Inspection on 13/12/05 for St Andrews, Paignton

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Andrews, Paignton 24/12/09

St Andrews, Paignton 29/06/09

St Andrews, Paignton 13/01/09

St Andrews, Paignton 28/01/08

St Andrews, Paignton 08/08/07

St Andrews, Paignton 01/03/07

St Andrews, Paignton 10/10/06

St Andrews, Paignton 16/05/06

St Andrews, Paignton 20/06/05

St Andrews, Paignton 13/10/04

St Andrews, Paignton 19/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 St Andrews 24 St. Andrews Road Paignton Devon TQ4 6HA Lead Inspector Sam Sly Unannounced Inspection 9.30 13 December 2005 th St Andrews DS0000018429.V252920.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 DS0000018429.V252920.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 DS0000018429.V252920.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Andrews Address 24 St. Andrews Road Paignton Devon TQ4 6HA 01803 559545 01803 391582 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) Mr John Davies Mrs Paulette Davies Vacant Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (21) St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A Manager to be registered by 15th June 2004 Date of last inspection 20th June 2005 Brief Description of the Service: St Andrews is a care home for up to 21 younger or older adults with mental health needs. The building is situated in a residential area of Paignton, within walking distance of the sea-front, shops and amenities. There is level access through a small front garden, with one step inside the lobby area to access the house. There is also a concreted area and lawn to the back of the home. The home has a lower ground, ground, first and second floor with stairs throughout. This may cause difficulties for residents with mobility problems as there are no bathing/shower facilities on the ground floor. An external fire escape connects all floors. On the lower ground floor there is a laundry, store room, bedroom, shower/bathroom, and lounge/staff sleep-in room. On the ground floor there are bedrooms, a kitchen, toilet, office, dining room and lounge. The first floor has a shower room, bathroom, and bedrooms, and on the second floor there are bedrooms and a toilet. Two of the bedrooms are shared by two residents. One bedroom currently being used by a resident is under 10sqm, when this resident leaves the home the use of this room must be reviewed. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and took 7 hours over a weekday in December, and was carried out by Sam Sly and Andrea Peryer (Regulation Inspectors). Evidence was gathered by talking to all but three residents, some of the staff on duty, the cook on duty, and the acting manager Sandra Brown. Records and paperwork relating to residents care plans, health and safety documents and staff records were also examined. The Owners, Mr. and Mrs. Davies were not present during the Inspection. No action plan was received by the Commission, after the last Unannounced Inspection until the 3rd November 2005, despite letters requesting one. This action plan had been completed by the acting manager not Mr and Mrs Davies. Since the last Unannounced Inspection on the 20th and 22nd of June 2005 one complaint has been received, investigated and upheld with regard to the conduct of Mrs Davies at St Andrews, and one complaint is still being investigated with regard to Mr. Davies’ conduct. The Commission has met Mr. and Mrs. Davies to discuss concerns on 21st July 2005. There have been additional visits to follow up compliance with statutory notices and requirements issued on 1st August and 13th September 2005. The Commission on 31st October 2005 regarding Fire Safety issues has served a further regulatory notice. There has been a condition of registration since 01/08/03 that a manager is appointed at St. Andrews. Mr. and Mrs. Davies are currently not complying with this condition, although there is an acting manager in position. Additionally other regulatory Authorities have issued requirements and statutory notices. Devon Fire & Rescue service issued a Regulatory Enforcement Notice with regard to fire doors on 11th August 2005 and Torbay Council Health & Consumer Protection Department issued statutory health and safety and food safety requirements on 25th November 2005. What the service does well: The acting manager and the care staff are well respected and liked by all the residents. The care staff are enthusiastic, dedicated and interested in the residents they care for. Residents say they feel confident about sharing concerns with the acting manager, and one resident said they were all ‘good staff’. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 6 The acting manager has worked hard to try to comply with the requirements of the Commission and other regulatory Agencies. What has improved since the last inspection? What they could do better: It is of serious concern that there were 18 requirements as a result of this Unannounced Inspection. 11 of which have not been met by previous timescales made by the Commission. This concern is compounded by the lack of a swift action plan from Mr and Mrs Davies, which would have indicated recognition of the shortfalls and a commitment to improving St Andrews. Mr and Mrs Davies must ensure assessment, risk assessment and care planning processes at St Andrews capture enough information for the staff to identify, make plans and work towards meeting resident’s needs and goals including educational, work and leisure needs. As the people responsible for the safety and welfare of residents, Mr and Mrs Davies must make themselves aware of all concerns and complaints at St Andrews and attend Adult Protection training. Mr and Mrs Davies must ensure the menu and food budget at St Andrews provides a consistently varied, nutritious, and properly prepared diet so that residents remain fit and healthy. Mr and Mrs Davies must comply with the requirements made by the Commission and other regulatory Agencies; the Fire Service and Environmental Health Department so that St Andrews is kept safe, clean and hygienic for residents. Mr and Mrs Davies must ensure that fit to be employed, and poor practice is picked up quickly so that residents are safe. The Commission must have an application from Mr and Mrs Davies to register a manager for St Andrews. Mr and Mrs Davies must also support, assist and give the current acting manager the resources she requires to run the home effectively and meet the needs of residents. This must include regular supervision of the acting manager, and the maintenance of good relationships with everyone working at St Andrews. If this does not happen residents will suffer. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 7 To ensure Mr and Mrs Davies are fully aware of the shortfalls at St Andrews, and that residents are reassured that their views are fully recognised, a robust quality assurance system must be implemented. This will then make sure St Andrews is continually improving. The Commission requires evidence from Mr and Mrs Davies that St Andrews is financially viable and able to meet the needs of residents. 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 DS0000018429.V252920.R01.S.doc Version 5.0 Page 8 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 DS0000018429.V252920.R01.S.doc Version 5.0 Page 9 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 Resident’s needs and aspirations are not fully assessed, potentially putting them and others at risk of harm and restricting their development and independence. Residents are not fully aware of, so cannot abide by, their terms and conditions. EVIDENCE: Four resident’s assessments were examined. There was lots of information documented in a range of paperwork including Care Programme Approach plans, and the acting manager was able to demonstrate an understanding of residents needs, however, in no one place was there a thorough, clear assessment for each resident, and some needs and risks were not recorded anywhere. The acting manager said that the local Mental Health Team had nearly completed a re-assessment of each resident, and once complete Care Programme Approach reviews would be shared with the residents and the Home. The acting manager said residents still did not have up-to-date contracts, as Mr and Mrs Davies held some of the information required to up-date them. . Regulatory Enforcement Notices had been issued to Mr and Mrs Davies in January 2004 with regard to breaches in regulations regarding assessments, St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 10 which, at that time, were complied with thereby raising the quality to a satisfactory standard. It is therefore of great concern to the Commission that despite further requirements at the Unannounced Inspection on 20th June Mr and Mrs Davies have failed to ensure resident’s assessments reflect their needs. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Without clear recorded guidance, in the form of risk assessments and plans, residents cannot be confident that staff will support them to achieve their goals, aspirations and a more independent lifestyle. Residents are involved and supported by staff to make decisions about their lives. EVIDENCE: Four resident’s risk assessments and care plans were examined. As with the assessment records there was lots of information documented in a range of paperwork including Care Programme Approach plans, and the acting manager was able to demonstrate some of resident’s needs were being met and some residents were being supported to become more independent, however, in no one place was there a thorough risk assessment for each resident or a clear plan including goals for staff to work with residents at achieving. Plans had not been reviewed regularly either. It was unclear in one plan how the resident’s legal discharge requirements under the Mental Health Act 1983 were being met. The acting manager said that the local Mental Health Team had nearly completed a re-assessment of each resident, and once complete Care St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 12 Programme Approach reviews would be shared with the residents and the Home. Regulatory Enforcement Notices had been issued to Mr and Mrs Davies in January 2004 with regard to breaches in regulations regarding care plans and risk assessments, which at that time, were complied with thereby raising the quality to a satisfactory standard. It is therefore of great concern to the Commission that despite further requirements at the Unannounced Inspection on 20th June Mr and Mrs Davies have failed to ensure resident’s risk assessments reflect their needs and care plans show how these needs will be met. Through discussion with staff and residents it was demonstrated that residents were supported to make decisions about their lives and what they do. On the day of Inspection the acting manager spent time, and showed patience when explaining to several residents their rights and choices in different situations. The acting manager has supported residents to access additional benefits and financial assistance where necessary. Mr and Mrs Davies have recently rescinded their Department of Work and Pensions appointeeship for several residents, and Torbay Council finance department are in the process of reviewing all the residents benefit entitlement and helping them set up bank accounts. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Residents are not offered a consistently, nutritious and balanced diet inclusive of special dietary needs which leaves them at risk of ill health. The lifestyle of residents is seriously curtailed, not due to a lack of enthusiasm of staff, but due to a lack of financial commitment from Mr and Mrs Davies. EVIDENCE: St Andrews has a dedicated cook, however it had come to the notice of the Commission a considerable number of times since the last Inspection that the cook was requested to leave his job by Mrs Davies, thereby leaving the preparation and cooking of meals to care staff and reducing the number of care staff left to work with residents. The cook was spoken to at this Inspection and said this practice had now stopped. Torbay Council had visited St Andrews in November 2005 and although three Food Safety requirements were left, the requirements relating to their previous Inspection in November 2004 had been met. The kitchen floor was dirty in places, and surfaces did not look like they were regularly wiped. Cleaning chemicals were not locked away, and vegetables in the storeroom were on the floor. One of the freezer’s seal had perished and needed replacing. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 14 The meals being provided were not reflective of resident dietary needs or choices and no menu plan was followed. The meal on the day of Inspection was Shepard’s pie. Most resident said the meals were alright, and several commented on the variety they had received the previous week when the cook had been away and different staff had been cooking. One resident had helped cook their own meal at this time. The cook said he did the food shopping and there were adequate supplies however, discussion with staff and the acting manager found that resident’s special dietary needs, due to health problems like diabetes were still not being catered for. There were no sugar-free meal choices and the acting manager and staff were still occasionally buying residents special food. Also several residents were buying their own food to substitute or add to the food provided at St Andrews. It is of concern to the Commission that a requirement was made at the last Unannounced Inspection in June 2005 with regard to providing a healthy balanced diet, which had not been met. Discussion with staff and residents found that staff were regularly taking residents out for coffee, to the shops and out locally, however records showed, and staff said, that they were frustrated by a lack of financial resources to pay for getting out and doing things. At their last meeting in November resident’s had expressed an interest in doing a whole range of Christmas Activities like: Karaoke, listening to the Salvation Army band, having a party, having a mince pie evening, going to a Church service and having a cake-making session however the acting manager did not have a budget to do any of these activities, and those activities that were being arranged were though the kindheartedness of staff. The residents said they enjoyed a fire-works party in November; the acting manager paid for the food and fire works. A staff member reported that when staff used their cars or paid for activities for residents, although they were sending receipts to Mr Davies as agreed by him; these receipts were not being refunded. There was no information at St Andrews about educational, employment or leisure activities available to residents and no budget available to pay for them. Staff encouraged friendships and family contact and one relative had recently visited and was pleased with the care of the resident. Resident’s rights are respected. Staff were observed to respect the privacy of residents and were interacting at all times with them. Residents had unrestricted access in the home, and were encouraged to help with laundry and room cleaning. Most residents were able to access the local town and shops themselves, and staff accompanied others. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 15 St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 16 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): 20 Medication procedures at St Andrews are being adhered to and protect residents. EVIDENCE: The procedures for receiving, storing, administering and disposing of medication were observed and were being adhered to safely. Medication was stored in a metal cabinet, which was lockable and fixed to the wall. The Home operates a blister pack, single dose system, which is distributed by the pharmacy. It is clearly labelled and staff said that packs were taken to the resident at the time specified on the pack, the prescription and the administration sheets. A medication administration record was on the whole well completed by staff. Two residents self-medicated. A policy on medication administration was available for staff, and some staff had signed to say they had been given this information at Induction. There was no separate fridge to store such items as eye drops, creams or liquid antibiotics, and there were no records to prove that the pharmacy carried out regular reviews St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents can be confident that their views will be listened to and acted on by the acting manager, but cannot be confident that Mr and Mrs Davies, the people responsible for their welfare and safety, are aware of their concerns and can protect them from harm. EVIDENCE: There was a clear complaints procedure, which was being used by the residents. Issues were investigated, acted on and recorded appropriately by the acting manager. However, it was not clear that Mr and Mrs Davies were regularly reviewing the complaints book and action taken by the acting manager, which had been made a requirement at the last Unannounced Inspection in June 2005. The Commission has received one complaint since the last Inspection, and another complaint had been concluded. Both complaints concerned the misconduct of Mr and Mrs Davies, and both complaints were upheld. The Commission is considering further regulatory action with regard to these complaints. The majority of staff have attended Adult Protection training, and there were appropriate policies and procedures in St Andrews. However, a Notice issued in February 2005 required that Mr and Mrs Davies attend Adult Protection training due to the lack of a registered manager at the Home and this has still not happened. The acting manager said she had enquired into training courses and there were long waiting lists. There are some care staff that require this training too. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 18 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, 29 & 30 The environment at St Andrews is cleaner and more homely, but significant safety deficits are putting residents safety at risk. EVIDENCE: The acting manager, staff and the new maintenance person have worked hard to improve and maintain a generally clean and adequately furnished and decorated environment. There has been no cleaner for many months now, so care staff have to do cleaning tasks as well as caring for residents. A series of serious Fire safety risks led to the Commission issuing a regulatory notice on 31st October 2005 after finding a wedge in a Fire door. There was no evidence of this practice at this Inspection, and the acting manager had given all staff clear instruction to prevent reoccurrence. Devon Fire & Rescue also issued an Enforcement Notice on 11th August regarding serious fire safety risks, and had agreed that Mr and Mrs Davies had until the 13th January 2006 to put right deficits with the internal fire doors. At the Inspection it was found that none of the doors had been changed. Torbay Council Protection & Environmental Health Department had also made requirements at a visit on November 2004 that had previously not been met, however a follow-up visit by them on 25th November found the requirements St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 19 met. However, three new Food hygiene and additional Health & Safety requirements were made at that visit. The acting manager had been present at the Department’s visit but had not received a copy of the report. The Commission found therefore that requirements had not been acted on, including a risk assessment and improvements to window restrictors. Due to the residents needs within St Andrews, a requirement was issued on the day of Inspection to comply immediately with this requirement. The layout of the home with bathroom/showers only on the lower ground and first floors makes it difficult for some residents, with mobility problems or not confident using stairs, to use these facilities. One resident is unable to bathe or shower, as they cannot physically get to a bath or shower. There were also no additional aides or adaptations in bathroom/showers or other parts of the home for residents with mobility problems, although an Occupational Therapist had assessed the home with regard to the general resident group. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 & 34 & 36 Residents benefit from a competent, enthusiastic dedicated care staff team, but these benefits are diminished by deficits in the recruitment and supervision practices and a lack of positive support from Mr and Mrs Davies. EVIDENCE: Most care staff spoken to; including the acting manager had not been given job descriptions or contracts by Mr and Mrs Davies despite working at St Andrews since February 2005. This left them feeling insecure and not fully clear about their responsibilities and rights. The cook did not have a job description to match his job; instead he had a care assistant description. Care staff demonstrated sound values, dedication to residents, and motivation to improve their lives. They also showed a frustration and despondence at the lack of positive support from Mr and Mrs Davies. All care staff had attended a course on mental health conditions, and adult protection issues earlier in the year and still spoke enthusiastically about what they had learned. Some staff received NVQ training at their previous employment. The acting manager had sourced NVQ training that care staff could access however, Mr Davies had not yet agreed to fund this training. The supervision notes for staff were examined, and although regular sessions were taking place with all staff it was noted that some issues of poor practice had not been discussed and recorded. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 21 Staff rota’s showed that the acting manager works 8am until 5pm Monday to Friday, the cook works 8am until 2pm six days a week, and there are usually 4 care workers in the morning and 3 in the afternoon. The care staffing levels have dropped in the past months when Mrs Davies has requested the cook to leave the building requiring care staff to then cover the cooking duties. The turnover of staff is low and those that have recently left have been dismissed or resigned. Regular staff meetings are taking place. There was no training budget, or training plan for staff, which frustrated the acting manager and care staff. Staff recruitment files were examined and it was found that two staff had started work before a Criminal Record Bureau or Protection of Vulnerable Adult list check had been completed. Also a reference for one care worker was still outstanding, and notes had not been made for two staff interviews. The Commission is concerned that these shortfalls are indicators of a slide in standards once again since a statutory notice was issued with regard to staff recruitment in February 2005. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 & 43 Despite the best efforts of the acting manager and care staff, residents do not benefit from a competently managed, well run, financially viable Home where their health and safety is protected and their views underpin development. EVIDENCE: Mr and Mrs Davies have still not applied to register a manager at St Andrews despite there having been a condition on the registration of the home since June 2004. Since this time there has always been different acting managers in post, and the Commission received and processed the application for one previous acting manager, however she left St Andrews before the process was complete. The Commission has received no application for the current acting manager despite her being in post since February 2005. The acting manager said she is now able to get in contact with Mr Davies when required, which had been a problem in the past, and in the past few weeks Mrs Davies was civil to her and care staff when in St Andrews which has again been an issue in the past, however, she had received no formal supervision and there was no evidence of any management meetings. The acting manager had no access to financial budgets so could not move ahead with training, St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 23 improving the food provision at the home, or improving the activities programme. There was evidence that staff felt supported by the acting manager, and benefited from her leadership and direction and residents felt able to be open about concerns with staff, and able to contribute to what they wanted to happen at St Andrews. However, the lack of positive leadership, support and financial backing from Mr and Mrs Davies meant innovative changes and developments at St Andrews could not become reality; for example residents had lots of ideas for Christmas activities which would not be achieved due to a lack of money from Mr and Mrs Davies. The acting manager said that a Quality Assurance system based on a Mulberry House format (a system purchased by Mr and Mrs Davies) had been started and that she had completed all the parts required of her. An action-planning timetable was seen, but it made little sense, as other parts of the system were not in the building. Evidence of the rest of the system could not be examined, as again it was not in the building. A statutory Notice was issued in February 2005 requiring a Quality Assurance system be implemented; and as yet this is fully complied with. As evidenced previously in this report the Inspection found, or other Enforcement Agencies had previously found shortfalls and deficits in the storage of chemicals in the kitchen, fire safety concerns, health and safety and food hygiene concerns including inappropriate window restrictors, putting residents potentially at risk. There was no business and financial plan available or evidence of financial income or expenditure, and the lack of budgets for training, resident’s activities plus shortfalls in food requirements and the evidence that staff were paying for specialist foods, petrol costs and sundries for residents gave the Commission serious concerns about the financial viability of St Andrews. St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 24 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 2 X X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X 2 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 X 2 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Andrews Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 1 2 X X 2 2 DS0000018429.V252920.R01.S.doc Version 5.0 Page 25 YES 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 YA2 Regulation 14 Requirement Residents must have comprehensive assessments (Previous timescale 26/09/05 – not met) Residents must have suitable contracts, signed and agreed by them (Previous timescale 19/02/05 & 26/09/05 - not met) Residents must have comprehensive care plans, signed and agreed by them. Care plans must be reveiwed and amended (Previous timescale 26/09/05 – not met). Residents must have comprehensive risk assessments, signed and agreed by them and reviewed regularly (Previous timescale 26/09/05 – not met) Residents educational, work and leisure needs must be met. All chemicals must be stored in a locked cupboard. The menu and food budget at St Andrews must cater for residents special dietary DS0000018429.V252920.R01.S.doc Timescale for action 20/01/06 2 YA5 5 (c) 20/02/06 3 YA6 15 20/01/06 4 YA9 13 (4) 20/01/06 5 6 6 YA14YA13YA12 12 (1) YA42YA17 YA17 13(4)(a) 16 (2) (i) 20/02/06 20/01/06 20/01/06 St Andrews Version 5.0 Page 26 7 8 YA22 YA23 22 and 12 (4)(a) 13 (6) 9 YA42YA30YA24 16 (j) 10 YA42YA24 13(4) 11 YA42YA24 23(4) 12 YA29 23 (n) 13 YA34 19 needs. Residents must all have a consistently properly prepared, varied, wholesome and nutrious diet and not have to buy their own food (Previous timescale 26/08/05 – not met). Mr and Mrs Davies must regularly review complaints about St. Andrews. Mr and Mrs Davies must attend formal adult protection training, as must any care staff that missed the previous sessions. (Previous timescales 22/06/05 & 26/09/05 & 13/11/05 – not met). Mr and Mrs Davies must meet the health & safety and food hygiene requirements of Torbay Council Environmental Health Department dated 25th November 2005. Mr and Mrs Davies must risk assess and put into place strategies to ensure residents are not at risk of falls from windows. Mr and Mrs Davies must comply with the Fire Service Enforcement Notice issued on 11th August 2005. There must be suitable facilities and equipment for those residents who are old, infirm or have mobility needs (Previous timescale 19/02/05 & 27/09/05 – not met) All staff employed in the home must have the appropriate fitness checks carried out before employment such as Criminal Record Bureau and Protection of Vulnerable Adult checks (Previous timescale 22/06/05 & 26/08/05 - not met) 20/01/06 20/01/06 20/02/06 13/12/05 20/01/06 20/02/06 20/01/06 St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 27 14 15 YA36 YA37 19 18(1) All references must be followed up before employment and interview records kept. Supervision discussion with 20/01/06 staff about poor practice must be recorded. The Owners must give the 20/01/06 acting manager the support, assistance and resources she requires to manage the home. The Commission must receive an application for a registered manager at St Andrews (Previous timescale 26/08/05 – not met). Mr and Mrs Davies must maintain good personal and professional relationships with staff (Previous timescale 12/10/05 – not met). The quality assurance system at St. Andrews must be fully implemented. The Commission must receive a report of the findings with a time specific action plan for meeting deficits. Audited results must be available and must reflect the views of residents. Residents and stakeholders must receive feedback with regard to their contribution to the quality assurance system (Previous timescale – 22/06/05 & 12/10/05 not met). Mr and Mrs Davies must 20/01/06 formally and appropriately supervise the acting manager. Mr and Mrs Davies must 20/01/06 provide the Commission with evidence that they are DS0000018429.V252920.R01.S.doc Version 5.0 Page 28 15 YA43YA38 12(5)(a) 21(2) 20/01/06 16 YA39 24 20/02/06 17 18 YA43 YA43 18(2) 25 St Andrews running St Andrews in a manner to ensure it is financially viable. 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 YA14 Good Practice Recommendations The Owners should recompense staff for money they have spent on resident’s leisure activities, food and other expenses. There should be sufficient funds within St Andrews for staff to use when taking residents out for leisure activities. All residents bedroom doors should have locks that work. Residents should have information on opportunities for further education, distance learning, vocational, numeric and literacy training and education, employment and personal development should be reviewed as part of their next planning meeting. There needs to be a separate fridge or lockable storage in the current fridge for storing eye drops etc and the pharmacy report must be maintained in the home. 50 of care staff should have at least NVQ 2 by the end of December 2005. A staff training and development plan should be developed from staff supervision and appraisals. There should be a training budget in the home. There should be a business and financial plan open for Inspection in the home. 2 3 YA16 YA12 4 5 4 5 YA20 YA32 YA35 YA42 St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Andrews DS0000018429.V252920.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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