Inspection on 27/09/05 for 14-15 St James Road

This inspection was carried out on 27th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 25/04/05

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 Unannounced Inspection 27th September 2005 10:30 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 Adults 18-65. 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. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 14-15 St James Road Address 14-15 St James Road Exeter Devon EX4 6PY 01392 670160 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) Mrs Deborah Veronica Phillips Mr Warwick Nicholas Phillips Nebojsa Jokanovic Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The manager must obtain the Registered Manager’s Award by 1st December 2006 The manager must obtain NVQ 4 in Care or Registration as a 1st level Nurse with the Nursing and Midwifery Council by 1st December 2006 25th April 2005 Date of last inspection Brief Description of the Service: 14-15, St. James Road cares for a maximum of seventeen people, both men and women who have or have had a mental illness 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 DS0000021830.V250721.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors Stephen Spratling (Regulation Inspector) and Brian Brown (Pharmacist Inspector) from 10.30am until 2.30 pm on Tuesday 27th September 2005. There were 10 residents living at the home and the inspectors met with five of them, one of who was not able to communicate verbally with the inspector. In addition to the manger the inspectors spoke with the one member of care staff who was on duty. They also looked a variety of records and around the building. What the service does well: What has improved since the last inspection? What they could do better: Care plans though much improved need to include all needs that residents have and be updated when needs change. Management of medicines needs to improve. Recruitment procedures though better still have room for improvement. Assessment of risks to residents regarding upper floor windows need to be more individualised. Maintenance in and around the home takes too long to get done and a lot of work is outstanding. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 Page 6 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. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 the following standard(s): The manager confirmed that the home has taken no new residents since late 2004. Therefore none of these standards were assessed. EVIDENCE: 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 the following standard(s): 6 Care planning is much improved though further work is needed to ensure plans are developed to include all needs and changes in need. EVIDENCE: The inspector looked at the care plans of three residents. All three contained some useful descriptive plans, much improved from the last inspection, to help staff know what they should do to care for residents and to recognise signs that their health may be deteriorating. Two had been signed when recently reviewed with the service user. Three residents said they had been involved in reviewing their care plans. One had not been updated to reflect changed needs of one person and another did not take into account that the resident manages their own medication, as it should have. The staff member spoken with said that they are now involved in care plan reviews. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 the following standard(s): 11, 15, 16 & 17 Residents are happy living at this home, well supported and treated with respect. They are encouraged to take responsibility for themselves but appreciate and respond positively to not being pressured. They receive food they like. EVIDENCE: All four residents who spoke with the inspector said they like living at the home. They all indicated that they like the staff feel free to come and go as they please and spend time, as and with whom they like. One person said that living at the home had helped them to “learn to pace themselves” and that though they still have “bad days” they happened less frequently with support from the new manager particularly. Another resident commented that one of the reasons they like the home is that it is “free and easy”, going on to say you can help yourself in the kitchen. All said that they are encouraged to be involved in chores around the house but do not feel pressurised. Residents confirmed that the food provided is good and they are encouraged to be involved in shopping and food preparation if they want to be. They confirmed that their privacy is respected and that staff knock on doors. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 the following standard(s): 20 The management of medication has the potential to place service users at risk. EVIDENCE: Pre-dispensing of medicines into pots occurs in advance of the administration. Hand written entries on the Medication Administration Record charts are not signed or dated. Tablets were found in a bottle with a hand written label and not as supplied by the supplying pharmacy. No record of supply of medication to those residents looking after their own medication had been made. Residents looking after their own medication do not have a secure lockable space in which to store them. No record of supply of medication to residents going on social leave had been made. The registered manager audits the Medication Administration Record charts but does not record this. Medicines are stored in lockable filing cabinets but in one area of the home these were not kept locked although in a locked room. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 the following standard(s): 22 Residents can be confident that their complaints will be taken seriously and addressed. EVIDENCE: The homes complaints procedure is clearly displayed in the entrance hall of the home, it contains all the required information though does need to be updated in light of the change of name of the commission. Residents all expressed confidence that if they had any problems they can easily talk to the manager or the owner. One resident said that the manager “was on his side” when he had had difficulties with a former staff member, going on to say he is easy to talk to. Another resident said that they can talk to anyone of the staff and that they would sort out their problems. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 the following standard(s): 24 & 30 Progress has been made on improving maintenance in the home but some areas are still shabby. There are areas of the home that present risks to the residents. EVIDENCE: A broken window seen at previous inspections had been mended and exposed wiring covered; some issues noted as requiring work remain outstanding e.g. in a 1st floor bathroom floor tiles remain loose; a 1st floor toilet floor needs to be properly sealed so that it can be cleaned properly; some paint work on doors skirting boards and walls needs attention; the kitchen in number 14 needs refurbishing as the cracked cupboards and surfaces can not be cleaned properly. Externally the grounds are generally tidier. A wall to the rear of the building, which was subject of concern due to subsidence, has been braced. Residents said they are happy with the accommodation and raised no concerns. One resident said they particularly like their bedroom and that it had been recently decorated. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 34 Staffing levels are sufficient to help ensure the needs of residents can be met. The procedures for recruiting staff have improved but further work is needed to ensure they are completely robust. EVIDENCE: Residents said that there are always staff around when you need them. The staff members spoken with confirmed that there are always two members of staff on during the day and one or two at night. The manager reported, and the staff member confirmed, that he lives on the premises and is available to respond to emergencies when only one staff member is on duty at night. The duty rota seen for the week of 26/09/05 reflected what the inspector was told. The inspector looked at the recruitment records of three members of staff. All contained the required information though some was dated as having been received since the person started in post this is an improvement from previous inspections. Where staff members Criminal Records bureau checks showed that they had a conviction, the manager reported that he had discussed with the staff member concerned but not recorded a risk assessment. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The home manger is competent and trusted by residents. Though improvements have been made risks to the health and safety of residents are not satisfactorily managed. EVIDENCE: The home manager has recently completed registration with the commission through which he demonstrated that he understands his role and responsibilities. Residents spoke highly of the manger, indicating they trust him to act in their best interests and that he listens to their ideas and concerns. Improvements to the systems of the home have been seen since the manager came into post. The Registration certificate on display in the entrance hall of the home does not reflect the current registration. A certificate confirming that the electrical wiring in the home is safe has previously been required but was not available on this inspection. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 Page 16 The inspector was shown a letter from an Electrical contractor confirming that they will carry out necessary work and provide a certificate. Since the inspection the manager has confirmed that all work has been completed and that the copy of the certificate will be supplied to the commission. A general risk assessment has been carried out regarding the need to restrict the opening of upper floor windows; while this is a good start these risk assessment should be done for each individual service user; so far the manager has concluded that window restrictors are not required. A 2nd floor fire extinguisher was checked and it was dated as having been serviced 08/05. The automatic door closure on No. 14 kitchen door was not closing the door properly and needs adjustment and a cupboard marked with a fire sticker as should be kept locked was not locked. The inspector spoke with Devon Fire Service officer following the inspection who confirmed that most of the work required earlier in the year had been satisfactorily completed. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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. 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 X X X X X Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 2 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 14-15 St James Road Score X X 1 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 1 x DS0000021830.V250721.R01.S.doc Version 5.0 Page 18 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 YA20 Regulation 13 (2) Timescale for action 1) The registered person 29/12/05 must ensure that all medicines are stored securely including those looked after by residents. 2) The registered person must record the supply of medication to service users looking after their own medication and also record the supply of medication leaving the home for social leave. The registered person must 29/01/06 having regard to the number and needs of the service users ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. (Loose floor tiles should be secured; the toilet floors should be properly sealed) Requirement 2 YA24 23 (2) (b) 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 Page 19 3 4 YA24 YA24 23 (2) (b) 23 (2) (d) Kitchen needs refurbished to be 25/04/06 5 6 YA42 YA42 13 (4) 13 (4) The registered person must 25/10/05 having regard to the number and needs of the service users ensure that the premises to be used as the care home are kept clean and reasonably decorated To paint all doors in home (requierment made following the last inspection timescale not expiered at time of this inspection) Copy of a current electical 15/11/05 wiring certificate must be supplied to the commission. Fire control measures should 29/11/05 be properly maintained at all times. Fire doors must shut properly and be kept secure if indicated. 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 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 Refer to Standard YA6 Good Practice Recommendations Care plans should reflect all needs and how they are to be met (e.g. how a resident is to be supported and supervised if managing their own medication) and be updated to reflect service users changing needs. When entries are hand written onto the Medication Administration Record charts they should be signed and dated by the person making the entry and then checked and signed by a second person. When audits are carried out the result of the audit should be recorded. The system for administration of medicines should be reviewed. The cabinets containing medicines should be kept locked and there should be an auditable trail of who has access to the keys to these cupboards. 3 YA34 Where Criminal Records bureau Checks indicate a potential staff member has a conviction, a risk assessment should be completed before they are employed. (see CRB guide entitled “Employing ex offenders a practical guide”) Individual risk assessments should be completed for each service user to inform the decision as to whether upper floor windows should be fitted with opening restrictors. 2 YA20 4 YA42 14-15 St James Road DS0000021830.V250721.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Exeter 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. 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