Inspection on 01/12/05 for Starr Hills Methodist Home

This inspection was carried out on 1st December 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.

Other inspections for this house

Starr Hills Methodist Home 04/04/07

Starr Hills Methodist Home 10/06/05

Starr Hills Methodist Home 07/01/05

Starr Hills Methodist Home 01/06/04

Starr Hills Methodist Home 09/09/02

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Starr Hills Methodist Home 18 Ansdell Road South Ansdell Lytham St Annes Lancashire FY8 5PQ Lead Inspector Mrs Lillian McMullen Unannounced Inspection 1st December 2005 10:15 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 Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Starr Hills Methodist Home Address 18 Ansdell Road South Ansdell Lytham St Annes Lancashire FY8 5PQ 01253 735037 01253 732466 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) Methodist Homes for the Aged Mrs Annette Herbert Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should, at all times, employ a suitably qualified and experienced Manager who is registered with the NCSC 10th June 2005 Date of last inspection Brief Description of the Service: Starr Hills is owned by Methodist Homes for the aged and offers personal care to residents of all religious denominations of both sexes aged 65 years and above. The physical standards of the home are good and all bedrooms are single with en suite facilities. Aids and adaptations are available to promote independence and ensure individual needs are met. A passenger lift is in place and ramps are situated in and outside the home that allows for freedom of movement. Starr Hills is located in the residential area of Lytham close to all local amenities. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, however some prior notice was given, the registered manager was notified by letter that an inspection would take place within an eight week period. The inspection took place over a period of five and a half hours. At the time of the inspection there was 35 residents living at the home. Prior to this inspection, resident and relative comment cards provided by the Commission For Social Care Inspection was sent to the home for completion. The ones returned in the main contained positive comments. The inspector spoke with three residents, two staff and the registered manager. Documentation in respect of complaints, protection, resident’s finances and medication records were viewed. What the service does well: This is a care home where residents are well looked after. The staff team work well together and show a good understanding of the needs of the people living at the home. Those residents spoken to said they felt lucky to be living at Starr Hills and felt they were being well cared for by the staff. Routines within the home are flexible so that the people who live there can enjoy the lifestyle of their choice. Residents are encouraged to have their say and help make decisions about the running of the home. Regular residents and relative meetings are held in order that their views and opinions can be aired in a formal arena. The atmosphere in the home is welcoming, relaxed and friendly. The physical environment of the home is good all bedrooms have full bathroom en suite facilities. The staffing levels are good and a recent recruitment drive has been successfully resulting in a full staff group now being in post. The home operates to a good standard with a clear management structure both internally and externally. Good policies and procedures are in place, which are regularly reviewed. A quality assurance system is in place, which has recently been reviewed by The Residential and Domiciliary Benchmark and the manager and staff are confident that they will retain the five stars awarded at last year. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 6 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. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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 Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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): EVIDENCE: All the above core standards were assessed at the previous inspection. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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): 9 Medication procedures ensure that residents receive their medication as prescribed. Medication is securely stored. EVIDENCE: The advice provided at the previous inspection has been acted upon and robust systems are in place. A monitored dosage system is in place, which is provided by Boots the chemist. All medication is receipted into the home and clear records are maintained of all unused medication, which is returned to the pharmacy. A sample of medication administration records were examined, these were found to be correctly completed, with dose omission and refused medication with the exception of one being appropriately recorded. The omission noted appeared to be an oversight by the staff member responsible for the administration and the inspector is confidant that this was a ‘one off’ oversight. All medication is stored securely with the keys held by senior staff. Controlled drugs were seen to be correctly stored and appropriately recorded. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 10 Residents should they wish and have the ability to do so can retain responsibility for their own medication following a successful outcome of a risk assessment. Locked facilities are provided in residents bedrooms for the safe storage of medication and residents who retain their own medication are asked to sign a disclaimer stating that they will keep it locked at all times. Only senior staff that have responsibility for administration of medication all have received external accredited training. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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): EVIDENCE: All the above core standards were assessed at the previous inspection. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 12 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): Good practices and policies are in place to enable concerns of residents to be raised and responded to. EVIDENCE: The home has a comprehensive complaints procedure, which is contained in the Service User Guide in addition the complaints procedure is presented in leaflet form and provided to residents and their relatives in the admission pack. The home has received two complaints since the last inspection both of which had been acted upon with successful outcomes. The inspector advised that care should be taken to ensure that a dated log is maintained of the investigation and the outcome. The Commission for Social Care Inspection has received no complaints within the last year and there have been no vulnerable adult referrals to Social Services. The complaint policy and procedure ensures that complaints would be responded to within a maximum of 28 days. However the home’s internal procedure states that an immediate response will be given with an outcome within seven days. Contained in the procedure is the name and contact details of external management should the complainant be unhappy with the outcome and wish to pursue the complaint further. Should no resolution be found the address of the Commission for Social Care Inspection is contained in the procedure. It was pleasing to note that the Methodist Homes for the Aged are keen to promote equal opportunities and the complaint leaflet states “We intend to Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 13 ensure that all our residents receive fair treatment in accordance with Methodist Homes for the Aged Equal Opportunity policy. Comment cards received from relatives revealed that all were aware of the complaint procedure and all stated that they had never had cause to complain. Residents spoken to said that if they had any concerns they would approach the staff or the manager directly. All residents expressed their satisfaction regarding the care they receive commenting that the staff work very hard and could not understand how anybody could find anything to complain about. Starr Hills has appropriate policies and procedures for the Protection of Vulnerable Adults that incorporates the local protocol for reporting any allegation or suspicion of abuse. This has recently been reviewed and was seen to be complainant with the D.O.H. guidance ‘No secrets’. Staff receive training in the protection of vulnerable adults through their induction training and the manager is aware that specific training in this area should be provided as mandatory. Starr Hills has also developed a variety of other policies and procedures for the protection of service users. Individual polices are discussed at monthly staff meetings to ensure that staff have the opportunity to discuss how each policy works in practice. A policy in respect of the non acceptance of gifts and staff being precluded from involvement in assisting in the making or benefiting from service users wills is in place. Evidence to confirm that staff are aware of these polices was available in the form of signed agreement to abide by the policy being retained on the staff file. The policies in relation to the Protection of Vulnerable Adults are underpinned by Methodist Homes for the Aged ethos as stated on the policy as ‘This policy is based on the belief that every vulnerable adult residing or attending a Methodist Home for the Aged resource has the right to live free from abuse’. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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): EVIDENCE: All the above core standards were assessed at the previous inspection. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 15 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 The standard of vetting and recruitment practices are good with appropriate checks carried out that helps to protect service users. EVIDENCE: There is a now a settled staff group at Starr Hills with a recent staff recruitment drive being successful. Observation of a number of staff files revealed that all staff are interviewed prior to employment with written references being sought and Criminal Records Bureau checks being carried out. Once employed all staff receive induction, which involves working supernumerary for at least the first two shifts and then shadowing an experienced member of staff. The shadowing continues until the registered manager feels the new staff member can work confidently and competently without supervision. Induction training is comprehensive and continues for the first six months of employment. All induction training is recorded and the content is cross-referenced to NVQ units and competences. Staffing levels are good and are sufficient for the number of residents living at the home. Residents said they were happy with the care they receive from the home and were well treated by the staff. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 16 Residents spoken to say they had ‘no complaints’ and confirmed that in their opinion there was always sufficient staff on duty. Staff spoken to said they were clear about their role and work well as a team to ensure the individual and collective needs of residents are met. A number of staff has completed their NVQ training and it is pleasing to note that the home has now achieved 75 of the staff group trained to a minimum of NVQ Level 2. In addition short courses are arranged to ensure staff have the necessary knowledge and skills to meet the needs of the residents living at Starr Hills. Individual records of achievement are maintained on staff files that clearly show the training attended and when refresher courses are due. The inspector suggested that a training matrix would enable this information to be easily accessed. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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): 31,33, and 35 The home is run in the best interests of the residents. Good quality assurance systems are in place that ensures the policies; procedures and practices are consistently monitored. Records are well maintained and resident’s finances protected. EVIDENCE: The registered manager is qualified and experienced in managing a care home she is keen to undertaken periodic training to expand and update existing skills and knowledge. There are clear lines of accountability within the home and a good management structure is in place with all staff receiving regular supervision. Staff meetings take place and the management team of Starr Hills also meet regularly. Staff spoken to state that they feel well supported and confirmed that the management team are always available to offer support and guidance. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 18 Observations made during the inspection revealed that staff worked well together and responded sensitively and respectfully to residents. Good internal and external quality assurance systems are in place, The external quality assurance system in place, has recently been reviewed by The Residential and Domiciliary Benchmark company and the manager and staff are confident that they will retain the five stars awarded at last year. In addition internal quality audits take place a regular intervals. Delegated members of the management team conduct the audits, the findings are then evaluated and the findings underpin any amendments to the home’s policies whilst also identifying any gaps in staff training. Robust systems are in place to protect resident’s finance’s the home does not have responsibility for any pensions all accommodation charges are paid by direct debit. Relatives or a solicitor are asked to assume responsibility for those residents who are unable to manage their own finances. However the home will provide some assistance in the management of personal monies. Small amounts of pocket money are retained in the office for safekeeping. Examination of the records revealed that all expenditure is recorded with receipts attached. Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations Starr Hills Methodist Home DS0000009718.V260366.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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. 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