Inspection on 25/04/05 for 14-15 St James Road

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

14-15 St James Road 03/09/08

14-15 St James Road 05/03/08

14-15 St James Road 23/05/06

14-15 St James Road 27/09/05

14-15 St James Road 22/11/04

14-15 St James Road 15/07/04

14-15 St James Road 16/03/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 14-15 St James Road 14-15 St. James Road Exeter Devon EX4 6PY Lead Inspector Stephen Spratling Announced 25 April 2005 09.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 14-15 St James Road Address 14-15 St James Road Exeter EX4 6PY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01392 670160 Mr Warwick Phillips and Mrs Deborah Veronica Phillips Care Home 17 Category(ies) of MD Mental Disorder (17) registration, with number of places 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 November 2004 Brief Description of the Service: 14-15, St. James Road cares for a maximum of seventeen service users, both men and women who have a mental health problem and who are between the ages of eighteen and sixty five.The home comprises two adjoining semidetached houses, which have an intercommunicating door at second floor level. To the rear of one is a small garden and to the rear of the other is a patio. One house has a roof garden accessible from the first floor. Each house has its own kitchen and living rooms.The home is situated in a residential area close to the city centre. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by two inspectors (Stephen Spratling and Mandy Sharp) from 9.30 until 3pm on Monday 25th April 2005. The inspection was mainly carried out in the office because there were several serious requirements from the last inspection that had to be looked at in detail. There were 11 residents living at the home, and the inspectors met with seven of them to see what it was like living there. Some residents had also filled out CSCI questionnaires. Mr and Mrs Phillips were there for the inspection and also the new manager Mr Nebojsa Jokanovic (Nebs). There were no staff to interview as the care assistants were coming on later that evening. An enforcement notice had been served in March 2005. This was to make sure that all recruitment checks were carried out. This was looked at and now the home is generally complying with the law. What the service does well: What has improved since the last inspection? What they could do better: There are still some problems with the environment at the home which need to be sorted out as soon as possible- these include a full risk assessment of the building, electrical wiring to be checked, a window to be repaired and some fire safety problems identified by a fire officer on a recent visit. The policy folder needs to be made up to date and sorted out. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 Good progress has been made on the Statement of Purpose which means that residents and potential residents are provided with details of the services that the home provides enabling an informed decision about admissions to be made. EVIDENCE: The revised Statement of Purpose now has the majority of the information needed and is available in the home for people to read. There are a couple of inaccuracies to be amended. There is also a residents guide which has useful information in so that the residents can be clear as to what the home provides, their rights and how to complain. There have been no new admissions in the last 12 months to the home but the manager knows that residents need a full assessment before moving in. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9,10 The manager has a good understanding about how the care plans and risk assessments need to be developed in the home and steady progress is being made. Residents are able to make choices about how they lead their lives. The manager is working on confidentiality issues in the home so that residents’ privacy is maintained. EVIDENCE: Three sets of residents’ notes were looked at, including the care plans. One resident had several health issues recently and this was written in to the care plan and there was a full risk assessment. The resident was involved in the risk assessment and agreed with it. The other care plans needed some more detail, updating, making accurate and new risk assessments. The residents said that they could choose what they wanted to do in and out of the home. They said that staff did not tell them what to do and said they didn’t want anything changed at the home. They are completing questionnaires about the home. One resident said that sometimes staff talked about residents, but the manager said that he sometimes had to remind residents not to talk about each other. There is a confidentiality policy, which the manager is reminding staff of in appraisals. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,1314,16 The home ensures that residents are part of the local community and go to various activities as they choose. Residents are supported to make choices in their lives. EVIDENCE: The residents are free to come and go from the home when they like. Some explained what they liked to do such as playing snooker, going to the pub, to the town, college, visiting friends and family. They were very content with what they did on a day-to-day basis. The manager is aware that he needs to encourage residents to be more active sometimes and is reminding staff of this. Two residents said that they loved living at the home and they were very happy there after many years in hospital. One said that ‘ these are the happiest years of my life’ .The fact that they had their ‘own space’ was very important to them, and than staff respected how they kept their rooms, and always knocked on doors. One said ‘this room is my home and it’s lovely’. Residents said that staff let them choose what they wanted to do and did encourage them. Some of the residents were going on holiday the next week to Cornwall which they were looking forward to. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 There are suitable arrangements in place to meet the personal and health care needs of the residents. EVIDENCE: Residents said that they received all the help and care that they needed. Residents go to the local doctors when they need health care. The CPNs and care managers do not visit very often, but the manager does try and encourage them to. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 There has been progress on producing a vulnerable adults procedure to ensure that staff know what to do if there is suspicion or allegation of abuse. EVIDENCE: The manager has written a new vulnerable adults policy, which is clear and easy to read. Many residents spend a lot of time in their rooms and the staff make sure they visit the residents at least twice a shift to make sure that they are safe and well. The manager is aware of resident’s potential for self-harm and manages this appropriately. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,30 Progress has been made on improving décor in the home but some areas are still shabby. There are areas of the home that present risks to the residents. EVIDENCE: Some rooms have been painted and there are new carpets in some bedrooms and the corridors, which make the home look smarter. The areas of the home that need urgent attention are a broken window in a bathroom and exposed wiring from a light. These problems have been raised before. There has been no risk assessment undertaken about the windows throughout the home, which have no restrictors and can open fully. Some areas of the home still look shabby such as some paintwork on doors, skirting boards and walls, and floor tiles coming off the bathroom floors. The living rooms are spacious and decorated nicely and the residents use them. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,36 The procedures for recruiting staff has improved and now provides more safeguards for people living at the home. There is now a good induction and training programme for staff, which will have a positive impact for the residents. EVIDENCE: A statutory notice had been issued in March 2005 because of the poor recruitment records and procedures. All staff records were inspected and the vast majority of them were now complete and therefore further enforcement action is not planned, unless the home breaches the law again. There was one new member of staff who had started work before a Criminal Record Bureau Check had come back, and the POVA First Check had not been carried out. The manager said he did not realise this had to happen but was fully aware now. Induction records are completed in detail and new staff also attend an induction provided by Learn Direct with an external NVQ assessor. The manager has introduced appraisals, training and staff meetings. These are focussed on the residents’ needs. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,42 There is leadership, guidance and direction provided to the staff by the manager to ensure residents receive good quality care. There are some serious health and safety issues at the home that potentially put residents at risk. EVIDENCE: The new manager has sent in his application form to be registered with the Commission but no cheque has been sent so it cannot be processed. Mr Phillips had agreed to send this in two days after the inspection. The new manager has improved many of the systems at the home such as the induction, appraisals, meetings, recruitment procedures, care planning risk assessments, mental health training. He has a vision of how care should be provided such as staff encouraging residents to lead a more active life where possible and developing the key worker system so that staff spend more one to one time with residents. The policy file is going to be updated as it contains policies that are never used and are not needed in the home. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 16 There is no electrical wiring certificate for the home and so it is unsure whether the wiring is safe or not. Mr Phillips agrees this needs dealing with urgently and agreed a timescale to get it done by. If this is not completed enforcement action will be taken. The fire officer has visited recently and identified serious fire safety issues, which he will be following up. Mr Phillips said he has sorted these matters out. 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 x x x 3 Standard No 11 12 13 14 15 14-15 St James Road x 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 3 2 x 3 Version 1.20 Page 18 D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc 16 17 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 1 x 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 23 (2) b Requirement You must make sure that the premises is kept in a good state of repair-broken window in bathroom to be mended, bathroom floor tiles to be secured, exposed wiring on light socket to be covered ( this is an outstanding requirement from Nov 04) To paint all doors in home Kitchen to be refurbished You must ensure that if a new member of staff starts work without CRB, A POVA First Check must taken up ( refers to one new member of staff) You must make sure that all parts of the home are free from risk where possible- a risk assessment needs completeing of the building and including risk associated with windows that arent fitted with window restrictors You must have a current Electrical Wiring Certificate (this is an outstanding requirement from Nov 04) Timescale for action 13.05.05 2. 3. 4. YA24 YA24 YA34 23 (b) 23 (b) 19 (1) 25.10.05 25.04.06 25.04.05 5. YA42 13 (4) 13.05.05 6. YA42 13 (4) 13.05.05 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 20 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. 2. 3. 4. 5. Refer to Standard 1 6 Good Practice Recommendations That the Statement of Purpose is fully accurate That all care plans are fully updated and include risk assessments 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 14-15 St James Road D54 D06_S21830_StJamesRoad_V214768_250405 Stage 4.doc Version 1.20 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!