Inspection on 13/02/06 for St Vincent House

This inspection was carried out on 13th February 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 Vincent House 28/05/08

St Vincent House 11/07/06

St Vincent House 21/07/05

St Vincent House 25/01/05

St Vincent House 07/07/04

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

CARE HOMES FOR OLDER PEOPLE St Vincent House Forton Road Gosport Hampshire PO12 4TH Lead Inspector Laurie Stride Unannounced Inspection 13th February 2006 10:20 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 Vincent House DS0000011868.V281502.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 Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Vincent House Address Forton Road Gosport Hampshire PO12 4TH 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) 023 9235 1668 St Vincent Care Homes Limited Mrs L Lawrence Care Home 34 Category(ies) of Dementia (13), Dementia - over 65 years of age registration, with number (26), Old age, not falling within any other of places category (34), Physical disability (16), Physical disability over 65 years of age (16) St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the categories DE and PD not to be admitted under the age of 55 years 25th January 2005 Date of last inspection Brief Description of the Service: St Vincent’s House is a large well maintained detached house set in its own grounds; the house is a grade II listed building and has a large enclosed rear garden. There is parking at the front of the building. The home is registered with the Commission for Social Care Inspection (CSCI) to provide residential care for up to 34 older people 26 of which may be suffering from age related mental health problems. There are 22 single rooms and 6 double rooms and the house is situated on the main road into the town centre of Gosport and is close to local amenities. St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two annual inspections and was unannounced, during which the inspector met service users, spoke with members of the staff and management team and viewed samples of the home’s records. A further visit to the home was made on the morning of 15/02/06 in order to see staff recruitment records. The inspection in total lasted approximately three and a half hours. The inspector looked at the key standards not assessed at the last inspection and therefore this report should be read in conjunction with the previous report. One requirement and one recommendation were made as a result of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 6 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 Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 7 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): None of these standards were assessed on this occasion. Please refer to the previous report of 21/07/05. EVIDENCE: St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 8 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): None of these standards were assessed on this occasion. Please refer to the previous report of 21/07/05. EVIDENCE: St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 9 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): 14 Working practices in the home support service users to exercise choice and control in everyday living. EVIDENCE: Staff confirmed that service users are supported to maintain their independence as much as possible, for example going to the shops with staff support if needed. Service users manage their own financial affairs or have the support of relatives and others in doing this. The deputy manager confirmed that service users can have access to their personal records on request and some were able to sign their own care plans. Service users are able to bring personal possessions such as items of furniture into the home, subject to agreement. It was observed that service users were able to choose when to get out of bed and had unrestricted access to the grounds and communal areas of the home. A notice board at the entrance to the office displayed useful local contacts such as Citizens Advice and Age Concern. St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 10 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): None of these standards were assessed on this occasion. Please refer to the previous report of 21/07/05. EVIDENCE: St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 11 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 The home provides service users with a comfortable, clean and safe environment. EVIDENCE: A tour of the premises was undertaken with the assistance of the deputy manager. The home provides a number of comfortable, well-furnished and accessible communal areas and well-maintained grounds. In most areas the layout of the home has been made suitable for service users with mobility problems through the addition of passenger lifts. A number of service user’s bedrooms were seen and these appeared comfortable and had been personalised by the occupants. Throughout the home radiators were fitted with covers to safeguard services users and window restrictors were fitted on the upper floors. An aid-call system was in place throughout the buildings. The home employs a maintenance person and a defect and action reporting book was used to record any maintenance issues. The deputy manager confirmed that the home contacted the Environmental Health Office with regard to any relevant St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 12 concerns in order to comply with legislation. A fire safety company conducted routine checks on fire safety equipment and fittings. St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 13 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 and 30 Service users are supported and protected by suitable numbers of trained and qualified staff. The procedures for all new employees starting work need to be adhered to in order to better protect service users. EVIDENCE: The home had a staff rota that showed the number of staff working at any time and also which of the staff members were qualified to NVQ level 2 or above. The deputy manager confirmed that there is normally a minimum of seven care staff, including herself, on duty in the morning and five during the afternoon and evening. There are three care staff on awake duty at night and the home also employs a number of other staff including two cooks, domestic and laundry assistants and gardeners. Staff were observed providing assistance to service users and visitors in a friendly and respectful manner. A service user confirmed that the staff were helpful and approachable. The deputy manager said there were twenty-one care staff including night staff and of these five had achieved NVQ level 3 and one had a level 2 qualification. Another four members of staff were in the process of obtaining NVQ2 awards and another was working toward the level 3 award. Staff recruitment records were not available on the day of the inspection so another visit was arranged for 15/02/06 when the registered manager and one of the company directors would also be present. A sample of three staff St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 14 personnel files was seen and these each contained completed application forms, two written references and copies of terms and conditions of employment. Staff photographs for identification purposes were in the process of being taken. The inspector advised that the home’s recruitment procedure be reviewed in order that candidates for employment were aware of the requirement to provide a full employment history with a written explanation of any gaps. In relation to two recently appointed staff members there was no evidence of satisfactory POVA First checks (Protection of Vulnerable Adults) having been obtained prior to them starting employment, although Criminal Records Bureau (CRB) checks had been applied for. The company director’s were aware of this error and were taking appropriate action and it was confirmed that the relevant staff members were being supervised while awaiting the return of satisfactory checks. It is a requirement that all relevant checks are carried out prior to staff commencing employment. Staff confirmed that a member of the management team was always available and that staff received training in health and safety and other relevant matters. Through discussion it was also confirmed that staff training needs are discussed as part of staff meetings. Written records showed training is provided in first aid, food hygiene, fire safety, moving and handling, infection control, dementia awareness, continence care, falls prevention, medicine management, care planning, abuse awareness and other subjects. Staff reported that a structured induction is given to new staff starting work by shadowing experienced and NVQ qualified staff. During the second day of the visit the registered manager demonstrated how new employees complete a structured induction work booklet. The inspector advised that the registered person check that the home’s induction process was in line with the Skills for Care standards. The registered manager was attending a forum on 22/02/06 to find out more about the forthcoming changes in relation to Common Induction Standards (CIS). St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 15 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 and 38 Service users benefit from a well run home. Systems are in place to safeguard service users’ financial interests and safe working practices are observed to ensure the health and welfare of service users. Quality assurance monitoring processes could be further developed to ensure service user and other stakeholders’ views are obtained and acted upon. EVIDENCE: The registered manager has worked at the home for approximately ten years, has completed an NVQ level 4 Registered Manager Award (RMA) and also attends other training updates in order to keep her knowledge and skills current. There are clear lines of accountability within the home and management structure. The deputy manager and senior carers qualified to NVQ level 3 assist the registered manager in ensuring that quality standards are maintained in the home. The registered manager said that staff supervision was currently being further developed and formalised and a training video had been obtained to assist with this process. St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 16 Commission for Social Care Inspection comment cards for service users and visitors were available in the hallway. It was advised that the home adapt a questionnaire or other form of obtaining stakeholders’ views for its own monitoring purposes. A file is kept containing cards and letters of thanks from relatives and friends of service users and an open door policy was seen to be in operation. The deputy manager confirmed that service user meetings and staff meetings took place regularly and records of these were kept. The home had an Investor in People certificate dated April 2005. As previously mentioned, service users manage their own financial affairs or have the support of relatives and others in doing this. The home keeps records of payments it makes and bills to service user’s relatives or representatives for services such as chiropody and hairdressing. The record of transactions was clearly written and receipts are obtained and held on file. Evidence was seen that the home promotes safe working practices. Statutory training and updates in health and safety matters is provided for all staff. A record is kept of maintenance carried out on the premises. The home’s fire safety logbook was inspected and showed that an external company and the home’s staff carried out regular checks on equipment and fittings. The Environmental Health Office had conducted a food hygiene inspection on 23/04/05 and there were no outstanding requirements. The registered manager said that the home had achieved silver awards in this respect for the past two years. Gas and electrical appliance servicing records and installation certificates were seen on file. The home keeps appropriate records of any accidents and also a record of falls suffered by service users in order to analyse any patterns and take preventative actions. Cleaning materials are kept in locked cupboards and the deputy manager confirmed that hot water taps in areas accessible to service users were fitted with thermostatic safety valves to prevent the risk of scalds. A current certificate of employer’s liability insurance was on display in the hallway. St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X 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 3 X 2 X 3 X X 3 St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 18 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 Timescale for action The registered person must 15/03/06 ensure that staff are employed in the home only once a POVA First and all other relevant checks have been obtained. Each time a member of staff is ready for employment without their full CRB declaration being available the registered person must inform CSCI of the home’s decision. Requirement 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 OP33 Good Practice Recommendations The home develops a questionnaire or other form of quality assurance tool for obtaining stakeholders’ views for its own monitoring purposes. St Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Vincent House DS0000011868.V281502.R01.S.doc Version 5.1 Page 20 - 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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