Inspection on 02/03/07 for St Thomas Rest Home

This inspection was carried out on 2nd March 2007.

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 17/01/06

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 2RX Lead Inspector Mrs Eileen Hulse Unannounced Inspection 11:00 2 March and 26th March 2007 nd 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.V329092.R01.S.doc Version 5.2 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.V329092.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Thomas Rest Home Address Belgrave Terrace South Shields Tyne And Wear NE33 2RX 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 F/P Mr Khalid Hamodi Care Home 55 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (1), Old age, not falling within any other category (55), Physical disability over 65 years of age (5), Sensory Impairment over 65 years of age (4) St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Room 15 may be used as a respite bed The home may from time-to-time admit persons under the age of 65 within the OP category of registration 17th January 2006 Date of last inspection Brief Description of the Service: St Thomas Complex comprises of two large converted houses that have been recently upgraded with a purpose built extension added to the main building. The main entrance is to the front of the building in Belgrave terrace. A lift is available within the Home to take people to the first floor. The Home provides personal care for up to 55 older people that includes an area of the home for 21 people with dementia care and the home also has an identified bedroom for service users requiring respite care. All the bedrooms within the building are single rooms and all have en-suite facilities. The Home cannot provide nursing care. 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.V329092.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and took 10hrs to complete over two visits to the home and was carried out as part of the annual inspection programme. The Acting Manager was present for all of the visits and some time was spent with the Acting Manager reviewing the progress of the service. Time was also spent talking with service users and their visitors to get their views of the service. How care staff support the service users was observed throughout the visit and a lunchtime meal was shared with the people who live there. We also looked around the building at the extensive upgrade that has recently taken place within the home. Information about the quality of life and care received by service users was collected using a system called ‘case tracking’. This involves following the care and experience of a group of service users by looking at care plans, talking with people, sampling records such as accident and fire records, medication systems used in the home and staff recruitment records. The requirements made in previous inspection reports were discussed with the Manager and discussions took place with other staff members who were on duty at various times throughout the visit. The judgements made are based on the evidence made available during the visit to the home and from information obtained from the home before the visit was made, which included the pre inspection questionnaire that was provided by the home Manager. This gave up to date information about the home to include within the report. Questionnaires completed by service users and their families also gave some insight on what it is like to live in the home. The weekly fees are £355.00 to £365.00 per week depending upon care needs. Additional charges are made for hairdressing, outings, toiletries, newspapers and personal items. What the service does well: The home is homely and welcoming and it has a good staff team that are friendly and caring and some service users made the following comments about the home and the staff: ‘I have made a lot of friends here, the staff are really good to me’ ‘The owner is very good to us we see him everyday and he knows us all’ ‘I was born and bred in South Shields so I wouldn’t live anywhere else’ ‘No complaints’ The home has good assessment procedures that are used to make sure that when a service user comes into the home their needs can be met. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 6 The home has good medication systems and staff are trained to make sure that service users are given their medication safely. The meals are tasty and nutritious and this was confirmed by some service users who stated the meals were lovely. During the two-day visit staff were seen to treat service users with dignity and respect at all times and one comment made was: ‘The staff are great here they are all a great help to me’ 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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.V329092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good assessments are included within the plans of care for all service users that help to form the basis of their care plan. This helps to ensure that before admission, the home is able to know if they can meet all of the care needs. The home does not admit emergency admissions and the home do not provide intermediate care. EVIDENCE: Records examined confirmed that the assessment process is carried out before anyone is admitted into the home. Records evidenced that the nominated Care Manager carries out the initial assessment, a copy of the assessment and care plan is given to the home and a date is agreed for the service user to visit the home or the manager visits the prospective service user in their own surroundings. The assessment process also includes the completion of the homes own assessment record, this record is completed St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 9 following a home visit by the Manager or Deputy Manager to the prospective service user. Following admission, each service user has a care plan developed from the assessment information so that, when followed by staff it helps the care needs to be met on a daily basis. The assessments cover the individual needs of the service user and they are recorded under various sections that include personal needs, mobility, and personal hygiene and health issues. The service user lives in the home for 6 wks to see if they like living there and for the home to ensure they can meet the needs. A review meeting is then held between representatives of the home, service user, family and care manager. In discussions with visiting families, they confirmed that they had been involved in the assessments of their relatives. One service user and their relative stated: ‘I had a choice of homes, we looked at a number of homes before choosing this one’ No service user is admitted into the home until the Manager has received the care managers care plan. The home does not accept emergency admissions St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans are easy to understand and contain detailed information on the care needed by service users, however, the care plans are not regularly monitored or evaluated and therefore do not inform staff of any changes that may be necessary that will ensure the needs are met on a daily basis. The medication system is well managed and service users have regular access to healthcare professionals and these contribute to the health and well being of service users. EVIDENCE: The care plans are divided into sections with a front index so that information is accessed easily to both service users and staff. Each care plan has an index page that details the sections that include assessments, health and safety, health consultation records, personal St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 11 preferences and daily reports. There is a personal information page and a pen picture that gives social details of the service user with a photo attached. The care plans are written in detail and include the assessment of need, the preferred outcome and what staff must do to make sure the outcome is achieved. One care plan stated the service user is deaf and it detailed how staff can communicate with the person such as, using hand gestures, lip reading and specialist headphones. Another care plan stated (x) preferred time of going to bed and the help required by staff at this time. Good personal preferences are recorded such as the service users preferred form of address, their food and drink preferences and how their religious needs can be met. However, some care plans looked at, need further information included such as x needs to be toileted at regular intervals but does not state how often. The care plans are not monitored and only one evaluation is completed. Without individual care plans monitored and evaluated it is difficult to asses if changes to the care plans are necessary and how often they need to be changed. Staff were observed throughout the two days to treat service users with dignity and respect at all times. A medication round was witnessed following the midday meal. There were no issues and the member of staff followed pharmaceutical guidelines, medicines were given to service users safely. The records were completed and signed by the person administering the medicines as each one was given out. The policies, procedures and practices for the ordering, receipt, and disposal of medicines are good. As part of the case tracking process, an audit trail of some medicines held in the home was carried out and was correct. All other records associated with medicines were satisfactory. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some social activities are made available to service users, however, they need to be improved to give service users more choice and a more stimulating and interesting lifestyle. Service users are offered and receive a varied, wholesome and nutritious diet and this helps to promote the well being of people. EVIDENCE: The home has been without an activities coordinator for some time although this post is currently being advertised and the activities that are currently in place are organised by the care staff. On the day of the inspection, there were no activities organised but staff stated that service users do visit the local pub and the local church visits the home to hold services and give Holy Communion. Whilst talking to service users about activities in the home, comments they made included: St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 13 ‘I miss not going out’ ‘Nothing much happens here’ ‘Its lovely here but every day seems the same as the last one’ There were no activities records available to evidence how service users spend their time and no information was displayed that would inform service users about forthcoming events. On the day of the visit, some service users were spending time in their bedrooms and other service users were sitting in lounges watching the TV or listening to music. There are no restrictions on visitors to the home and people spoken to during the inspection were complimentary about the home and the staff team and comments they made included: ‘There is 100 care here, I have no complaints at all’ ‘Every time I visit, the girls keep me informed of what is happening’ ‘I am totally happy about the care given here, everybody is so kind to my (relative) ‘The girls are lovely and work very hard to make the home good’ A meal was shared with the service users and it was observed staff were very helpful and attentive to service users throughout the meal in a discreet and sensitive manner. A relative also joined service users for lunch. The dinner was hot, tasty and well presented and consisted of a choice of fish, chips and peas or chicken curry and rice. Tureens were on each table to give maximum choice to service users on the amounts and preferences of the food. Tables were set with necessary condiments, tablecloths, place settings and cloth serviettes and hot and cold drinks were served throughout the meal. No menu choice was evident so service users did not know what was for lunch. Service users chatted throughout the meal and stated: ‘I like the food, all very good’ ‘One thing in here they don’t skimp the meals’ ‘We get some lovely meals’ St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear and easy to understand complaints procedure is available to service users and their relatives. This provides people with the opportunity to make a complaint should they have any concerns about the service. Service users are protected by robust policies and procedures that ensure they are safeguarded from abuse. EVIDENCE: The home has a complaints policy and procedure that is detailed and available to anyone who has a concern or complaint about the home. Records showed that any complaints made to the home are recorded and acted upon satisfactorily. The complaint book details the date, the name of the person making the complaint, the outcome of the investigation and the name of the member of staff receiving the complaint. In discussions with service users and relatives about the complaints procedure, it was evident they all know how to make a complaint and who to make the complaint to. The MAPPVA (Multi Agency Protection Procedure for Vulnerable Adults) procedures are in the home and accessible to the staff and all of the staff has received protection of vulnerable adults training from the Local Authority. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has been recently been upgraded and refurbished and the improvement has made the home a comfortable and pleasant place for people to live. EVIDENCE: The recent upgrade to the home has enabled all the bedrooms to be made into single rooms with en-suite facilities. A new extension has been added to the home that now includes a conservatory, a reminiscence room, a hairdressers and a unit upstairs can now cater for 21 people who have dementia care needs. The home now has five bathrooms, 4 shower rooms and three large lounges have been created. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 16 Throughout the building, there are new carpets and all the furnishings have all been replaced throughout the building. Everyone spoken with throughout the visit were complimentary about the home and the recent changes that had taken place. Staff comments included: ‘It’s a great place to work, we are a very happy and friendly home’ ‘All the work has been worth it, it’s a lovely environment to work in’ Both service users and visitors to the home also commented on the recent changes. Visitors said ‘the changes have made a vast difference for my relative’ another visitor said ‘I cannot say a wrong thing about this home, it’s absolutely lovely now’ St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were adequate numbers of staff on duty, and the experience of the staff currently working in the home, helps to ensure that service users needs are met and that they are supported at all times. Procedures for the recruitment of staff are in place, however, Criminal Records Bureau checks have not been obtained for four members staff and therefore, the home are not providing safeguards to protect the people who live there. Staff have received appropriate training to enable them to do their jobs competently, and are working well towards achieving relevant qualifications. EVIDENCE: The duty rota reflected the numbers of staff on duty on both days of the visits and the numbers were adequate to meet the current needs of service users living in the home. Staff on duty included the Deputy Manager, four care staff on the upstairs unit and three care staff working in the rest of the home. Fourteen care staff have achieved NVQ level 2 or 3 qualifications and the Deputy Manager is currently completing NVQ Level 4. Discussions with some staff confirmed that they have had training in fire safety, food hygiene, health and safety, and Protection of Vulnerable Adults (POVA). St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 18 Inspection of the staff files of the two most recently recruited staff was carried out. Neither of the files contained information on the process that was used when interviewing the prospective staff. Both files showed that staff had commenced working in the home prior to the Criminal Records Bureau (CRB) being obtained and no references were available. However, at the time of the inspection, CRB’s had been applied for. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is no Manager currently working in the home, however, the Deputy Manager is currently acting as Manager until the post has been filled. Staff follow safe working practices that promote a safe environment for service users, staff and visitors. EVIDENCE: The Manager of the home recently left her employment. CSCI was informed about this and given the name of the person who would act as Manager until a new Manager is employed. At the inspection, the provider explained that the Managers vacant post has been advertised and they are waiting to employ a person. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 20 The deputy manager has worked as Deputy Manager in the home for the last four years. She has achieved NVQ Levels 2 and 3 and is currently completing Level 4. Prior to her present position she worked at the home as a care assistant and then a senior care assistant. First Aid, Pova and medication training have recently been completed. Observation showed that staff followed safe working practices at all times and records evidenced that Staff have received training in fire safety, moving and handling and food hygiene. St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 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 X X 3 X x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement Care plans need to be monitored and evaluated to ensure needs have not changed An activities programme needs to be implemented that will engage service users and help them to lead fulfilling lives All security clearances and references must be obtained prior to staff coming into post in the Home to ensure service users are fully protected. (Previous timescale of 17 Jan 2005 not met) A Manager must be put into post to ensure the smooth running of the home Timescale for action 16/05/07 2 OP12 16 16/05/07 3 OP29 19(1) Schedule 2 16/05/07 4 OP31 9 01/05/07 St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Thomas Rest Home DS0000000241.V329092.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V329092.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!