Inspection on 28/07/06 for St Andrews Court

This inspection was carried out on 28th July 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Andrews Court 11/08/08

St Andrews Court 16/05/07

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 09/07/2008.

CARE HOME ADULTS 18-65 St Andrews Court 53 Beeches Road West Bromwich West Midlands B70 6HL Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 28th July 2006 11:00 St Andrews Court DS0000028406.V305410.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.V305410.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.V305410.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 553 4700 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 Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 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. 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. The home is currently being extended to include a new kitchen, laundry and treatment room. There will also be a large smoking room for residents to access. The home currently charges £950 per week for residency. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from the Commission for Social Care Inspection. It was conducted over four hours. Judgements made within this report are based upon the information received prior to the inspection in the pre – inspection questionnaire and from talking to support workers and the manager during the inspection. Staff and residents files were also seen in monitoring the homes progress in meeting previous requirements. A tour of the home was also conducted. The inspector would like to thank all of the residents, support workers and manager for their hospitality during the inspection. 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 DS0000028406.V305410.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 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 the following standard(s): 2 The outcome for service users in this group of standards was judged to be good. Residents 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: All residents have a full needs assessment before they are admitted to the home. There is very good multi agency working for all residents and there was evidence of Care Programme Approach documentation and risk reduction plans. each service user has an individual plan based upon their assessment and this is kept under regular review by support team and the residents. choices and restrictions are indicated within the plan. New residents are introduced slowly to St Andrews to give them time to make decisions about whether they feel that they will like living there. This also enables the other residents time to adjust to seeing a new face in the home and to accept the changes this brings. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 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 the following standard(s): 6,7,9 The outcome for service users was judged to be good. Service users were active in all aspects of care planning and are positively encouraged to lead as independent lifestyle as possible EVIDENCE: All of the residents files seen demonstrated how their individual needs will be met. There are clear plans that detail risks and relapse triggers for all residents. Those residents that do have restrictions placed upon their movements are aware of them and the home works well to support the residents. The home does not operate a key worker system but staff are able to demonstrate a good clear understanding of all of the residents needs. Residents are encouraged to manage their own finances and to lead as independent life as possible, there is adequate information for support staff to enable residents to take responsible risks and action is taken to minimize risk and hazards. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 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 the following standard(s): 12,13,15,16,17 The outcome for service users was judged to be excellent. Residents have an active life, and can be assured that they will lead fulfilling lifestyles in and outside the home. EVIDENCE: None of the residents at St Andrews are in paid employment, however they do take part in valued and fulfilling activities. Residents go to the local church to help and volunteer in local community projects. Some residents take part in college courses, including jewellery design, whilst others have completed 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 residents in meeting some of their goals. Some of the previous residents have been able to leave St Andrews and progress to independent living. This means that all residents participate fully in the running of the home and completing domestic St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 10 activities such as cleaning, laundry and cooking. Residents have access to all parts of the home. Residents are encouraged to cook their own meals, they also plan their menu for the week, plan the shopping list and then do the shopping. The home has two kitchens one is fully equipped to ensure that residents can cook their chosen meals, the other is new and provides the residents with a smaller kitchen where they can go and make themselves drinks and small snacks should they choose to. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The outcome for service users was judged to be good. The home provides good personal and healthcare support to all residents. there are robust systems in place to deal with the ordering, storage and disposal of medication. EVIDENCE: Each resident has within their individual plan guidance on how they wish to be supported. There are minor adjustments that could be made to further improve the good work already done. This would include making sure that all of the physical health needs of residents are documented in their care plans and actions that support staff need to be aware of included. Each residents needs are recorded on a tracker sheet and this provides an accurate diary of all hospital appointments and other health checks for each person. The home has good systems in place to ensure that residents receive their medication. At present none of the current residents are administering their own medication. The home receives support from residents GP’s, Mental health worker and psychiatrists when looking at the effectiveness of the medication that has been prescribed for each resident. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 12 There are adequate procedures in place to deal with ordering, storage and disposal of medicines. Support staff are attending training to improve their knowledge in the “safe handling of medicines”. Controlled drugs are stored securely within the premises. The home will benefit from much larger clinic room once the building and decorating work has been completed. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The overall outcome for this group of standards was judged to be good. Residents can be assured that their views will be listened to and acted upon, and that they will be protected from abuse. EVIDENCE: The home has received no complaints since the last inspection 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. This has been temporarily removed whilst the building work is finished. There are adequate systems in place for protecting residents from abuse and staff at the home are undertaking training to refresh their knowledge and skills. Staff spoken to during the inspection demonstrated an excellent knowledge of adult protection procedures and their role in reporting suspected abuse. The home has good systems in place for handling money and residents are encouraged to be responsible for their own money management St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The overall outcome for residents was judged to be good. Residents are living in a well maintained and clean home. EVIDENCE: The home is well maintained, a tour of the premises was undertaken and work to the extension is nearing completion. Once completed it will offer, a new treatment room for the storage of medicines, an office for the administrator, and a smoking room with French doors leading to the patio and garden. Residents will also benefit from a new laundry to enable them to be able to complete their laundry in a spacious room and a smaller kitchen where they will be able to make themselves drinks and snacks throughout the day. The rest of the home is well maintained and those residents rooms that were seen were decorated to their own preference and personalised with their belongings. Residents are encouraged to help with the domestic tasks around the home, but in particular are supported to keep their own rooms tidy and clean. At the time of the inspection the home was clean, hygienic and free from odour. It was pleasing to note that despite the disruption of the building work residents were settled and had managed the changes very well. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 The overall outcome for this group of standards was judged to be good. Residents can be assured that staff are recruited safely, provided in sufficient numbers and have the necessary skills and knowledge to meet their needs. EVIDENCE: The home is working well to meet it’s target of having all of the support staff qualified to a minimum of NVQ level2. Some support staff have completed their NVQ level 2 and are now progressing onto their NVQ level 3 training. Staff spoken to in the day of the inspection had a comprehensive knowledge of the residents needs and for the tasks they are expected to do. There are adequate staff on duty at all times, the manager and deputy are not included in the staffing numbers. On each shift there is usually one senior and three support workers. At night time the home is staffed with two nurses. All of the staff files seen contained all the required information and it was pleasing to see that staff are being recruited in a safe manner and that all appropriate PoVA and CRB disclosure had been completed. The manager is in the process of providing each member of staff with an individual training plan. All staff are encouraged to participate in training. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 16 Staff do receive regular supervision and records are kept. Staff reported that they found these sessions to be beneficial in giving them guidance and identifying training needs. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The overall outcome for this group of standards is judged to be adequate. 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, there is an outstanding requirement that she enrols on the NVQ level4 in management. There is currently no effective quality assurance system in place at the home. The manager must look at ways to introduce a system that demonstrates the residents of St Andrews are confident that their views will underpin the aims and objectives for the home. Information taken from the pre inspection questionnaire completed by the home demonstrates that all required servicing and insurance is in place and up St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 18 to date. There are risk assessments in place that address hazards within the environment and the risk reduction plan. Staff are enrolled in training programmes to ensure that they attend mandatory training in health and safety, infection control and first aid. Regular fire training is also undertaken by the home and appropriate records maintained. St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 19 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 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 3 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 1 X X 3 X St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 20 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. 2. Standard YA39 Regulation 24 Requirement 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 from12th October 2004. 2 YA37 9 The Registered Manager must be qualified to NVQ level 4 in management. This is an outstanding requirement from 01/04/06 01/10/06 Timescale for action 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Andrews Court DS0000028406.V305410.R01.S.doc Version 5.2 Page 21 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: 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 DS0000028406.V305410.R01.S.doc Version 5.2 Page 22 - 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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