CARE HOMES FOR OLDER PEOPLE
Stella Maris 8 Ellenborough Park South Weston Super Mare North Somerset BS23 1XW Lead Inspector
Nicola Hill Unannounced Inspection 6th March 2006 02:30 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 Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Stella Maris Address 8 Ellenborough Park South Weston Super Mare North Somerset BS23 1XW 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) 01934 632817 NONE Mr Ralph Timothy Morris Mrs Susan Anne Bartlett Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. May accommodate 18 persons aged 65 years and over requiring personal care. 29th September 2005 Date of last inspection 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 DS0000008058.V278853.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection of Stella Maris Hall was undertaken with the manager, Sue Bartlett. The inspection lasted approximately 3 hours, and the inspector gathered evidence for the report by reviewing records at home, briefly talking with staff, talking with some of the residents. Areas of discussion with the manager included development of a regular plan of activities at the home; the staff training in respect of achieving NVQ 2 qualifications, recruitment of staff and the quality audit of the home. The home is well managed by the current registered manager with the health, safety and welfare of service users and staff promoted by the procedures implemented at the home. The atmosphere at the home during the inspection was relaxed, with the staff enjoying the music with the residents. The residents who spoke with the inspector were spontaneous and positive in their comments. The hall, stair way and landing have also been redecorated since the last inspection and this creates a bright and welcoming first impression to visitors. What the service does well:
The residents stated that they enjoyed living at the home; the site of the home near the seafront and opposite the park was also stated as a reason for moving there. The residents felt the staff were kind to them, and offered support when needed. One resident stated that she made choices about what she did and when, and if she didn’t want to get up then she was able to stay in bed. In general the residents were quite happy at the home, they would appreciate more activities taking place, and being able to get out and about; however they were also happy to approach the manager and discuss any issues that arose with her. The residents have a benign attitude toward the manager, respecting her role whilst feeling concerned that she doesn’t work too hard. This typified the relationship observed between the staff and residents. The residents are given a weekly menu and supported to choose the meals they have. This allows the residents to exercise some control and have their decisions respected. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 6 The home is well maintained, one resident commented very favourably on the redecoration of her room, and had been able to bring in her own possessions in order to make the room more comfortable and make it her own personal space. The bedrooms are often larger than the required standard, and provide sufficient space for residents to create bed sitting rooms. The care plans reviewed by the inspector are comprehensive and demonstrated that the home assesses all aspects of daily living, including social care. 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. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This section was not assessed on this visit. EVIDENCE: Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 The care plans are clear and support the continued good health of the residents. EVIDENCE: The care plans reviewed by the inspector were comprehensive, and covered all activities of daily living. The care files also contain specific action planned for each area of need identified. The inspector but able to read the daily care record kept on file and noted that they were objective and informative in most cases, and provided a good insight into the daily activity of residents at Stella Maris. The residents at the home have varying health care need, for example, several residents have short term memory loss and are monitored by the mental health team. The inspector suggested that training from the community psychiatric nurses to members of staff be sought to ensure that staff are aware of current practice in relation to dementia care.
Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 10 The home has a unit dosage system for medication. This was used successfully by the staff at the home that have had specific training to do so. The inspector was able to spot-check the controlled drugs against the recorded stock levels. All the stock levels that were checked were found to be correct. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 The range of activities offered by the home is being developed, but links with the local community remain limited, as they are dependent on staff escorting residents. The home offers choice of menu, and displays this on the notice board. EVIDENCE: Some of the residents are more actively involved in groups than others. One resident told me that she joins in when she feels like it and she doesnt always want to attend but she is happy to be given the choice. Another resident spoken with told the inspection that they were bored but enjoyed the social aspect of the group of residents at Stella Maris. Some residents were happy with low key activities such as listening to music in the communal lounge. The residents stated that visitors were welcomed to the home and that they could use their room or the quiet lounge if they wished. The interaction between the residents appears to be quite good, with them visiting in each other’s rooms. This is an indication that the bedrooms offer sufficient space to be used as bed sitting rooms, which allow for privacy and sense of ownership by residents.
Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 12 The residents are given a weekly menu and supported to choose the meals they have. The inspector spoke with one resident about the meal that had been served lunch. This resident was able to confirm that, as they did not like what was on the menu, an alternative had been provided. The evening meal was served during the inspection; the residents stated how much they enjoyed the food, except that service could be quicker! The inspector also noted fresh fruit available to residents in the lounge; the residents appreciated this. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a satisfactory complaints system, which is accessible to the residents. EVIDENCE: No complaints have been received since the last inspection; the residents stated that they were able to talk directly with the staff and manager about concerns. The staff at the home have accessed the adult protection training through North Somerset Council. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23,24 The service users bedrooms are comfortable and well maintained. EVIDENCE: The inspector viewed all the bedrooms that have undergone refurbishment since the last inspection. The bedrooms have been decorated in neutral colours, which make them appear very light and airy. The furniture is matched and new carpets have been laid. One resident commented very favourably on the redecoration, and had been able to bring in her own possessions in order to make the room more comfortable and her own space. The hall, stair way and landing have also been redecorated since the last inspection and this creates a bright and well maintained impression of the home.
Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 15 The home has also converted an inaccessible bathroom to an accessible shower room, which will enhance the facilities offered by the home. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30 EVIDENCE: There have been no recruits to the home since last inspection. There is now only one vacancy at the home and therefore the home can provide a continuity of care to its residents. The manager stated that she is confident in the skills and ability of the staff and is working with, as they are all very experienced. The intention is to raise the standard of knowledge and skills within the team through further training, which will allow for further delegation of responsibility through the staff group. The manager at the home has continued to provide support for the development of the staff team by offering training. The staff team are reluctant to undertake the NVQ 2 training for a variety of reasons despite it being offered to them. This means that the home does not meet the required standard for the number of staff with NVQ 2 qualifications. The inspector and the manager discussed how this should be addressed and in particular the impact this will have on the service assessment rating, which will be available to the general public from 1st April 2007, and will be used to measure the quality of the service for potential residents. The manager will discuss this further with staff.
Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The manager was able to demonstrate awareness of residents’ needs and plans the day to day running of the home to meet those needs. EVIDENCE: The recent high number of vacancies at the home has meant that staff hours were affected and the manager was spending more time being a hands on carer. This has impacted on her ability to fully implement all the issues identified by the last inspection. However, the home is well managed by the current registered manager with the health, safety and welfare of service users and staff promoted by the procedures implemented at the home. The atmosphere at the home during the inspection was relaxed, with the staff enjoying the music with the residents. The residents who spoke with the inspector were spontaneous and positive in their comments.
Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 18 The quality audit of the home has not yet been completed. The staff supervision at the home has been introduced, and has allowed for some staff development to take place. On the tour of the building no health and safety hazards were identified. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X 3 3 X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 2 X X Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP12 Regulation 16 Requirement The home clearly demonstrates there are a weekly activities plan that stimulates and supports the social needs and preferences of the residents. The manager continues to implement the supervision system, which provides required number of supervision sessions for staff. The registered manager ensures that 50 of staff have or are working toward the NVQ 2 qualification. Timescale for action 06/09/06 2. OP36 19,24 06/09/06 3 OP28 19 06/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations The quality audit of the home is carried out and used to inform service development. Stella Maris DS0000008058.V278853.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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