Inspection on 15/11/05 for St Theresa`s Rest Home

This inspection was carried out on 15th 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 Rest Home 15/06/06

St Theresa`s Rest Home 23/08/04

St Theresa`s Rest Home 27/05/04

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 Theresa`s Rest Home 6-8 Queen Anns Garden Enfield Middlesex EN1 2JN Lead Inspector Mr David Hastings Unannounced Inspection 15th November 2005 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 Theresa`s Rest Home DS0000045869.V261301.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 Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Theresa`s Rest Home Address 6-8 Queen Anns Garden Enfield Middlesex EN1 2JN 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 8360 6272 020 8360 6272 Mrs Lila Cecilia Paul Mr Jose Roy Paul Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home will not admit service users with a diagnoses of dementia. Three specified service users who have developed dementia may be accommodated in the home. The home must advise the registering authority at such times as any of the specified service users vacates the home. 25th April 2005 Date of last inspection Brief Description of the Service: St Theresas is a privately run home owned by Mr Jose Paul & Mrs Lila Paul and registered to accommodate twenty-three older service users of either sex. The home is a large converted house in a tree-lined road in Enfield. The bedrooms are on three floors and are comprised of thirteen single bedrooms and five double bedrooms. One single room and one double have en-suite facilities. The lounge/dining area is on the ground floor with a conservatory attached. There is a large garden to the rear of the house. The home is well serviced by public transport and there are shops nearby. The stated aim of the home is to foster an atmosphere of care and support which both enables and encourages our residents to live as full, interesting and independent a lifestyle as possible with rules and regulations kept to a minimum. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 15th November and lasted five hours. The inspector spoke with eight residents and three staff. A partial tour of the home took place and seven service user plans were examined along with other documents relating to staffing, medication, health and safety and service user information. The inspector was assisted by the registered provider who was open and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Five requirements and one recommendation have been issued as a result of this report. Some of the water temperatures in wash hand basins were too hot and some of the residents commented that the home was sometimes a bit chilly. The manager needs to put her times of work on the weekly rota. All staff that undertake fire drills need to have their names recorded and the fire emergency plan needs to be reviewed. The one recommendation was that staff review the residents individual plan of social activities. The inspector is confident that these requirements will be complied with by the registered provider within the timescales given. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 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 Theresa`s Rest Home DS0000045869.V261301.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 Theresa`s Rest Home DS0000045869.V261301.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): 3 and 4 (6 not applicable) Service users have their needs professionally assessed before admission so that they know the home can meet all their needs. EVIDENCE: Three assessments were seen for the last three service users to be admitted to the home. These were detailed and had been carried out by social workers. None of the assessments indicated that the service users had dementia and the manager was clear that no service user would be admitted to the home with such a diagnosis. This is in line with the home’s conditions of registration. The manager informed the inspector that she also assesses any potential service user. A number of service users have developed dementia during the time they have lived at the home. The registered provider has applied to the CSCI for a minor variation for these named service users. This was a requirement from the last inspection that has now been complied with. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 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, 8 and 9 All service users have an individual plan of care that staff understand and follow in order to meet the service users’ health, personal and social needs. Service users have good access to health care professionals when required. Service users get the right medication at the right times by appropriately trained staff. EVIDENCE: Seven service user plans were examined. These contained information regarding all aspects of care outlined in Standard 3 and were sufficiently detailed to enable staff to understand the individual needs of service users. Staff interviewed had a good understanding of these plans and were able to give detailed accounts as to how they meet the needs of people living in the home. There was evidence that plans are being reviewed monthly and that service users are involved in the review of their care. This was a requirement from the last inspection that has now been complied with. Care plans contained information about the health needs of service users and evidence that service users have access to heath care professionals including GPs. This was confirmed by service users that the inspector spoke with. Risk assessments were contained in all plans examined and these were varied and detailed. Risks covered manual handling and pressure care. No service users St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 10 currently have pressure sores and pressure relieving equipment is being used for service users who have been assessed as being at risk. Written information was seen regarding doctors’ visits. This information included the outcome of the doctor’s visits and any amendments to the care plans as a result. This was a requirement from the last inspection that has now been complied with. The records in relation to the receipt, administration and disposal of medication were examined. All records were accurate and the inspector was very impressed by the senior care worker responsible for medication records who had a good understanding of the relevant procedures. Records indicated that all staff who administer medication have undertaken the appropriate training. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 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): 12, 14 and 15. Service users are able to choose from a variety of activities provided by the home. Service users are helped to exercise choice and control over their lives. The home offers a good range of well cooked, fresh meals which the service users enjoy in pleasant surroundings. EVIDENCE: Service users’ recreational interests are recorded in their plan of care. The home has a schedule of activities displayed in the home. Staff were observed sitting and talking with service users and a bingo session took place in the afternoon. Most service users said they were satisfied with activities available in the home. A few service users that the inspector spoke with said they thought the home could provide more activities and one service user told the inspector that staff had discouraged her from helping out with small domestic tasks. This is a shame as helping out with manageable tasks can increase service users’ feelings of worth. The inspector recommended to the manager that the schedule of activities be reviewed to include a more “person centred” approach to keeping service users occupied. There was evidence from care plans that service users can choose when to get up and go to bed and what menus they would prefer. No service users currently manage their own finances as this is either dealt with by their family or by the local authority. There was evidence that service users are St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 12 encouraged to bring in their own personal possessions and furniture. Service users that the inspector spoke with confirmed that they were able to exercise choice and control over what they did at the home. Service users that the inspector spoke with were positive about the food at the home and confirmed they had a choice of menu. The cook was aware of the different dietary needs of service users and the kitchen was clean and well stocked with food. Lunch was relaxed and unhurried and staff were observed providing discreet assistance were needed. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 13 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 Complaints are taken seriously and the manager of the home acts upon any concerns quickly. EVIDENCE: There have been no complaints since the last inspection and it was clear from discussion with service users and the manager that any issues or concerns are dealt with and acted upon as they arise. Service users were clear about whom they would complain to if needed. The home has a satisfactory complaints procedure, which contains timescales and makes reference to the CSCI. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 14 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, 22 and 26 The owners are working hard to improve the general condition of the premises and the home is clean, comfortable and has a homely atmosphere. EVIDENCE: The home is an older property and many of the problems were inherited when the new owners took over in September 2003. The registered provider is well aware of this and has put in place a rolling maintenance plan for refurbishment and redecoration. A requirement issued at the last inspection that the home be assessed by a occupational therapist in order to ascertain whether suitable aids and adaptations are in place has now been complied with. The manager informed the inspector that the assessment took place on 26/09/05 and that a report will follow shortly. During a tour of the premises the inspector noted that the temperatures of a number of wash hand basins were above the required 43 degrees. A requirement has been issued that water temperatures are regular checked and recorded and overly high water temperatures are reduced. A requirement has also been issued that the registered provider ensures that written confirmation is sent to the CSCI from a qualified plumber that wash St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 15 hand basin temperatures can be safely maintained at 43 degrees whilst not affecting the hot water storage and supply to the kitchen and laundry. The inspector also noted that some parts of the home were rather cold, as the heating had been switched off. A number of service users also commented that the home could be a bit cold at times. The inspector acknowledges that the home needs to be aired but a comfortable temperature must be maintained at all times. A requirement relating to this has been issued in the relevant section of this report. Staff at the home have now undertaken infection control training and certificates were seen on files examined. This was a requirement from the last inspection that has now been complied with. The laundry area was clean and the washing machine has a sluice cycle for heavily soiled laundry. On the day of the inspection all parts of the home were clean and free from offensive odours throughout. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 16 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 Service users are supported by a committed and caring staff team who have a good understanding of service users’ individual needs. Staff receive the training they need to carry out their duties and responsibilities effectively. EVIDENCE: Service users that the inspector spoke with were very positive about the staff at the home. One service user commented that, “they look after us very well here”. There appeared to be sufficient staff on duty to meet the needs of the service users on the day of the inspection. Staff rotas were available for inspection and found to be satisfactory except that the manager was not recording when she was due to be in the home on the duty rota. A requirement relating to this has been issued in the relevant section of this report. Staff interviewed had an excellent understanding of the needs of the service users and interactions observed between staff and service users were supportive, friendly and caring. Staff files that were examined contained a signed copy of staff terms and conditions this was a requirement from the last inspection that has now been complied with. It was clear from discussion with staff and from the staff training record that the manager is very proactive with regard to staff training. Staff spoken to said there were good training opportunities at the home. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 17 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): 35 and 38 Service users’ financial interests are safeguarded by clear accounting procedures. Overall there are good policies and procedures in place to monitor heath and safety compliance in the home. The fire emergency plan must be reviewed and amended where appropriate. EVIDENCE: As stated previously in this report, no service users currently manage their own financial affairs. The home does hold small amounts of money on behalf of service users. This money is used to purchase small items and to pay for hairdressing. A random selection of this money was inspected and found to be accurate with clear audit trails including individual receipts. Satisfactory certificates were seen in connection with gas safety, electrical installation and portable appliances and Legionella checks. A satisfactory record of accidents was examined. Fire safety records were examined. Fire St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 18 drills were taking place however the names of those staff taking part in these drills were not being recorded. The fire emergency plan did not contain a plan of the building and no review date for the plan was indicated. Two requirements in relation to these matters have been issued in the relevant section of this report. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x x 3 x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x 2 St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 20 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 OP19 Regulation 13(4) c Requirement The registered provider must ensure that written confirmation is sent to the CSCI from a qualified plumber that wash hand basin temperatures can be safely maintained at 43 degrees whilst not affecting the hot water storage and supply to the kitchen and laundry. The registered provider must ensure that all parts of the home are maintained at a comfortable temperature. The registered provider must ensure that the manager’s hours of working are clearly recorded on the weekly duty rota. The registered provider must ensure that the names of staff undertaking fire drills are clearly recorded on the fire safety records. The registered provider must ensure that the fire emergency plan is reviewed, includes a floor plan of the building and is sent to the local fire officer. Timescale for action 01/01/06 2 OP19 23(2) p 01/12/05 3 OP27 18(1) a 01/12/05 4 OP38 23(4) e 01/12/05 5 OP38 23(4) c 01/01/06 St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 21 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 OP12 Good Practice Recommendations The registered provider should ensure that the activities programme is reviewed in order to provide a more “person centred” approach to service users. St Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Theresa`s Rest Home DS0000045869.V261301.R01.S.doc Version 5.0 Page 23 - 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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