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

This inspection was carried out on 7th 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 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) 28/02/06

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 Cathy Howarth Unannounced Inspection 7th December 2005 10:00 St Anne`s (Dewsbury 1) DS0000026350.V268385.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 Anne`s (Dewsbury 1) DS0000026350.V268385.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 Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 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.V268385.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 5 service users with learning disability can be accommodated at 7 Burking Road, Dewsbury. 5 services users with learning disability can be accommodated at 2 Oxford Road, Dewsbury 4 service users with learning disability can be accommodated at 61 Track Road, Batley. 7th February 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 faclilities is approximately a mile from each house. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors, Cathy Howarth and Stephen French. It was unannounced and involved all three premises, which make up this service. Inspectors looked at some core standards in each house, met with service users, staff and examined relevant records. Inspectors 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: Support plans for service users should be improved to make sure that service users’ choices about their lives are implemented. Staffing should be improved to give more flexibility and choice for service users in choosing social activities. Staff training should be given a higher priority and should be monitored to make sure staff all receive appropriate training to meet the needs of service users. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 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.V268385.R01.S.doc Version 5.0 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.V268385.R01.S.doc Version 5.0 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): 5 Service users receive a written contract on admission. EVIDENCE: Evidence was seen that the service users receive a written contract on admission. These contain, amongst other things, information on the fees payable and what they do and do not include. The contracts had been signed by the service user and the manager. Due to the complex needs of some of the service users staff should ensure that if the service user lacks capacity then the contracts should be discussed with a relative or an advocate prior to them being signed. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 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): 6,7,and 9 Individual care plans did not contain sufficient detail and did not reflect the care that the service users receive. 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. EVIDENCE: Each service user has a personal centred plan which has been devised from information gathered from the community care assessment and information from relatives and other members of the multidisciplinary team. Two care files were examined in each house. These contained risk assessments for such things as going out alone. Assessments had been reviewed. There was evidence that staff assist service users in deciding what they do during the day and where they go for leisure time. On the day of the inspection two service users were waiting for a taxi to take them into town. Care Plans were not very specific in the actions the staff are to take to enable the needs of the service users to be met. These need to be improved. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 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): 11, 12,13,14,15,16,17 Staff support service users well to participate in daytime activities and in maintaining family contacts. EVIDENCE: There was evidence in service users’ records that community based activities take place. Service users are supported by staff in visiting places of local interest. An objective in a service user’s care plan to have an outing weekly had been achieved. Some of the service users attend a day centre and one service user is employed in a recycling plant part time. Staff are responsible for arranging daytime activities for the service users. It was noted that whilst staff attempt to spend time with service users who are at home during the day, this could be limited due to the fact that there is only one staff member on duty, and a number of other tasks such as cooking and cleaning has to be done. The staff stated that some of the service users had had a holiday this year. A range of leisure equipment is available to service users including, TV, Videos, DVD’s, and a stereo. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 11 There was evidence in records that service users are supported to maintain contact with their families; staff confirmed this. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 12 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): 18, 20 Service users receive personal support from care staff in a way that they prefer. Staff administer medication safely. EVIDENCE: Staff were observed to offer personal support to service users in a respectful and positive manner. Some personal support plans contained details describing service users preferred and required routines, likes and dislikes. Some plans however did not contain sufficient detail and should be further developed. This is important for service users who cannot easily communicate their needs. Evidence that service users receive additional specialist support and advice from occupational therapists and speech therapists was seen in service users records examined. There was evidence in service users’ records that staff support service users to attend healthcare appointments where necessary. All staff have received training in the administration of medication. Due to the complex needs of some of the service users they would be unable to self medicate therefore the staff administer all medication. Stock balances of St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 13 medication checked, tallied with the medication administration records held by the home. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 14 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, Service users are confident that any issues they raise will be dealt with appropriately by the manager. EVIDENCE: The home has a complaints policy, a copy of which is contained in the contract service users receive when they are admitted to the home. The manager investigates complaints and evidence was seen that a complaint received on the 7/4/05 had been handled appropriately. One service user spoken to informed the inspector that he was aware of the complaints policy and felt that any complaints he had would be addressed by the manager. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 15 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, 30 The houses were all found to be clean and tidy. Service users live in a homely environment. EVIDENCE: All three houses were seen by inspectors and were found to be clean, tidy and pleasantly decorated. As this inspection took place shortly before Christmas, it was good to see that all three homes were seasonally decorated. There are minor maintenance repairs to be carried out in the houses, such as TV repair at Track Rd to improve the picture and at Burking Rd, the sink drawer in the kitchen needs repair and the lounge and bathroom windowsills need to be repainted. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 16 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): 33, 35 Staff training needs to be monitored more positively. Staffing levels do not allow for service users to have flexibility in planning social events. EVIDENCE: Inspectors noted that staff in all three houses reported that there have been some staffing difficulties as a result of sickness and vacancies, which are unfilled. Rotas have been covered by staff working extra hours and bank staff. In all three houses, inspectors noted that staff rotas make it difficult for service users to be able to do evening activities without special arrangements having to be made for staff to cover. As Christmas was approaching there were parties and other events planned which necessitated extra staffing being available. On a normal weekly basis, the opportunities for service users appear to be limited by the fact that only one staff is generally on duty. Inspectors looked at staff training records in order to assess the level of competence within the team. These records were unfortunately found to be out of date. Therefore it was difficult to assess the current level of training within the staff teams. St. Anne’s have an induction training course, but at Track Rd the newest member of staff’s record did not show that this had been attended. Training records should therefore be updated without delay to ensure that managers can be clear about where training needs for staff are to be met. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 17 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): 42 Overall the health and safety management systems in the service were found to be good. EVIDENCE: In all three houses, inspectors found that there was high level of awareness around heath and safety issues. Records were found to be up to date and staff appear vigilant with continuing this. Fire safety was found to be taken seriously, with systems of regular testing and fire drills. In Track Rd and Oxford Rd, the inspector noted that there were bolts fitted to some final exit doors. Staff were clear that these should not be used but it is recommended that they are removed to ensure that this is not done by an inexperienced or agency staff member in error. A recent fire safety inspection at Oxford Rd has highlighted some areas for improvement. These need to be addressed without delay. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 18 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 X X X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Anne`s (Dewsbury 1) Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000026350.V268385.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO 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 YA42 Regulation 23(4) Requirement The recommendations of the fire safety officer in relation to Oxford Rd must be complied with. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA6 YA30 YA33 YA35 YA42 Good Practice Recommendations Service user plans should be more detailed to ensure that specific needs can be addressed. The minor improvements noted in the environment section of this report should be carried out. 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. The bolts fitted to final exit doors in Track Rd and Oxford Rd should be removed. St Anne`s (Dewsbury 1) DS0000026350.V268385.R01.S.doc Version 5.0 Page 20 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.V268385.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!