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

This inspection was carried out on 4th December 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

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 Kevin Ward Key Unannounced Inspection 4th December 2006 08:00 St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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.V322054.R02.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.V322054.R02.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.V322054.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. St Andew`s may care for the person named in the application for variation dated 19 April 2006 24th February 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. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focused on assessing the main key Standards. As part of the inspection process the inspector reviewed information about the home that is held on file at the Commission such as notifications of accidents and incidents. A pre inspection questionnaire was also completed by the manager, which provided more helpful information about the home. The inspection involved meeting the people that live at the home and asking them for their opinions about the service they receive. The inspection also included talking at length with a member of support staff and a telephone conversation with the deputy manager. Various records, such as care plans, risk assessments and fire safety records were also sampled for information as part of this inspection. The current fees for the service are £400 per week. This does not include personal items, such as clothing that people are required to purchase from their personal monies. The people living at the home pay a contribution to the cost of the care, based on an assessment of their individual financial circumstances. What the service does well: People are encouraged to make everyday choices and express their independence by taking part in everyday chores, shopping for clothes and venturing out independently, where this is deemed to be safe. Most people attend day services at least part of the week and an activities coordinator has supported people to go on a range of outings during the year. People have been assisted to go on holidays to enjoy a break away from home. People attend church where they wish to do so and they are supported to maintain relationships with important people in their lives. A visiting relative spoke highly of the support provided by staff and confirmed that he is made to feel welcome whenever he visits the home. There have been no complaints made at the home since the last inspection. The people that live at the home and their relatives have been informed how to complain should they wish to do so. Staff have received adult abuse training to help to safeguard the welfare of the people at the home. Staff are provided with training that is relevant to equip them for their work including Health and Safety related training and care courses. The people living at the home and their relatives have been surveyed for their views about the service as part of the home’s quality assurance arrangements. The questionnaires were seen to contain many positive views of the service. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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.V322054.R02.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.V322054.R02.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Appropriate assessment procedures have not been followed recently. EVIDENCE: Two people have moved into the home during the course of the year. A social work assessment has been carried out for one of these people and the home has also completed a basic assessment of this persons needs. No evidence of an assessment could be found for the other person. A member of staff explained that this was because the person concerned was staying at the home on a temporary basis with a view to returning to their own address when environmental adaptations had been completed. Both people are said to have moved to the home under urgent circumstances, which did not allow the opportunity for them to visit the home beforehand. The staff member explained that normally people are provided with opportunities to visit the home and meet with the other people living at the home before making a decision to move in. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are some shortfalls in some peoples care plans and risk assessments, necessary to underpin good care practices at then home. People are supported to make choices and participate in everyday decisions that affect them. EVIDENCE: Four people’s care records were viewed to check how their needs are met. The two people who have moved into the home this year did not have care plans and risk assessments in place advising staff how to meet their needs. Two other peoples care plans were seen. These documents contained essential levels of information to enable staff to provide people with the support they require to meet their personal care needs. One person has mental health needs but this information is not detailed in his care plan file. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 10 This information is necessary so that staff are clear about how this persons mental health needs effect him and so that staff are clear about how they should intervene and manage any behavioural challenges that are presented on occasions. A member of staff confirmed that the team has recently received mental health training to help them to understand this person’s need better. The people living at the home confirmed that they are involved in their care reviews. Social work review documents were seen as evidence of periodic reviews by placing officers. People are supported to make decisions and choices in a variety of ways, e.g. People confirmed that they are supported by staff to shop and choose their own clothes and one person said that they had been assisted to go to the hairdressers during the previous weekend to have their hair cut at the hairdressers. People’s likes and dislikes are recorded in their care plans for staff to follow and one person explained that they like to go out places on his own and that this is respected by staff. The people living at the home confirmed that they have house meetings to discuss issues that affect them. This was confirmed in house meeting record, which show that people have been consulted on topics such as holidays, fire safety, and Christmas arrangements. Risk assessments were seen on peoples care files covering a number of everyday hazards that they are likely to encounter, such as kitchen safety, falls, use of stair lift and support out of doors. There are currently three people over 70 years of age living at the home. A member of staff explained that no one at the home has pressure sores. None of these people currently have skin care risk assessments in place. A member of staff explained that two people with mobility needs receive some degree of assistance from staff to help them to shower. A shower chair is available to help the two people concerned to shower safely. However the shower facilities are quite cramped for people with mobility needs. A member of staff confirmed that both people are able to weight bear but require some support to shower safely. Moving and handling risk assessments have not been completed for the people concerned to support safe practice. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 and 17 Overall the quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported to access a satisfactory range of outings and activities, although there are limited opportunities for people to get out at weekends where staff support is required. People are provided with meals that they enjoy. EVIDENCE: Most of the people living at the home attend planned day services, college courses or supported employment placements during the week. A staff member remains on duty to support anyone remaining at home and an activities co-ordinator is employed 16 hours per week to arrange outings and activities for people. One person explained that she had been out to the hairdressers with her key worker at the weekend and was supported to do some Christmas shopping. Another person said that he had attended the local Church of England service at the church across the road from the home. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 12 A member of staff also reported that another person likes to attend a Catholic Church service some weekends. A member of staff explained that currently there is no one living at the home with other religious requirements. One person said that he enjoys going places on his own and another persons care records show that she has been made familiar with local bus routes so that she can travel some places independently. This indicates that people are being supported to exercise their independence where they are able to do so. The people at the home explained that they have been assisted to go on a number of outings during the year. Further evidence of this was seen in a photographic record which confirms that people have been assisted to get out and see interesting places, such as, a butterfly farm, falconry centre, theatre trips, Stratford, Solihull library theatre, Brindley Place, Black Country Museum. An outing has also been planned to help people to celebrate the Christmas season. People also commented that they sometimes go for meals or a drink at the pub. A member of staff also reported taking people on occasional trips to the cinema or to see Rock and Jazz bands. However an examination of rotas show that normally there is only one member of staff on duty at the weekends, which allows limited opportunities for the people who need to be supported to venture out into the local community to do so. A visiting relative spoke very highly of the support provided at the home and confirmed that he is made to feel welcome and kept updated on important matters. One person said that she sees her boyfriend quite often and the records show that he is encouraged to visit the home so that this important friendship can be maintained. Two people commented that they take part in shopping for groceries sometimes. A number of people were seen to help themselves to breakfast independently and a member of staff was seen to make breakfast for a person with mobility problems. An examination of menus and food diaries demonstrates that people are provided with traditional wholesome meals. A member of staff explained that three staff have recently attended a course on healthy eating and menu planning and that this had encouraged an increased emphases on healthier eating so that staff now encourage low fat foods and more fruit. Where there are concerns about people’s weight this is being charted and monitored. A member of staff said that none of the current people living at the home have any special dietary needs and explained that training has been previously provided for managing the dietary needs of people with diabetes. The people living at the home confirmed that they enjoy the meals provided at the home. A member of staff indicated a satisfactory awareness of people’s food preferences. This is made easier by the fact that the vast majority of people have lived at the home for many years and there have been few staff changes in this time. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care and health needs of most people are properly monitored and addressed and suitable medication procedures are in place at the home. The rating for this group of Standards is compromised due to their being no care plans and records for two people at the home. EVIDENCE: The people living at the home made positive comments about the support they receive and indicated that they like the staff that work there. A member of staff explained that most people are independent in attending to their personal care needs and this was observed to be the case, as the majority of people got themselves washed and dressed before breakfast. The people who stayed at home stayed in bed a little later and got ready at their own pace. A member of staff was seen to support people in an unhurried fashion, in keeping with their preferred routines. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 14 One younger person explained that she had been to the hairdressers at the weekend; her haircut was observed to be fashionable and age appropriate. A person who needs assistance to shower explained that he receives the appropriate levels of support necessary to meet is needs and is otherwise given freedom to act independently in other respects. Discussions with people confirmed that they are supported by staff to attend personal health appointments where necessary. This was verified in people’s health records, e.g. people are being assisted to gain access to local health professionals, such as dentist, optician, chiropodist and well person checks. One person’s file also contains evidence to confirm he has received appropriate access to consultant psychiatrist and neurology appointments. Care plans and health records were not available for two people, consequently it was not possible to confirm that they are receiving appropriate support to address their health needs. Medication is safely stored in a locked cupboard. A member of staff was seen to give out medication to some people and record it immediately, in keeping with good practice. Written risks assessments and a risk questionnaire were seen to be in place for a person, who administers her own medication, to ensure that she understands how to administer and account for her tablets safely. People’s medication records contain a record of the number of tablets received in the home so that medication is accounted for properly. The medication returns book was not available at the time of this site visit. A member of staff said that they had received medication training in the last 2 years. The managers training plan for the coming year shows that a medication training update has been planned. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable procedures are in place to enable people to complain and of staff to report any concerns they may hold about the welfare of the people living at the home. 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. Most people that were spoken to said that they would report any concerns to the manager or their keyworker. Responses in relatives questionnaire sent out as part of the inspection indicate that people have been informed how to complain but have not had need to do so. A person’s relative who was seen during the inspection site visit also confirmed this. A copy of the visitor complaints policy was also seen at the home. As previously noted, periodic house meetings take place, involving the manager and the people who live at the home. This provides an opportunity for the manager to check if anyone has any concerns. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 16 A member of staff said that they had recently received “prevention of vulnerable adults abuse” training and referred to his course materials, held at the home. The staff member demonstrated a satisfactory understanding of the different types of abuse that can occur and how they should be reported. There have been no reports of abuse at the home since the last inspection of the home. A record is in place to account for people’s monies. One person was seen to sign the record to acknowledge receipt of monies passed to him by a member of staff. A member of staff said that savings accounts are opened in people’s own names only. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with comfortable accommodation. There is scope for improving disability access in the shower, in the light of people’s changing needs as they get older and some floor coverings need replacing. EVIDENCE: Overall the home is comfortable and homely. Two good-sized lounge areas are available and both are comfortably furnished for people. Good work has taken place to hang the festive decorations and dress a Christmas tree for the Christmas season. Overall people’s bedrooms are comfortable and clean and adequately furnished to meet their needs. There is ample evidence of pictures and personal possessions to confirm that people have been supported to personalise their bedrooms, as they would like. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 18 The home has an upstairs bathroom / shower room that is used by people with mobility needs. The shower tray in this room is surrounded by a Perspex enclosure that leaves little space for disability access, or to use the shower chair. A stair lift is in place on the main staircase to enable people with mobility problems to get up and down the stairs. Whilst overall the home was clean, one person’s bedroom carpet is dirty and needs to be cleaned or replaced. The lino in a downstairs WC is also worn and stained and an unpleasant odour was apparent in this area of the home. Protective gloves and aprons area available for staff to use where appropriate. The home has two large washing machines with sanitary wash programmes. A member of staff confirmed that there is not currently a requirement to manage soiled, continent laundry at the home. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are appropriately vetted and trained to ensure that they are suitable to work at the home. Staffing levels need to be reviewed to ensure they meet people’s changing needs. EVIDENCE: The staff rotas show that there is typically one person on duty over and above the manager. The home has a vacancy for a cleaner and a member of staff explained that this vacancy was in the process of being filled with a view to someone staring shortly. As previously noted most of the people that live at the home are fairly independent with regard to their personal care needs, although three people are over 70 years of age and their needs are increasing. During the week most people go out to day services and are supported to get out and about with assistance from an activities co-ordinator, however there is minimal scope for people with higher support needs to get out at the weekends as there is only one person on duty. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 20 A member of staff explained that the manager had come into the home especially the previous Saturday to support one person but an examination of the previous two months rotas show that extra staff provision is rarely provided at weekends. Confidential staff files were locked away at the time of the site visit and were not accessible by the member of staff on duty. Since the inspection site visit the deputy manager has sent documentary evidence and written confirmation that new staff are subject to proper vetting to ensure that they are safe to work at the home, including taking up Criminal Record Bureau checks and references. The deputy manager reports that Criminal Record Bureau checks are being renewed every three years to ensure that this information remains current. A member of staff confirmed that he has regular planned supervision and receives training updates on all the relevant Health and Safety related subjects that are required to support safe practices, including first aid, food hygiene, fire safety, adult abuse and medication. In the pre inspection questionnaire, the manager reports that further training in these areas of practice are planned for the coming year. Staffing training information provided by the manager prior to the inspection site visit reports that 75 of staff hold National Vocational qualifications (NVQ’s) to equip them for their caring role at the home. The deputy manager explained that the manager is due to attend a course to equip him to provide moving and handling to the staff at the home. This is particularly necessary given the increasing ages and changing needs of some people at the home. Common examples of other training provided to staff in the last year, include, handling difficult situations, assertiveness, Bi polar disorder, advocacy and representation and organisational culture, in addition to some training focused at managers. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place for supporting quality assurance at the home and for maintaining a safe environment. This rating is compromised by the fact that there are no proper nighttime management support arrangements for staff. EVIDENCE: The registered manager has many years management experience. As reported in the last inspection report” the manager, who is a qualified social worker, holds the Registered Managers Award and is a qualified NVQ Assessor. Other training courses have included Recruitment and Selection, Supervision and Coaching, and Appraisal and Performance Skills. The manager, who delivers care, also undertakes core and specialist training courses”. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 22 There is currently no nighttime management on call rota with named contacts for staff to phone in the event of an emergency. A member of staff said that he would seek advice from staff in other homes if necessary. A member of staff confirmed that staff are provided with regular planned management supervision to support him in his work and that he has frequent contact with the manager during the week. Quality assurance arrangements at the home include quality assurance questionnaires completed by service users, relatives and professionals. A sample examination of the questionnaires demonstrated that the questions being asked were appropriate to assist in the task of monitoring service quality. Until recently the home has routinely carried out monthly monitoring visits and copies of the reports are held on file at the home. The deputy explained that the visits ceased for a time following misunderstood advice from the Commission for Social Care Inspection but that the visits have now resumed. In the pre-inspection questionnaire the manager reports that relevant Health and Safety equipment checks are being carried out. The fire safety records were sampled. The records demonstrate that fire alarms and emergency lights are tested at the correct frequency and that fire drills have been carried out at the home. A record of fridge and freezer temperatures was seen to confirm that these appliances are being appropriately monitored to ensure that they maintain food within the correct temperature range. St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 1 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 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 x 2 x 3 x x 3 x St Andrews (Father Hudson`s) DS0000004297.V322054.R02.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 2 3 Standard YA2 YA6 YA6 Regulation 14 (1) (a) 15 15 Requirement Ensure that anyone moving into the home has their needs fully assessed before they move in. The manager must ensure that care pans are in place for everyone at the home. Ensure that suitable information is recorded in the care plan of any person with mental health needs, explaining how their condition affects him and how staff should safely manage their behaviour. Moving and Handling risk assessments must be put in place for anyone with mobility problems to support safe care practices, e.g. when using the shower. (See main body of the report). Review the staffing levels to ensure: a) People’s needs can be met safely. b) There is sufficient staff to provide opportunities for people who can’t go out independently to do so. Timescale for action 31/12/06 31/12/06 31/12/06 4 YA9 13 (3) (c) 31/12/06 5 YA13 18 (1) (a) 14/01/07 St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 25 6 YA19 17 (1) Schedule 3 7 YA24 23 (2) (a) 8 YA30 23 (2) (d) 9 YA37 18 (2) Ensure that suitable health records are properly maintained for the two people that have moved into the home this year, as long as they remain at the home. The registered person is required to review the shower facilities to ensure that they are suitable and safe to meet the needs of people with mobility problems and to allow for people to be supported in accordance with good moving and handling practices. Take action to clean or replace the dirty bedroom carpet, discussed with staff at the inspection site visit. Make clear the nighttime on call management arrangements so that staff have a named manager to contact in the event of an emergency. 31/12/06 31/01/07 31/12/06 28/12/06 St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 26 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 YA9 Good Practice Recommendations The manager is recommended to carry out skincare risk assessments for the older people living at the home as a precautionary measure and to provide staff training in these subjects St Andrews (Father Hudson`s) DS0000004297.V322054.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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.V322054.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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