Inspection on 29/10/07 for St Andrews (Father Hudson`s)

This inspection was carried out on 29th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Andrews (Father Hudson`s) 04/12/06

St Andrews (Father Hudson`s) 24/02/06

St Andrews (Father Hudson`s) 19/09/05

St Andrews (Father Hudson`s) 21/02/05

St Andrews (Father Hudson`s) 08/07/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Andrews (Father Hudson`s) 37 Blythe Road Coleshill Birmingham West Midlands B46 1AF Lead Inspector Martin Brown Key Unannounced Inspection 29th October 2007 St Andrews (Father Hudson`s) DS0000004297.V353698.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 (Father Hudson`s) DS0000004297.V353698.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 (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 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.V353698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. St Andrew’s may care for the person named in the application for variation dated 19 April 2006 4th December 2006 Date of last inspection 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. The manager advised that current fees range from £400 to £600 per person per week. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been made using evidence that has been gathered by the Commission for Social Care Inspection. The inspection visit was unannounced and took place on 29th October, between 1pm and 6 pm. Additional telephone contacts with the manager and with five relatives of service users were made following the inspection. All service users were seen and spoken over the course of the inspection, as were staff on both the morning and afternoon shifts. A tour of the premises was made, relevant documentation was looked at, and observations of the interactions between residents, staff and their environment were made. Policies and procedures, and care records were examined, and three service users were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. Specific elements of other service users’ care were also looked at in detail. The Annual Quality Assurance Assessment, hand written by the manager, also informed the inspection in a clear and relevant manner. Staff and service users were welcoming and helpful throughout. Service users, after initial wariness of a new ‘face’ in the home, later became quite happy to talk and give their views on the service and their lives. What the service does well: The service provides spacious, comfortable, homely environment, where people feel secure. Many people had been there for many years, some as many as twenty years, and said they liked it there and wouldn’t want to move. Several relatives commented on the ‘non-institutional’ atmosphere, saying that it was very homely and friendly and that the staff were very welcoming. Staff showed a thorough knowledge of the residents, their needs, and how to meet them. Users of the service all had very individual interests and activities, which were catered for, and everyone was relaxed in each other’s, and the staff’s, company. Comments from relatives were unanimously positive, with comments such as ‘wonderful’ and ‘very caring’ and ‘no better place’ being typical. Comments from service users, though less effusive, were also positive, with ‘I like it here’ ‘everyone is nice’ and ‘its friendly’ being typical. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 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.V353698.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service assesses the needs and aspirations of prospective service users, and does not accept people whose needs it cannot meet. EVIDENCE: The service currently has two vacancies. A care plan and assessment was seen for the most recent admission. The Annual Quality Assurance Assessment returned by the manager for the home detailed a suitable process by which prospective service users are assessed, make visits and stays in line with the individual’s needs. A relative commented to the effect that the service always made sure that any prospective service users were complementary to those already at the home, and that the home made sure that people had plenty of information and time to make decisions about whether or not to move there. Another family spoke of looking at several services, and being sure that ‘St. Andrews was definitely the right place’. Service users spoken with all expressed no regrets about their move to the home. The most recent arrival was pleased to have moved to St. Andrews. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ assessed and changing needs are reflected in their care plans, and their needs are regularly reviewed. Service users are supported in making decisions about their lives and are supported in taking managed risks as part of an independent lifestyle. EVIDENCE: The care plans of four service users were looked at. These all showed evidence of regular review and of involvement of service users where they wished, and of relatives. Relatives spoken with all said they are invited to reviews led by social services. Records for one service user recorded his wish not to attend more recent reviews. Staff were able to discuss knowledgeably a variety of service users’ needs and how they were able to meet them. One person’s mental health needs were detailed as an additional part of a care plan, and were consistent with staff discussion of that person’s needs and how they were managed. Details of the management of a urine infection were in place. Service users were able to discuss their likes, and interests, which some did at length, regarding these as more interesting topics than the quality of support and care they received, which they were able to briefly describe with words such as ‘good’. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 10 The possibility of producing more ‘user friendly’ guides for each service user, with brief, clear descriptions of likes and dislikes, activities enjoyed and future goals, accompanied by photographs, was discussed with staff, although it was appreciated that this might not be appropriate for all service users, and that most were able to readily articulate their likes and dislikes. Risk assessments were in place relating to specific risks and how they were managed. One of the most apparent was that of travelling independently, especially with regard to local roads. Some service users were able to tell how they got about independently, others advised that they did not feel safe out on their own. These comments echoed staff views and information in risk assessments. Service users were seen to move around the house safely. One service user has a frame, and has a ground floor room. Discussions with staff, service users, and relatives all demonstrated a respect for decisions made by service users. Service users attend, or do not attend, a variety of activities according to their wishes. Records of regular service user meetings showed a variety of topics being discussed, such as residents’ wishes for holidays and activities. Discussion with residents showed that the service supported them in pursuing their individual activities, whether this be country and western, sewing, or sport. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a variety of activities to meet their individual interests and needs, and are supported in maintaining appropriate relationships. Rights and responsibilities are recognised, and a healthy diet is offered via enjoyable, relaxed mealtimes. EVIDENCE: Service users were able to tell me about their individual activities and interests, and show evidence of these. Some of the service users do not wish to do so many activities as when they were younger, and some are more comfortable than others in going out independently. The service provides transport for those who need to get to specific destinations for some daytime activities; one person gets public transport by himself to get to a supported part-time job he has. One person keenly told me about the local church he goes to, while another showed me models, pictures and other artefacts to do with his specific hobbies and interests. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 12 Service users spoke of recent holidays they had enjoyed. Staff gave examples of the wide variety of holidays abroad that people had enjoyed; some residents acknowledged these briefly, but most talked about the most recent holiday they had enjoyed, at a holiday camp in Somerset. One service user spoke of various shows he had enjoyed, and showed me souvenirs of them. There is an activities organiser employed part-time, who is able to work flexibly to support service users to take part in specific activities that they expressed an interest in, from shopping to the cinema or eating out. Service users spoke positively of this person. The service supports and encourages family contact. All relatives spoken with were extremely positive about the service, emphasising how approachable, supportive and welcoming the staff and management were. There was evidence was of relationships being supported positively by the service and being maintained in potentially difficult circumstances. Service users are encouraged and supported with self-help skills and chores, although a cleaner is employed to keep the substantial property thoroughly clean. One service user attends a day service which involves self-help skills, and staff acknowledged that she has usually had enough of ‘those sorts of jobs’ upon returning to St. Andrews. A relative commented very positively on how service users have always been ‘encouraged to use their skills and talents’. Menus showed a flexible approach to meals and the provision of a variety of good wholesome food, with provision with individual likes and dislikes. Staff advised that there were no special diets at present, although these had been catered for in the past. The evening meal was freshly prepared and enjoyed by all in an easy-going atmosphere. All service users spoken with said they enjoyed the food, and staff had a thorough knowledge of individual preferences and catered for these. The dining area is set out with a number of small tables, with two or three on each table. Staff advised that there had once been one large table, but people had been happy with the change to a number of smaller ones. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal and health support in ways that they prefer and need, with the involvement of outside professionals as required. Service users can be confident that identified shortcomings in the administration of medication will be promptly rectified. EVIDENCE: Comments from relatives and service users demonstrated that personal support was being offered in a way that individuals were comfortable with, but in ways that met their needs. Discussion with staff and examination of care records demonstrated that one person’s specific support needs were met in a manner that were also sensitive to his fluctuating mental health needs, and that appropriate support from relevant professionals was utilised. One person’s immediate continence problems were currently being managed with medical advice and support. Staff were able to demonstrate a thorough awareness of individual needs and how these were supported. All relatives spoken with commented on the caring and knowledgeable nature of the staff, and many commented on the fact that St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 14 while they provided necessary support, they ensured that individuals retained skills and independence by not doing things for them that they could do themselves. Records showed appointments with relevant health professionals such as local doctors, dentists, and chiropodists in place. Medication practice and recording was looked at. The majority of medication is dispensed by the ‘Nomad’ system, in conjunction with the local pharmacy. One person continues to administer some of her own medication, which she is comfortable with. This is fully documented. Other medication is administered by staff, at her request. Medication is kept securely, in a locked cupboard, and is administered from a secure, portable proprietary carrier. The administration record is kept separately. All medication administered was recorded, except for one medication given earlier that morning. The staff responsible immediately owned up to this, and signed it. A discussion was had with the staff concerning the fact that the Medication Administration Record Sheets were kept in a folder separate from the medication cupboard, and was therefore in danger of being overlooked. Staff transferred it to the cupboard, immediately, to ensure such an omission was far less likely in the future. Some medication has to be dispensed directly from foil wrapping. All this medication was signed appropriately to indication administration at correct times and in correct dosages, but there was no record of any count to allow a check that medication amounts received and remaining tallied with that dispensed. This was discussed with staff, who agreed that stock control needed to improve to fully evidence that all medication was being administered. The manager later acknowledged that this was necessary and would be put into place as a priority. There are no photographs of individual service users in front of individual sections of Medication Administration Record Sheets. Staff agreed that this could help identify relevant record sheets. They also agreed that brief notes concerning individual medications, their effects and possible contra-indications might be useful. Staff showed a generally good, but not complete, understanding of the reasons for all the medications being administered. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that they are protected from abuse and that any concerns expressed are heeded and acted upon. EVIDENCE: There have been no complaints about the home to the Commission for Social Care Inspection since the last inspection and a member of staff explained that there have been no complaints directly to the home during the same period. Comments by the people living at the home confirmed that they have been told how to complain, no one spoken to had any complaints; all were very complimentary about the home, and especially the staff. All relatives spoken with were extremely complimentary about the service, with ‘wonderful’ being a word used several times. One relative commented that if people living at the home had any complaints or concerns ‘they would be sure to let people know’. Staff showed a good awareness of abuse and whistle blowing, and showed me the complaints book, which was blank. Records of service users’ meetings showed issues being raised and addressed. Where there were concerns, these tended to concern other service users, and records indicated they were mild, and infrequent. The system for supporting service users to manage finances was seen and explained by a staff member. This was clear, transparent, and tailored to individual needs. One relative noted that the home ‘is very careful with people’s money’ and gave an example of how it was ‘very correct’ with its financial procedures. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 16 It was noted that one regular transaction recorded payment by one service user to another for ‘ironing’. Staff advised that both service users had consented to this, and it was seen as a positive way of the one service user to earn extra money. It was clearly recorded in an individual care plan. The service user paying the money was now unlikely to able to iron clothes, owing to physical difficulties, although initially he may have been able to. Staff, and later, management, agreed that, while this arrangement had been set up with the best of motives, it may be more appropriate for the home to pay the service user for such a chore, rather than expecting the other service user to. The manager advised that he would address this. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users enjoy a homely, comfortable and well-maintained environment. Their well-being is compromised by the use of toilet facilities without hand wash basins. EVIDENCE: The home is roomy and comfortable, with two spacious lounges, a large kitchen, and suitably sized dining room and laundry. Residents, along with the two cats, made themselves comfortable on armchairs. The home retains a lot of the original Georgian features, which gives it a ‘grand’, but still homely feel. All service users spoken with said they liked the home. Several were keen to show me their bedrooms, which were personalised with furniture, items and pictures of personal value. All bedrooms seen were clean and well-maintained. There was a slight odour in one small area downstairs. The reasons for this were discussed, as were ongoing plans to manage this. Upstairs are a shower room and toilet, a bathroom and toilet, and a small toilet. Only the shower room had a hand washbasin. Staff advised that service users are requested to go to their rooms nearby to wash hands after using the toilet. There is room in the bathroom for a washbasin to be fitted. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 18 There is less room in the small toilet, but staff agreed that removing the second door in there would create additional space, as well as making the use of the toilet easier. A cleaner is employed to maintain a good state of cleanliness throughout. the home is set away from the road in extensive grounds. At the rear is a large grassed area, formerly used, staff advised by sheep. A fence with barbed wire at the top separates this area. Staff agreed that this fence, and especially the barbed wire, now served no real purpose. Although the kitchen is spacious, some of the food preparation and storage takes place in the laundry, with instructions for one sink to be used for vegetable preparation, with storage of potatoes noted underneath. Staff advised that a recent visit of the Environmental Health Officer had not commented upon this. An inspection of several years ago had agreed this practice. After later discussion, the manager agreed that it would be good practice to separate the functions of the kitchen from that of the laundry. Laundry facilities are satisfactory, clean and tidy, with commercial washing machines in use. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users appreciate the attentions of a consistent, dedicated, staff team who are familiar with their needs. The small staff team is vulnerable to being over – stretched by any further illness or absence, leading to a potential restriction in activities for service users. EVIDENCE: In the absence of the manager, staff files were unavailable for examination. The previous inspection noted that these were all satisfactory, and there have been no new staff since that time. Staff showed a good awareness of procedures regarding Moving and Handling where relevant, and were able to explain the procedure in the event of a fall. The Annual Quality Assurance Assessment returned by the manager showed over half the staff with National Vocational Qualification level 2. This also stated that staff had received training in areas such as medication, fire safety and first aid. This also acknowledged that further training in medication was to take place. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 20 The staff throughout the inspection showed a thorough knowledge of the service users and their needs, and how to meet them. Service users in turn were very positive regarding the staff, as were all the relatives spoken with. “They really care about the residents” and the “staff are wonderful” were typical comments. Several commented on the good-natured banter between staff and residents, and how they treated everyone as individuals. There were two staff on duty, with one being the sole staff on duty later. The manager advised that more staff would be introduced if the current vacancies were filled. There are contact numbers available in the event of an emergency. Staff advised that the only emergencies they could recall was where a service user had had to go to hospital, and another member of staff was called in to go with that person. An activities person works flexible hours to allow additional activities to take place. The staff team is small, with one person currently off sick. Flexible working allows activities for service users to continue to take place. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well-run service run in their best interests, and where their health, safety and welfare is promoted. EVIDENCE: The manager was not present during the inspection, but the Annual Quality Assurance Assessment returned prior to the inspection supplied much necessary information. Relatives spoken with said the staff and management were all very welcoming and approachable. This detailed that necessary electrical and fire equipment checks were taking place. Fridge/freezer and water temperature checks are regularly done and were satisfactory. Records showed that fire tests were taking place regularly. There had not been a fire drill for well over six months. These had previously been taking place regularly at six monthly intervals. When this was pointed out to the manager, he readily acknowledged the error, and advised he would promptly rectify that. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 22 Staff spoken with had shown a good awareness of procedures in the event of the smoke alarms sounding. The Annual Quality Assurance Assessment also detailed quality assurance measures taking place, principally questionnaires. Relatives spoken with talked of receiving questionnaires. The feedback from all relatives spoken with regarding the service was unanimously positive, praising caring staff and effective management. Copies of regulation 26 visits by the Registered Provider or their representative show these are taking place, with the most recent one being in September. Records of service user meetings showed service users’ views being listened to. Service users were more interested in talking to me about their hobbies, activities, holidays and interests, rather than any care concerns. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 23 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 3 26 3 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 3 36 x 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 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 24 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. Standard YA20 Regulation 13(2) Requirement Staff must sign Medication Administration Record Sheets immediately after giving prescribed medication to confirm that this is done so that it is clear that this has been done correctly. The service must be able to account for numbers of tablets dispensed or medication that is not part of the pharmacyprepared system, so that service users can be confident all medication is accurately dispensed. The service must review the practice whereby a service user is paying another service user for a service (ironing clothes) that it might reasonably expect the home to provide as part of the provision of care. There must be accessible hand washing facilities in all toilets. Timescale for action 11/11/07 2. YA20 13(2) 11/11/07 3. YA23 13(6) 11/12/07 4. YA27 2392)(j) 11/02/08 St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 25 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. 4. 5. Refer to Standard YA20 YA20 YA24 YA30 YA33 Good Practice Recommendations Photographs of individual service users at the front of individual Medication Administration Record Sheets would help identify each individual record more readily. Brief notes concerning individual medications would assist staff knowledge of their purpose and possible side-effects to look out for. The rear fence, in particular the barbed wire on it, should be removed if it is no longer necessary, as it is a potential hazard, and detracts from the ‘homeliness’ of the house. Vegetables, and any other foodstuffs, should be stored in the kitchen, rather than the laundry, to minimise risks of infection and avoid compromising good hygiene. The recruitment of extra staff would make the small staff team less vulnerable to staff shortages owing to sickness, training or annual leave. St Andrews (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 (Father Hudson`s) DS0000004297.V353698.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!