Inspection on 17/11/05 for St Theresa`s

This inspection was carried out on 17th November 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 17/05/05

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 Unannounced Inspection 17th November 2005 09:30 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 Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Theresas Address St Therese Close Callington Cornwall PL17 7QF 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) 01579 383488 01579 383488 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), Physical disability (15), Terminally ill (3) of places St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 3 adults with a terminal illness (TI) Service users to include up to 15 adults with a physical disability (PD) Total number of service users not to exceed a maximum of 45 Service users to include up to 45 persons of old age (OP) Date of last inspection 17th May 2005 Brief Description of the Service: St Theresas 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 DS0000009245.V254172.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted between 9.30am & 5.0pm during a normal working day. Time was spent with the registered manager, service users and staff. Records relating to service users and statutory requirements were inspected. The home appeared to be well organised with staff having a clear and positive view of their roles. The registered manager described changes that have been put in place in the last 12 months. These have been designed to improve service users’ care and provide more opportunities for staff training. The care staff have good support from the administration team who are based in the home. The registered manager said that the responsible individual was very supportive with regard to his role in the business. What the service does well: What has improved since the last inspection? A need for more staff at peak times, especially the mornings, has been addressed. The home now has enough staff so that it can cover sickness and holidays without undue problems or the use of agency staff. The supervision of staff is now well established and staff are using these sessions as an opportunity to discuss their training needs etc. A small bathroom has been converted into a shower room which, it was reported, is well used. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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): 1,2,3,4,5 St Theresa’s provides information to prospective service users and their families and assesses people, following enquiries, to ensure that a person’s needs and St Theresa’s skills are compatible. EVIDENCE: A statement of purpose & service users guide is available for all service users, a copy being placed in every room. Prospective service users are visited in advance in order to determine their needs and St Theresa’s ability to meet these. Service users are provided with contracts that, where applicable, show the fee and any NHS nursing component. Few people are able to visit the home in advance on their own account due to their ill health or frailty, although they would be welcome to do so. They rely on families to undertake this on their behalf. The home should consider placing a copy of the most recent inspection report where it can be easily read. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 9 A number of people may be admitted on a RAZ scheme which is a local initiative to help people recover from illness before returning to their own home. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10,11 The staff seek to meet all a service user’s needs, identifying these and keeping written records that are supplemented by verbal handovers & good communication. Specialist advice is sought as needed. Staff demonstrated a good knowledge of the people in their care and the service users said that they were content with the attention they received and the way it was provided. EVIDENCE: All service users have individual care plans that are reviewed regularly. Service users, or a relative if more appropriate, are asked to read and sign to indicate their agreement with the plan. The registered manager said that there were still some outstanding care plans that needed signing but these are mostly where a relative’s help is needed. A list of the relatives that need to be contacted is kept and people are approached when they visit. The inspector and registered manager discussed how some problems that form an important part of a person’s care but could be regarded as sensitive, should be included in a care plan. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 11 The registered manager is planning to change the daily recording format as the present one has a lot of unused sheets that make it bulky and unwieldy. Care plans are kept readily available for reference by all staff. The trained staff and care staff receive regular training and updating sessions to ensure that they are able to delver care of a high standard. The home readily refers to outside specialists and agencies where there is a need. Medication is administered only by trained staff who always deal with this on a one:one basis, signing the medication administration record sheets as medication is administered. The registered manager does a weekly audit of the Controlled Drugs medication, records and storage. She also checks the medication administration record sheets and investigates any discrepancies should they occur. Service users may be responsible for their own medication following a risk assessment but this tends to be a minority. Letters of thanks and appreciation that had been sent following a stay or the care of a person who had died, were noted. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15 The home tries to promote contact with their former lives and communities as much as possible for service users by encouraging visitors and friends to visit. Time is given to people’s social needs and entertainment but a wish not to participate in any activities is respected. Nutrition is regarded as important with people being given assistance when ever necessary to promote this. EVIDENCE: The inspector talked with various service users, mostly those who chose to stay in their own rooms. The majority were content and said they passed their time in comfort with the television, radio and newspapers etc. There were others who were philosophical rather than accepting about their need to have nursing care. The home employs an activities organiser whose hours have been increased to full time. She keeps a record of what is organised. Much of her time is spent in one:one sessions with service users but trips out and musical sessions are also put on. Art/craft sessions are arranged if there is a celebration (therefore a theme) approaching but the level of frailty precludes a lot of complex activities. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 13 Visitors are welcome and people were seen to be coming and going during the day. People can visit families and friends in their homes if they wish and links with the community are encouraged. The cook visits everyone each day to discuss the menu and choices with him or her. A varied menu is provided with any special dietary needs being recorded. Ingredients are available during the evening or night so that should someone want a drink or snack, this can be provided. Staff were seen to be sitting quietly with service users who needed help with their meals so that the person requiring help received full attention. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 the following standard(s): 16,18 Service users are protected from harm by the home’s response to concerns and complaints. Staff receive training and information on the protection of vulnerable adults (PoVA). EVIDENCE: The home has a complaints procedure and looks into any complaints or concerns promptly, responding to the complainant within its stated time frame. A record of any incidents (as opposed to complaints) is kept with the circumstances, investigation and outcome recorded. Staff were well versed in the protection of vulnerable people and the registered manager said she had had to discuss certain procedures with staff where they debated that intervention could be construed as abuse whilst non intervention could be interpreted as neglect. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 the following standard(s): The premises are well maintained, clean and warm. Service users are provided with rooms and equipment that meet their care needs. Staff are trained in the use of the use of this equipment. EVIDENCE: The environment was toured briefly with a number of rooms being inspected in more detail. The premises were seen to be clean and warm. Some essential repairs were underway to address a leaking roof in the conservatory so there was some noise and part of a corridor was restricted for access during the day. Housekeeping staff felt they had sufficient supplies and equipment to deal with any problems of spillage or soling but said that there were no serious difficulties at the moment. Service users’ rooms were seen to be personalised with pictures and mementoes etc. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 16 The communal space is arranged in groups in the main central area but there are alternative sitting areas by the dining room and in the conservatory. In good weather there is an enclosed garden, which is accessible to wheelchairs. Accommodation is arranged along wings. Rooms meet the spatial standards currently prevailing. The egress from some rooms into one corridor is a tight turn for anyone using a wheelchair and this can have a bearing on arranging a room for anyone who is able to manoeuvre a wheel chair independently. There are four rooms that rely on a ventaxia for ventilation rather than an opening window. The registered manager is aware that these rooms are less satisfactory and therefore tries to keep them for people who are only staying for a short period of time. A variety of equipment to aid independence, prevent pressure areas and assist the staff in providing care was seen. The home is well supplied with hoists and all staff are trained in their use, service users having been assessed for the most suitable equipment with which to move them. Toilets and bathrooms were clean with raised toilet seats, frames and hand rails to help people. A small bathroom has been converted into a shower room as an alternative facility. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Service users are cared for by staff who have been properly vetted before starting work and for whom on going training is encouraged at all levels. EVIDENCE: Staffing numbers have been increased to provide more help at peak times. Staff reported that this was good as they had found themselves rushed to provide all the care a person needed in the mornings in particular. Staff were noted to be observant stopping to adjust a person’s posture as they were passing. At night all staff are awake, the trained member being supported by carers. National Vocational Qualifications training is encouraged with more than 50 of the care staff having either achieved NVQ level ll or being enrolled and part way through. A new carer explained the programme of induction that she was working through and seemed very clear and competent in understanding the scope of her duties. She was clear about the tasks she was not yet ready undertake as well. The registered manager is reviewing the induction programme in accordance with the new guidelines/standards. Recruitment is thorough. Staff files sampled showed that all had written references, Criminal Records Bureau & PoVA checks in place before starting their employment. A chart of on going training needs is kept with any requests for specific topics being noted. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 18 St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 The home is managed by a competent person who is supported by effective administrative staff and an involved owner. An independent audit of the home’s safety & quality etc. is undertaken as an additional safeguard for service users. EVIDENCE: The registered manager is well qualified and holds a management degree. She has successfully implemented new procedures in the last 12 months to encourage staff to be more participative in the running of the home. Service users and/or relatives are regularly canvassed for their views on the service provided by the home with an independent person auditing the responses as well as reviewing the home’s health & safety policies and practice. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 20 The home will hold money for service users in ‘safekeeping’, recording any expenses accrued. Problems with the personal finances for two service users, identified previously, have now been resolved. The home does not involve itself with collecting pensions or benefits, preferring that a relative or trusted friend should undertake this. Staff supervision is in place and, after initial concerns, it has developed into a active two way process. The records required by statute are maintained. The registered manager requires that any fall or slip is recorded in the accident book and she reviews these to see if any patterns of behaviour or problems are indicated. Fire training is provided regularly to staff; alarms and lighting is tested & recorded. The responsible individual visits regularly and spends time with staff and service users. He continues to be forgetful about forwarding his reports to the Commission for Social Care Inspection on a monthly basis. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 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 3 3 3 3 3 N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 22 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. 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 OP1 Good Practice Recommendations The registered manager should consider placing copy of the most recent inspection report on the notice board, or similar place, for people to read. St Theresas DS0000009245.V254172.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection St Austell Office 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 DS0000009245.V254172.R01.S.doc Version 5.0 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. 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