) might be difficult for service users to open, although the reality is that most people need assistance to open windows at present. The four rooms without natural ventilation are fitted with extractor fans. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 16 The communal space is arranged centrally with an additional conservatory/sunroom area that looks out onto a garden with raised beds and water. The main sitting area is arranged in small groups. The inspector asked service users if they always sat in the same place? Most said they did and that it had not occurred to them to ask to move to a different part of the room. The home provides a variety of seating to suit people who have specialised positioning needs. It was noted that nearly half the service users needed to be hoisted when transferred from chair to chair. Staff dealt with this efficiently, explaining to the person concerned what was going to happen. Two people were noted to be independently mobile in electric wheel chairs. Alcohol gel dispensers were freely positioned around the home so that staff and visitors could use these as part of the home’s infection control measures. Gloves are readily available and used. The laundry was not inspected. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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 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) 27,28,29,30 Service users are looked after by a team of staff, many of whom have worked in the home for a number of years. Training is being actively promoted with – the registered manager says – an increasingly good response. EVIDENCE: Staff showed a good knowledge of the people in their care and were seen to working collaboratively. Comments were made to the inspector from various differing sources that more staff were needed. This was based on the premise that, due to the increased dependency levels, it was not always possible to get some people up until quite late in the morning. This was discussed with the registered manager & registered person. The file for a new member of staff was sampled. The recruitment process appeared to be properly carried out. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 18 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) 31,32.33,37 Service users’ interests are looked after by an experienced manager who is supported by an effective administration team. Records are maintained properly and kept secure. EVIDENCE: The registered manager is experienced and competent with a management degree. Staff are encouraged to participate in the running of the home with any suggestions given due consideration. A member of the administrative team conducts regular surveys with the service users to ascertain their (& their relatives’) opinion on the services provided. The records required by statute are kept and those inspected were current and up to date. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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. 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 x x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x x 3 x St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 20 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 No statutory requirements are being made at this time. 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 12 Good Practice Recommendations The home should reflect on how more time for social interaction and hostessing services can be provided for service users. St Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell, Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Theresas D52-D04 S9245 St Theresas V214890 170505 Stage 4.doc Version 1.30 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. 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