Inspection on 11/07/05 for St Andrew`s House

This inspection was carried out on 11th July 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Andrew`s House 07/06/07

St Andrew`s House 05/01/06

St Andrew`s House 20/09/04

St Andrew`s House 21/06/04

Similar services:

Southfields

Thorndene

Insight - Eastchurch

Magenta

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33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 St Andrews House 93 Downland Way Tattenham Corner Epsom Surrey. KT18 5SH Lead Inspector Mr P Benthom Announced Inspection 11 July 2005 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. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Andrews House Address 93 Downland Way Tattenham Corner Epsom Surrey KT18 5SH 01737 210304 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) Mrs R Young Mrs R Young CRH (PC) 4 Category(ies) of Learning Disability (LD) 4. registration, with number of places Learning Disability over 65 years of age (LD(E)) 4. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: Learning Disability (LD) 36 - 65 years and LD(E) 54 years and over. 2. The number of persons for whom residential accommodation and personal care is provided at any one time shall not exceed four (4). Date of last inspection 20 September 2004 Brief Description of the Service: St Andrews House is a terraced house located in Epsom Downs at Tattenham Corner. The home is registered to provide personal care for up to four service Users with learning disabilities. The service Users’ accommodation comprises of 4 single bedrooms, lounge, kitchen, dining room, toilets and bathroom. The home has its own well-kept garden and is located close to the local village shops and is a short distance from Epsom town centre, which has a good range of shopping and leisure facilities. The home has its own vehicle to transport the Service Users. The physical standard of the Home is exceptional and it continues to offer an extremely high level of care to its Service Users. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the first of the year 2005/6 and was conducted by an inspector from CSCI. There was a relaxed and friendly atmosphere at the home on the day of inspection and two pf the three Service Users were observed to be happy and well cared for. The inspection of the home was very positive, particularly in relation to care practice and the provision of a very homely environment for service users. The proprietor and her husband were on duty and continue to illustrate a thorough knowledge, interest and concern for the service users, two of whom were at home. One Service User has been ion hospital for over four weeks with a fractured femur. What the service does well: What has improved since the last inspection? What they could do better: It was felt that the home is operating extremely well and that all policies, procedures and practice issues are of an exceptional standard. No areas were identified as requiring action on this occasion. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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 St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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) 1,2,3,4 and 5 The home has produced a Statement of Purpose and Service Users Guide. The home manager carries out assessments of prospective Service Users EVIDENCE: The manager is able to carry out full assessments on service users prior to admission. Relatives and/or representatives are involved in this process when service users have problems expressing themselves. Observation and discussion with staff members and an inspection of records indicated that the home had the capacity to meet the service users’ assessed needs. The registered manager stated that unplanned admission to the home is avoided and emergency placement would not be considered. Recently the home admitted a Service User for respite care and did an assessment whilst she was living there. However it was recognized before the end of the respite period that the placement could not meet her needs effectively and she was discharged. This was capably undertaken by the registered manager. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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, 8, 9 and 10 The systems for Service User consultation are good with a variety of evidence that indicates Service Users views are both sought and acted upon. EVIDENCE: Each service user has a care plan in place, which is thorough and covers the assessed needs of the service user. Care plans reflect involvement from other agencies such as the local GP and primary health care teams. It was evident that the needs of individual Service Users were identified and an action plan put in place to meet their needs. There was evidence of reviews being carried out by the key workers and of the action taken as a result of the review. It is general practice at St Andrews House to involve Service Users in a number of daily activities within the home. There are regular Service Users meetings held and they are given the opportunity to express their views. There was evidence that risk assessments were usually carried out on each of the service users on a regular basis. Staff are aware of the need for confidentiality and are aware that information about service users is confidential. They are aware of the home’s policy, which is clear and to the point. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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, 13, 14, 15, 16 and17 Service Users are encouraged to become as involved with the local community as they wish to and in line with their individual programme of care. EVIDENCE: Each Service User has the opportunity to follow hobbies and interests outside the home. There are sufficient lounge areas in the home, and all Service Users have spacious and well-designed bedrooms. All the Service Users have regular holidays twice a year and are accompanied by staff. Service Users chose the destination with appropriate staff input. All Service Users have regular contact with their families, and there is weekly contact with families and friends by telephone. Service users were given open access to the home subject to their individual risk-assessments and the inspector saw Service Users using different parts of the home. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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 and 20 Staff provide appropriate personal support to service users which met their individual needs. EVIDENCE: The health care needs of Service Users are kept under constant review and appropriate assistance was sought when necessary. Where possible Service Users are involved in decisions about their health care needs. Medication procedures and records were examined and medication administration charts viewed showed that medication administered was recorded and stored appropriately. Staff undertaking medication administration received relevant training prior to undertaking this task and demonstrated that they understood the importance of this training and the need to administer medication safely. Service Users in this home are all currently physically fit and mobile. Staff provide appropriate personal care. The home has a policy and procedure regarding the administration of medication. Medication is stored in a locked metal cabinet. None of the current Service Users have been prescribed with controlled drugs. All Service Users have their own medication file and records viewed were seen to be up to date and accurate. Staff conduct a full audit of all medication once a week. The Royal Pharmaceutical Society Guidelines are in place. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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) 22 and 23 There is a comprehensive complaints procedure in place which serves to protect Service Users from any aspect of abuse EVIDENCE: The home has an Adult Protection procedure including a Whistle Blowing policy. On the day of the Inspection the Inspector was not aware nor was he made aware of any complaint having been made about this service. The home has developed its complaints procedure to incorporate details of the Commission for Social Care Inspection. The complaints procedure was found to be clear and easy to read. All Service Users are provided with details of the company’s complaints procedure. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 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, 27, 28, 29 and 30 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: The position of the home is suitable for its purpose; it is easy to get to, safe and well maintained, meeting service users’ individual and shared needs in a comfortable and informal way. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. The premises were bright, homely and comfortable. The lighting and heating appeared sufficient as to meet the needs of the service users. Service users bedrooms contain furniture and fittings that were homely and non-institutional and these were provided with full discussion with service users. There are two bathrooms and toilets available for service users. The shared and private areas in this home are of a very good standard. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 14 The premises were clean and tidy and odour free. Infection control systems are in place. There were appropriate arrangements in place for hand washing and for the washing of personal clothing. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 15 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) 31, 32, 33, 34, 35 and 36 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: At the day of the inspection personnel files were seen and considered to be correct. All documents required by Schedule 2 of the Care Homes Regulations 2001 were accessible in individual files. Staff meetings are in place and are organised monthly. Staff meeting-minutes were seen as part of the inspection procedure. The manager gave confirmation of a professional and full induction period for new members of staff. All members of staff receive supervision on a regular basis. 100 of staff have completed or are undertaking NVQ training. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 16 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, 39, 40, 41, 42 and 43 The manager has a clear development plan and vision for the home, which she has effectively communicated to the Service Users, staff and relatives. EVIDENCE: The proprietor/manager has completed (December 2003) NVQ Level 4 and the Registered Managers Award. There were policies and procedures in place for the health, safety and welfare of service Users and staff. The proprietor’s accountant monitors the expenditure of the home and the proprietor is fully aware of her financial responsibilities to the Service Users in providing a good safe environment. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 17 The frequency of staff meetings and informal supervision was indicative of an open and helpful atmosphere. Important policies and procedures were in place. Systems exist to show these had been communicated to staff. Also those of importance to service users had been shared with them. Records examined included; care plans, medication procedures, risk assessment policies and service user activity programmes. They were seen to be in good order. Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 18 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Andrews House Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 2 H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 19 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 Regulation Requirement There are to be no requirements from this inspection Timescale for action 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 Good Practice Recommendations There are to be no recommendations from this inspection St Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Andrews House H58 H09 s13794 St Andrews v216568 110705 Stage 4 ann.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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