Inspection on 11/12/06 for St Anne`s (Dewsbury 1)

This inspection was carried out on 11th December 2006.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Anne`s (Dewsbury 1) 28/02/06

St Anne`s (Dewsbury 1) 07/12/05

St Anne`s (Dewsbury 1) 07/02/05

St Anne`s (Dewsbury 1) 17/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 St Anne`s (Dewsbury 1) 2 Oxford Road Dewsbury West Yorkshire WF13 4LN Lead Inspector Jacinta Lockwood Unannounced Inspection 11th December 2006 11.45 St Anne`s (Dewsbury 1) DS0000026350.V324500.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 Anne`s (Dewsbury 1) DS0000026350.V324500.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 Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s (Dewsbury 1) Address 2 Oxford Road Dewsbury West Yorkshire WF13 4LN 01924 459028 01924559936 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) jenkinlodge@st-annes.org.uk St Anne`s Community Services Miss Bernadette Marie Airth Care Home 14 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (14) of places St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 5 services users with learning disability can be accommodated at 2 Oxford Road, Dewsbury 5 service users with learning disability can be accommodated at 7 Burking Road, Dewsbury. 4 service users with learning disability can be accommodated at 61 Track Road, Batley. 28th February 2006 Date of last inspection Brief Description of the Service: St. Anne’s (Dewsbury 1) is the collective name for a project of three houses, registered to provide residential care to adults with learning disabilities. The registered manager and deputy manager oversee all three houses and each house has their own staff team, with some flexibility between each house. There is a key worker system in place for each service user. The three houses are very different in character and are located within a mile of each other. Each house is in keeping with its location and public transport facilities are situated close by. Dewsbury, with all its facilities is approximately a mile from each house. The Commission was informed that as at 07.09.06 the scale of charges was £307.83 per week. Information about the service in the form of a Statement of Purpose and a Service User’s Guide together with the latest Commission for Social Care Inspection report are available from the home. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection one inspector made an unannounced visit to the service on 15.12.06. The visit started at 11.45am and ended at approximately 6.15pm. The inspector spent time in each of the houses and had an opportunity to meet service users and staff. A tour of the premises was also conducted in each of the houses, although not every bedroom was seen. A sample of records were inspected, including service user support plans and associated documentation, service users’ medication, staffing rotas, staff training records, maintenance documentation, and some policies and procedures. The inspection findings are also based on a range of accumulated evidence received by the Commission (CSCI) since the last inspection, for example, notifiable incident reports when service users are involved in an accident or incident. The registered manager also returned a completed pre-inspection questionnaire which was used to inform the inspection. To obtain the views of those who use and have contact with the service, surveys were sent to a sample of ten service users, eight were returned, eight relatives, two were returned and to nine health and social care professionals, one was returned, at the time of writing. The inspector met and spoke with nine service users. The inspector also took the opportunity to observe the interaction between service users and staff members. The inspector would like to thank all those who contributed to the key inspection and to service users and staff for their time and hospitality during the site visit. What the service does well: The service provides a good homely environment for service users. Their personal space reflects their individual tastes and interests. And service users said they liked living at the home. Service users are supported to take risks and to be involved in community activities. They are supported to maintain contact with families and friends. Relationships between staff ands service users were seen to be good. Service users are aware of how to complain and are confident their views will be listened to. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 6 Staff administer medication safely. 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 Anne`s (Dewsbury 1) DS0000026350.V324500.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 Anne`s (Dewsbury 1) DS0000026350.V324500.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, 5 Service users’ needs are assessed before they move into the home and they receive an individual written licence agreement with the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One service user’s records were examined on each of the houses. These included an assessment of need and there was evidence that reviews had also taken place to ensure that the home could continue to meet the needs of service users. Each service user also had a licence agreement and there was evidence that service users are given a month’s notice of any increase in charges. However, the licence agreement didn’t always specify the room to be occupied. And the document on one service user’s file was blank, although staff reported this had only recently been received and was due to be completed. (See Recommendations.) St Anne`s (Dewsbury 1) DS0000026350.V324500.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 Individual support plans did not contain sufficient detail. Evidence was seen that staff assist service users to make decisions about their lives. Risk assessments were in place to support service users to maintain their independence. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One file was examined in each house. Each service user had a personal centred plan, based on the community care assessment and information from relatives and other members of the multidisciplinary team. These contained risk assessments for such things as personal safety. Assessments had been reviewed. There was evidence that staff assist service users in deciding what St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 10 they do during the day and where they go for leisure time. On the day of the inspection a service user was waiting for a taxi to take him to a social occasion and another went household shopping with a member of staff. It was clear from discussion with staff that they were knowledgeable about service users’ care and support needs. However, personal support plans lacked detail as to the actions staff are to take to enable the needs of the service users to be met. This is particularly important where new or agency staff are employed to ensure consistency for the service user. It was also evident that some relevant assessment information had not been included within the support plan. Support planning has been identified during previous inspections as an area for development. The registered provider must take action to address this. (See Requirements.) St Anne`s (Dewsbury 1) DS0000026350.V324500.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 Service users are supported to engage in ordinary daily living activities. They maintain contact with family and friends. Service users have access to a varied and culturally appropriate diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence in service users’ records that community based activities take place. Staff support service users to visit places of local interest and also to go on holiday. Two service users spoke of working on a farm, which they enjoyed. Service users also attend day centres. All the service users returning surveys indicated that they can do what they want to throughout the day and night. One commented that “If I want to go out to the theatre or pictures, I ask staff and they will arrange to take me on an evening”. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 12 A range of leisure equipment is available to service users including, TV, videos, DVD’s, and a stereo. There was evidence in records and staff confirmed that service users are supported to maintain contact with their families and friends. Service users take part in household activities and one said that staff support him to tidy his bedroom. Service users are involved in choosing menus and shopping for food. Service users were seen to and said that they enjoyed their meals, which they share with staff. Service users cultural and dietary needs are catered for. St Anne`s (Dewsbury 1) DS0000026350.V324500.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 Service users’ healthcare needs are met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from records and discussions with staff that service users’ health care needs are met; records also indicated that any problems identified are quickly addressed. Staff spoken with said that service users have access to regular dental checkups, and visits from chiropodists and opticians. Detailed reports of follow up appointments and medication were present within each service user file. A GP survey noted that staff have a clear understanding of service users needs and communicate clearly and work in partnership with him. Relatives returning surveys indicated that they are kept informed of important matters. One stated that staff always take their wishes into account. Medication is stored securely. Three samples of medication were checked and reconciled with records held. Owing to the nature of their disability, none of the current service users self-administer medication. Staff receive medication St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 14 training so that they know how to manage and administer medications safely. A medication risk assessment was available and had been reviewed. St Anne`s (Dewsbury 1) DS0000026350.V324500.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 Service users’ views are listened to and acted upon. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is available to service users in words and symbols. It was evident from complaints records that service users have used the procedure and that appropriate action was taken to address concerns raised. Relatives returning surveys indicated that they were aware of the home’s complaints procedure but had not had cause to use it. A GP reported that no complaints have been received about the home. Relevant policies and procedures were in place. Staff were able to discuss what they saw as abuse and the action to take were they to see or suspect abuse. Records show that staff receive training in adult protection. All service users returning surveys indicated that they are treated well by staff. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Service users live in a homely, comfortable and safe environment which is clean and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A limited tour was made of each of the houses, including the bedrooms of some service users. Bedrooms seen reflected service users’ personal tastes and interests and a service user said that he liked his bedroom. Each of the houses provided a comfortable and homely environment. A good standard of decoration and furnishing was found throughout the homes, fixtures and fittings were domestic in nature. A toilet roll holder was broken in one of the toilets at Burking Road and should be repaired. (See Recommendations.) Although liquid soap was seen, it would be useful to provide paper towels to promote good hygiene practices. (See St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 17 Recommendations.) One toilet at Burking Road does not contain handwashing facilities and a sink should be installed here to promote good hygiene practices. All areas of the homes were found to be clean and tidy and no offensive odours were present. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 The staff team are trained and competent to meet service users’ individual and joint needs. Service users are protected by the home’s recruitment policy and practices. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from records and discussion with staff that a range of relevant training is provided to ensure that they are skilled and competent to support service users. Staff were observed to support service users in a skilled and respectful manner. Written information from the home’s registered manager states that 53 of staff hold a qualification at NVQ (National Vocational Qualification) at level 2 or above. At the time of the inspection staffing levels within all three home was good, however staff rotas identified that, on a couple of occasions, there have been reduced staffing levels. Staff spoken with felt that, generally, staffing levels were suitable but that it was more difficult to support service users when St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 19 staffing levels were reduced. An existing staff vacancy is covered by staff within the team or by agency staff. The registered provider should ensure that staffing levels are maintained at all times. (See Recommendations.) It was evident from discussion with a member of staff that relevant checks are carried out before a person begins to work with service users and that training and supervision forms part of the induction process. A representative of the Commission carried out an audit of St Anne’s staff recruitment records on 12.04.06. The audit found good practice for the recruitment of staff. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Service users benefit from a well run home. Service views are sought about the running of the home. The health, safety and welfare of service users are promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives returning surveys indicated that they are satisfied with the overall care provided at the home. From surveys and speaking with service users it was evident that they like living at the home. Staff spoken with felt supported by team members and the home’s management. Service user meetings are held and these afford service users the opportunity to contribute their views and ideas about the day-to-day running of the home. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 21 Visits by the registered provider also take place to monitor the quality of the service. Appropriate health and safety records are maintained. Evidence was available that health and safety checks are carried out. Records show that service users as well as staff are involved in fire safety drills so that they know what to do if the fire alarm rings. However, the records showed that some staff are overdue for a fire drill and this should be addressed. (See Recommendations.) St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 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 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 x 3 X 3 X X 2 X St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Service user support plans must contain relevant assessment information and detail how their needs are to be met by staff. Timescale for action 26/01/07 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. Refer to Standard YA5 YA6 Good Practice Recommendations Service users should have an up-to-date and fully completed copy of the home’s Licence Agreement. Service user plans should be more detailed to ensure that specific needs can be addressed. (This recommendation is repeated.) Paper towels should be provided close to hand washing facilities. Staffing levels should be maintained at all times. The shelving unit within the staff sleep in room at Burking Road be relocated. (Not assessed on this occasion.) All staff should be involved in a fire drill twice each year, therefore, those staff who are overdue for a fire drill DS0000026350.V324500.R01.S.doc Version 5.2 Page 24 3 4. 5. 6 YA30 YA33 YA24 YA42 St Anne`s (Dewsbury 1) should be involved in one. St Anne`s (Dewsbury 1) DS0000026350.V324500.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. 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