Care Home: St Stephens Residential Home

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What the care home does well The information available to potential users of the service and their representatives is informative and could assist people in their decision making as to whether the home meets their needs. The pre admission assessment process is individual and ensures that the home is capable of meeting identified care needs. Care plans are regularly updated and include evidence that people using the service and or their representatives have had some involvement in their construction. The management and administration of medication is good and carried out safely. An activities coordinator was recently appointed in order to further develop the range and frequency of events within the home. The home has an open culture to complaints. Complaints that are received are well recorded with the actions taken. Improvements continue to ensure that people living in the home do so in a comfortable and well maintained environment. Staff training continues to be good with regular events taking place. The registered manager is suitably qualified and takes a keen interest in updating her knowledge via the internet including our web site. What has improved since the last inspection? Since the previous inspection the former manager designate has become the registered manager of St Stephens care home. At the time of the previous inspection a number of shortfalls were identified in a range of differing areas of the home. All of the requirements set out in our previous report are met. What the care home could do better: St Stephen`s is providing a good service for people who reside there. The registered manager is however aware that some areas could be improved further. Care plans need to give at all times an accurate account of each individuals current care needs. The record keeping associated with the care planning needs to be clear so that mixed messages do not occur which could potentially result in care needs not been fully met. Further discussion needs to take place to ensure that people using the service are aware of the choice of food on offer and that individual preferences are met to the best of the home`s ability. CARE HOMES FOR OLDER PEOPLE St Stephens Residential Home St Stephens Terrace Droitwich Road Worcester Worcestershire WR3 7HU Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 24th January 2008 09:05 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 Stephens Residential Home DS0000018676.V336821.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 Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Stephens Residential Home Address St Stephens Terrace Droitwich Road Worcester Worcestershire WR3 7HU 01905 29224 01905 26574 ststephens@festivalhousing.org 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) Partnership Care Services Dulcie Turner Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (51), of places Physical disability over 65 years of age (51) St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th August 2006 Brief Description of the Service: St Stephens is registered to provide accommodation and care for 51 older people who may also have needs relating to physical disabilities and/or a dementia illness. A specialist dementia service is not provided however care can be offered to people who have mild to moderate dementia care needs. The home is situated on the outskirts of Worcester city centre, close to local amenities. The building was upgraded and refurbished in 1999. It is a large three-storey building with a shaft lift to enable easy access between floors. There are 44 single bedrooms, 22 of which have en-suite facilities, and 4 double bedrooms, all of which have en-suite facilities. Three of the double rooms are currently used as singles. All bedrooms meet or exceed the National Minimum Standards (Older People) for usable space. There is a wide choice of communal lounges and dining areas and all rooms are well fitted and furnished. St Stephens has an attractive level central garden with a raised fishpond and a seating area as well as a new sensory garden. Car parking facilities are providing at the front of the home. Public transport is available with a bus stop close by providing access to Worcester and Birmingham. The stated aim of St Stephens is to ‘provide a safe and comfortable environment for all our residents, who have found for various reasons that they can no longer manage in their own homes.’ The recently revised Service Users Guide (A Guide for Residents) does not reflect information relating to fees in the home. The reader may wish to contact the service directly for up to date details of the fees payable. The registered provider of this service is now Spa Housing Association Ltd. As a result of a change of the Organisation’s name, the registration certificate for St Stephens needs to be amended. This matter is being addressed by the Commission. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, the Commission, carried out this inspection without any prior notice The manager was present throughout most of our time within the home. This inspection took into account information we had received since the last inspection as well as the visits to the home. During the inspection, discussions were held with the manager, a number of staff members and people using the service. We had a look around the home and observed what was happening. In addition we viewed the care documents regarding some people using the service such as care plans, risk assessments and daily records. We also viewed medication records, staff training records and recruitment records. What the service does well: The information available to potential users of the service and their representatives is informative and could assist people in their decision making as to whether the home meets their needs. The pre admission assessment process is individual and ensures that the home is capable of meeting identified care needs. Care plans are regularly updated and include evidence that people using the service and or their representatives have had some involvement in their construction. The management and administration of medication is good and carried out safely. An activities coordinator was recently appointed in order to further develop the range and frequency of events within the home. The home has an open culture to complaints. Complaints that are received are well recorded with the actions taken. Improvements continue to ensure that people living in the home do so in a comfortable and well maintained environment. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 6 Staff training continues to be good with regular events taking place. The registered manager is suitably qualified and takes a keen interest in updating her knowledge via the internet including our web site. 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. The summary of this inspection report can be made available in other formats on request. St Stephens Residential Home DS0000018676.V336821.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 Stephens Residential Home DS0000018676.V336821.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): Standards 1, 3, and 5. Standard 6 is not applicable to this service. Quality in this outcome area is excellent The pre admission assessment process ensures that the home is provided with relevant information in order that care needs are identified and assurance given that they can be met. People are supplied with sufficient information about services available to give them the opportunity to choose whether the home will be able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During our previous inspection we were given a copy of the home’s ‘Welcome Pack’ which contained a range of documents appertaining to St Stephens. This document was not viewed on this occasion but reference to it was made during our discussions with the registered manager. Shortly before this inspection we, the Commission, were supplied with a copy of both the Statement of Purpose and Service Users Guide (A Guide for Residents). Both documents are St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 9 informative and were available within the home for people to refer to. Information regarding the current level of fees is not included within the users guide however this would be included within the agreement to occupy document. A copy of this document was seen during our visit. The registered manager recognises the importance of supplying up to date and relevant information about the services the home can offer. The residents guide contains information upon people’s rights and how dignity is protected. The guides have been awarded the Plain English / Crystal mark. We were informed both during our visit as well as within the AQAA (Annual Quality Assurance Assessment) that information is available for people on audiotape as well as different formats including other languages should these be requested. A pre admission assessment is undertaken prior to any admission into the home of a potential user of the service. Time and effort is devoted to make admissions into the home personal to the individual concerned. The registered manager prefers this assessment to be done in the home itself in order that individuals are able to get a feel for the home. In the event of people not managing for some reason to visit the home their representatives are encouraged to visit and an assessment is conducted in the environment where the individual is currently residing. A letter confirming the homes assessment and the ability to meet care needs is sent to potential service users or their representative following the assessment. Intermediate care is not offered at St Stephens and the home has no plans to provide such a service in the future. St Stephens Residential Home DS0000018676.V336821.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): Standards 7, 8, 9 and 10. Quality in this outcome area is good Personal care is delivered individually with people having access to medical services as needed. The administration and management of medication is safe. People using the service are treated respectfully. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this inspection the care documentation relating to a number of people residing in the home was viewed on a computer in the manager’s office. Care plans reflected individual choices and goals and were regularly reviewed. We saw evidence of input from people using the service and their representatives. Care staff on duty demonstrated a good knowledge of individual’s care needs. Carers are actively involved in the record keeping having access to the computer system within the home. One person living at the home confirmed St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 11 that if she ever felt unwell the carers would send for the person in charge who would then get the doctor to visit. During our visit an emergency situation arose which required emergency services to be called out. The situation was handled well by the senior member of staff on duty. Information was made readily available for the emergency crew however some of it was later found to be slightly out of date. On one survey returned to us some considerable time before the inspection one relative commented ‘Always attentive to my **’s needs and health issues.’ Another person commented ‘I was contacted when ** fell and hurt her arm.’ At the same time we also surveyed a number of GP’s. No concerns were raised; one commented ‘A very caring home’. It was evident that recent difficulties expressed to us prior to the inspection regarding obtaining continence supplies are now sorted. Evidence was available of the actions taken by the registered manager to resolve this matter. We were present during a formal handover period between shifts. The handover was well managed whereby the senior staff member sought assurance that care staff were fully aware of current care needs. Staff who attended the handover were attentive and demonstrated a desire to receive the information. As part of the inspection we assessed the management of medication within the care home. In order to do this we inspected the records and other documents held as well as viewing the storage of medication and the administering of medication. We viewed a report written by a pharmacist who supplies medication to the home following their visit in November 2007. A number of areas needing some improvement were noted at that time. It was either evident or reported that all the areas identified have received suitable action to further improve the practices and systems within the home. We viewed the current months MAR (Medication Administration Record) sheets. These were up to date and contained information such as known allergies and evidence when the medication was booked into the home. Handwritten amendments on MAR sheets were double signed to evidence that a second person had checked the original entry, this is good practice. Items such as creams and ointments are recorded on a separate sheet, as carers need to sign for these items once applied. We carried out a number of audits of medication and found no discrepancies between the written records and the medication held. The majority of boxed medications had the date of opening recorded upon them although this was not always the case. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 12 The storage of controlled medication was in order with accurate records in place. As part of some recent information received the MAR sheets of one particular person were viewed dating back to last year. We found evidence to support that medication in the form of a painkilling gel had run out for a period of time although painkillers in tablet form were still used. The information regarding the frequency of application differed on the MAR sheet to the direction on the container. The information on the care records relating to the period of time when the gel had run out was insufficient to demonstrate the necessary care needs and the action taken by staff within the home. As a result of the above findings the registered manager introduced a new section within the care plan as a means to ensure that a similar occurrence did not happen. Staff were seen knocking on bedroom doors before entering peoples personal space. Doors were closed while staff were carrying out personal care needs. The conversations we heard between people using the service and staff were respectful. We brought to the attention of the manager that staff need to be wary of discussing peoples care needs in front of other service users. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. The appointment of an activities coordinator should ensure that the social needs of people using the service can be better met. A varied menu is provided although concerns regarding some aspects of dishes available are on going despite the managers attempts to address these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No visitors were consulted during this inspection although a number were seen within the home. People residing at the home commented that they receive visitors and nobody voiced any concerns regarding this. On a couple of occasions we witnessed staff contacting relatives or representatives to inform them on incidents such as a fall that had occurred. During the visit a number of people commented about the activities provided, including: St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 14 ‘Yesterday we had exercises in the top lounge.’ ‘Boring sometimes – nothing to do.’ ‘Would like more outings.’ ‘We had a pantomime here.’ People using the service were aware of a recently appointed activities coordinator who was consulted as part of the inspection. Activities were taking place within the dining room during this inspection. The activities coordinator had prepared a schedule for the week including events such as pamper hour, cards, quiz and knit and natter. St Stephen’s care home is situated next to St Stephen’s church. Although nobody has taken up the offer of joining in social events within the church a number of people do attend a service followed by a coffee morning within the home once a month. A Roman Catholic priest visits a number of people residing in the home on a regular basis. One person in the home stated that staff bring meals to you in your room if you are unwell. This conflicted with information we recently received at the Commission when it was stated that this did not happen, and a comment from one person who said that some staff do bring you a cup of tea and some don’t. During the visit we saw no evidence of staff denying people drinks or meals in their rooms. Over recent inspections we have made comments regarding concerns about the tea menu at St Stephen’s. We saw evidence within the minutes of meetings involving people using the service as well as within the complaints log that these concerns have continued. Over recent months the manager has made changes to the menu such as reducing the number of days when soup and sandwiches are available as well as another choice in line with comments received. Following further comments made by people using the service these items were reintroduced. The day’s menu is displayed on a board within the dining room. Menu cards are placed on individual tables. One person commented that at times information on the board differed to the information on the menu cards. The need to revise the menu cards to reflect the current menu was accepted by a senior member of staff. On one of our visits we were able to join people using the service during lunchtime. People were able to help themselves to vegetables from serving dishes. Staff were seen to be sensitive and courteous when serving meals or assisting people to eat. People using the service were asked to select what they wanted for that afternoon’s tea and the following days lunch time either while waiting for or having their lunch. It was suggested that this practice could be confusing to St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 15 people and therefore may benefit from a review. It was noted that a carer was not offering people the cooked tea option, which appeared on the menu board until challenged by one person. Following this challenge the carer then continued to omit the cooked option when asking other people what they wanted. Other choices included soup and sandwiches. The variety of soup or sandwich content was not given to people when asking them to make a selection to assist people making a decision. Although a number of people were not content with the food offered other people were favourable and made comments such as: ‘ Very good ’ ‘ well cooked ’ and ‘ presented well ’ The dry foods store was well stocked with a number of small tins of baked beans and spaghetti supporting statements that such food would be supplied on request to an individual or a small group of people. At the time we visited this area of the home the cook was waiting for a supply of fresh vegetables, no fresh vegetables were used that day. We were informed that usually 1 x fresh and 1 x frozen are used daily with the exception of the weekend when all fresh is used. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 16 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): Standards 16,17 and 18. Quality in this outcome area is good The complaints procedure is readily available and the manager encourages people to voice any concerns they may have in order to improve the service. Procedures and staff training in safeguarding protect people from potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information regarding how people are able to complain about the service provided is freely available within the home. The procedure is displayed on notice boards as well as included within the guide available for people using the service. The procedure within the users’ guide is lengthy giving details of a number of stages and the timeframes for these stages. Although reference is made to the Commission it is not totally clear that complaints about St Stephens can be referred to the Commission at any time within the procedure. The agreement to occupy (terms and conditions) document stated that people are able to contact the Commission at any stage within the complaints procedure. The complaints records were viewed. The records seen were in good order and gave a good account of the action taken and provided evidence that the St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 17 outcome was recorded and when appropriate the actions taken to prevent a reoccurrence. The registered manager demonstrated an openness to receive comments, concerns and complaints about the service provided. People using the service are reminded of the complaints procedure as part of regular meetings that are held. Two residents representatives were appointed by people using the service who are able to act as spokespersons regarding any issues people might want to raise. Since the previous inspection at St Stephens we have received two complaints regarding the service provided at the home. One of these complaints was addressed satisfactorily within the home prior to our visit. Elements of the second complaint were addressed and discussed with the registered manager as part of this inspection. A notice in the dining room stated that people using the service are automatically registered to receive postal votes but if people preferred to attend a polling station they should see a senior member of staff. Information was also displayed regarding accessing advocacy services and safeguarding people from abuse. Staff consulted had knowledge regarding the action that would be expected of them were they to be aware of actual or potentially abusive situations within the home. Training records showed that the majority of staff have received training in safeguarding provided by Age Concern, this was confirmed by staff members on duty. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 18 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): Standards 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent People who live at St Stephens are offered an environment, which is suitable for purpose, well maintained, safe and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St. Stephens care home is registered to care for up to 51 people under the categories detailed earlier within this report. There are a total of 44 single and 4 double bedrooms. En- suite facilities are provided in 22 of the single and all of the double rooms. Currently 3 of the double rooms are used as ‘luxury singles’. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 19 Communal facilities within the home are spacious with a large dining room and two lounges (one in which smoking is permitted) on the ground floor and additional lounge areas on the first and second floor. The floor covering in the dining room is new since our last visit and looked attractive while also easy to clean. One of the ground floor lounges contains a large flat screen television, which has sky fitted to provide a greater range of choice. A loop system is to be fitted to provide better facilities for people with a hearing aid. A seating area in the front foyer remains a very popular area for people living in the home to sit and chat, read a book or newspaper or just watch the comings and goings. A lounge on the first floor has a computer with Internet access provided for people using the service who want to use modern technology. The lounge on the top floor is seldom used other than during reviews or meetings. Since our previous inspection new chairs have been purchased adding to what were already comfortable areas Communal toilets are located near to lounge and dining areas. All communal toilets seen were clean and free from odour. Improvements and renewal or replacement of carpets and décor continue as part of a rolling programme. A representative of the housing association was reported to take a keen interest in the continual improvement of the fabric of the home. Some areas of the home are in need of decorating such as woodwork damaged by wheelchairs. We were informed that quotes were recently obtained and that work will take place on these areas. Some other areas were damaged due to some dampness however these repairs are also scheduled to take place. A passenger lift is provided to enable people to access all areas of the home. Improvements have taken place with the lift to ensure that it complies with the Disability Discrimination Act. The controls are now lower (to enable it to be operated by wheelchair users) in Braille (to assist people with a sight impairment) and a voice indicator informs passengers of the floor they are on. The actions taken are commendable. Other aids are available including newly purchased hoisting equipment. Night staff visually check wheelchairs to ensure they are safe to be used. A small sample of bedrooms were viewed all of which were suitably furnished. It was evident that individuals are able to bring personal possessions into the home as desired. Wardrobes seen were secured to the wall to prevent them falling over. All bedrooms have a suitable lock fitted to the door. People using the service who were consulted stated that their rooms were comfortable. One person described the hot water supply as ‘ warm and plentiful.’ St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 20 Suitable laundry facilities are available whereby two washing machines are in place both of which have a sluice facility. Hand washing facilities are provided within the laundry. The laundry was clean and tidy. The manager has an excellent understanding of issues regarding infection control involving external specialists as necessary and new guidance and material from the Department of Health. It was reported that an officer from Worcester City Council Environmental Heath section visited the home just before Christmas 2007. We were informed that training was offered the day before the start of this inspection regarding the document Safer Food Better Business. This document is a practical approach to food safety. Although this training had not happened at the time of this inspection we did not see anything giving cause for concern regarding food safety We have previously stated how well maintained the grounds surrounding St Stephens and especially a small area to the rear of the home are. The back patio area has a seating area and a raised fishpond. In the past the home has entered and won the Worcester in Bloom (small business category) competition. A secure sensory garden was recently completed and looked very attractive. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. The home recognises the importance of having a skilled and experience staff team in sufficient numbers in order that individual care needs can be met. Recruitment procedures are robust and involve people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels remain similar to those mentioned in our previous reports in that 6 carers cover the morning shift while the afternoon shift consists of 5 carers. Additional staff are available between 8.00 am and 10 am to ensure that people get breakfast when they come down to the dining room rather than having to wait. The night shift consists of 3 wakeful carers. At least one member of the senior team is on duty throughout the waking day and on call and sleeping in during the night. The morning staff commence duties at 7.30 am and are sent around the home to assist people getting up. St Stephens does at times rely on agency staff to cover vacancies, annual leave, sickness and training. The rota showed times when agency staff had been employed. Although it would be preferable to have permanent staff on duty at all times it was nevertheless noted that the same agency members of staff were frequently used in order to enhance consistency. In addition to the St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 22 ability to call upon agency staff, a number of ‘bank’ staff are also available some of whom work frequent hours. The laundry is staffed between 9.00 am – 2.00 pm Monday – Friday. At other times carers need to carry out laundry duties, in addition to other duties. Recruitment procedures within St Stephens are suitably robust. The registered manager has a good understanding of the requirements to ensure that suitable and sufficient checks are carried out before employment commences. People using the service are involved with the recruitment process where possible. Some of the documentation regarding a recent appointment was still at head office and therefore was not seen as part of this visit. The registered manager confirmed that CRB (Criminal Records Bureau) checks are re checked after a period of three years. This is good practice and is commended. The manager reported that currently 55.5 of carers have completed their NVQ (National Vocational Qualification) training therefore over the 50 level needed to meet the National Minimum Standard. Further staff are currently undertaking this training which will ensure that the home is in excess of the target level. One senior member of staff is taking a level 3 NVQ while another is undertaking the Registered Managers Award, which is a level 4 NVQ. Having a high number of qualified staff can assist in bringing about quality care provision. St Stephens has in the past and continues to have a good record in providing staff training. The registered manager is well aware of the benefits of having a well-trained workforce. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36, 37 and 38. Quality in this outcome area is good. The home is run and managed by a competent manager who upholds the interests of people using the service. Systems are in place to ensure that a quality service is given. Staff members under the leadership of the manager promote the health, safety and welfare of people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the former deputy manager who was for a period of time working as manager designate has become the registered manager. The registered manager is suitably qualified to manage a care home for older people having an NVQ (National Vocational Qualification) level 4 in both care and management. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 24 It was evident throughout this inspection that the manager ensures she has up to date information and knowledge in good practice issues regarding the care of older people. This information is primarily gained from the Internet including the Commission’s web site. The manager had a sound knowledge of corporate policies and procedures as well as what was happening within the home. The registered manager supplied us with a full and detailed AQAA (Annual Quality Assurance Assessment) at the time requested. The document returned to us was clear and gave us the information we required with a range of evidence. The AQAA informed us of improvements made and about plans for the future development of St Stephens. Under Regulation 26 of The Care Homes Regulations 2001 the registered provider or a representative is required to visit the home at least once per month and write a report. Copies of these reports were available for inspection. The AQAA stated ‘A new quality assurance package to assist with service improvement is being used to review each area. The process involves residents, staff and relatives making assessments on how well the service is doing.’ The documentation provided by the registered manager regarding quality assurance was extensive. People using the service are able to hold small sums of money in safekeeping. A sample number of records and monies held were checked and found to balance. Recording regarding hairdressing money were good. The quality of staff supervision has improved since the last inspection. Records held evidenced that staff receive regular formal supervision lasting between 45 minutes and 1 hour. Staff consulted confirmed that this is happening. Copies of the previous inspection report were on display around the home. The availability of the previous report demonstrates an openness regarding the availability of information to current and prospective people using the service. The registered manager has made good efforts to ensure that people using the service are aware of their right to access records held about them within the home. At the time of the last inspection we reported that a review of policies and procedures was taking place. We reported upon one procedure which was in St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 25 need of further expansion, this policy was viewed again as part of this visit and found to be improved. Under Regulation 37 of The Care Homes Regulations we need to be informed of certain events and happenings within care homes. The registered manager has a good awareness of the situations whereby we need to be notified and has in the past kept us informed of events. Fire safety records were viewed and found to be in good order with regular testing and servicing taking place. We saw sufficient evidence to demonstrate that the necessary servicing of equipment and machinery takes place to ensure the health, safety and well being of people using the service. St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 18 3 4 4 4 4 4 4 4 4 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 4 X 3 X 3 3 X 3 St Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 15 (2) (b) Requirement Care plans must be an accurate reflection of current care needs to ensure that identified needs are met consistently. Timescale for action 31/03/08 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 Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham B1 2DT 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 Stephens Residential Home DS0000018676.V336821.R01.S.doc Version 5.2 Page 29 - 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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