CARE HOME ADULTS 18-65
St Andrews (Father Hudson`s) 37 Blythe Road Coleshill Birmingham West Midlands B46 1AF Lead Inspector
Maggie Arnold Unannounced Inspection 19th September 2005 10:30 St Andrews (Father Hudson`s) DS0000004297.V251741.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 (Father Hudson`s) DS0000004297.V251741.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 (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Andrews (Father Hudson`s) Address 37 Blythe Road Coleshill Birmingham West Midlands B46 1AF 01675 462240 01675 434010 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) Father Hudson`s Society Mr Alan Everitt Care Home 11 Category(ies) of Learning disability (11) registration, with number of places St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st February 2005 Brief Description of the Service: St Andrews is a registered care home for 11 service users with learning disabilities. The Father Hudson’s Society provides 24 hour care and support. The home is in a large detached 18th century house, surrounded by gardens with an open outlook to the rear and setback off a busy road just off the main street of the small town of Coleshill in Warwickshire. It is within a short walking distance of the town and all local amenities and facilities, as well as bus routes to Birmingham and Nuneaton. Plenty of parking is available in the grounds. Service users all have their own bedroom with ample shared space on the ground floor. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Monday 19th of September between the hours of 10.30am and 3.30 pm. The manager and two staff were on duty in the home to meet the needs of the seven residents who were at home for the day. What the service does well: What has improved since the last inspection? What they could do better:
Two requirements and two recommendations arose from this inspection. Of most concern was the overall management of the residents’ personal allowances held by the home. It should be noted that there is no suggestion of misappropriation of residents’ money. The home is required to maintain accurate records of residents’ monies that can be cross-referenced with St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 6 invoices and receipts. In order to improve the system it is suggested that the home consider the following recommendations. 1) Two signatures, one of which should be the resident’s signature, to be made for each financial transaction. A reason why there is only one signature is to be noted, for example, only one member of staff on duty. Reasons for residents not signing should be recorded on their individual file. For example, poor comprehension or unable to write or initial their name. 2) Receipts to be numbered with the corresponding number recorded on the financial transaction record. Rather than have numerous receipts in the wallets, receipts should be routinely separated out of the day-to-day file on a monthly or three monthly basis. 3) With regards to shared receipts, such as taxi fares, individual records should clearly state where the original receipt is held and number of residents contributing to the cost. It should be noted that there is no suggestion of the misappropriation of residents’ finances. Mistakes on records evidencing that supervision had taken place, had been tippexed out. Mistakes on statutory records should be simply crossed through and initialled and dated by the person making the correction. With regards to residents who are self medicating. It is strongly recommended that audit checks should be carried on a regular basis. Details of the audit should be recorded on the residents’ files. 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 (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 7 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 (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 8 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&5 Prospective residents individual needs and aspirations are assessed prior to coming to live in the home. This ensures that the home is able to meet the needs of the residents. Residents have individual contracts which help to ensure that they are informed regarding what the home has to offer and any additional costs. EVIDENCE: Two plans and accompanying records were selected for scrutiny. Both files contained referrals with detailed assessments from the placing agencies. Copies of contracts that detailed charges and were signed and dated were also held of the files. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 9 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): 6-10 The detailed care plans and accompanying risk assessments works towards ensuring that the residents assessed needs and personal goals are met. The home consults with and encourages the residents to participate in various aspects of life in the home. This gives the residents a degree of responsibility and fosters self-confidence. The secure storage for residents’ records protects the privacy of residents. EVIDENCE: The care plans were very detailed and covered all aspects of the residents’ specific needs and preferences. Areas covered included social and spiritual needs, communication, eating and drinking, sleep patterns, personal hygiene/ dressing and housekeeping responsibilities. There was evidence that the care plans were developed from the referring agencies initial assessment. The seven residents in the home at the time of the inspection were spoken to throughout the inspection process and the inspector had the opportunity to have 1-1 interviews with three of the residents.
St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 10 The residents confirmed that they were encouraged to make decisions about their lives and aspects of living in the home. For example, subject to risk assessments, residents take responsibility for domestic tasks such as ironing, setting and clearing tables and looking after their own room. Records of a confidential nature are securely stored in locked cabinets in the main office. The office is locked when not in use. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 11 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, 14, 15 & 17 Residents are given opportunities for personal development and enjoy varied leisure activities. The home is pro-active in encouraging appropriate personal and family relationships. This works towards a feeling of well being and good quality of life. Residents enjoy meals that are varied and wholesome. EVIDENCE: Discussions with the residents and staff combined with records seen evidenced that the residents benefit from a variety of age and peer appropriate activities. Not all of the residents choose to attend a day care service. For those that do the home works with the day centre to help the resident to develop the skills being learnt at the centre. For example, one resident is undertaking an independent living programme and this is being re-enforced by the home. Subject to risk assessments, residents also visit the local shops. For example, on the day of the inspection one of the residents went to buy a newspaper from a local newsagent.
St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 12 Six relatives completed the Commission’s comment cards. The cards ask ten questions covering all aspects of the service. Questions covered aspects such as how welcoming is the home, privacy, consultation, general satisfaction and staffing levels. All six respondents indicated that they were happy with the service. Comments made included “ …always been welcomed at any time and always tell us of any problems”, “Great care has been taken to register…for educational courses most suited to …needs”, “Has learnt new skills and communication skills greatly improved since …came to St. Andrews”, “…very lucky to live at the home”. The inspector had the opportunity to lunch with the residents and manager. It is pleasing to note that it is common practice for staff and residents to eat together. The meal was a very relaxed affair with residents helping as appropriate. Residents commented on how much they enjoyed the meals and confirmed that a choice of meals, plus snacks as they wished, were available. The kitchen is a good size with plenty of space for residents to help if they so wish. There were plenty of varied stocks of food including fresh vegetables and fruit. Records showed that statutory checks of refrigerator and freezer temperatures are routinely taken. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 13 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 Residents benefit from the discrete, individually based care and support that is provided in a sensitive manner by the home. The home has appropriate systems in place for the safe management and storage of medication. EVIDENCE: Discussions with residents combined with records seen evidenced that personal care and support is provided in accordance with the residents’ needs and preferences. Wherever possible residents are given the choice as to whether a male or female member of staff provides personal support. Discussions with the manager and records seen demonstrated that residents’ benefit from regular health care checks including attending Well Woman/Man health screening clinics. There was also documentary evidence to confirm that the home also ensures that, if required, residents are supported to access the appropriate mental health services. Medication consent forms signed by the resident are held on their file. The home has a monitored dosage system (MDS) and accompanying daily medication administration record (MAR) sheets for the management of the
St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 14 residents’ medication. The medication and records are securely stored when not in use. Medication and MAR sheets seen were all in good order. It is pleasing to note that one resident is responsible for the management and safekeeping of their own medication. A discussion with the resident evidenced that in addition to knowing when and how many tablets to take they also knew what the different tablets were for. It is recommended that from time to time the home undertake an audit check of the medication held by the resident. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 15 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): 23 The overall poor management of residents’ personal allowances potentially places the residents at risk and compromises the accountably of the home. EVIDENCE: No complaints have been received by either the home or the Commission since the last inspection, which took place in February 2005. The home is responsible for the safekeeping and recording of most of the residents’ personal allowances. Records seen fell below an acceptable standard. For example, receipts were difficult to cross reference with records and some receipts were missing, but have since been found. A number of receipts had fallen out of wallets and were loose in the filing slings or bottom of the filing cabinet drawer. Advice was given as to how the records might be improved. It should be noted that there is no suggestion of the misappropriation of residents’ finances. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 16 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 St. Andrew’s is clean, comfortable and homely with ample communal areas to suit the residents’ needs and preferences. All of the residents enjoy the privacy of individual bedrooms that meet their needs and lifestyles. EVIDENCE: St. Andrews is a very large detached 18th Century house that has been adapted to meet the needs of the present client group. There is ample shared space consisting of two large lounges (one of which is a designated smoking area) and a smaller, but adequate, dining room. A brief tour of the premises found the home to be homely, light and airy. The home was also clean and free from offensive odours and potential hazards. The home has nine single and one double bedroom. The manager advised that, in view of the double room being occupied by a single person for a significant length of time, there are no plans to fill the vacancy. Bedrooms seen were individually decorated, comfortable and personalised to reflect the interests and preferences of the residents. Two of the residents showed the inspector their bedrooms. Both said that they enjoyed spending time in their room and that the rooms were furnished and decorated to their liking. Both rooms had lots of personal mementos and photographs. All of the bedrooms have a small
St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 17 lockable facility for the sole use of the occupant and residents have their own bedroom door key. The home has sufficient toilet and bathroom facilities to meet the needs of the residents. Grab rails are fitted in the bathrooms and a shower seat is available for use. At present none of the present residents require any specialist equipment to maximise their mobility. A stair lift if fitted to the 1st floor. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 18 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): 31-34 & 36 Residents are protected by the home’s recruitment policy and procedures. Residents also benefit from the support of a skilled and knowledgeable staff team who receive regular training and supervision. EVIDENCE: In addition to the manager, there are five care staff, a part time domestic and a part time activity organiser. The manager advised that he does not employ agency staff. The existing staff team covers staff holidays and sick leave. The manager said that it is approximately six years since the last staff vacancy occurred and that there is very little staff sick leave. At the time of the inspection there was a care worker, domestic and the manager on duty to meet the needs of the seven residents in the home. Staff were well informed and during the course of the inspection process were observed to be supportive and courteous when working with the residents. One staff file was examined on this occasion. The file held all the statutory information as required by regulation. The staff member whose file had been inspected was also interviewed. He confirmed that supervision and staff meetings took place on a regular basis. Both the supervisor and supervisee sign and date a record sheet to confirm that supervision has taken place. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 19 Mistakes on the record sheets had been tippexed out. Tippex must not be used on statutory records. Recording mistakes on statutory records should be crossed out and initialled by the person making the entry. Notes of supervision sessions were not seen. The staff member gave detailed answers to a number of questions and scenarios regarding the home’s policies and procedures, including fire safety, complaints, missing persons, First Aid and vulnerable adults policies and procedures. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 20 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): 42 & 43 Procedures are in place that work towards promoting the health, welfare and safety of the residents. The comfort, safety and well being of the residents is promoted by a well organised home that is subject to regular visits in accordance with the Care Standards Act 2000: Care Homes Regulations 2001: Regulation 26. EVIDENCE: Discussions with the manager and staff member combined with records seen evidenced that systems are in place to protect and promote the health, safety and welfare of the residents. For example, staff receive core training in moving and handling, fire safety, First Aid, basic food hygiene and infection control. Substances potentially hazardous to health are securely stored when not in use and risk assessments are routinely reviewed. At the last inspection, which took place in February 2005, the home was required to ensure that a copy of the Landlord’s Gas Safety Certificate was St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 21 kept on the premises. At the time of writing this report the manager has advised that the home now has a copy of the certificate. In accordance with the Care Standards Act 2000:Care Homes Regulations 2001: Regulation 26, a representative of Father Hudson’s Society undertakes unannounced visits to St. Andrew’s and a copy of the report is forwarded to the Commission. St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 22 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 3 x x 3 Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
St Andrews (Father Hudson`s) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 3 DS0000004297.V251741.R01.S.doc Version 5.0 Page 23 No 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 2 Standard YA23 YA36 Regulation 17(2) Sch 4:9 & 13 17(2) Sch 4:6(f) Requirement Timescale for action 30/11/05 The home is required to ensure the accurate records of residents’ monies held by the home. Tippex must not be used on 30/11/05 statutory records. Recording mistakes on statutory records should be crossed out and initialled by the person making the entry. 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 YA20 Good Practice Recommendations It is recommended that, from time to time, the home undertakes an audit check of the medication held by selfmedicating residents. Details of the audit should be recorded on the residents’ files. In order to improve the accountability of residents’ finances, it is strongly recommended that the home adopt the suggestions detailed in the section titled “What they could do better” on page seven of this report. 2 YA23 St Andrews (Father Hudson`s) DS0000004297.V251741.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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