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Inspection on 15/06/05 for St Williams Residential Care Home

Also see our care home review for St Williams Residential Care Home for more information

This inspection was carried out on 15th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

St Williams is a relatively small care home, providing nicely maintained accommodation, with comfortable furnishings and individually decorated bedrooms. The home was very clean and tidy, with service users and relatives saying that it was always cleaned to a high standard. The atmosphere at St Williams is friendly and welcoming, with service users describing it as `a home from home`. There is a stable and well trained staff team, many of whom have worked at St Williams for a very long time. The service users who were spoken to made positive comments about the service like, `service very good, all homely and do what they can for you`, `good food, nice bedroom, I`m happy, the staffs lovely, the staffs great`. Management arrangements in the home are well organised, with staff, service users and relatives speaking highly of the manager and deputy.

What has improved since the last inspection?

St Williams continues to be a well organised service that provides a good standard of care to the people living there.

What the care home could do better:

It has been recommended that the service user satisfaction surveys that are carried out by the home are developed to include gathering the views of people who use the home for respite and professionals who visit or use the service, like GP`s, social workers and district nurses. This is to help make sure that the views of all service users and people who have contact with the service are taken in to account. The home should also seek advice from the local Fire Authority about safe ways of propping doors open in the home. This is to make sure that all service users are protected if there is a fire in the home.

CARE HOMES FOR OLDER PEOPLE St Williams Residential Care Home Cornwall Avenue Darlington Co Durham DL1 2LJ Lead Inspector Rachel Dean Unannounced 15th June 2005 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 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 Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Williams Residential Care Home Address Cornwall Avenue Darlington Co Durham DL1 2LJ 01325 486166 01325 482337 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes (GL) Ltd Mrs E M Wilson Care Home 22 Category(ies) of OP -22 registration, with number of places St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 February 2005 Brief Description of the Service: St William’s is a care home providing residential care for up to twenty-two older people. BUPA Care Services purchased the home in 1997. St. William’s, which is a former convent, is a large detached property situated at the top of a cul-de-sac in a residential area of Darlington. Public transport links to the centre of town are good and there are a number of small shops conveniently located. Accommodation is provided on two floors. Seven single rooms are situated on the ground floor and a further thirteen single and one double room are located on the first floor. A passenger lift is provided for ease of access to both floors. There are two lounges on the ground floor and a small quiet lounge on the first floor. The spacious, ground floor dining room is also used for activities and social events. The residents of St. William’s are able to enjoy the benefits of the well-maintained garden to the front of the house, which provides a safe, pleasant environment in clement weather. St. William’s aims to promote independence within each individual’s own abilities. A residents’ charter of rights is prominently displayed, emphasising residents right to privacy, dignity, choice and independence. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 15th June 2005. The manager of St Williams was on holiday at the time, but the deputy manager was on duty and was able to take part in the inspection. During the inspection six service users and one relative were spoken to about their experiences of living in and visiting the home. The deputy manager and two members of care staff were also spoken to. A selection of records and policies and procedures were inspected. What the service does well: What has improved since the last inspection? What they could do better: It has been recommended that the service user satisfaction surveys that are carried out by the home are developed to include gathering the views of people who use the home for respite and professionals who visit or use the service, like GP’s, social workers and district nurses. This is to help make sure that the views of all service users and people who have contact with the service are taken in to account. The home should also seek advice from the local Fire Authority about safe ways of propping doors open in the home. This is to make sure that all service users are protected if there is a fire in the home. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 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 standard(s) These areas were not inspected during this inspection. EVIDENCE: St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 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 standard(s) These areas were not inspected during this inspection. EVIDENCE: St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 10 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 standard(s) These areas were not inspected during this inspection. EVIDENCE: St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16 & 18 Service users feel happy approaching staff and the manager with any concerns or complaints they have and are confident that any problems will be resolved properly. Service users are protected from abuse and harm by policies, procedures and well trained staff. This means that any concerns are handled properly and service users are well protected. EVIDENCE: St William’s has in place a policy and procedure that says how concerns and complaints should be dealt with by staff. This information is made available to service users and their relatives, with a copy displayed in the home’s reception area and copies in the home’s Service User’s Guide (this is an information pack that is given to every service user when they come into St Williams). A record of all complaints is kept at the home, showing what the concerns were and how the staff at St William’s handled them. Inspection of these records showed that complaints are taken seriously and handled in a fair and courteous way. The service users and relative spoken to during this inspection confirmed that staff were approachable and that any concerns they raised were put right. For example, one person said ‘you just tell who’s in charge at the time, but I’ve got no complaints, its home from home’. Policies and procedures are also in place to help protect service users and staff from harm and abuse. The staff spoken to during this inspection were aware of these procedures and stated that they would feel comfortable reporting any concerns that they had. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 & 26 St Williams provides well maintained and pleasantly furnished accommodation, making it a comfortable and homely place for people to live. The home is well maintained by a team of domestic and maintenance staff, providing a clean, hygienic and pleasant place for people to live. EVIDENCE: During this inspection a tour was made of the building so that the inspector could see how the building was maintained. The home was nicely decorated, with comfortable furnishings and a homely atmosphere. Bedrooms were each decorated individually and had people’s personal possessions in them, making them homely and individual. The home was found to be very clean and tidy, with no unpleasant smells apparent. The service users spoken to confirmed that their rooms were very comfortable and that the home was always kept clean and tidy. Some examples of comments made to the inspector are; ‘nice bedrooms’, ‘very comfortable’, ‘always clean and tidy, oh they’re spotless’, ‘there is no smell in this place’, ‘its always clean, those toilets out there, there’s always someone cleaning them….no nasty smells here’. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. St Williams provides a stable staff team with enough people on duty during the day and night to provide a good service to service users. New staff are recruited in a safe and thorough way, ensuring that the staff working at St Williams are suitable for the job that they do and can provide service users with the care that they need. Staff at St Williams are provided with training to ensure that they provide good care and can meet the needs of service users. EVIDENCE: Staffing levels at St Williams were found to be maintained at appropriate levels, with staff, service users and relatives agreeing that there were enough staff on duty in the home. The home operates a number of different shift patterns to ensure that there are three staff on duty during busy periods and at least two staff on duty at other times. During the day time these levels are supplemented by the deputy manager and manager being on duty. They work both weekdays and weekends. Rotas were inspected for the week of the inspection and the three weeks previous to the inspection. These showed that the staffing levels described were provided at all times. Comments from staff included; ‘there are enough staff to do things and not rushing about, we’ve got time to spend with the residents as well’. Service users were also positive about the staff team, with comments being made like; ‘the staffs lovely, the staffs great’, ‘they’re all homely and do what they can for you’. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 14 During the inspection a selection of three staff files were inspected. These were found to be well organised and showed that new staff went through thorough checks before being allowed to work at the home. Training is given high priority at St Williams. Training records were available for all staff and showed that new staff undertake suitable induction training. NVQ training is progressing well, with nine staff having achieved NVQ level 2 and three having achieved NVQ level 3. Training in other areas, such as health and safety, first aid, food hygiene, moving and handling are provided and training to up date staff on infection control is being planned. Staff confirmed that they are given the training and support they need and that they can ask for training to be arranged if they think it would be useful. Comments from staff included; ‘you weren’t thrown in at the deep end, no’, ‘training, training, training, lots’. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 38. St Williams has in place ways of monitoring its own performance and making sure the home is providing a good service. This helps the home develop its service in a way that takes account of the views of service user. The home has in place policies and procedures, including record keeping and audit arrangements, for assisting service users manage their personal allowances where they are unable or do not wish to do this themselves. Service users and staff at St Williams are protected by policies and procedures for maintaining health and safety in the home. EVIDENCE: St Williams has in place ways of monitoring its own performance and making sure the home is providing a good service. This includes checks that are done in the home and checks that are done by the BUPA quality team and senior St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 16 BUPA management team. Customer satisfaction surveys have also been done during the last two years. However, it is recommended that customer satisfaction surveys are developed to include service users who have been staying at the home for respite and other professionals who visit the home (GP’s, Care Managers, District Nurses) to help to get information on their experiences of the care provided at the home. BUPA policies and procedure are in place for assisting service users manager their personal allowances, where they are not able or do not wish to do this for themselves. This system includes a pooled account for keeping residents money and a pooled cash float that is available in the home so that service users can access money when they need to. The account is set up to provide individual balances and calculate the interest owing to each service user. Receipts and records of transactions are kept and an internal audit system has been sent up. Suitable arrangements, including policies and procedures and staff training, are in place at St Williams to help keep staff and service users safe. Discussions with the deputy manager and the inspection of records indicated that the management of health and safety at St Williams has not changed since the last inspection. Maintenance records are well organised and show that regular maintenance checks are completed, for example, regular fire alarm and equipment checks, hot water temperature checks and portable appliance testing. Health and safety risk assessments, safe working files and procedures for using hazardous chemicals in the home were in place. However, it is recommended that advice is sought from the Fire Authority regarding the home’s current practice of propping some doors open with wooden chocks. Where necessary appropriate door closure systems should be fitted that allow doors to be propped open and keep service users safe in the event of a fire. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 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 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 18 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 Regulation Requirement None identified during this inspection. Timescale for action 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 33 Good Practice Recommendations 3. 38 It is recommended that customer satisfaction surveys are developed to include service users who have been staying at the home for respite and other professionals who visit the home (GP’s, Care Managers, District Nurses) to help to get information on their experiences of the care provided at the home It is recommended that advice is sought from the Fire Authority regarding the home’s current practice of propping some doors open with wooden chocks. Where necessary appropriate door closure systems should be fitted that allow doors to be propped open and keep service users safe in the event of a fire. St Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Williams Residential Care Home B54 S0825 St Williams V228406 220605 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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