Inspection on 29/09/05 for Stella Maris

This inspection was carried out on 29th September 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

Stella Maris 11/09/06

Stella Maris 06/03/06

Stella Maris 02/03/05

Stella Maris 01/09/04

Stella Maris 02/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Stella Maris 8 Ellenborough Park South Weston-super-Mare North Somerset BS23 1XW Lead Inspector Nicola Hill Announced 29 September 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. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Stella Maris Address 8 Ellenborough Park South Weston-super-Mare North Somerset BS23 1XW 01934 632817 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) Mr Ralph Timothy Morris Mrs Susan Anne Bartlett Care Home 18 Category(ies) of 1. Old age (OP) - 18. registration, with number of places Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate 18 persons aged 65 years and over requiring personal care. Date of last inspection 2 March 2005 Brief Description of the Service: Stella Maris provides care and support for older people. Situated close to the beach and parks in the southern part of Weston-super-Mare, the home is well positioned for the local amenities and services. The accommodation comprises two floors, the upper floor being served by a stairlift and a ground floor extension to the rear. The majority of rooms on the ground floor (12) seven of which have en-suite facilities; there are six rooms on the first floor and landing of which three have en-suite facilities. The home also benefits from two lounges, one a designated quiet lounge with library facilities. There is a large dining area. The home is sited within walking distance of the seafront and overlooks a private park. Stella Maris is situated near community facilities such as churches and shops. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector undertook the announced inspection of Stella Maris with the manager Sue Bartlett. Talking with the residents at Stella Maris and consultation with staff provided evidence for this report. The inspector also reviewed care files for residents, and administrative records relating to the implementation of health and safety at the home. The inspector received nine comments cards from residents and three comment cards from visitors to the home. The inspector spoke with several residents, all of who were very complimentary about the lifestyle offered to them. The residents also discussed the activities they were able to follow in the home and access to the community facilities. What the service does well: What has improved since the last inspection? All the requirements from the last inspection have been met. The four-week menu planning which allows for individual choice has been introduced. The main lounge areas have been re-carpeted and there is a programme of redecoration in progress. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 6 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. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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 Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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) 3 There is clear information available about the service for potential service users. This is supported by a verifiable admissions procedure that is informative and supportive of service users wishing to move into the home. EVIDENCE: The inspector reviewed the case files for six residents who have recently been admitted to the home. For all of the new residents there is a pre-admission assessment that has been completed by the manager and which details the level of support needed by the resident. The information from the preadmission assessment is informative and covers all aspects of daily living. From this information the manager is able to make a decision about the appropriateness of the admission. The day prior to the inspection the manager had admitted a resident as an emergency, direct from Weston General Hospital. The pre-admission assessment was available for this resident and further information will be obtained in order to formulate a care plan. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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) 7,8,9,10 There is a clear and consistent care planning system in place to meet individual needs and aspirations that includes the residents. The welfare and health care needs of the residents are well met with evidence of access to various health care providers. EVIDENCE: All residents at the home have an individual support plan, which outlined actions needing to be taken to support the residents to be as independent as possible. Care planning takes place with resident involvement and therefore residents are aware of the information held on them, and sign their agreement to care plans. The physical appearance of the residents was that they were well dressed with clean coordinated clothing, well groomed and were observed to be treated with respect. The case tracking through the case files indicated that the health, personal and social care needs were fully identified and the home use a dependency profile Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 10 tool. The care files contained evidence of health need being reviewed and visits to hospitals, GPs, etc. recorded with outcomes. The daily records at the home are completed in a non-judgmental, factual manner. They supply a good source of information and insight into the daily lives of the resident. The home also has a monthly review of all residents care. The home are meeting a wide range of need, two of the residents have catheters; two have mental health needs and CPA; one resident currently has MRSA in a wound site which is redressed twice a week. The home has implemented effective infection control practice to ensure that the MRSA is confined. The community nurses support the home with residents who have health care needs requiring nursing intervention. The home has a unit dosage system for medication that was checked and found to be correct. The controlled drugs recording and storage was also implemented as per recommendation. The inspector noted one error with a medication not included in the unit dosage system; this was brought to the attention of the manager for remedial action. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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 standard(s) 12,13,14,15 The activities for residents currently are the responsibility of the home support workers; they are variable and supplemented by external entertainers. EVIDENCE: During the visit the inspector was able to observe residents socialising with each other and interacting with staff. As part of the care planning process the recreational and social preferences for the residents at the home are identified. It was noted that the activities available were quite limited; this was discussed with the manager and staff team. The difficulties faced by the home are that the numbers of residents wishing to participate in activities is quite small and the group have diverse preferences. The inspector suggested that activities be planned to accommodate small groups such as a news discussion group, which could take place in the lounge, and residents can join in as they wish. The manager is also planning to arrange minibus transport for visits to popular venues. The inspector then spoke with several residents who confirmed that various activities were available. Some of them admitted that there was not a lot to do and it was boring at times, however, they also admitted that sometimes they just liked to sit and chat. There was interest in the minibus trips and Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 12 residents stated they preferred activities that were run by permanent staff, as the staff knew them. Residents stated that they were free to have visitors and that visitors were always made welcome at the home. Links with the local community are quite good and support the residents with social opportunities such as attending the local WI. The meals in this home are good offering choice and variety; the home is able to cater for any special dietary needs. The home have a new system of menu planning, there is a four-week menu with a wide variety of meals planned to meet residents preference. The residents are given a week’s menu plan and are able to choose from the menu their meals for the coming week. This allows for very individualised menu planning and for the kitchen to be aware of the amounts of choice to be cooked, and any requested alternatives. All the staff at the home have a food hygiene certificate; the kitchen was clean and well organised with evidence of recording temperatures for the fridge/freezer and cooked proteins. The dining room is spacious and well presented with sufficient space for all the residents. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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 standard(s) 16 Residents are able to self-advocate and raise concerns or complaints. EVIDENCE: There have been no complaints received by the home since the last inspection. The inspector was able to review the complaints/request book kept at the home for residents to use and noted that one resident had made a request and this had been fulfilled. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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 standard(s) 19,26 Stella Maris is an extended Victorian house that provides its residents with an attractive and comfortable place to live. EVIDENCE: The inspector did not go into all the rooms in the building as some residents choose to remain in their room. However, there is a welcoming first impression and all areas of the home seen were clean, comfortably furnished and free from unpleasant odours. Walking around the building indicated that fire safety precautions in respect of the staff room must be observed to remove any health and safety risks to either the residents or staff team. The window in the dining room is waiting to be repaired. The quiet lounge has new furniture and soft furnishings, which enhance the cosy, homely atmosphere. The handyman has redecorated several of the bedrooms that were in need of improvement. There are ancillary staff at home that maintain its cleanliness. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 15 The inspector discussed with the manager and the proprietor of the home the difficulty in finding the home as the sign is too small to be seen easily from the road. There is also limited parking available near the home, both these factors could be deterrents for potential residents. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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 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) 27,28,29,30 There is an established staff team at the home who have a very good understanding of the residents support needs, providing a continuity of support to the residents. EVIDENCE: The rota indicated that the minimum staffing levels at the home are met relative to the dependency and number of residents at the home. Training for staff is available and there is an expectation that staff will attend statutory training updates as required. All staff have attended training days over the recent months, although the staff records did not reflect this and should be updated. Two new staff have joined the team at Stella Maris, the individual staff files indicate that the recruitment for staff meets the necessary standard in that references and CRB checks are completed prior to commencement in post. There is one carer at the home who is under 18; currently this person carries out general duties and no personal care for residents. NVQ training was also discussed with the staff and the manager. Currently the staff team are not keen on studying for NVQ in care. However, the staff are aware of its importance in demonstrating that they are suitably experienced and knowledgeable to be able to care for their residents. The manager is aware that the NVQ is available at no cost through North Somerset Council, and will support staff to achieve this qualification. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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 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) 31,32,35,36,38 The relationships between the manager and residents are good and create a supportive and caring atmosphere in which the residents feel secure and comfortable. EVIDENCE: The manager has achieved NVQ 4 in care. The staff team as a whole works well together and is able to raise issues in the staff meetings. One member of staff stated to the inspector that she enjoyed her work and the support of the staff team; this made coming to work a pleasure. The residents spoke highly of the staff team and the atmosphere of the home. The residents were able to identify the manager at the home as being approachable, and stated that all the staff were pleasant and would listen to them. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 18 The supervision for staff is not at a level that meets the recommendations of the standard. This was discussed with the manager so that a way in which the standard could be met is identified. This may mean that supervision for care staff is delegated to the senior care workers and the manager would then supervise the senior care workers. The supervision should be meaningful and may include direct observation of staff at work. Currently the quality assurance systems used at the home are an annual resident questionnaire, a review of the environment, which is linked to risk assessment, and the regular visits made by the proprietor. The inspector discussed with the manager the possibility of implementing internal quality audits which covered areas of the working of the home not already audited i.e. care planning, medication. The home retains personal needs for several residents, the inspector sampled several and these were checked and found to be correct. The Regulation 26 records indicate that the responsible person has visited the home on a regular basis. The inspector reviewed the health and safety records for the following: • • • • • • Fire alarm system - all found to be up to date. Portable electrical appliances - due October 2005. Fire safety risk assessment. Call bell check and servicing. Accident records - three accidents since last inspection. Stair lift/bath hoist - maintenance record to be sent to the inspector. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 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 Standard No 16 17 18 Score 3 x x 3 3 x x 3 2 x 3 Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 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. 1. Standard 12 Regulation 16 Requirement The home plans activities which stimulate and support the social needs and preferences of the residents. The manager implements a supervision system which provides required number of supervision sessions for staff. Timescale for action 29/12/05 2. 36 19,24 29/12/05 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 38 Good Practice Recommendations All lifting equipment is serviced every six months and a record kept for inspection. Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier, Taunton TA1 4AL 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 Stella Maris D53_D02 S08058 Stella Maris V243968 290905 Stage 4.doc Version 1.40 Page 22 - 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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