Inspection on 05/01/06 for St Andrew`s House

This inspection was carried out on 5th January 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 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 11/07/05

St Andrew`s House 20/09/04

St Andrew`s House 21/06/04

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Southfields

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

CARE HOME ADULTS 18-65 St Andrew`s House St Andrew`s House 93 Downland Way Tattenham Corner Epsom Surrey KT18 5SH Lead Inspector Peter Benthom Unannounced Inspection 5th January 2006 10:00 St Andrew`s House DS0000013794.V252680.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 St Andrew`s House DS0000013794.V252680.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. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Andrew`s House Address 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) St Andrew`s House 93 Downland Way Tattenham Corner Epsom Surrey KT18 5SH 01737 210304 Mrs R Young Mrs R Young Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. The number of persons for whom residential accommodation and personal care is provided at any one time shall not exceed three (4). 11th July 2005 Date of last inspection 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 Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second 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, both of whom were at home. The home is registered for service users but since the discharge of the third service user to hospital and then to a nursing home, the remaining two vacancies have not been filled. What the service does well: What has improved since the last inspection? There is a continual commitment from the proprietor to offer as much opportunity as possible to staff to undertake appropriate training. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 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 House DS0000013794.V252680.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 St Andrew`s House DS0000013794.V252680.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): 1, 2, 3, 4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The manager was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The Statement of Purpose was seen to be in place and contained all information required in Schedule 1 of the Care Home Regulations 2001. The Service User Guide was seen to be appropriate in its content, but requires some updating of relevant information and a copy to be held centrally. The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. St Andrew`s House DS0000013794.V252680.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, 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 proprietors and of the action taken as a result of the review. It is general practice at the service 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. St Andrew`s House DS0000013794.V252680.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, 12, 13, 14, 15, and 16 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 Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 11 Service users make use of the local facilities and go out to pubs and restaurants. Supported by members of staff they go shopping for their toiletries, clothing and footwear. Meals are cooked from fresh ingredients and individuals are respected and enabled to make choices. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 12 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 and 20 The healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. EVIDENCE: Service Users in this home are all currently physically fit and mobile. Staff provide appropriate personal care. All service users are registered with the local GP. A local surgery provides health care to the service users, which includes health checks, continence assessment and some staff training. The arrangements for all aspects of administration of medication were observed to be satisfactory. Medicines for each service user were recorded and stored accordingly in line with the RPS (Royal Pharmaceutical Society) guidelines. 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. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 13 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 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. All Service Users are provided with details of the company’s complaints procedure. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 14 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, 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: Overall the home was in good condition; appropriately decorated, well maintained and furnished to a high standard. The secluded garden is particularly attractive and of a large size, stocked with garden furniture. There were sufficient bathrooms and toilets to meet the national minimum standard. The communal areas in the home were considered safe and accessible for the Service Users. All areas were found to be clean, tidy and well organised. The shared and private areas in this home are of a very good standard. There were appropriate arrangements in place for hand washing and for the washing of personal clothing. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 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 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): 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: Communication between staff was good. All documents required by Schedule 2 of the Care Homes Regulations 2001 were available in individual files. Staff meetings are in place and are organised monthly. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 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 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, 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. The manager illustrates a full commitment to the home and its Service Users. Detailed policies and procedures were in place in relation to safe working practices. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 17 Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 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 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Andrew`s House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000013794.V252680.R01.S.doc Version 5.0 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 N/a Regulation N/a Requirement There are to be no requirements from this inspection Timescale for action 05/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard N/a Good Practice Recommendations There are to be no recommendations from this inspection St Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office 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 Andrew`s House DS0000013794.V252680.R01.S.doc Version 5.0 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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