Inspection on 21/02/06 for St Anne`s (Dewsbury 2)

This inspection was carried out on 21st February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Anne`s (Dewsbury 2) 07/12/05

St Anne`s (Dewsbury 2) 07/01/05

St Anne`s (Dewsbury 2) 10/09/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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 2) 13 Birkdale Road Dewsbury West Yorkshire WF13 4HG Lead Inspector Stephen French Unannounced Inspection 21st February 2006 09:30 St Anne`s (Dewsbury 2) DS0000026352.V283748.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 2) DS0000026352.V283748.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 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Anne`s (Dewsbury 2) Address 13 Birkdale Road Dewsbury West Yorkshire WF13 4HG 01924 459878 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 Mrs Lesley Murphy Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (15) St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate 10 service users at Temple Road and 5 service users at Birkdale Road 7th December 2005 Date of last inspection Brief Description of the Service: Temple Road is a care home providing care and accommodation to ten people with enduring mental health problems. It is purpose built and owned by St Anne’s Shelter and Housing Action. The home is situated on the outskirts of Dewsbury and has two floors. All bedrooms are single and there are sufficient communal facilities to incorporate a choice of lifestyles for service users. Birkdale Road can accommodate up to five service users. It is situated a few miles from Temple road. It is a converted private dwelling and all rooms are single. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of the bi-annual inspections and was undertaken on the 21st February 2006 and was unannounced. The inspector would like to thank the manager and staff for their hospitality and cooperation during the inspection. As part of the inspection a number of service users’ and staff files were examined as well as policies and procedures. A tour of the home was conducted which included a number of service users’ bedrooms and communal areas. This was a positive inspection and the manager and her staff are to be commended for maintaining a good level of care. Service users spoken to said that the staff at the home were very friendly and always around to help. Staff were observed interacting with service users and it was obvious that they had built up a good relationship with each individual. What the service does well: Service users’ needs are assessed prior to them moving into the home to ensure the home can meet those needs. Each service user has a care plan, which informs the staff of the care and support they need. The care plans are reviewed regularly with the involvement of the service user. The home provides a safe comfortable friendly atmosphere in which the service users can live. Staff promote the service users’ independence and support them in accessing community based activities. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Anne`s (Dewsbury 2) DS0000026352.V283748.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 2) DS0000026352.V283748.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): 2 The service users’ needs are assessed prior to them moving into the home. EVIDENCE: The home receives a community care assessment for the service user, which has been completed by their social worker prior to them moving into the home. The manager also visits prospective service users and completes a preadmission assessment, which has been developed by St Anne’s. The assessment forms the basis of the support plan and informs the staff of the care and support the service user will require. Completed assessments were seen for a service user recently admitted to the home. St Anne`s (Dewsbury 2) DS0000026352.V283748.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): 6,8,10 Each service user has an individual care plan, which is reviewed at regular intervals. Service users are involved in these reviews and agree any changes made to the plan. Service users have the opportunity to participate in the running of the home this includes the employment of care staff. The homes policies and procedures are not in suitable formats therefore the service users do not have an understanding of them. EVIDENCE: Three service users’ care plans were examined as part of the inspection. There were support plans in place which identified the areas the service user required support from staff. Action plans were in place for such things as monitoring mobility and managing finances and most of these were reviewed either monthly or six monthly. There was evidence in the files examined that the service users had been involved in the review of their care plan and had agreed to the changes made. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 10 Risk assessments were in place for such things as smoking, going out to the shops unaccompanied, bathing and showering and these had been reviewed six monthly. There were assessments for service users who were likely to display aggressive or inappropriate behaviour. These described how staff should handle the situation and the practices to be used to prevent the situation arising. Service users are supported to assist care staff in the day-to-day running of the home. The manager informed the inspector that service users are involved in the selection of new staff. Some service users are involved in the interview process while others will provide the manager with questions they wish the manager to ask on their behalf. The service users usually show a prospective employee around the home and answer any questions they may have. Unfortunately the home’s policies and procedures are not in a suitable format for the service users to have an understanding of them. The manager stated that St Anne’s as a group is looking into how this can be achieved The home produces an annual questionnaire to seek the views of service users and their families on the quality of care that they receive. The most recent questionnaire was sent out in October 20005 and the inspector noted that the home had received very positive feedback. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14, The service users are well known within the local community. Leisure activities are appropriate for this particular service user group. EVIDENCE: Within the care files examined there was information on how staff support the service users to integrate within the community. Staff accompany service users out to the local pubs, shops, restaurants and the local leisure facility. One service user helps a neighbour with her garden and the home has a good rapport with the local community. Service users are able to participate in the civil process if they wish and staff would arrange postal votes or take the service users to the local polling station. Service users enjoy trips to the local sports centre where they play ten-pin bowling. There are also day trips arranged to places of local interest such as museums and theatres. Staff also arrange shopping trips and take a number of service users out to lunch. The home used to arrange outside entertainers to visit the home but the service users said that they would prefer to go out for the day, rather than have entertainers visit the home. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 12 The service users enjoy an annual holiday and evidence was seen in the care files that staff have so far arranged holidays for four service users; destinations include Scarborough, Blackpool, Weymouth and Ireland. On the day of the inspection one service user informed the inspector that he was looking forward to going out to the local pub to play snooker. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 Staff support the service users through illness and death. EVIDENCE: Service users are able to spend their remaining days within the home unless their needs change and they require nursing care, or they require hospitalisation. Within the personal support plans there is information on the service users wishes regarding terminal care and death. Service users, with the help of staff, had completed a document entitled “After I Die” which informed staff and family of their wishes such as hymns and where their belongings should go. On the day of the inspection staff and service users were attending the funeral of a service user who had recently died. They had arranged for the family and friends of the service user to meet back at the home for refreshments. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 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): 23 Service users are protected from abuse. EVIDENCE: The home has policies and procedures in place surrounding the protection of vulnerable adults. Staff receive training in this as part of their induction training. Evidence was seen that all staff have attended an update on this subject this month. Staff spoken to gave good responses to questions asked surrounding the protection of vulnerable adults. There are also policies and procedures in place for dealing with challenging behaviour and aggression and staff have attended training days to help them deal with such behaviour . Within personal support plans examined, there were risk assessments in place for service users who may exhibit challenging behaviour. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 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 25 27 28 30 The home is comfortable and homely and suits the needs and lifestyles of the service users living there, but the décor is looking tired and worn. EVIDENCE: The lounge and dining room at Temple Road are very homely in character and there is a smaller lounge on the first floor, which is non-smoking. There is a small kitchenette on the first floor, which the service users are able to use if they wish. The main lounge is in need of redecoration and the suite has cigarette burns in the arms and seat and should be replaced. The flooring in the upstairs kitchen needs replacing and the cupboards are in need of cleaning. The service users’ bedrooms contain personal items such as photographs, ornaments and small pieces of furniture. There are toilets and bathrooms within close proximity to communal areas and service users’ bedrooms. The toilet pan on the first floor is in need of replacing as it is badly marked. The home was clean and fresh and there were no unpleasant odours present. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 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): 31,36 The manager and her staff are aware of the aims and objectives of the home and are aware of their roles and responsibilities. Staff are appropriately supervised. EVIDENCE: Staff at the home show a great empathy towards this particular service user group and were observed interacting appropriately with service users. Staff spoken to on the day of the inspection were aware of the needs of the service users. Evidence was seen in care files examined that staff involve outside professionals when the need arises. The manager and her deputy complete formal supervision on all staff. The supervision includes, amongst other things, the staff’s training objectives for the coming months. Records examined confirmed that staff are receiving at least six supervisory sessions per year. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 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): 37,39 The home is well managed. The views of the service users on the care that they receive are obtained and any issues are addressed by the manager. EVIDENCE: The manager has been employed at the home for some time. She has an NVQ level three in care and is part way through her Registered Manager’s Award. She is aware of the aims and objectives of the home and leads her staff team well. The home seeks the views of the service users and their families on the home and the care that they receive. Questionnaires are sent out annually and the inspector saw the results of a recent poll. Thirty-six questionnaires were sent out and twenty-five had been returned. There were many positive comments such as “atmosphere very friendly and homely” and “excellent support from staff”. Negative comments were in the main about the décor of the home. St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 18 St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 19 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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 2 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 x 33 x 34 x 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 x 2 x 3 LIFESTYLES Standard No Score 11 x 12 x 13 3 14 3 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x 3 3 x 3 x x x x St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations Risk assessments should be reviewed at least six monthly or more frequently if needed. A daily entry should be recorded in the service user’s care file. Policies and procedures should be in suitable formats to ensure the service users have an understanding of them. The lounge and dining room requires redecoration, a new suite should be purchased The toilet should be replaced. 2. 3. 4. YA8 YA24 YA27 St Anne`s (Dewsbury 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 21 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 2) DS0000026352.V283748.R01.S.doc Version 5.1 Page 22 - 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. 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