Inspection on 20/04/05 for St Andrews Court

This inspection was carried out on 20th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Andrews Court 11/08/08

St Andrews Court 16/05/07

St Andrews Court 28/07/06

St Andrews Court 08/12/05

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 09/07/2008.

CARE HOME ADULTS 18-65 St Andrews Court 53 Beeches Road West Bromwich West Midlands B70 6HL Lead Inspector Mike Kirton Unannounced 20th April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Andrews Court Address 53 Beeches Road, West Bromwich West Midlands, B70 6HL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 553 4700 Mrs Paulette Rowena Shirley Mrs Paulette Rowena Shirley Care Home 12 Category(ies) of Mental disorder, excluding learning diability or registration, with number dementia of places St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 12th October 2004 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 WC’s (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. There is a room just outside the office where the medication is stored and a lift that goes from the ground floor to the second floor. 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. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection five service users, five staff members, the deputy manager and registered manager/owner were spoken to. The premises were toured and the kitchen and food storage facilities inspected. Additionally the individual care plans, staff files and medication records were examined What the service does well: What has improved since the last inspection? 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 Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 4 Good admission procedures are being followed giving perspective service users the opportunity to get to know the home, staff and other residents. Improvements need to be made with undertaking and completing assessments. EVIDENCE: Prospective new service users are able to visit the home over as often as is necessary, increasing their length of stay each time. Staff are involved in discharge arrangements including attending Care Programme Approach (CPA) and discharge planning meetings. Application forms were also being completed and copies of the referrer’s assessments were kept on file. Although there is often ample time for the home to undertake an assessment to identify the users specific needs in relation to the service being provided this information was not available. Service users reported that the home was ‘good’ and understood that they were there for rehabilitation for a period between 6 months and 2 years. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, & 9 For the service to provide and demonstrate an effective rehabilitation process for all users they must provide more detail in the care plans with timescales for completion of individual tasks. This includes areas such as managing medication, further training, education and housework tasks. EVIDENCE: There are care plans on file and daily plans for individuals’ responsibilities for tasks around the home. These were not found to cover all identified needs or based upon the assessment of risk. Whilst more independent service users said they enjoy living at the home and feel motivated to complete tasks others reported that they did not like it. There are some restrictions in place such as not being able to eat or drink in the lounge areas, which do not promote independence and appear unnecessarily restrictive and institutionalised. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards were not assessed. EVIDENCE: St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Significant improvements have been made to the administration of medication with service users much more involved in the process. This must now be recorded in their care plan. EVIDENCE: Administration records were found to be complete and accurate along with records for the receipt and return of medications. Service users are now also putting their own tablets into their medic packs however there was no evidence that this is undertaken following an assessment or plan of care. Copies of prescription must be held and packs must be dated when started to ensure a record is available of the quantities held. Care plans must also be put in place for medication only to be given when needed (PRN). St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards were not assessed. EVIDENCE: St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 & 30 The home continues to provide a very comfortable, homely and wellmaintained environment. Service users independence is promoted through having access to the kitchen and laundry areas and private rooms with toilet and washing facilities, which they assist in maintaining. EVIDENCE: All areas of the home were found to be clean, tidy and well maintained. The only area requiring modernisation is the smoking area and adjoining toilets. The majority of bedrooms have en-suite shower facilities, however all have their own toilets. The laundry facilities are suitable for the needs of the service users who all wash their own clothes individually with assistance if required. Service users reported that they were happy with how the home is maintained and were pleased with the standard of their own bedrooms. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32,33,34,35 & 36 Whilst the staff working at the home all demonstrated positive attitudes and skills there is a failure in the management to ensure the required employment, training and supervision procedures are being followed. EVIDENCE: Staff interview all reported to enjoy working at the home and in particular the time allowed to work closely with service users on an individual basis. The main theme to emerge was that the home was ‘like a family’. Whilst commitment was demonstrated towards further training and development a need was identified particularly amongst the newer employees, to undergo specific training in mental health awareness. Although staff files had improved including the addition of a new front sheet and records of interviews serious concerns were raised again regarding the failure to obtain criminal record checks (CRB & POVA) before employment commenced. There were also insufficient induction and training records although this did vary amongst the staff files. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Further checks must be implemented to ensure food is stored correctly and is not kept when out of date. EVIDENCE: A variety of food items were found to be out of date or stored incorrectly. This appears to be a result of buying in bulk and failing to use older products first. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 15 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 x 2 2 2 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 2 1 2 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Andrews Court Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 16 YES 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 1 Regulation 4&5 Requirement To produce a Statement of Purpose and service user guide and to ensure that all details are included as required by Schedule 1. To forward a copy of the completed documents to the NCSC. These are outstanding requirements from the last inspection. All perspective service users must receive written confirmation as to whether their needs can be met. The use of advocacy services should be encouraged with contact details displayed. These are outstanding requirements from the last inspection. Each service user must have a completed and signed contract, which meets the requirements under this standard. These are outstanding requirements from the last inspection. Care plans need to be developed and implemented with all service users and reviewed at least every six months or as required. Timescale for action 01/08/05 2. 3 14 & 15 01/05/05 3. 5 17 01/06/05 4. 6 15 01/06/05 St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 17 5. 9 6. 10 7. 17 8. 19 9. 18 These are outstanding requirements from the last inspection. 12, 13, 16 Individual risk assessments must & 23 be completed on all identified areas. These are outstanding requirements from the last inspection. 15(2)(a) The homes policies around & 17 access to information need to be developed to enable service users to see their care plans when requested and include procedures for viewing other records. These are outstanding requirements from the last inspection. 12(1)(a) To introduce a recognised nutritional screening tool. These are outstanding requirements from the last inspection. 12 & 13 All health care needs must be assessed and monitored (using the tracker sheet). These are outstanding requirements from the last inspection. 20 All staff administering medication must be trained. Copies of prescription must be kept to check against medication received from the pharmacy. Records must be made of when medication is started. A formalised staged approach, aimed at encouraging and supporting service users to self medicate needs to be introduced within a risk-managed framework. Service users consent to staff administering medication must be obtained. Guidance must be issued for the administration of PRN E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc 01/06/05 01/07/05 01/05/05 01/06/05 01/05/05 St Andrews Court Version 1.30 Page 18 10. 22 22 11. 24 23 12. 34 17 & 19 13. 34 17 & 19 medication. A copy of a photograph must be kept on file. These are outstanding requirements from the last inspection. The homes complaints procedure must include a timescale of 28 days in which a response will be given. It must also state that the CSCI can be contacted at any time during the process. The policy should also be developed to encourage service users and visitors to raise any concerns they may have. These are outstanding requirements from the last inspection. To provide a documented maintenance and renewal programme for the fabric and decoration of the premises. To forward a copy to the CSCI. To carry out a written audit of fittings and furniture provided, where residents choose not to have all of the facilities specified in standard 26.2, decisions must be recorded on individual care plans. To ensure radiators have guaranteed low surface temperatures or are fitted with guards. These are outstanding requirements from the last inspection. To ensure that all information required by the Care Homes Regulations 17(1)(2) schedules 2 and 4 are obtained prior to commencement of duties. These are outstanding requirements from the last inspection. Obtain a signed decloration from 01/06/05 01/08/05 20/04/05 25/04/05 Page 19 St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 14. 35 18(1)(a) 15. 36 18 16. 39 24 17. 40 12 & 13 all staff without a CRB and/or POVA. CRB & POVA applications must be sent within 5 days with the Commission notified of any dely. Staff without a CRB and/or POVA must not work alone. These are outstanding requirements from the last inspection. To implement an induction and foundation programme which meets the Training Organisation for Personal Social Services specification. All staff must have an individual training plan. To provide staff with training commensurate with their duties in the following areas: 1)Basic food hygiene. 2)First aid awareness 3)Moving and Handling 4)Health and Safety 5)Infection Control 6)Vulnerable adult abuse 7)Equal opportunities 8)Awareness including disability equality. 9)Mental Health These are outstanding requirements from the last inspection. All staff must have supervision and an annual appraisal. These are outstanding requirements from the last inspection. The Home must establish an effective quality assurance system, which includes feedback from stakeholders in the community and service users’ questionnaires. These are outstanding requirements from the last inspection. Policies and procedures must be 01/08/05 01/06/05 01/08/05 01/08/05 Page 20 St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 18. 42 13(4) 19. 43 23 developed covering the areas set out in Appendix 2. These should be signed by the manager, dated and reviewed. They should then be signed by staff as read and understood. These are outstanding requirements from the last inspection. To adjust thermostatic mixer control valves on the first floor bath to maintain a safe temperature of 41 – 43 C. To adjust thermostatic mixer control valve on the first floor shower to maintain a safe temperature of 39 C. To carry out a documented risk assessment to identify and undertake control measures to minimise risk of scalding to service users until valves have been adjusted. The Manager must ensure that all food is stored correctly and dated when frozen or opened. The Manager must ensure that all food is within its ‘use by’ date. Risk assessments must be completed for the environment and for activities involving staff, service users and visitors. These are outstanding requirements from the last inspection. To produce a business and financial plan, a copy to be available to the NCSC. This plan should take into account planned and costed changes and be reviewed annually. These are outstanding requirements from the last inspection. 01/05/05 01/08/05 St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 21 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. 2. 3. Refer to Standard 32 37 40 Good Practice Recommendations To give consideration as to how the Home will ensure that 50 of care staff are qualified to NVQ II by 2005. To ensure that the Manager is qualified to NVQ IV in management by 2005. The registered manager should date, sign and provide evidence of regular review of all policies. St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill Halesowen B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Andrews Court E55 S27406 St Andrews Unannounced V222330 190405 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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