Inspection on 30/04/09 for Star Residential Home Ltd

This inspection was carried out on 30th April 2009.

CQC found this care home to be providing an Good service.

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

Star Residential Home Ltd 15/05/08

Star Residential Home Ltd 11/12/07

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Extracts from inspection reports are licensed from CQC, this page was updated on 28/06/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Star Residential Home Ltd 56-64 Star Road Peterborough PE1 5HT Lead Inspector Janie Buchanan Unannounced Inspection 30th April 2009 09:00 DS0000069558.V375226.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Star Residential Home Ltd Address 56-64 Star Road Peterborough PE1 5HT 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) 01733 777670 01733 552311 Star Residential Home Limited Mrs Dawn Bent Care Home 30 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Old age, not falling within any other category (30) Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Category MD is for named service users for the duration of their residency. 15 May 2008 Date of last inspection Brief Description of the Service: The Star is situated in a residential area close to Peterborough city centre. The home consists of former terrace houses that have been adapted and extended to provide accommodation for 30 older people. All rooms are for single occupancy. The home has 10 WCs, 4 bathrooms (one including a hydrotherapy bath), 2 showers, 2 shower wet rooms and a shaft lift. Eleven bedrooms have en-suite facilities. There are also two lounges, a dining area, a sun lounge, a quiet room and a separate smoking area for residents. The weekly fee’s range from £387 to £440 depending on residents’ needs. The inspection report is available on the residents’ notice board in the home. Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2star. This means the people who use this service experience good quality outcomes. For this key inspection we (the Care Qaulity Commission) looked at all the information that we have received, or asked for, since the last key inspection. This included: • the annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Surveys returned to us by people using the service and from other people with an interest in the service. • What the service has told us about things that have happened in the home, these are called ‘notifications’ and are a legal requirement. • We visited the home and talked with 4 people living there, the manager and 4 members of staff. We undertook a tour of the premises to check health and safety matters and viewed a range of the home’s policies and proecdures. • We also spoke with a district nurse who was visiting one of the residents. One requirement and three recommendations have been made as a result of this inspection. What the service does well: The Star offers a small, friendly environment which is clearly appreciated by its residents and their visitors. One resident told us; ‘very good, it’s like an extra part of my family’. One relative commented; ‘they look after mum very well’; another; ‘every member of staff I saw and spoke to seemed very experienced’. The ratio of staff to residents is currently high, ensuring that residents’ needs are met quickly and efficiently. The manager is readily available to both residents and staff and staff told us they felt well supported and listened to. What has improved since the last inspection? Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 6 The management team have worked very hard to improve standards at this home with considerable success. Staff’s knowledge and understanding of care plans is much improved ensuring that they have the information to care for residents properly and consistently. Complete and accurate records of all medication administered to residents are now kept and the home regularly monitors the temperature of the storage area to ensure that medication is not impaired. The similar looking upstairs corridors have improved vastly and are now places of interest and stimulation to residents and their visitors. The overall running of the home continues to improve, with the management team clearly committed to developing and sustaining standards and working well with external agencies to achieve this. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Star Residential Home Ltd DS0000069558.V375226.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 Star Residential Home Ltd DS0000069558.V375226.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People using the service experience good quality outcomes in this area. Admission procedures to the home are good, ensuring that residents’ needs can be met there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a statement of purpose and service users’ guide available for prospective residents, giving details of the facilities on offer at the home, and each resident is issued with a contract that states the terms and conditions of their stay, and the fees payable. Prospective residents are actively encouraged to visit the home as part of their admission procedure and residents who completed our survey told us they had received enough information about the home before they moved in so they could decide if it was the right place for them. Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 9 Each resident has an assessment of their needs carried before being admitted to the home and additional information from other health care professionals is sought where necessary. All residents’ files that we checked contained good evidence that appropriate information had been sought about their needs before they entered the home. Star Residential Home Ltd DS0000069558.V375226.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, 10 People using the service experience good quality outcomes in this area. Residents’ needs are monitored closely by the home to ensure their continued well-being and care plans clearly details their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We checked the care plans for three residents and there was a huge improvement. Residents’ needs in a range of areas were clearly identified, along with detailed guidance for staff in how to meet them. For example, for one resident who had diabetes there was information about the type of tablets she took; how often her blood sugar was to be monitored; the acceptable range her blood sugars should be and the frequency of her chiropody visits. In another plan there was excellent information about the resident’s mental health needs and how it impacted on her everyday life. Residents’ needs had been reviewed monthly with good evidence that they had participated in the review. We sat and went through one resident’s care plan with her. This resident agreed it was a good reflection of her needs and that staff actually did Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 11 what was stated in the plan. At our last inspection we had concerns that staff were not given time and encouragement to read residents’ care plans. This has clearly changed and one staff member told us: ‘we always familiarise ourselves with the care plans as they are constantly being updated’. Residents get the medical support they need and one commented; ‘they get the doctor if I’m ill even if I say I’m ok’. Another told us she hadn’t fallen over for ages since moving in. One relative told us: ‘mum has bad legs and they had a nurse and doctor to see her and kept me informed’. Nutritional and skin assessments are undertaken every month as are residents’ weights so that their well being is monitored closely. We spoke to a district nurse who was visiting to dress a resident’s leg ulcer. She told us that she received appropriate referrals form the home and that staff were able to give her good information about her patients. She told us she had no concerns about the quality of care in the home. We checked medication storage and a sample of medication administration records (MAR). There have been significant improvements since our last inspection: • • • • • The actual amount of variable dose medication administered was clearly recorded Hand written additions to the printed medication records had been signed and checked for accuracy Temperature records of the storage area were kept to ensure medications did not deteriorate Stock control was good The medication cupboard was ordered and tidy. Star Residential Home Ltd DS0000069558.V375226.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. Residents have access to activates for stimulation and entertainment and mealtimes are enjoyable We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home offers a range of activities and outings for residents. There are regular cooking sessions, music entertainment, trips into town, pub lunches and the local mayor visited the home recently to meet residents. One staff member told us that she and her friend did some ‘belly dancing’ for residents which they greatly enjoyed. Although there is no formalised activities schedule as such, staff told us they try and do something everyday with residents and that extra staff were easily available to take residents out if needed. A volunteer visits three times a week to read books to residents and reminisce with them using picture cards. Despite this however, one resident told us he would still like to go out more and another member of staff felt there should be a better activity budget. Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 13 Relatives who completed our survey told us that the home regularly helps residents keep in touch with them. One commented; ‘the manageress gave me her mobile number and we spoke regularly’. Lunch on the day we visited consisted of lamb chop or Shepherds Pie with carrots, mashed potato and cabbage. Vegetables and gravy were served separately allowing resident to help themselves to what and how much they wanted. Those that needed help to eat were offered it sensitively by staff. One resident was given a plate guard to help her maintain her independence whilst eating. Star Residential Home Ltd DS0000069558.V375226.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. Residents are protected by the home’s safeguarding procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information about how to complain is contained in the residents’ guide and residents who completed our survey told us that they knew how to make a complaint and identified the manager as someone they could talk to easily if they were not happy. There are posters in resident bedrooms that state ‘a copy of the home’s complaints procedure can be found in the glass cabinet in the lounge.’ The procedure itself should be more easily available to residents and a copy should be available in each of their bedrooms, rather that making residents go in search of it or have to ask staff to take them to the lounge to access it. Staff have received training in protecting vulnerable adults (POVA) and showed a satisfactory knowledge of what to do if an incident was reported to them. The deputy manager has attended the enhanced safeguarding course. One member of staff was able to quickly find the POVA folder and the number of the person she would contact if she had concerns. There have been no POVA incidents at the home since we last inspected. Star Residential Home Ltd DS0000069558.V375226.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 People using the service experience adequate quality outcomes in this area. Residents live in a comfortable environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There have been a number of improvements to the environment of the home since we last visited. Long and similar looking corridors in the upstairs part of the home have been transformed into themed ‘memory lanes’ to provide interest and stimulation for residents, and to help them find their way around. However some bedrooms are very dark with poor overhead lighting. Bedside lighting in a number of bedrooms was broken, therefore making residents reliant on staff to turn their light off at night. Bedroom no 11 had two doors to it, one leading into the lounge and another onto the corridor which could be confusing for the resident living there. The fire door to bedroom no 10 did not close properly, possibly allowing smoke and flames to escape in the event of a fire. There was a strong smell of urine in bedroom number 15. Although Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 16 comfortable and clean one relative told us: ‘if they had a little more money the furniture in some of the rooms could be updated-not quite so basic’ There is an garden area to the rear of the home that residents can use, however the pathway around it has an overgrown lavender push encroaching on it making it almost impossible for residents to use safely and there is also a garden seat blocking it. Star Residential Home Ltd DS0000069558.V375226.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience adequate quality outcomes in this area. Residents are looked after by caring staff in sufficient numbers to meet their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There are currently three staff on duty during the day and two staff on at night to meet the needs of 14 residents currently. This is a good ratio of staff to residents and residents who completed our survey told us that staff were available when needed and responded quickly to the call bell. We received many positive comments about the staff and one resident told us; ‘this is a fabulous place, the girls look after me very well’. One relative commented; ‘the home has very caring staff and I feel this is the most important thing’. All the staff we spoke to seemed positive about their work and genuinely committed to providing a good service to the residents; however they told us their morale had dropped recently due to changes in their working hours. We checked the personnel files of three recently recruited members of staff. These contained satisfactory evidence that appropriate checks had been undertaken before the person started working at the home. However the home is starting employees to work with only the POVA first check whilst awaiting their enhanced CRB disclosure. Although this is allowed in exceptional Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 18 circumstances only, it is not good practice and puts residents at unnecessary risk. In one file we checked, the home had obtained a reference from a prospective worker’s father. This is poor practice as it is unlikely that this reference would be objective about the person’s working practices. Staff told us they had received good training appropriate to their role and were up to date with all their mandatory courses. However when we tried to check this by looking at staff training files it was almost impossible as the information was very muddled and confused and could not be found easily by the manager. Star Residential Home Ltd DS0000069558.V375226.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 People using the service experience good quality outcomes in this area. Residents benefit from living in a well run home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager completed her registered manager’s award in June 2008 and has worked very hard in the last year to improve the service and meet the requirements made during our last inspection. Staff we interviewed rated her highly, telling us she was very approachable and clearly committed to residents’ welfare. They told us there were regular meetings where they could raise issues of concern and were kept up to date with issues affecting the home. Staff files that we checked showed that they received regular supervision of their working practices. Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 20 We checked a number of records in relation to health and safety (fire alarms, call bells, portable appliances, hoists, gas safety and lift servicing) which showed us that the home regularly monitors and services its equipment to ensure its safety The home holds cash for some of its residents. We checked a sample of cash sheets which showed that an accurate record of all transactions undertaken on behalf of residents was kept, along with receipts showing how their money had been spent. However the home should avoid holding large amounts of money for residents: it should be spent or paid into a bank account where it can be kept safely and accrue interest. The owner of the home regularly gives out questionnaires to residents requesting the feedback about the quality of care they receive, the availability of staff, the meals and activities. We read 5 of these surveys which showed that the respondents were happy with the service they received. Star Residential Home Ltd DS0000069558.V375226.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 3 3 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 3 x 3 Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 22 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 OP30 Regulation 18(2) Requirement Accurate, orderly and up to date training records for staff must be kept so there is a clear and easily accessible way of telling what training they have completed and what training they are due. Timescale for action 01/07/09 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 OP19 Good Practice Recommendations Residents should have good strong lighting in their bedrooms to help them see and the many broken bedside lights must be fixed so that residents can control their own lighting options. Full enhanced CRB disclosures should be obtained before a member of staff starts working at the home to ensure that residents are protected and only the right people are employed to look after vulnerable adults. 2 OP29 Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 23 3 OP35 Large amounts of money should not be kept on behalf of residents by the home. Instead it should be put into their own accounts where it can be held safely and accrue interest Star Residential Home Ltd DS0000069558.V375226.R01.S.doc Version 5.2 Page 24 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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