Inspection on 08/12/05 for St Andrews Court

This inspection was carried out on 8th December 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 no outstanding requirements from the previous inspection report, but made 5 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 28/07/06

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 Mr Mike Kirton Unannounced Inspection 8th December 2005 9:00 St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 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.V263143.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 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. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Following the last unannounced inspection several monitoring visits were made to ensure compliance with outstanding requirements. This inspection took place over 4 hours and included interviews with the proprietor, deputy manager and the most recently appointed staff member and service user. Informal discussions also took place with staff and residents who were present during a tour of the buildings. The individual files were examined for both a staff member, service user, and records relating to health and safety. 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.V263143.R01.S.doc Version 5.0 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.V263143.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 20th April 2005. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 20th April 2005. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 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): 12,13,14,15,16,17 St Andrews provides excellent opportunities for service users to become more involved in community activities and develop their skills for independent living. This approach has been successful in enabling them to move onto a less supportive environment and maintaining links with existing support networks including family and friends. EVIDENCE: Each service users has an individual daily living plan showing which activities they are involved with and what responsibilities they have around the home with housework tasks. There are also rosters in the kitchen for preparing meals, drinks and washing up. Service users spoken with were involved with many activities outside the home including day centres, colleges, leisure centres, and gyms. They described feeling very supported by the staff and felt that St Andrews had given them the confidence and skills needed to live an independent life. An annual holiday had taken place in September where the majority of service users went to Spain. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 10 Staff are able to support service users on an individual basis with all their planned activities, which are developed towards their goals identified in their care plan. Visiting arrangements are flexible and links with family, friends, and outside organisations are maintained and encouraged. Drinks and snacks can be prepared at any time with assistance if needed. Service users who are able are provided with a budget with which they undertake their own shopping and plan meals. A cooked dinner is prepared at midday for those not yet ready for this level of independence. All individual preferences and dietary requirements are taken into account. Where an issue is identified with an individuals diet specialist medical advice is obtained and an agreed plan is implemented. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 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 The home has good records and systems of communication with outside agencies to ensure service users health care needs are met. Any restrictions on lifestyle or differences of opinion are discussed and agreed with the individual. EVIDENCE: All support required by service users is clearly identified in their individual care plan and weekly programme. This includes agreed daily routines. Feedback received confirmed that they maintained control over their lives. Comments included ‘I lead an active life’, ‘I feel more confident’ and ‘I have the support from the staff when I need it’. All healthcare needs are identified in the extensive pre-admission assessment information received. These are monitored and reviewed on a regular basis and a record is maintained of each visit undertaken. Each service users has a Care Programme Approach (CPA) which identifies who their key worker is (usually their social worker or CPN). This person liaises with the home and other professionals involved in their care to ensure mental health needs are monitored. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 12 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 Improvements have been made to the complaints procedure and training on adult protection has been provided for all staff. The manager has a good understanding of the importance to protect vulnerable adults and would take immediate action to ensure their safety. EVIDENCE: The comments and complaints procedure has been updated to include contact information for people to approach the Commission should they wish. This had not yet been displayed around the home but immediate action was taken to ensure this was done. No complaints have been received since the last inspection. Discussions took place as to how this system could be improved and incorporated into their quality assurance system such as making comment forms and a posting box available. Staff at St Andrews have recently undertaken adult protection training. Those interviewed were clear about their responsibilities and would report any incidents to their manager. The home has a whistle blowing and adult protection policy in place and is familiar with the Protection of Vulnerable Adults (POVA) procedures. Action is required to ensure a copy of Sandwell Social Services policies are available and that they have clear procedures for reporting incidents, including contact details for the police and adult protection officers. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 20th April 2005. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 20th April 2005. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 15 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 manager has demonstrated that she is committed to ensuring high standards of care are maintained, systems are improved, and outstanding requirements are met. Positive action is taken to ensure the health and safety of service users is protected. EVIDENCE: The manager, with the support of her deputy and staff team have acted on and met many of the outstanding requirements. She is a qualified nurse and worked as a Community Psychiatric Nurse (CPN) for many years. Feedback received during the inspection confirmed that she was approachable and has an open management style and expected high standards within the home. Mrs Shirley must however now complete her NVQ level 4 in management. The home must implement a quality assurance system including the views of service users, staff, visitors and others involved with the home, which is published on an annual basis along with an action plan for improving the service provided. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 16 Records required to ensure the health and safety of staff and service users were inspected. All food was stored correctly and fridge, freezer, water, and cooked meat temperatures were recorded. The home has a gas landlord, electrical wiring, and portable electrical equipment certificate. A satisfactory fire safety inspection was recently carried out, a fire risk assessment is in place, and all equipment is regularly serviced and tested. Staff undertake training every year and a fire drill every 6 months. Monthly safety inspections are carried out however risk assessments on the building and staff/service users activities are still required. St Andrews Court DS0000028406.V263143.R01.S.doc Version 5.0 Page 17 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 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 4 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Andrews Court Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score 2 X 1 X X 2 X DS0000028406.V263143.R01.S.doc Version 5.0 Page 18 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 YA1 Regulation 4&5 Requirement Publish a Statement of Purpose and service user guide in line with the required standards. These are outstanding requirements from12th October 2004. The Registered Manager must be qualified to NVQ level 4 in management. 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. Policies and procedures must be 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 from12th October 2004. DS0000028406.V263143.R01.S.doc Timescale for action 01/04/06 2. 3. YA37 YA39 9 24 01/04/06 01/04/06 4. YA40 12 & 13 01/04/06 St Andrews Court Version 5.0 Page 19 5. YA42 13(4) Risk assessments must be completed for the environment and for activities involving staff, service users and visitors. These are outstanding requirements from12th October 2004. 01/04/06 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.V263143.R01.S.doc Version 5.0 Page 20 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.V263143.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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