Inspection on 09/02/06 for St Andrew`s Home

This inspection was carried out on 9th February 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Andrew`s Home 25/07/06

St Andrew`s Home 21/09/05

St Andrew`s Home 28/01/05

St Andrew`s Home 10/09/04

St Andrew`s Home 11/03/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 St Andrew`s Home 92 Drewstead Road Streatham London SW2 1AG Lead Inspector Lynne Field Unannounced Inspection 9th February 2006 09:00 DS0000022753.V275131.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 DS0000022753.V275131.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. DS0000022753.V275131.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Andrew`s Home Address 92 Drewstead Road Streatham London SW2 1AG 0208-769-0668 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) Crown Wise Limited Ms Ruma Devi Luckeenarain Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) DS0000022753.V275131.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. up to three persons only can be aged 65 years and above Date of last inspection 21st September 2005 Brief Description of the Service: St Andrews Home is a private home registered for eight for adults with mental health problems. Which was first registered in January 1995. The home is in a residential street near a park, within walking distance of Streatham High Road with all its transport and other facilities. It is decorated and furnished to a high standard. The majority of service users have been at the home since it first registered and it was originally registered for adults with a mental disorder under 65 years. When three service users became over this age, the home applied for a variance to its registration and the registration certificate has been amended to reflect that the home can accommodate up to three service users with mental health problems who are over 65 years of age. The home provides service users with the various degrees of support that they need with daily living. Where appropriate, the home also helps to prepare service users for more independent living, although it is recognised that for some of the service users, this may not be possible due to the extent of their mental health problems. At the time of the inspection there were no vacancies. DS0000022753.V275131.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on the 9th February 2006. The acting manager and registered provider were present and took part in the inspection process. The registered provider is at the present time also the registered manager. The inspector interviewed one member of staff. The acting manager spoke about wanting to continue in the position of acting manager till she had completed her NVQ Level 4 at the previous inspection but at this inspection she told the inspector she now felt more confidence about to applying to become the registered manager. The inspection included a tour of the home and examination of records on care plans, staff records and building maintenance records. Three service users and one member of staff were spoken to individually. Regulation 26 of The Care Homes Regulations 2001, reports of monthly visits made to the home, are submitted to CSCI by the registered provider. During the inspection staff interaction with service users was observed to be very regular and conducted in a respectful manner. What the service does well: What has improved since the last inspection? The record keeping and care plans continue to improve and there is more information relating to the service users every day life to help staff give the service users the care they need. The shower has been refurbished. The registered provider, the acting manager and staff continue to make sure the home is well maintained and a pleasure to live in. DS0000022753.V275131.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. DS0000022753.V275131.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 DS0000022753.V275131.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): N/A These standards were not inspected during this unannounced visit. The finding of the previous inspection (September 2005) was that the standards were being met. EVIDENCE: There have been no recent admissions in to the home. DS0000022753.V275131.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 Families and professionals are involved when reviews are held. Care plans are thorough and reflect service users’ needs and goals. Risk assessment reviews take place and are recorded. EVIDENCE: Three service user files were inspected. Care plans give a thorough description of service users’ behaviours, reactions and preferences and how the service user was to be treated. Care plans are reviewed six monthly or more regularly if needed and monthly for the service users over the age of 65. Individual risk assessments are monitored and reviewed by the staff with service users every six months or when the need arises. Details of any changes to the risks are recorded in the service users care plans. All the care plans, service user contracts and risk assessments that were seen by the inspector were signed by the service user and the registered provider. There was cultural needs activates information on file for each service user that outlined the activities the service user likes to do, such as “plans and prepares simple Caribbean dishes with support”. DS0000022753.V275131.R01.S.doc Version 5.1 Page 10 The home has a sauna room which the service users are able to use at any time. The inspector saw evidence in the form of a placement meeting report, that placement review meeting are being held with care managers and include the service users family. DS0000022753.V275131.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): 11,12,13,14,16,17 Service users are able to take part in age, peer and culturally appropriate activities, leisure activities and are part of their local community. They are actively encouraged to develop daily living and social skills by the registered provider and staff of the home. Meals are varied and enjoyed by service users. A healthy diet is provided and mealtimes are relaxed and flexibly timed to fit in with individual activity plans. EVIDENCE: Each service user has a personal activities folder, which contains different activities the service user likes to do. This includes cultural needs activities, daily activities and home activities programs. These are discussed and agreed with their key worker. At the previous inspection one service user told the inspector she was able to choose activities she enjoyed doing and said she sometimes goes out alone or at other times, goes out with another service user for walks, which she still does. At other times she will go to the local café for a cup of coffee or tea although she could always make a drink or have a snack in the home she said it was nice to go out. DS0000022753.V275131.R01.S.doc Version 5.1 Page 12 Service users are encouraged to help with household chores. This is discussed at service users meetings where it was recorded that all service users expressed their satisfaction with their allocated chores. Service users said they enjoyed the food served at the home. They said they decided what was on the menu with the staff, which was plan for the next four weeks. Service users said they could choose from the menu or if there was not anything they wanted on the menu that day, the staff would make them something of their choice. Service users said there was plenty of food to eat. One service user told the inspector “the menu was nice and she had put on weight since coming to live in the home”. The inspector was shown the book where the meals are recorded. If there is a change to the menu it is recorded in this book along with a record of the temperature taken of the food before it is served. DS0000022753.V275131.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): 18,19,20 Service users receive personal support, in the way they prefer. Medication is being handled safely. EVIDENCE: Three service users care files were inspected. These were found to contain all the information that would need staff to support the service users in their preferred personal care routines and there details of how much help an individual requires with different personal care tasks. A key worker system is in operation, with each service user having a member of staff from within the team to co-ordinate their support and care planning. The record of health appointments attended indicated that each service user is supported by staff if this is what the service user requires, to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. This included the outcome of the appointment. Service user medication is stored securely in a locked medication cabinet in the staff office. The inspector checked two of the service users medication at random. All medication stocks checked where in order. One service user is being monitored to administer their medication. DS0000022753.V275131.R01.S.doc Version 5.1 Page 14 The registered provider has sent a copy of the medication policy that had been reviewed and updated. The inspector was shown the report by the local pharmacist who comes into the home every six months to check the medication. This indicated there were no issues that needed to be addressed by the home. Since the last inspection the inspector was shown the medication audit that has been set up and is done weekly. The registered provider told the inspector the medication policy still needed to be reviewed and updated. DS0000022753.V275131.R01.S.doc Version 5.1 Page 15 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): 22,23 Service user’s views are listened to and acted upon and there are safeguards in place to protect them from abuse, neglect and self-harm. EVIDENCE: The home has a complaints policy, a copy of which is in the service users’ guide. The inspector saw the complaints book. There was one complaint recorded since the last inspection by a service user who was being asked to wash up. The registered manager told the inspector all complaints are taken seriously and appropriate action had been taken to ensure service users’ complaint was addressed immediately. The actions and outcome taken by the home were recorded and the service user had signed this to say they were happy with the outcome. The inspector was shown a copy of the minutes of the service user’s meeting, which are held monthly. There were discussions about the service users doing household chores; fire drills and service users were asked for their views on the social evening. DS0000022753.V275131.R01.S.doc Version 5.1 Page 16 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): 24,25,27,28,30 The home is bright, clean, comfortable and safe. Service users rooms are comfortable and are decorated to reflect their personalities. EVIDENCE: The inspector was given a tour of the home. The home has a large dining room leading on to a large lounge/conservatory room at the back of the house, which over looks the garden; this acts as the main lounge. There is a small kitchen area where service users are able to make themselves a drink or light snacks. There is a personal computer available for use by the service users. The conservatory leads on to the garden, which was landscaped to provide a patio area with a barbeque, secluded out door seating area and water feature last summer. Both rooms were well used on the day of the inspection. The only access to the upper floors is by the staircase. The home is unsuitable for service users with impaired mobility, except the ground floor, where there is one bedroom with ensuite facilities. Bedrooms are personalised and reflect the taste and interests of the service user and has a wash hand basin. Service users said they are happy with their DS0000022753.V275131.R01.S.doc Version 5.1 Page 17 bedrooms. There is a facility in each bedroom for receiving incoming telephone calls. There is a separate toilet for visitors, service users and staff on the ground floor and two other toilets and a bathroom on the next two floors. The shower in the sauna room has just been refurbished. There is a laundry, which is next to the kitchen, has a washing machine and a dryer. There is a sink installed for clothes that need to be hand washed. Service users told the inspector they were assisted by the staff to do their washing and one service user said they enjoyed doing the ironing. DS0000022753.V275131.R01.S.doc Version 5.1 Page 18 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): 32,34,36 The home is supported by an effective staff team that know the service users well. The policy relating to the recruitment of staff needs to be revised. Recruitment practices need to be more robust as some checks were incomplete. EVIDENCE: Two staff files were examined. These included two written references as required and a file of checks with the Criminal Records Bureau was kept separately. The registered manager said there had been no new staff employed at the home since the last inspection but would follow the recruitment policy and procedure in accordance with equal opportunities policies. The inspector was unable to check this previous requirement was met at this inspection because there had been no new staff recruited since the previous inspection. Through out the inspection the inspector observed staff interacting with service users and the qualities seen included good listening skills, a calm and confident manner, and a good grasp of the basic areas of need they needed to meet, including communication. Four members of staff are still in the process of taking an NVQ Level 2 or 3. The registered provider stated that it is planned for all staff to be qualified to DS0000022753.V275131.R01.S.doc Version 5.1 Page 19 at least NVQ level 2. The acting manager is taking NVQ qualification at Level 4. One member of staff told the inspector they had supervision every two months, which was recorded and kept, in their file. The member of staff and the manager signs this. DS0000022753.V275131.R01.S.doc Version 5.1 Page 20 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): 37,38,39,42 Service users know the home is well managed and planned. The health, safety and welfare of service users is promoted and protected. EVIDENCE: As stated in the last inspection report the registered provider for the organisation is also the registered manager for this home. This has been the arrangement for some time now and has been identified as inappropriate at previous inspections. After registered provider continual attempts to recruit a manager was unsuccessful, the deputy member of staff who has been acting manager following a successful interview, for nearly a year, has agreed to apply to be the registered manager. The registered provider is satisfied that the acting manager is able to undertake the post. The acting manager is in the process of taking NVQ level DS0000022753.V275131.R01.S.doc Version 5.1 Page 21 4. The acting manager must make an application to become the registered manager. A requirement has been given. The registered provider has been conducting monthly, unannounced visits to review the service and copies of the reports have been sent to CSCI to evidence the provider’s monitoring of the service. Records indicated that all fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. DS0000022753.V275131.R01.S.doc Version 5.1 Page 22 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 Standard No Score 1 x 2 X 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 4 25 3 26 X 27 3 28 4 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 3 3 X X 3 x DS0000022753.V275131.R01.S.doc Version 5.1 Page 23 No 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 YA37 Regulation 8 (2) (a) Requirement Timescale for action 30/05/06 2 YA34 13 (6) 19 The registered person must ensure an application for the registration of a manager of the home is made to the Commission for Social Care Inspection. The registered person must 30/06/06 ensure that the recruitment policy is revised to include the specific checks that will be required from prospective staff prior to being employed such as CRB checks, POVA checks and an occupational health check or personal health statement. 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 DS0000022753.V275131.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022753.V275131.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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