Inspection on 11/08/08 for St Andrews Court

This inspection was carried out on 11th August 2008.

CSCI found this care home to be providing an Adequate service.

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 Andrews Court 16/05/07

St Andrews Court 28/07/06

St Andrews Court 08/12/05

St Andrews Court 20/04/05

St Andrews Court 12/10/04

St Andrews Court 26/04/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 St Andrews Court 53 Beeches Road West Bromwich West Midlands B70 6HL Lead Inspector Lesley Webb Key Unannounced Inspection 11th August 2008 10:00 St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 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 Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 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 Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrews Court Address 53 Beeches Road West Bromwich West Midlands B70 6HL 0121 553 4700 0121 5534200 pmclarenhouse@aol.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Paulette Rowena Shirley Mrs Paulette Shirley Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection July 2007 Brief Description of the Service: St Andrews Court is a privately owned residential home registered to provide 24 hours care and support for twelve people experiencing mental ill health. The home aims to provide an intensive rehabilitation service to enable users to return to living independently. The three-storey property occupies the end corner of Beeches Road and is similar to other properties in the area. It is within walking distance of the town centre, local shops, and post office, and is easily accessible from the M5 motorway. Parking is available at the front of the home and there are extensive gardens at the rear. On the ground floor are two bedrooms with showers, four separate WCs (two for staff use), lounge, quiet room and a smoke room. There is also a large kitchen, dining area, office and staff room. Laundry facilities are separate and there is a storeroom where the food stocks are kept. On the first floor are seven bedrooms three with en-suite showers, a toilet, and bathroom with toilet, shower and bath. The second floor has three bedrooms two with en-suite showers and a separate bathroom with toilet and shower facility. All bedrooms have en-suite toilets. The home also has a separate kitchen and smoking room for resident’s use and a treatment room. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We carried out this inspection over one day. The home did not know we were coming. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the inspection the home supplied information to us in the form of its Annual Quality Assurance Assessment (AQAA). We also received six surveys completed by people living at the home. Information from both these sources was also used when forming judgements on the quality of service provided at the home. People who live in the home were case tracked. This involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: Assessments of need are completed before any new person moves into the home. This ensures the home is aware of the support a person needs before offering them a placement. A variety of visits to the home are offered to people before they move in permanently. This helps people decide if the home is suitable for them. The daily notes and review records completed by the home are very detailed and informative. These give comprehensive information relating to all areas of support people residing at the home receive. People who live at this home are able to make choices about their life style, and supported to develop their life skills. As one person explained, “we have cooking programmes; do all parts of it, from the shopping, cooking, washing up afterwards”. A choice of menus are in operation that meet the dietary needs of people St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 6 People are supported to maintain their personal care in order that their dignity is maintained. All of the six residents surveys we received before our inspection confirm people living at the home know who to speak to if not happy and how to make a complaint. As at previous inspections the home is decorated and furnished to a very high standard, making it a nice place for people to live in. Staff in the home; generally have the skills to support the people who live there. What has improved since the last inspection? What they could do better: Written agreement from the relevant health specialists must be obtained when medication is administered at times that differ from those on the dispensing labels. This is needed to ensure residents are not placed at risk of maladministration due to the types/strengths of medication that are being administered. The frequency of residents meetings should increase to offer greater opportunities for residents to be involved in decision-making. A written policy must be implemented for the administration of ‘as required’ and ‘homely remedies’ medication to ensure people living at the home are protected by its systems and management of medication. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 7 Medication competency assessments should be introduced that are reviewed on a regular basis to ensure staffs practices reflect knowledge gained through training. A complaints log should be implemented that includes informal issues and outcomes. This will help evidence the home is open to criticism and views concerns as a way of developing the service. The home must ensure we are notified of all suspected abuse at the time when this is first reported to ensure the wellbeing of residents is monitored. A review of the current recording systems for training should be undertaken, with copies of certificates maintained in the home and an up to date training matrix put into place. This will help monitor sufficient numbers of staff are suitably qualified to support people living at the home. The home should implement quality monitoring systems, including obtaining and recording the opinions of residents, friends, relatives and visitors. This will help the home measure if it is consistently meeting the needs of residents. Greater numbers of staff should receive training in moving and handling training, food hygiene and first aid to ensure people living at the home are not placed at risk of injury or harm. Risk assessments should be completed for all areas of the building, the contents of which can then be assessed when the monthly visual checks are undertaken. This will promote the health and safety of both residents and staff. A full list of recommendations is detailed at the back of this report. 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. The summary of this inspection report can be made available in other formats on request. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 8 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 Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be assured that they will have their needs assessed in full prior to admission. This ensures the home can meet their needs. EVIDENCE: We examined documentation relating to the newest person to move into the home and found that assessments of need were completed before they moved in. This ensures the home is aware of the support a person needs before offering them a placement. The needs assessment includes a personal history, daily living skills, risk assessments, physical and mental health, early warning signs and relapse prevention plans. There is very good multi agency working for all residents and there is evidence of Care Programme Approach documentation and risk reduction plans. Each person has an individual plan based upon his or her assessment and this is kept under regular review. Records also evidence that a variety of visits to the home are offered before people move in permanently. These include day visits, overnight stays and longer. The range of visits to the home was also confirmed by one resident that we spoke to who explained, “I came here so many times before moving in I lost count, lots and lots of day visits, overnights and then stayed for fortnight”. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 10 Six residents surveys were completed and returned to us before our visit. Five state they were asked if they wanted to move into the home and received enough information before so they could decide if was suitable and one that they did not. Additional comments made include ‘I came here straight from a mental hospital, I was told I had to go here’ ‘I came to see what it was like, I asked if I could come to St Andrews’ ‘I was slowly introduced to this home taking over night leave then weeks then months before moving in’. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals generally are involved in decisions about their lives, and play role in planning the care and support they receive. EVIDENCE: As at previous inspections all of the residents’ files we sampled contained clear plans of care that detail risks and relapse triggers for individuals. The needs summary obtained from the assessment information is used as a basis for the development of the support plan. This plan is discussed with the individual, who signs their agreement, however we did note that this had not taken place on two of the three plans we sampled. The plans are comprehensive and include agreed objectives and support tasks. The home should be congratulated for the daily notes and review records it maintains. These are very detailed and informative, giving comprehensive information relating to all needs of individuals residing at the home. People that do have restrictions placed upon their movements are aware of them and the home works well to St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 12 support them in this area. As at the previous inspection this was reinforced in the questionnaires completed by six of the eight people currently residing at the home. Asked ‘do you make decisions about what you do each day’ and ‘can you do what you want during the day and evening’ four responded ‘always’ and two ‘sometimes’. The majority of people completing the questionnaires made additional comments indicating that they recognised that some choices and restrictions are in place due to their mental ill health needs. The people who currently reside at this home are able to express their opinions. They informed us of rules with regard to living at the home and consequences if these are broken. As one person explained, “no eating supper in the smoking room because of health and safety, do not pull fire doors closed as affects how they shut and can be dangerous if there was a fire”. Residents meetings take place in order to support people in decision-making processes. We found written evidence that these occur once a year. It is recommended that the frequency of these increases to offer greater opportunities for residents to be involved in decision-making. Residents that we spoke to confirmed their enjoyment of these meetings, with many saying they would like more of them. All people who reside at this home are subject to a risk assessment at the point of referral as part of the Care Programme Approach. The risk assessment is developed in consultation with the individual and action is taken to minimise identified risks. We did note that in a few instances risk assessments have not been completed to support identified needs as detailed in the plans of care. We advised that when plans are next reviewed the home ensures risk assessments are in place that work in conjunction with plans of care. This will promote a holistic approach to care management. The home has a Missing Person Procedure in place. This gives instructions on immediate action to be taken to safeguard people living at the home. Since the last inspection this has been reviewed to include instructions with regard to notifying CSCI in line with Regulation 37 of the Care Home Regulations 2001 to ensure the home meets its legal obligations. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live at this home are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: As at the previous inspection all of the people residing at this home have structured support plans in place to increase their independent living skills based on their capabilities. For example each person is supported to plan, prepare and cook their own meals, tend to their own laundry and clean their own rooms. As one person explained, “we have cooking programmes; do all parts of it, from the shopping, cooking, washing up afterwards. Have to wear aprons and wash hands. There are only 3 people allowed in the kitchen at a time because of health and safety”. The home has a real emphasis on rehabilitation and works well with individuals in meeting their goals. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 14 None of the people living at St Andrews are in paid employment, however they do take part in valued and fulfilling activities. Some take part in college courses; many regularly attend a local gymnasium and one resident volunteers at a local advocacy group. The home has recently introduced a weekly group outing. All residents that we spoke to confirmed their enjoyment of this. Comments made include, “just started weekly day trip about month ago, go different places, zoo, daytrips, going sea life centre, its really good” and “Started doing these trips together a few weeks ago, try and do something as a group every week, its good, have a laugh”. Friends and family are welcome to visit the home. Several individuals also visit their families, some spending nights and weekends away. People are free to develop friendships (including intimate friendships) of their choice and advice with regard to contraception is given if needed. As at the previous inspection we found that a choice of menus is in operation, that dietary and minority ethnic groups are catered for and facilities for making drinks and snacks are available. The home maintains records of alternative meals chosen by individuals and there is an additional kitchen, separate from the main kitchen that is used by people living at the home to make drinks and snacks when the choose. Residents that we spoke to confirmed their enjoyment of meals provided. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is generally based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: People that we spoke to confirmed they are supported to maintain their personal care in order that their dignity is maintained. The level of support people require varies but in the main consists of prompts from staff rather than physical support. As at the previous inspection evidence indicates that generally people living at this home have access to a range of specialist community services should they require them. These include the mental health teams, general practitioners and other specialists. Tracking sheets are used to detail appointments and those we sampled evidenced visits to the hospital for blood tests, dental appointments, psychiatrist assessments and dentists. When giving feedback to the registered manager and deputy we advised that the home look to St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 16 implementing health action plans to promote a holistic approach to health management. We also advised that they ensure all residents are given the opportunity to undertake hearing and optician tests as the records of some people we looked at do not evidence they have undertaken these recently. After our main inspection last year we arranged for the commissions pharmacy inspector to visit the home to assess medication practices further. The pharmacy inspector visited July 2007 making several requirements and recommendations. During this inspection we assessed what action the home has taken to address these and found that many are now met. For example medication record charts are now checked for accuracy by the deputy manager, they now include residents date of birth and General Practitioner name, written directions for medication recorded on the medicine charts now match the directions printed on the label of the medicine container and records for controlled drugs now ensure safe storage, administration and monitoring. A thermometer is now maintained in the medication cabinet. Records are still needed that demonstrate the temperature is being monitored to ensure medication is stored according to the manufacturers instructions. Medication policies have been reviewed however policies are still needed for ‘homely remedies’ and the use of ‘PRN’ (as and when required) medication. We were informed staff have received medication training from the local supplying pharmacy. We discussed this with the deputy manager advising that competency assessments be introduced that are reviewed on a regular basis to ensure staffs practices reflect knowledge gained through training. When examining three residents’ files we found a form for consent for medication to be administered by staff, but none have been signed. When the pharmacy inspector visited the home it was identified that some medication is being administered at times different from that stated on the dispensing labels. This is still the case at this inspection. The deputy manager informed us times have been changed and agreed with consultants. We asked if this is recorded anywhere who stated, “very rare, might be on plan, its discussed with CPN, might be recorded”. We could not find any written agreement on the three residents files we case tracked. Action must be taken to ensure written agreement for changes in times of administration is maintained to ensure residents are not placed at risk of maladministration. Records for the receipt and disposal of medication were available and the date of opening was recorded on the majority of the medication containers. This meant that a medication audit could be undertaken to ensure that medication had been administered according to a medical practitioners directions. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 17 St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home are able to express their concerns, and have access to a robust, effective complaints procedure. Policies and procedures within the home protection from abuse, neglect or self-harm. EVIDENCE: As at the previous inspection the home has received no complaints and has good systems in place to be able to deal with the concerns, complaints and enquiries. The home displays the complaints procedure in the hallway for all residents to be able to freely access. All of the six residents surveys we received before our inspection confirm people living at the home know who to speak to if not happy and how to make a complaint. Additional recordings include ‘I speak to X, the manager and my social worker if not happy’ ‘if I have difficulties I go to my social worker. I have not had to need to use the complaint procedure’ and ‘I can speak to staff if I’m unhappy’. Residents that we spoke to during our visit confirmed the contents of surveys as correct, informing us they would raise concerns with either the home or their social workers. When reading the daily records for three of the residents we saw that the home received a concern from a centre that a resident attends. We discussed this with the registered manager advising that a complaints log be implemented that includes informal issues and outcomes. This will help St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 19 evidence the home is open to criticism and views concerns as a way of developing the service. Since the last inspection the home has reviewed its Protection of Vulnerable Adults Policy to include National and Local authority guidance so that staff can be clear of their responsibilities in reporting suspected abuse. The majority of staff have undertaken abuse training again this ensures they understand what to do in reporting suspected abuse. There has been one allegation of abuse since the last inspection. This was not upheld. The home did not notify us of this in line with Regulation 37 of the Care Home Regulations 2001. The registered manager stated that the form for informing us was filed by mistake. The home must ensure we are notified of all suspected abuse at the time when this is first reported to ensure the wellbeing of residents is monitored. Some of the people who currently live at the home have behaviours that can challenge with appropriate support plans and monitoring records in place. The training matrix stated six staff having received training in this area. It is strongly advised greater numbers of staff undertake challenging behaviour training and that this is renewed at least every 3 years. This will help ensure staff have sufficient knowledge to support residents. Information supplied by the home to us prior to the inspection states all residents have their own bank and building society accounts as part of their rehabilitation programme and that they are supported by staff with their budgeting programmes St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who live there to do so in a safe, well maintained and comfortable environment, which encourages independence. EVIDENCE: As at previous inspections the home is decorated and furnished to a very high standard. A tour of the premises was undertaken with no issues identified. On the ground floor are two bedrooms with showers, four separate WCs (two for staff use), lounge, quiet room and a smoke room. There is also a large kitchen, dining area, office and staff room. Laundry facilities are separate and there is a storeroom where the food stocks are kept. On the first floor are seven bedrooms three with en-suite showers, a toilet, and bathroom with toilet, shower and bath. The second floor has three bedrooms two with ensuite showers and a separate bathroom with toilet and shower facility. The St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 21 home also has a separate kitchen and smoking room for resident’s use and a treatment room. The kitchen was seen to be well stocked and clean. Since the last inspection the Environmental Health Department has inspected the kitchen and has assessed that the home will not need to be visited again for eighteen months. The laundry room was inspected with the appropriate washing and drying facilities in place. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home generally are skilled and in sufficient numbers to support the people who live at the home. EVIDENCE: As at previous inspections staff were observed to be approachable and attentive to the needs of individuals. Those spoken to during the inspection had a good understanding of the needs of individuals that they were working with. Of the six residents surveys that we received three state staff ‘always’ treat them well, two ‘usually’ and one ‘sometimes’. Additional comments recorded include ‘there’s not a member of staff that treats us indifferently we are all treated the same’ and ‘it depends’ We looked at staffing rotas for June to August 2008 and found that staffing levels appear to meet the needs of people living at the home. The registered manager is identified at undertaking 37 hours a week supernumerary to care, a Registered Mental Health nurse is allocated on every shift and between three and support workers are on shift depending on the number of residents at the home. The home is not registered to provide nursing care and the registered St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 23 manager explained the reason for ensuring qualified nurses are employed as being, “because of people we deal with, type of job, we do need qualified, some referrals ask about qualified staff being on duty”. The home should be congratulated for this as it offers further safeguards to residents. We looked at three staff files in order to assess if the homes recruitment and selection practices offer protection to residents. Of those files seen all of them contained an application form and suitable written references, it was also pleasing to see that checks such as the PoVAfirst and Criminal Record Bureau disclosures were in place ensuring people living at the home are protected from harm. We noted that on two of the files we examined copies of training certificates were not in place. A training matrix was examined, giving details of twenty staff employed at the home (not including the registered manager). Of these seven have undertaken training and eight mental capacity act awareness. The matrix details seven staff having completed a National Vocational Qualification (NVQ) at levels 2 or 3 and eight staff qualified as Registered Mental Health nurses. When discussing training with the registered manager and deputy we were informed that the training matrix is not up to date, as it does not contain information with regard to new staff who work at the home and other training that staff have attended. We advised that a review of the current recording systems for training be undertaken, with copies of certificates maintained in the home and an up to date training matrix put into place. This will help monitor sufficient numbers of staff are suitably qualified to support people living at the home. Of the three staff files sampled all contained evidence that staff received a sixweek induction when first being employed at the home and regular, formal one to one supervision. One staff meeting has taken place since the last inspection. It is recommended that the frequency of staff meetings increase to inform and support staff further. We also advised the registered manager that the home should evidence that new workers undertake a minimum of three days shadowing as part of their induction where they are not included on rota. This will help them become familiar with the running of the home and the needs of the residents. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by a manager who is experienced and competent. Quality monitoring systems must be introduced in order that the home can measure if it is meeting its aims and objectives. Improvements to some aspects of health and safety are needed so that residents’ wellbeing is promoted. EVIDENCE: The manager is both competent and experienced. The home is still required to implement quality assurance procedures and systems, including obtaining and recording the opinions of residents, friends, relatives and visitors. This has been outstanding for several years and action must be taken to ensure monitoring systems are introduced for all aspects of St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 25 the service. Evidence sited in other areas of this report demonstrates that monitoring systems need to improve. As at previous inspections monitoring of various aspects of the service already takes place in the form of service user reviews, some health and safety checks and staff supervision but that nothing yet is in place that audits these various monitoring systems or that collates information and is then used to further develop the service. Prior to this inspection the home sent us its Annual Quality Assurance Assessment (AQAA) as we requested. The contents of this were brief in parts and many sections were not completed resulting in minimal information about the service provided to residents. It is recommended that greater detail is included when next requested by the CSCI. This will help evidence quality services that residents receive. The training matrix details seven staff having undertaken moving and handling training (three of these are out of date), four health and safety, ten food hygiene, ten first aid (two out of date), and thirteen fire awareness. We advised that greater numbers of staff receive training in these areas to ensure people living at the home are not placed at risk of injury or harm. We sampled a number of health and safety records and found servicing of equipment for fire, water, gas and electric to be up to date, promoting the wellbeing of residents. There are currently no written risk assessments for the building with regard to health and safety. We were shown a document that is used to record monthly visual checks of the premises. At the front of the folder where these are maintained we found a blank risk assessment form. As we explained to the registered manager and deputy risk assessments should be completed for all areas of the building, the contents of which can then be assessed when the monthly visual checks are undertaken. This will promote the health and safety of both residents and staff. West Midlands Fire Service inspected the home March 2008 instructing that a written risk assessment be completed, that is reviewed annually. We were informed this has been completed. We noted that monthly fire drills take place. It is recommended that the records of these be expanded to include the names of people who participated (currently state ‘all staff and residents’) in order that records evidence that all staff, including new workers and night staff have received guidance in the event of a fire. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 26 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 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 1 X X 2 X St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Written agreement from the relevant health specialists must be obtained when medication is administered at times that differ from those on the dispensing labels. This is needed to ensure residents are not placed at risk of maladministration due to the types/strengths of medication that are being administered. The home must introduce quality monitoring systems so people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. This will help the home measure if it is consistently meeting the needs of residents. Timescale for action 30/09/08 2 YA39 24 01/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 28 No. 1 2 3 Refer to Standard YA7 YA9 YA19 Good Practice Recommendations That the frequency of residents meetings increases to offer greater opportunities for residents to be involved in decision-making. The home should ensure risk assessments are in place that work in conjunction with plans of care. This will promote a holistic approach to care management. The home should consider implementing health action plans to promote a holistic approach to health management. The home should ensure all residents are given the opportunity to undertake hearing and optician tests to promote good health. A written policy must be implemented for the administration of ‘as required’ and ‘homely remedies’ medication to ensure people living at the home are protected by its systems and management of medication. It is recommended that temperature records are available for the clinic room to ensure that residents’ medication are stored within the correct temperature range. Competency assessments should be introduced that are reviewed on a regular basis to ensure staffs practices reflect knowledge gained through training. Residents written consent for medication to be administered by staff should be obtained. A complaints log should be implemented that includes informal issues and outcomes. This will help evidence the home is open to criticism and views concerns as a way of developing the service. The home must ensure we are notified of all suspected abuse at the time when this is first reported to ensure the wellbeing of residents is monitored. Greater numbers of staff should undertake challenging behaviour training that this is renewed at least every 3 years. This will help ensure staff have sufficient knowledge to support residents. A review of the current recording systems for training should be undertaken, with copies of certificates maintained in the home and an up to date training matrix put into place. This will help monitor sufficient numbers of staff are suitably qualified to support people living at the home. DS0000028406.V370396.R01.S.doc Version 5.2 Page 29 4 YA20 5 YA22 6 YA23 7 YA32 St Andrews Court 8 YA35 9 10 YA36 YA39 11 YA42 The home should evidence that new workers undertake a minimum of three days shadowing as part of their induction where they are not included on rota. This will help them become familiar with the running of the home and the needs of the residents. That the frequency of staff meetings increase to inform and support staff further. Greater detail should be included in the Annual Quality Assurance Assessment when next requested by the CSCI. This will help evidence quality services that residents receive. Greater numbers of staff should receive training in moving and handling training; health and safety, food hygiene and first aid to ensure people living at the home are not placed at risk of injury or harm. Risk assessments should be completed for all areas of the building, the contents of which can then be assessed when the monthly visual checks are undertaken. This will promote the health and safety of both residents and staff. That fire drill records be expanded to include the names of people who participated in order that records evidence that all staff, including new workers and night staff have received guidance in the event of a fire. St Andrews Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Court DS0000028406.V370396.R01.S.doc Version 5.2 Page 31 - 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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