CARE HOMES FOR OLDER PEOPLE
St Vincents 33/35 Leicester Street Southport Merseyside PR9 0EX Lead Inspector
Mrs Trish Thomas Unannounced Inspection 13:30 14 February 2006
th 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 Vincents DS0000005292.V280753.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 Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Vincents Address 33/35 Leicester Street Southport Merseyside PR9 0EX 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) 07104 546386 The Daughters of Charity of St Vincent De Paul Ms Rose Lowry Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 13 OP The service should employ a suitably qualified and experienced manager who is registered with the CSCI 22nd September 2005 Date of last inspection Brief Description of the Service: St Vincents is a care home providing personal care and support for up to 13 retired Sisters from the community of St Vincent de Paul and sisters from other religious communities. The home is situated in Southport town centre overlooking the marine lake and with easy access to public transport. The home has 4 floors served by a passenger lift and stannah chairlifts on the back stairs. The Sisters have single accommodation and a number of rooms have an ensuite facility. Bathrooms are adapted to assist those who are less able and the home also has a Jacuzzi room. Recreational areas comprise of 2 lounges and a dining room. All areas are very clean and well maintained. The Registered Providers are The Daughters of Charity of St Vincent De Paul and the registered manager is Ms Rose Lowry. St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an un-announced inspection and took place during the afternoon period. Methods used were, discussion with five of the sisters, discussion with the senior carer, Paula Spruce, and three members of staff, touring the premises and reading records relating to care, medication and staffing. Two requirements from the last inspection were checked and had been addressed. For a full account of standards assessed during the year 05/06 this report should be read alongside that for the inspection of 22nd September,05. What the service does well: What has improved since the last inspection?
St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 6 Requirements from the last inspection as to vetting clearances and references for staff appointed to the home, had been addressed. Staff files contain the information set out in Schedule 2 (Care Home Regulations), and Criminal Records Bureau Clearances for staff were up to date. 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 Vincents DS0000005292.V280753.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 Vincents DS0000005292.V280753.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): 3 Assessments are carried out for all sisters who are admitted to St. Vincents, to ensure that their needs will be met by the home’s resources. EVIDENCE: Pre-admission assessments were read in a sample of sisters’ care files. These were records of each individual’s social and personal care and health needs and formed the basis of their individual care plans. Assessment of need is continued post admission by staff, and care plans are regularly reviewed and updated. St Vincents DS0000005292.V280753.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): 7,8,9,10 Care plans which were read, were addressing the assessed health and personal care needs of the sisters. Standards of care in the home are good and sisters were benefiting from the support provided. The procedure in place for managing prescribed medication is satisfactory and was being adhered to by staff. Staff are respectful, and sisters’ right to privacy is upheld. EVIDENCE: Care plans were in place for all sisters and a sample of three was read. Information contained in care plans included assessments, action plans, reviews and risk assessments. Action plans, which were read, were in accordance with assessment and review findings. Levels of support had been adjusted, in accordance with any deterioration or improvement in the condition of each individual. All sisters are registered with a G.P. and have access to paramedical services. There were records on the care plans of pressure care and moving and handling assessments as appropriate. The medication room was visited and the system, audit records and medication administration sheets were seen. The Senior carer, Paula Spruce, described
St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 10 key aspects of the home’s procedure for managing prescribed medication. This was being adhered to in practice, by staff when administering medication to the sisters. Bedrooms are for single occupancy and staff, were observed speaking respectfully to sisters. Respect for sisters’ privacy and dignity was reflected in the way in which care plans were written and maintained. Staff were seen to knock and wait for a response before entering bedrooms. St Vincents DS0000005292.V280753.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 Sisters follow a lifestyle in St. Vincents, which supports their chosen religious beliefs. Sisters maintain contact with family friends and the local community. Sisters have choice and control over their lives, in harmony with their religious vows. EVIDENCE: There is an integral chapel in the home, where Mass is said daily by a visiting chaplain. The sisters follow the routines of their religious life, and also maintain contact with family, friends and others within their religious community, (both country-wide and overseas). There are in-house social events recorded in an activities diary. Personal computers are provided with email facilities in bedrooms, as preferred. One of the sisters was accessing the latest news bulletins on-line, when I visited her in her bedroom. The sisters have served various communities within their professions and missionary work, and continue to support the local parish with energy. Their work includes Eucharistic Ministry, administration duties for the nearby church, and service to homeless people in the area.
St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 12 The sisters are following their chosen vocation and the routines of their religious life, within a homely environment. There was evidence of consultation with them as to standards in St.Vincents, in that care files contain completed Quality Assurance Questionnaires, and Food Satisfaction Questionnaires. Sisters were welcoming and expressed no concerns during the inspection. St Vincents DS0000005292.V280753.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): Not assessed EVIDENCE: St Vincents DS0000005292.V280753.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): 19,22,26 The building is well maintained and fit for its purpose. Specialist equipment and aids are provided throughout the home. The home is maintained to very high standards of hygiene. EVIDENCE: A tour of the premises was carried out, accompanied by the Senior carer, Mrs Paula Spruce. A decoration programme has been recently completed and the home looked very attractive and welcoming. There are two bright and spacious lounges, a dining area, and an integral chapel. There is a central kitchen and laundry and a small kitchen for preparation of hot drinks and snacks, on an upper floor, convenient to bedrooms. All bedrooms are for single occupancy, comfortably furnished and containing personal items in accordance the individual’s vocation and preference. There is a patio at the rear and a parking area and seating at the front of the building. The home provides access to all levels through provision of a ramp to the front entrance and internally, a passenger lift and chair lifts to upper floors. The home has a hoist, parker baths and a Jacuzzi. Aids and adaptations are
St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 15 provided for each individual, in subject to home’s/professional assessment, and all moving and handling training for staff was up to date. In accordance with information in a care plan, pressure care and mobility equipment (mattress and hoist), were in place for one sister, who was visited in her bedroom. Fluid charts had been maintained and every consideration paid by staff, to her comfort and dignity. All areas of the building, which were visited, were very clean and ordered whilst maintaining a homely feel. Staff of St. Vincents follow infection control procedures and are provided with protective gloves and aprons when needed. The Senior carer confirmed that staff receive training in infection control, health and safety, and food hygiene. St Vincents DS0000005292.V280753.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): Not Assessed. EVIDENCE: St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 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): 35,38 Sisters’ financial interests are safeguarded through the home’s procedures and practice. In general, the health, safety and welfare of the sisters are promoted and protected. A shortfall was noted regarding fire safety. EVIDENCE: Records of individual budget management were seen, and these were satisfactorily maintained. There were no requirements from the inspection of 22/9/05 regarding Health and Safety (Standard 38). During this inspection the laundry door and the door of sisters’ kitchen, were seen as being wedged open. Fire doors must be kept closed at all times. A requirement is made in the relevant section of this report.
St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 18 St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X 3 X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 20 No 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 OP38 Regulation 23(4) Requirement The manager must ensure that fire doors are not wedged open. Timescale for action 15/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Vincents DS0000005292.V280753.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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