Care Home: St Agnes Retirement Home

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What the care home does well All the surveys received gave positive comments one person living in the home said it was `like home from home.` During the inspection staff were observed to have a very close and friendly rapport with people living in the home. This created a very happy and relaxed atmosphere. People spoken to say that they felt respected and had managed to continue as normal a life as possible. All persons spoken to say that the staff and acting manager were very caring and supportive. Care records showed an understanding of a person centred approach to care taking into account the persons individual needs and likes and dislikes. What has improved since the last inspection? All the requirements made at the last inspection have been met with the exception of the appointment of a registered manager. This was not due to any fault of the provider as a manager was supposed to start the week of the inspection but turned down the post at the last minute. Personnel files showed that all relevant checks are now being carried out to protect people using the service from abuse. All staff have attended or are booked to attend statutory training. The laundry area is now sited in a separate building, ensuring that there is no fire risk to people in the home. During the inspection decoration of communal areas was being carried out. What the care home could do better: No requirements were made as a result of this inspection. The provider has re advertised the manager`s post and this will be reviewed at a latter inspection. CARE HOMES FOR OLDER PEOPLE St Agnes Retirement Home 7 Neva Road Weston Super Mare North Somerset BS23 1YD Lead Inspector Juanita Glass Key Unannounced Inspection 09:30 2 and 9th October 2007 nd 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 St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 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. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Agnes Retirement Home Address 7 Neva Road Weston Super Mare North Somerset BS23 1YD 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) 0870 4210240 121spp@tiscali.co.uk Mrs Gail Joanne Poole Mrs Doreen Hiley, Mrs Kim Elizabeth Vowles To be appointed Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Age of persons who may be received in the home - 65 years and over May accommodate two people who are aged 59 years and above, who may also have a learning difficulty. This condition applies to specific residents and will no longer apply should these residents leave. 26th October 2006 Date of last inspection Brief Description of the Service: St Agnes is a retirement home providing care for a total of 24 service users. The home provides care for those residents over 65 years old and for two people with learning disabilities. St Agnes is situated in a quiet residential area of Weston-Super-Mare. It is within easy reach of the town centre area, has local shops, parks and the sea front nearby. The house stands in gardens to both the front and rear. The accommodation is arranged over two floors, the first floor accessible via a stair lift. The acting manager confirmed the current fees of £356.37 per week. Additional costs are charged for toiletries, hairdressing, newspapers and chiropody. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in the presence of the acting manager Mr Stephen Poole. We obtained evidence to support the findings in this report by a review of documentation, discussion with the acting manager, staff and people residing in the home. We carried out a written survey and received 1 from a Health professional, 4 from relatives and 10 from people residing in the home. On the day of the inspection we spoke to 5 people in private and a group of people in the lounge area. The provider also completed an Annual Quality Assurance Assessment, which was forwarded to the Commission for Social Care Inspection What the service does well: What has improved since the last inspection? All the requirements made at the last inspection have been met with the exception of the appointment of a registered manager. This was not due to any fault of the provider as a manager was supposed to start the week of the inspection but turned down the post at the last minute. Personnel files showed that all relevant checks are now being carried out to protect people using the service from abuse. All staff have attended or are booked to attend statutory training. The laundry area is now sited in a separate building, ensuring that there is no fire risk to people in the home. During the inspection decoration of communal areas was being carried out. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Agnes Retirement Home DS0000045717.V342076.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 St Agnes Retirement Home DS0000045717.V342076.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 6 does not apply Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Agnes understands the importance of having sufficient information for people when choosing a care home. Admission to the home only takes place if the service is confident staff have the skills and ability to meet the assessed needs of the individual. EVIDENCE: Care records reviewed show that a full preadmission assessment is carried out prior to any new person moving into the home. The care records for the last three people to move into the home-contained very clear assessments, which formed the basis of the working care plans. Care records also contained enhanced care plans from the placing authority or a hospital discharge care plan. The records reviewed showed that the manager had an understanding of the importance of obtaining the persons individual needs creating a person centred approach to care and record keeping. Evidence was seen of individual St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 9 comments included to show personal likes and dislikes to be considered on admission. People spoken to said that they had been involved in the admission process and they felt their opinion had been important. One person stated that they really liked the idea of being able to visit the home so that they could get a personal view of how it was run before taking up residence. Everybody said they had been given plenty of information regarding the home. St Agnes Retirement Home DS0000045717.V342076.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service receive effective personal and health care support using a person-centred approach. Residents’ individual plans clearly recall their personal and health care needs. People within the service are treated with respect and dignity. The home has an efficient medication policy, procedure and practice guidance which staff have access to and understand their role and responsibilities. EVIDENCE: Care plans reviewed showed a clear understanding of the individual needs of residents. Comments made by people were included making the care plan personal to them. They contain clear guidance for staff highlighting individual preferences and needs. Records were regularly reviewed and up dated. The records showed evidence that residents are assisted in attending health care services, the home has a visiting chiropodist and prescriptions were seen for glasses. People have been assisted to attend outpatient appointments and St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 11 district nurse input is sort when necessary. Some people using the service choose to maintain control over their lives and will contact the GP themselves if they require an appointment. One person spoken to on the day of the inspection had just returned from the dentist. Staff interaction with people residing in the home was observed on both days of the inspection. There was a very friendly and caring rapport, people could be heard laughing and chatting through out both days. People spoken to say that they could not fault the care they received it was both caring and respectful. They praised staff for their hard work which one person said never seemed to be too much for them. All staff handling medication have attended training and a random audit showed the home was following its policies and procedures, which are in line with current guidelines, no errors were noted. St Agnes Retirement Home DS0000045717.V342076.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are involved in meaningful daytime activities of their own choice and ability. The service has a strong commitment to enabling people to maintain personal and family relationships. Staff support residents in maintaining choice and control over their lives as far as is possible. Meals are balanced and nutritional and can cater for a variety of cultural and dietary needs. EVIDENCE: Although staff had not been keeping a clear record of the activities made available people living in the home said there was always plenty to do. Several people said they preferred not to take part in some activities and staff respected that choice. The weekend before the inspection people had been making Xmas cards and during the inspection staff carried out armchair exercises and generally chatted with people and read magazines with them. One person said that staff are always ready to sit and have a chat and one member of staff regularly plays a game of cards with them. The acting manager confirmed that they did have a visiting clergyman but this had not St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 13 been happening recently. One person said that if they wanted to go to church they would just say they were going and staff would make it possible. Some people residing at the home said that they could follow a life very much of their own choosing and could go out when they wanted or they could contact their own Gp if they felt the need. This was reflected in care plans and staff were aware of the persons right to exercise control over their life. One person said they did not feel restricted at all. Another said it was like home from home and they had not lost any of their friends or contacts by moving into the home. A wholesome and appetising meal was made available on both days of the inspection. The meal of the day is displayed on the notice board with alternatives made available. The menu consists of traditional meals that the people residing in the home prefer. Everyone spoken to said they enjoyed the meals in the home. Meal times were observed to be relaxed and unhurried whilst appropriate fluids and snacks were made available through the day. St Agnes Retirement Home DS0000045717.V342076.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supplied with a clear complaints procedure that they can understand. The procedure is clearly displayed throughout the service and is given to other agencies involved with the home. The manager is working towards all staff in the home receiving training in safeguarding adults and how to respond in the event of an alert. EVIDENCE: The homes complaints policy and procedure shows a clear timeline and action to be taken in event of a complaint. A copy is clearly displayed in the entrance hall and subsequent copies are available in resident’s rooms included with the service user guide. The policy and procedure also directs the complainant to the CSCI and to North Somerset social services. The manager maintains a full record of complaints. A copy of the North Somerset policy and procedure for Safeguarding Adults under No Secrets has been made available for all staff. Staff spoken to showed an awareness of the policies and procedures in place to safeguard vulnerable adults. Staff records showed that some staff had received appropriate training whilst others were booked on the next course. The home also has a very clear whistle blowing policy, which all staff spoken to were aware of and said they were prepared to use if necessary. People spoken to said they knew how to make a complaint if they needed to and the Procedure was in the guide in their room. One complaint had been received St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 15 since the last inspection. CSCI had been copied in to the complaint at the time and all appropriate action had been followed by the home. At the time of this report the complaint had been dealt with and resolved. A full record is maintained by the manager. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant safe place to live with the rooms that meet the national minimum standards. A high standard of cleanliness is maintained within the home. EVIDENCE: We carried out a tour of the premises. St Agnes is spacious and homely. The furnishings and lighting are domestic in style whilst providing adequate light to read by. The furniture and fittings are of good standard and communal areas are pleasantly decorated. A programme of re-decoration is currently being followed. People spoken to said that they liked their rooms and had bought in their own furniture which made them feel more at home. One person spoken to was in the process of planning changes and things they would like to add to St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 17 their room like tea making facilities and a small fridge. They said they would discuss with the manager what they could have. The home shows a good standard of housekeeping and no offensive odours were apparent. The manager and staff showed a clear awareness of infection control policy and guidelines. The manager can obtain guidance from outside agencies if required. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The service ensures all staff receive relevant training focused on delivering improved outcomes for people within their service. The service has a good recruitment procedure that clearly defines the process to be followed. EVIDENCE: People using the service confirmed that there were always enough staff on duty to meet their needs adequately. One person spoken to said that they never had to wait long for their bell to be answered. The provider stated in the Annual Quality Assurance Assessment (AQAA) that they had employed more domestic staff freeing up care staff to be more readily available to socialise and deliver care to people living in the home. The home currently does not meet the required 50 care staff trained to NVQ level 2 in Care. However of 19 staff 6 already have the qualification and 8 are doing either NVQ 2 or 3 so the home will exceed the 50 on completion. Evidence was seen of staff attending statutory training or being booked on a course in the very near future. Staff had also received training in Dementia and Eye Care. All new staff now complete a full induction before working unsupervised. St Agnes has a good recruitment procedure that clearly defines the process to be followed. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 19 The manager now obtains all the necessary documentation and carries out the required checks before a new member of staff commences work in the home. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although there is not a registered manager the acting manager has the required qualifications and experience to run the home. He encourages an open and inclusive ethos. Staff are adequately supervised with consideration being placed on personal development and training relevant to their role in the home. Efficient systems are in place to monitor the quality of the service provided. The home works to a clear Health and Safety policy, which all staff are fully aware of. EVIDENCE: The acting manager has the experience and expertise to run the home during the absence of a registered manager. A manager was to take up post on the St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 21 first day of the inspection but turned down the post 24 hours before they were due to arrive. This leaves the acting manager and provider in the position of having to re advertising the post and go through the selection process again. During the inspection, through discussion with staff and people living in the home, it was made apparent that the acting manager is providing a supportive and professional level of leadership and the lack of a registered manager does not put the home or the people living in the home at any risk. The acting manager has complied with all the requirements made at the last inspection, introduced a regular supervision programme and provided appropriate training for staff. People using the service said they felt well supported and cared for they also said they could talk to the acting manager whenever they wished to. The acting manager confirmed that he ran an open door office and was available at any time. The acting manager and staff show a very clear understanding of the diverse needs of residents living in the home. The home has an efficient system in place to monitor quality. An annual comment survey is given to people living in the home and relatives the home is currently waiting for the questionnaires to be returned. Staff personnel records showed that regular staff supervision was being carried out, these identified areas for personal development and training. The implementation of health and safety within the home was satisfactory. All residents have personal risk assessments which state clearly that they are aware of the risk they take if the want to go out on their own into town or to local clubs. A review of the fire log showed all tests, training and drills were being carried out to the Avon and Somerset Fire Brigade guidelines. All service records were available for inspection and up-to-date. St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 22 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 3 X 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 3 X X X X 3 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 3 X 3 X 3 X X 3 St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 23 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 St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Agnes Retirement Home DS0000045717.V342076.R01.S.doc Version 5.2 Page 25 - 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. 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