CARE HOME ADULTS 18-65
St Andrews Court 53 Beeches Road West Bromwich West Midlands B70 6HL Lead Inspector
Lesley Webb Key Unannounced Inspection 16th May 2007 08:45 St Andrews Court DS0000028406.V334247.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.V334247.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.V334247.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 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.V334247.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th July 2006 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.V334247.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector undertook this visit over one day with the home being given no prior notice. During the visit time was spent talking to people who live at the home, examining records and observing care practices before giving feedback about the inspection to the registered manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking two individuals care provided at the home. Eight survey forms were completed by people who live at the home and the relatives of four individuals also completed and returned questionnaires to The Commission For Social Care Inspection. Information from these and from documentation supplied by the home prior to the visit was used when forming judgements on standards of service provided. The current fee charged for people living at the home is £950.00 per week. The inspector was shown full assistance during the visit and would like to thank everyone for making her welcome. What the service does well:
All people have a full assessment of needs completed before they are admitted to the home to ensure the home can be confident of meeting needs of individuals. The Commission received six relatives’ surveys for Social Care Inspection (CSCI) prior to the visit. Compliments include, ‘the care home provides a caring and supportive environment whilst operating firm boundaries. My relative has an individual care plan, he has received help to straighten out his finances, he has signed on with a local G.P and is becoming involved in sport and educational activities’. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. Asked ‘do you make decisions about what you do each day’ and ‘can you do what you want during the day and evening’ half responded ‘always’ and half ‘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. 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. All of the people residing at this home have structured support plans in place to increase their independent living skills based on their capabilities. As one member of staff explained, “these needs are identified in the assessment process and form part of the action plan. The whole point of what we do here is to maintain or
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 6 promote independence”. The home has a real emphasis on rehabilitation and works well with individuals in meeting their goals. Friends and family are welcome to visit the home. As one person living at the home explained, “my boyfriend sees me four or five nights a week and at weekends and we go away on holiday together. Visitors are welcome, my dad comes once a week and takes me to church”. The health and personal care that people receive is based on their individual needs. For example one person states ‘staff take care of my brothers physical needs and given him emotional support. It is the best care home he has been in’ and another ‘the home make sure my relative has regular checkups such as blood pressure, blood and sugar levels’. People living at this home are able to express their concerns, and have access to a robust, effective complaints procedure. Of the eight service user questionnaires completed all stated they would feel happy to approach staff to raise concerns. 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. Individuals spoken to during the inspection felt that they receive very good support from the staff. For example one person explained, “Staff help you sort your problems, there for you to talk to if feel down”. Recruitment practices and procedures are robust, ensuring people living at the home are protected from harm and the management of health and safety safeguards people living at the home. What has improved since the last inspection? What they could do better:
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.V334247.R01.S.doc Version 5.2 Page 7 The homes adult protection, aggression and restraint policies must be updated to ensure they comply with relevant legislation and protect people who live at the home from risk of injury or harm. Sufficient numbers of staff must receive training in areas such as challenging behaviour, mental health, moving and handling and health and safety to ensure staff are suitably qualified to support people living at the home. Improvements to quality monitoring systems must take place 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. 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.V334247.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.V334247.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people considering moving into this home have the information needed on which to make decisions on its suitability. People can be assured that they will have a full needs assessment prior to admission and the home will be satisfied it can meet their needs. EVIDENCE: As at previous inspections all people have a full needs assessment before they are admitted to the home. The files of the two most recently admitted people to move to the home were seen at the inspection in order to inspect assessment procedures and practice. It was found that the home itself has very good systems in place for ensuring that peoples needs are fully assessed before any decision is taken about them moving to the home. 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 was evidence of Care Programme Approach documentation and risk reduction plans. Each person has an individual plan based upon their assessment and this is kept under regular review by the support team and the residents. Choices and restrictions are indicated within the plans. The Commission
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 10 received six relatives’ surveys for Social Care Inspection (CSCI) prior to the visit. All state that the home always or usually meets the needs of their relative. Additional compliments were also recorded including, ‘in the previous care home my son was in he used to have a bath weekly, here he has a bath daily. He has clean clothes on every day and looks clean whereas before they struggled to change him daily’ and ‘the care home provides a caring and supportive environment whilst operating firm boundaries. My relative has an individual care plan, he has received help to straighten out his finances, he has signed on with a local G.P and is becoming involved in sport and educational activities’. St Andrews Court DS0000028406.V334247.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 are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: As at previous inspections all of the residents files sampled contained clear plans of care that detail risks and relapse triggers for individuals. The Support Plans of two people were seen in order to assess the home’s care planning processes and practice. 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. The plans are comprehensive and include agreed objectives and support tasks. From discussions with the people living at the home it was confirmed that they are fully involved in the development and review of their support plans. 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
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 12 restrictions placed upon their movements are aware of them and the home works well to support them in this area. This was reinforced in the questionnaires completed by eight of the ten people 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’ half responded ‘always’ and half ‘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. All relatives that completed questionnaires also confirmed the consensus that the needs of individuals are being met; all of who state the home always gives the support or care their relative expects. An additional comment was also made by one relative of ‘the staff here are very friendly, polite and approachable. They are very helpful and always give us advice which is very handy’. 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. This risk assessment is developed in consultation with the individual and action is taken to minimise identified risks. 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. It is recommended that instructions relating to notifying CSCI in line with Regulation 37 of the Care Home Regulations 2001 also be included to ensure the home meets its legal obligations. St Andrews Court DS0000028406.V334247.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: 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 member of staff explained, “these needs are identified in the assessment process and form part of the action plan. The whole point of what we do here is to maintain or promote independence”. None of the people living at St Andrews are in paid employment, however they do take part in valued and fulfilling activities. Individuals go to the local
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 14 church to help and volunteer in local community projects. Some take part in college courses, including pottery, whilst others have undertaken courses with the Open University. Residents are also taken out by support workers and enjoy nights in the pub and other social activities during the weekend. Relationships are encouraged as is maintaining links with family and friends. The home has a real emphasis on rehabilitation and works well with individuals in meeting their goals. 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 one person living at the home explained, “my boyfriend sees me four or five nights a week and at weekends and we go away on holiday together. Visitors are welcome, my dad comes once a week and takes me to church”. Information supplied to CSCI by the home prior to the visit states 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. This information was assessed as accurate when the inspector visited the home. For example 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. St Andrews Court DS0000028406.V334247.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 based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Evidence indicates that 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, opticians and the dentist. All surveys completed by relatives of residents praised the support given by the home in this area. For example one person states ‘staff take care of my brothers physical needs and given him emotional support. It is the best care home he has been in’ and another ‘the home make sure my relative has regular checkups such as blood pressure, blood and sugar levels’ The home has a separate clinic room for the storage of medication. Records are kept of all medicines received, administered and leaving the home to ensure that there is no mishandling of medication. In the main it appears medication systems appear adequate however the inspector said that she
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 16 would contact a CSCI pharmacy inspector for advice in relation to information required on medication administration sheets and times of administration to ensure everyone is protected by the homes current systems and practices. Medication policies were found to be in place for both using and not using the ‘medi dose pack’ system, administration, recording, training, errors and controlled drugs. The home was instructed to devise and implement written procedures and protocols for the use of ‘as required’ medication and homely remedies, again to ensure people are protected by the homes current systems and practices. St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 17 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 adequate. 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. Protection policies and procedures within the home need to be reviewed in order to offer comprehensive 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. Of the eight service user questionnaires completed all stated they would feel happy to approach staff to raise concerns. People that the inspector spoke to during the visit confirmed this information. For example one person explained, “I used to lose my temper but I am a lot better now. They talk to you about that. The complaints procedure, when I first came here it was explained to me, but I have never had reason to complain, the manager has our best interests at heart, I think this a very professional place”. The Protection of Vulnerable Adults Policy requires reviewing to include National and Local authority guidance; so that staff can be clear of their responsibilities in reporting suspected abuse. The home has a policy for aggression, restraint and abuse that also requires reviewing as it currently does not include training that staff must undertake if the need to restrain someone should occur and also contains information that conflicts with local authority guidelines in relation to adult protection. If implemented, the policy
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 18 in its current form has the potential to place both people who live at the home and staff at risk of injury or harm. Information supplied to CSCI prior to the inspection by the home states that states all service users 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. The records and finances of two people were examined and found to be accurate. It is recommended that receipts be numbered to correspond with recordings on personal allowance sheets for ease when auditing. St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 19 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 to 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: The home is maintained, decorated and furnished to a very high standard. A tour of the premises was undertaken. Since the last inspection the extension to the rear of the building has been completed resulting in a new smoke room, staff room, residents kitchen, laundry and clinic facilities. Also six bedrooms, the dining room and hallways have been decorated, ensuring people live in a comfortable and homely environment. The kitchen was seen to be well stocked and clean. It was noted that there are no fly screens at any of the windows, that the majority of the food items in the fridge were not labelled with the date of opening and that no food analysis is in place. However records of fridge, freezer and water temperatures are
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 20 maintained. The registered manager explained that she had contacted the Environmental Health Department on several occasions to request they visit the home and give advice but as yet this had not taken place. The inspector said that she would contact them and request a to ensure people living at the home are protected from risk of infection. The laundry room was inspected with the appropriate washing and drying facilities in place. Of the eight questionnaires completed by people living at the home all state that the home is always fresh and clean. St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 21 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): 32,34,35 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 are skilled and in sufficient numbers to support the people who live at the home. EVIDENCE: 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. The home has a very good relationship with the multi disciplinary team, who are consulted at regular intervals. Individuals spoken to during the inspection felt that they receive very good support from the staff. For example one person explained, “Staff help you sort your problems, there for you to talk to if feel down”. Four staff files were viewed in order to assess the homes recruitment and selection practices. 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. It is recommended that the home review its application form, as this currently does
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 22 not ask for details of full employment history or for explanations for gaps in employment. This would offer further protection to people living at the home. A training matrix was examined, giving details of twenty staff employed at the home. Of these thirteen have undertaken training in medication, thirteen adult abuse, eight mental health and three challenging behaviours and aggression. The inspector explained that the home must ensure sufficient numbers of staff receive training in areas such as challenging behaviour and mental health to ensure people who live at the home receive the required support to meet their needs. Of the four staff files sampled all contained evidence that staff receive 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. St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 23 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 good. This judgement has been made using available evidence including a visit to this service. The home is well run by a manager who is experienced and competent. Developments must be made in the quality assurance systems within the home to ensure residents are confident that their views underpin all self-monitoring, review and development by the home. EVIDENCE: The manager is both competent and experienced. Since the last inspection she has enrolled on the NVQ level4 in management and is due to complete by September 2007. The home is still required to implement quality assurance procedures and systems, including obtaining and recording the opinions of service users, friends, relatives and visitors. The registered manager explained that she has purchased a quality assurance system that is awaiting implementation. She
St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 24 confirmed that monitoring of various aspects of the service already takes place in the form of service user reviews, 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. A service user survey was completed 29/9/06 by seven of the ten people living at the home and three residents meetings have taken place this year. Subjects discussed include if people are aware of the complaints procedure, if staff are helpful and friendly, opinions on cleanliness of the home, meals and activities. Responses ask for more lamb curries, pizza, would like to cook more, would like to attend Sandwell College to learn hairdressing and would like to change her room. A formalised quality assurance system will ensure action is taken in a timely fashion to address requests made by people living at the home. Information supplied by the home prior to the inspection states that the fire department visited the home 08/09/05, fire equipment was checked December 2006, the most recent fire drill took place06/04/07, fire training November 2006, fire alarms were tested 24/04/07, the central heating checked 26/04/07, a Legionella check was undertaken on 12/03/07, an electrical wiring certificate issued January 2007, the emergency lighting was checked January 2007 and the lift serviced 13/01/07. A random sampling of records during the inspection found this information to be accurate and that management of health and safety safeguards people living at the home. A training matrix was examined, giving details of twenty staff employed at the home. Of these five have undertaken training in health and safety, ten food hygiene, five moving and handling, nine first aid and fifteen fire. Sufficient numbers of staff must receive training in moving and handling and health and safety in order that people are not placed at risk of injury or harm. St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 25 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 X 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 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 3 2 X 3 X 2 X X 2 X St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement 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. The homes vulnerable adults policy must be updated to include information from National and Local authority procedures in order that people who live at the home are protected from risk of injury or harm. To review and amend the aggression, restraint and abuse policy to ensure it complies with relevant legislation and protects people who live at the home and staff from risk of injury or harm. To ensure sufficient numbers of staff receive training in areas such as challenging behaviour and mental health to ensure people who live at the home receive the required support to meet their needs. Timescale for action 01/08/07 2 YA23 13(6) 01/08/07 3 YA23 13(6) 01/08/07 4 YA32 18(1)(a) 01/08/07 St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 27 5 YA39 24 To make improvements to 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 is an outstanding requirement from 12th October 2004. Sufficient numbers of staff must receive training in moving and handling in order that people are not placed at risk of injury or harm. 01/09/07 6 YA42 13(3)(5) 01/08/07 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 YA9 Good Practice Recommendations That instructions relating to notifying CSCI in line with Regulation 37 of the Care Home Regulations 2001 be included in the Missing Persons Procedure to ensure the home meets its legal obligations That receipts are numbered to correspond with recordings on personal allowance sheets for ease when auditing and to offer further protection to those living there. That the home reviews its application form, as this currently does not ask for details of full employment history. This would offer further protection to people living at the home. That the frequency of staff meetings increase to inform and support staff further. 2 3 YA23 YA34 4 YA36 St Andrews Court DS0000028406.V334247.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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
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