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

This inspection was carried out on 28th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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) 11/12/06

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 Elizabeth Hendry Unannounced Inspection 28th February 2006 09:15 St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 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.V268388.R01.S.doc Version 5.1 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.V268388.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Anne`s (Dewsbury 1) Address 2 Oxford Road Dewsbury West Yorkshire WF13 4LN 01924 459028 01924 559936 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) 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.V268388.R01.S.doc Version 5.1 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. 7th December 2005 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. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over the course of a morning, in order to ensure the inspection did not encroach on the service users and enable their attendance at a social event. Service user care plans were viewed, records evidenced, and a brief tour of the homes were undertaken. Service users and staff were spoken with at all homes. The inspector would like to thank service users and staff for their welcome and assistance during these visits. What the service does well: What has improved since the last inspection? What they could do better: Individual care plans require further development to ensure the needs of each service user are clearly identified with methods for staff to follow to meet those needs. Adequate staffing levels should be maintained to ensure the safety and well being of service users. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 6 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 Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 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.V268388.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: On the day of the inspection the registered manager was unavailable, as a result pre admission assessments were not accessible and therefore not inspected. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The care planning system requires review to ensure the needs of the service users are clearly identified and met. EVIDENCE: Staff spoken to were knowledgeable as to the individual need and personal limitations of the service users in their care. However of the care plans and person centred plans viewed many did not contain the information required to clearly identify the level of support and care required. One member of staff spoken with said that each service user has a person centred plan, which has been developed using the care manager’s assessment. Staff confirmed that service users are fully aware of the contents of their care plan and are involved as much as is practicable in the ongoing review of each plan. Evidence was seen to support this in the form of service user signatures. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 10 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): These standards were not inspected on this occasion. EVIDENCE: St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 11 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): 19 Service users health care needs are met. EVIDENCE: Records viewed confirmed that the health care needs of the service users are fully met; records also indicated that any problems identified are quickly addressed. Detailed reports of follow up appointments and medication were present within each service user file. Staff spoken to said that service users have access to regular dental checkups, and visits from chiropodists and opticians. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Arrangements in place for the protection of service users are not satisfactory. EVIDENCE: A discussion took place with members of staff regarding the procedure to follow when reporting instances of possible abuse. Of those spoken with many were unclear of the procedures in identifying and reporting possible incidents of abuse. Only three staff training records were able to be accessed at the time of the inspection and of those viewed all had attended adult protection training. Those members of staff whose files could not be viewed confirmed that they had been booked to attend a forthcoming adult abuse awareness training course. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 13 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 The standard of the environment is good providing service users with an attractive and homely place to live. EVIDENCE: A brief tour of the homes were undertaken to ensure recommendations issued at the last inspection had been addressed. Bolts to final exit doors in two of the homes have been removed and recommendations issued by the fire safety officer have now been actioned. Service users were seen to have personalised their bedrooms. A good standard of decoration and furnishing was found throughout the homes, fixtures and fittings were domestic in nature. All areas of the homes were found to be clean and tidy and no offensive odours were present. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 14 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 and 34 Staff have a good understanding as to the support needs of service users. This is evident from the positive relationships that have formed between staff and service users. EVIDENCE: Staff members spoken with had a clear understanding as to the personal needs of each resident in their care. One service user said that the staff are friendly and that they have made them feel at home. Three staff training records were viewed, certificates for a wide variety of training course relevant to the service user group were present. When questioned staff confirmed that individual training needs are identified during annual appraisals. It was unclear from these training records what actual training members of staff required and what had been organised. Copies of certificates viewed identified that updates are over due for manual handling. At the time of the inspection staffing levels within all three home was good, however staff rotas identified that at times there are reduced staffing levels, which has a direct result on the level of choices service users are offered. Staff recruitment files were not inspected on this occasion due to the absence of the manager. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 15 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): 39 Quality assurance procedures within the home ensure that the home runs in the best interests of the service users. EVIDENCE: The homes place a high priority on ensuring quality care for all residents. Minutes of fortnightly service user meetings were evidenced and clearly identified that personal views and opinions regarding the day to day running of the home are taken into consideration. Staff spoken with said that service users are encouraged to chair these meetings. Service users spoke encouragingly of these meetings and one said, “They enjoy attending to make sure that they get what they want”. The home uses the CSCI inspection reports and monthly provider visits as a guideline as to what the service does well and what requires further development. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 16 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 X 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 X 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X x X X 3 X X X X St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 17 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 YA23 Regulation 13(6) Timescale for action The registered person shall make 30/04/06 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA6 YA24 YA33 YA35 Good Practice Recommendations Service user plans should be more detailed to ensure that specific needs can be addressed. The shelving unit within the staff sleep in room at Burking Road be relocated. Staffing levels should be reviewed to offer more flexibility and choice for service users. Staff training records should be up to date to inform managers about staff training and development needs. St Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Anne`s (Dewsbury 1) DS0000026350.V268388.R01.S.doc Version 5.1 Page 19 - 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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