Inspection on 01/03/06 for St Andrew`s

This inspection was carried out on 1st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Andrew`s 08/06/07

St Andrew`s 19/09/06

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Andrew`s 114 Kiln Road Fareham Hampshire PO16 7UN Lead Inspector Craig Willis Unannounced Inspection 1st March 2006 10:20 St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 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 Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Andrew`s Address 114 Kiln Road Fareham Hampshire PO16 7UN 01189 581950 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) Truecare Group Limited To Be Confirmed Care Home 5 Category(ies) of Learning disability (5) registration, with number of places St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd May 2005. Brief Description of the Service: St Andrew’s is registered to provide care and accommodation for five people with learning disabilities between the ages of 18 and 65. The home is situated on the outskirts of Fareham and on a main road. The home is on one level and all service users are provided with a single bedroom with en-suite facilities. Service users share the use of a lounge, kitchen / diner and a bathroom. The home has a large, split level garden to the rear. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of St Andrew’s in the year April 2005 to March 2006, although it is the first inspection since Truecare Group Limited has been registered as the provider. Key standards not covered in this report were assessed during the inspection of 3rd May 2005. During the visit the inspector spoke with all three of the service users and met the manager and two members of staff. The inspector saw all of the communal areas of the home and spent time assessing the home’s records. What the service does well: What has improved since the last inspection? This is the first inspection of the home since Truecare Group Limited has been registered as the provider. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 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 St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 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): 2 The home has good systems to assess the needs of service users before they move in. EVIDENCE: The home had completed a needs assessment for all three service users. Currently, all three service users have moved from another Truecare service and the home had copies of the initial assessment, which had been updated prior to their move to St Andrews. Copies of care management assessments and reviews were also available. The manager reported that a full assessment would be completed for any potential service users before they move into the home. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 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, 7 and 9 There are clear care planning and risk assessment systems in place, which provide staff with the information required to meet the needs of service users. Service users are provided with good support to make decisions about their lives. EVIDENCE: All three service users had care plans in place setting out how their assessed needs should be met. These plans had been reviewed prior to them moving into St Andrews and further revisions have been made since the move where the support required relates to the new environment. Service users spoken with said that they felt these plans contained accurate information about the support they require. The manager reported that these plans will be further reviewed with service users as they settle into their new home or move on to other services. Restrictions on service users, for example on going out alone, were recorded in the care plans and had been signed by service users, indicating their agreement. Service users are supported to manage their own finances where able and details of the support required are included in care plans. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 10 Risk assessments were available for all three service users. These documents set out the risks to service users and the actions that should be taken to minimise them. The risk assessments were integrated with the care plans, to provide comprehensive information to staff on the support that should be provided. The risk assessments for one service user had been recently amended due to a number of incidents. These assessments covered the risks to the service user from the busy road that the home is located on, accessing the community and travelling in the home’s vehicle. A review of this service user’s placement was held on the day of the inspection and amendments were made to the service user’s care plans as a result. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 11 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): 12, 13, 14, 16 and 17 The home supports service users to take part in a good range of leisure and educational activities and to be part of their local community. The rights and responsibilities of service users are recognised, although the provision of suitable locks on bedroom doors would enhance privacy. Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: Service users are supported to take part in a range of activities including sessions at a day service, visits to the pub, playing football and attending a local church. One service user told the inspector that they worked at the Southampton Football Club stadium on match days and is an officer in the boys’ brigade. Service users said they use the local facilities such as the shop and pubs. Staff had details of other local facilities and events that service users may be interested in. Service users care plans contain details of the daily routines in the home, such as cleaning, and the support that they require. One service user who smokes St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 12 said it had been made clear that they could not smoke in the house before moving in. The requirement made at the last inspection that the locks on the bedroom doors should be changed and service users offered a key to their room had not been complied with. The manager reported that that he had ordered the new locks and was waiting for the maintenance contractors to fit them. Service users spoken with said that they would like to be able to lock their bedroom door when they went out. The home had a planned menu that provided a varied and balanced diet. The menu stated that it was only a guide, and service users should be consulted daily about what meals they wanted. The inspector witnessed staff providing a choice of meals for a service user during the visit. Service users spoken with said the food was good and they could always get snacks if they wanted, although two said they would like to be more independent with food preparation. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 13 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): 19 and 20 The physical and emotional health needs of service users are well met with evidence of access to a range of health services. The medication system at the home is well managed, which protects service users. EVIDENCE: Service users’ records contained details of support to attend a range of health services, including GP, dentist, psychiatrist, chiropodist and outpatient appointments. The records included any advice that was given by the practitioner. Service users spoken with said that they could see their doctor when they needed to. Details of the emotional support service users needed were included in their care plans. At the time of the inspection two of the service users were administering their own medication and one service user was being supported to manage their medication. A monitored dosage system was being used and medication was stored in a locked cabinet in the office. Medication administration records had been fully completed. All staff had completed medication training. The home had a copy of Truecare’s medication policy and procedures, which included the ordering, administration and disposal of medication. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 14 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 and 23 Service users are confident the home will listen to complaints and act on them. The home has suitable procedures in place to protect service users from abuse and staff have a good understanding of adult protection issues. EVIDENCE: The home has a complaints procedure in place, which indicates who will investigate complaints, the time within which a complainant can expect a response and the contact details of the Commission for Social Care Inspection. Service users spoken with said that they would speak to the manager or a member of staff if they wanted to make a complaint. Two service users said they were confident any complaint they made would be taken seriously and acted upon. The home has copies of the Hampshire adult protection procedures, adult protection guidance from the Department of Health and Truecare’s adult protection policy. Staff have received adult protection training and those spoken with had a good understanding of action they should take if abuse was witnessed or reported to them. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 15 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 and 30 The systems for maintaining and cleaning the home are good, which provides a homely and safe environment for service users. The implementation of clear procedures about washing laundry will help to ensure good food hygiene standards. EVIDENCE: The home is furnished with good quality, domestic furniture and fittings and is well decorated throughout. Service users spoken with said they thought the home was well maintained, although they would like more input on the decorations. Reports of senior managers’ visits to the home indicated that money had been made available to replace some of the carpets that were stained. The manager reported that Truecare had a maintenance team and outside contractors, who he ordered work through. The home has suitable washing machines, situated in a side lobby off the kitchen. It was noted that vegetables and fruit were being in this area. The manager agreed to move these food items on the day of the inspection. The manager also agreed to ensure that he gives written instructions to staff and service users that dirty laundry must not be taken through the kitchen whilst St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 16 food was being prepared or eaten. This will be followed up at the next inspection. The home was clean and fresh smelling throughout. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 17 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): 32, 33, 34 and 35 The home is staffed in sufficient numbers by qualified staff, who have demonstrated their competence. The home has robust recruitment procedures, which help to protect service users. There is a good induction and training programme, which gives staff the skills and knowledge required to meet the needs of service users. EVIDENCE: Of the six permanent staff members, three have the NVQ level 3, two are completing the award and one is due to start the award this year. The manager reported that he was committed to providing NVQ training for all staff. The home’s staffing rotas showed that there were at least two members of staff during the day, one awake overnight and one asleep and on-call overnight. The manager reported that as more service users move into the home the staffing levels will be increased to meet their assessed needs. The records of four staff members were viewed during the visit. All records contained a copy of the original application form, identification details, confirmation that an enhanced disclosure from the Criminal Records Bureau had been obtained and a health declaration. Staff had received a company induction and had completed the Learning Disability Awards Framework induction. The home had a training programme in place and staff had undertaken training in physical interventions, first aid, St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 18 adult protection, infection control, health and safety, fire safety, medication and food hygiene. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 19 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, 39 and 42 The home is well run by a competent manager. The planned introduction of an independent quality assurance system will help to ensure that the home continues to improve. The home has good systems to ensure the safety and welfare of service users. EVIDENCE: The manager has previously been the registered manager of one of Truecare’s other care homes and reported that he had the NVQ level 4 in care and was completing the registered manager’s award. The manager said he will be submitting a registration application to the Commission for Social Care Inspection. Since the home has opened monthly visits have been made by senior managers to assess the quality of the service provided. These reports contained details of action that was required and an update of the previous month’s actions. The manager reported that Truecare were in the process of introducing a new quality assurance system, which would be carried out by an external company. This will be followed up at the next inspection. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 20 The home has records of weekly checks on the fire alarm system, fire extinguishers, emergency lighting and the fire exits. The temperature of the fridge and freezer is recorded daily and daily checks are made of the hot water temperatures. The manager reported that the gas system was checked on 22/2/06 and he was waiting for the safety certificate to be sent through. Checks have been made on the home’s static wiring and the manager has arranged for portable electrical appliances to be tested. The manager reported that the home’s fire risk assessment was being completed the following week. Staff have received fire safety training. St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 21 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 3CHOICE OF HOME Standa3rd No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 3 X X 3 X St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA16 Regulation 12 (4) Requirement The registered person must ensure that bedroom doors are fitted with locks that can be operated from the outside of the door. Timescale for action 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 St Andrew`s DS0000066327.V285234.R01.S.doc Version 5.1 Page 24 - 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. 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