Inspection on 17/01/06 for St Thomas Rest Home

This inspection was carried out on 17th January 2006.

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 Thomas Rest Home 04/02/09

St Thomas Rest Home 02/03/07

St Thomas Rest Home 22/06/05

St Thomas Rest Home 08/12/04

St Thomas Rest Home 04/06/04

St Thomas Rest Home 19/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Thomas Rest Home Belgrave Terrace South Shields Tyne And Wear NE33 2PX Lead Inspector Mrs P A Worley Unannounced Inspection 17th January 2006 10:30 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 Thomas Rest Home DS0000000241.V263215.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 Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Thomas Rest Home Address Belgrave Terrace South Shields Tyne And Wear NE33 2PX 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) 0191 454 6662 0191 454 6662 Mr Khalid Hamodi Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (1) of places St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The PD category relates to the current service user only. Room 15 may be used as a respite bed Date of last inspection 22nd June 2005 Brief Description of the Service: St Thomas Complex comprises of two large converted houses, with two entrances, one in Belgrave terrace and one in Beach Street. A long winding corridor links the houses, although at the present time temporary access between buildings is for staff only as it is assessed as too steep for residents to use safely. Access into the Home is available at either building and passenger lifts are available within the Home for access to the first floor. The Home provides personal care for up to 28 older people and has an identified bedroom for service users requiring respite care. The Home does not provide nursing care. The Home is currently undergoing major building work to extend and upgrade the facilities and services. Appropriate arrangements have been made that comply with Fire Regulations and Environmental Health requirements during this development. The Home is located on the outskirts of the town centre, close to the park and sea front. There are many community amenities in close proximity including shops, churches, park and medical centres, and a frequent bus service is available outside the Home. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day, by one Inspector. Time was spent talking with residents and staff. No visitors attended during the inspection to speak with on the day. Inspection of a sample of records was undertaken that included care plans, medication records, staff files and residents personal allowance records. Time was also spent looking around the building to check the facilities and equipment available for service users and the general maintenance and safety arrangements of the property during the building works. A new manager has taken up appointment and had been in post for two weeks prior to the inspection. Staff and residents said they welcomed her and found her to be pleasant and approachable. She is currently in the process of making assessments about the care and service provided in order to identify any areas that may be in need of improvement or further development. She is well supported by the Deputy Manager who has managed the Home in an acting capacity for the past year. What the service does well: What has improved since the last inspection? A new Manager has recently started work at the Home and has settled well. She said she works well with the person who has been the Acting Manager for many months, and who has been very helpful since she started. Residents said she was welcomed to the Home and they find her approachable and supportive. Staffing on night duty has increased as required at the last inspection to make sure of safety and security of residents. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 6 Risk assessments have been put in place where fire doors need to be kept open to allow residents to move freely, and remain safe from fire. Notifications of events that that may affect the health or welfare of residents in the Home are now reported to the Commission as required by the Regulations. 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 Thomas Rest Home DS0000000241.V263215.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 Thomas Rest Home DS0000000241.V263215.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): Standards 3 & 4 were assessed at the last inspection and were met. Only one new resident has been recently admitted to the Home for respite care, since the last inspection and was still there at the time of the inspection. She confirmed that appropriate assessments had been carried out before she decided to move into the Home. EVIDENCE: A number of other residents in the Home stated that their needs were being met to their satisfaction and activities that could be observed throughout the day indicated that they were. St Thomas Rest Home DS0000000241.V263215.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. Each resident has an individual plan of care that sets out their health, personal and social needs and care. The records continue to show improvements but the information provided still needs to be more detailed. The systems for the administration of medicines are satisfactory with clear records, to ensure residents’ medication needs are met. EVIDENCE: The good effort made by the Acting Manager to improve the documentation format of residents care plans has continued with a good level of basic information recorded including input by GP’s and other relevant professionals. However, further developments are necessary and discussion took place with the Manager regarding this. Together with the Deputy Manager, she intends to review the care plans, along with other records, policies and procedures within the Home, to improve and update them. Examination of the medications systems indicated that clear systems were in place for safe practice with medicines. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 10 The policies, procedures and practices for the ordering, receipt, and disposal of medicines were satisfactory. The standard of medicine administration records (MAR) was good but a recommendation was made to obtain two signatures, to witness any verbal instructions or changes to medication doses, for example where the dosage of Warfarin tablets is changed regularly by the Hospital/Clinic, and the Home is informed by telephone. An audit trail of some medicines carried out was correct. All other records associated with medicines were satisfactory. St Thomas Rest Home DS0000000241.V263215.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): 12, 13 & 14. Residents are offered opportunities, and are encouraged, to participate in a variety of social activities, as and when they choose. Links with families, friends and the community are maintained and encouraged and service users are supported in making choices about their daily lives. EVIDENCE: Conversations with the Manager, staff and residents, and the programme displayed in the Home showed that various in-house activities were organised. Activities include, for example; video sessions, quizzes, dominoes, knitting and listening to music. Links with the community are maintained and a number of residents spoke of the trips out to lunch at hotels and restaurants over the Christmas period and of visits out with their families and of their visits to the Home. Some spoke of the limited outings at this time of year due to the cold weather but looked forward to the summer. Some residents spoke of activities and that they preferred or just having a quiet time watching television or just chatting. Residents who prefer this life style said staff respected their wishes to spend time as they wished. They also confirmed that they choose what time they wish to retire and rise, have baths, and where they spend their time, and staff supported them in this. Visitors are welcome at any time and this has been observed at previous inspections, St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 12 although none visited at the time of this inspection. Residents confirmed that there were no restrictions on visiting and that they were able to receive visitors in private if they wished. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 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. The Home has a satisfactory complaints procedure, which ensures that complaints are handled objectively, and residents indicated that their concerns are listened to, taken seriously and acted upon. EVIDENCE: A satisfactory complaints procedure is available but is in need of review. The Manager indicated that this would take place along the general review of all policies and procedures in the Home, in due course. A suitable record format is available to record complaints, which also needs to be reviewed, but no complaints have recently been made. No complaints about the Home have been received into the Commission. Audits and monitoring of complaints are to be included in the quality assurance systems to be further developed by the Manager. Residents, who were spoken to, said they knew who they could go to if they had a complaint to make and felt confident the Manager and staff would deal with them appropriately. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 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. Residents live in a safe, clean, well-maintained home despite the temporary arrangements in place during the major building works taking place. The Home is comfortable and pleasant. Sufficient and appropriate facilities are provided to suit their needs. EVIDENCE: A selection of bedrooms was viewed, also the communal areas including bathrooms and toilets. Only fourteen residents are now resident between the two existing houses and all are now accommodated within the Belgrave Terrace house. Those residents that moved rooms said they had been happy to do so. Some of the bedrooms in the unoccupied house have been decorated as part of the planned upgrading and refurbishment programme of the existing home, to come in line with the extension building when it is completed. The only room occupied in the Beach Road house now is the Manager’s office and appropriate security measures to the Home are being taken whilst that St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 15 house is not used. The Home was clean, comfortable and generally well maintained. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 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, 28, 29 & 30. The numbers of staff, which are in excess of those required for the number of residents accommodated, and the experience of the staff provided in the Home, ensures that service users needs are met and that they are supported at all times. Procedures for the recruitment of staff are in place but in one case had not been followed therefore did not provide adequate safeguards to protect the people living in the Home. Staff have received appropriate training to enable them to do their jobs competently, and are working well towards achieving relevant qualifications. EVIDENCE: Despite the reduced numbers of residents occupying the Home, the staff numbers have remained as before. This ensures that residents needs to be met more efficiently and enables staff to be available to support residents, one another and the new Manager, whilst planning for the forthcoming changes when the building extension is completed, which is good. Eight of the twenty-three care staff have achieved NVQ level 2 or 3 qualifications and seven staff are currently undertaking NVQ level 2 training. When completed the level qualified will be at 65 , which will be in excess of the standards’ recommendation. Discussions with some staff confirmed that St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 17 they have had training in fire safety, food hygiene, health and safety, and more recently Protection of Vulnerable Adults (POVA). The Manager indicated that she was in the process of reviewing the training programme for staff and would be developing a programme to include special health and care needs, as well as the required statutory training. Inspection of the staff files of the two most recently recruited staff was carried out. One contained the appropriate details including security clearances and references, but the other showed that the individual had commenced work prior to the Criminal Records Bureau (CRB) being obtained. No references were available. The post was taken up prior to the new Manager starting but was discussed with the Provider, who had made the appointment and agreed it was unacceptable procedure. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 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 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, 33, 35 & 38. The Manager has appropriate qualifications and experience to manage the Home, and needs to apply to the Commission for registration as manager. Some systems to are in place to determine the quality of the service provided by the Home but need further development to ensure that it is run in the best interests of the residents. Systems are in place and function well, to safeguard service user’s personal allowances. Records are clear and well documented but would benefit from review and some improvements. Staff follow safe working procedures and promote and protect service users’ health, welfare and safety. EVIDENCE: St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 19 The new Manager has been in post for two weeks and has the appropriate qualifications and experience to run the Home. She has already made a number of assessments such issues as the policies, procedures, care and services provided by the Home, and is in the process of identifying priority areas for development. She spoke of the support given to her in this by the Acting Manager of many months, when she arrived. Residents spoken with said they saw her regularly and felt able to speak comfortably to her on matters of their care. One resident said, “the new manager is very nice and easy to talk to”. Application needs to be made to the Commission for registration as manager. A quality assurance statement is available some systems are in place that include monthly health and safety and building checks, and service user questionnaires. Resident and staff meetings are held and monthly reports are submitted to the Commission as required by Regulation 26. The Manager plans to develop the systems and audit documents for all areas of the service and will take in the extended Home, when complete. Residents personal allowance monies held by the Home are kept securely and are held in individual containers. Receipts are kept to support transactions but of the sample inspected only one signature was recorded. A summary of individuals’ balances is kept for easy referral and audit but individual records are kept for each resident with details of transactions. The system is adequate but should be reviewed along with the others to be reviewed, in order to create a more robust system. A check of three residents monies balances against their records, showed them to be correct. Staff practices concerning health and safety were generally satisfactory and risk assessments are in pace where appropriate for fire doors and other areas of the Home where potential risks are present. Staff practices concerning moving and handling were carried out appropriately. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 20 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 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 21 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 OP29 Regulation 19(1) Schedule 2 8 Requirement All security clearances and references must be obtained prior to staff coming into post in the Home. The Manager must apply to the Commission to become registered manager. Timescale for action 17/01/06 2. OP31 01/03/06 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. 2. Refer to Standard OP28 OP37 Good Practice Recommendations Staff NVBQ training should be pursued in order to achieve the appropriate numbers that are qualified at a minimum of NVQ Level 2. Review, amendments and further development of all policies, procedures and recording systems should be pursued as planned. St Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Thomas Rest Home DS0000000241.V263215.R01.S.doc Version 5.1 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. 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