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

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 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) 21/02/06

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 7th December 2005 09:30 St Anne`s (Dewsbury 2) DS0000026352.V271580.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 2) DS0000026352.V271580.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 2) DS0000026352.V271580.R01.S.doc Version 5.0 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.V271580.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate 10 service users at Temple Road and 5 service users at Birkdale Road 7th January 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.V271580.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 7th December 2005. Not all of the standards were assessed on this occasion and the inspection focused on a number of core standards. As part of the inspection a selection of service users and staff files were examined. A tour of both of the houses was conducted and a number of service users and staff were spoken to. At Birkdale road building work was in progress to relocate the laundry and staff sleeping in room. All five service users were out visiting Temple Road. Service users living at Temple Road were observed to be spending their day in either the communal lounges or their bedroom. One service user showed the inspector around the home. The inspectors would like to thank the manager and staff for their hospitality. What the service does well: What has improved since the last inspection? The home has introduced personal centred plans for each service user. Risk assessments now concentrate on the risks associated with daily living. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 Page 6 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.V271580.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 2) DS0000026352.V271580.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 Each service user has a contract, which informs them of the terms and conditions of admission to the home. EVIDENCE: Each service user has a contract, which is signed on admission. The contract informs the service user the fees payable, their frequency and what is and is not included in the fees. The contracts are signed by the service user or their representative and the home manager. Completed contracts were seen for three service users. St Anne`s (Dewsbury 2) DS0000026352.V271580.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): 6,7,9 Each service users has an individual plan, which is reviewed at regular intervals. Staff support service users to make decisions in their lives. Risks to service users are minimised through a risk assessment framework. EVIDENCE: As part of the inspection a number of service users individual support plans were examined. Since the last inspection the homes have introduced personal centred plans for each service user. Each plan has measurable objectives and is reviewed weekly. There is evidence that the service users were involved in the drawing up of these plans and there was some very good detail recorded within the files examined. Staff support the service users to make decisions about their own lives. Risk assessments were in place for such things as crossing the road, going out with other service users and using equipment within the home. Risk assessments had been reviewed. Daily entries in the care files examined were very detailed and gave an overview of the service users psychological and social wellbeing. St Anne`s (Dewsbury 2) DS0000026352.V271580.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, Service users are supported in continuing education and social activities. They are encouraged to maintain community links. EVIDENCE: Within the personal centred plans there was evidence that service users skills were being developed with the support of staff and outside agencies. There was evidence that some service users access colleges of further education and voluntary services. Due to the complex nature of some of the service users disabilities, employment is not practical. One service user attends the local gym regularly. On the day of the inspection service users who live at Birkdale road were out visiting their sister home Temple Road. Service users are able to choose where they go on holiday Families are encouraged to continue contact with service users and staff offer support to enable service users to visit elderly relatives. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 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): 18,19,20 Service users receive personal support in a way that they prefer. Service users health care needs are met. Service users are able to self administer medication if they wish. EVIDENCE: Personal support plans contained excellent detail describing service users preferred and required routines, likes and dislikes. This is particularly important for service users who cannot easily communicate their needs in order to ensure that consistency and continuity of support is achieved. Evidence that service users receive additional specialist support and advice from physiotherapists, occupational therapists, speech therapists etc. was seen in service user records. There was evidence in service users records that staff support service users to attend healthcare appointments where necessary. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 Page 12 Care staff administers medication to the service users. If a service users wishes to self medicate then a risk assessment and support plan is completed and this is kept under review. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 Page 13 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 complaints will be dealt with appropriately. EVIDENCE: Within the terms and conditions of admission there is a copy of the homes complaint policy. The manager investigates complaints and evidence was seen that a complaint received in June 2005 had been handled appropriately. Service users spoken to said that should they have a complaint they would speak to the manager. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 Page 14 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 home is clean and tidy and well maintained. Some areas need improvement. EVIDENCE: The environment at Birkdale Rd is very small and homely. Facilities are domestic in nature. On the day of this visit decorations had been put up in preparation for Christmas. At Temple Rd the home is less homely being larger and more institutional. However efforts are made to redress this as far as possible. The lounge and dining areas were found to be quite homely. The Green Room upstairs, which is non-smoking, is very pleasant but under-used it, seems by service users. In both homes there were found some areas that needed attention. At Birkdale Rd, the kitchen area around the boiler and underneath the kickboards needs cleaning. Inspectors were informed that the boiler here is due for replacement. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 Page 15 At Temple Rd, the payphone needs to be cleared of stored items that make it difficult to use, and the TV needs attention, as the picture was very poor. Also there were a large number of items in the back garden, which have been thrown out but not yet disposed of. These need to be moved without delay. Inspectors were informed that the lounge at Temple Rd is to be redecorated soon. Both houses were found to be clean and tidy on the day of inspection. St Anne`s (Dewsbury 2) DS0000026352.V271580.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): 32,33,35 Staff working at the home have the relevant skills and qualifications. At the moment there are sufficient numbers of staff to meet the needs of the service users. EVIDENCE: Staff working at the home have a range of skills and experience. Training records were examined as part of this inspection and there was evidence that relevant training is attended on a regular basis. New care staff complete the Learning Disability Award Framework induction and foundation training. There is a comprehensive training and development plan in place. Training that staff have received includes, movement and handling, first aid, food hygiene, adult protection, health and safety and Schizophrenia awareness, This is in addition to NVQ training, which is ongoing There are five service users accommodated at Birkdale Road. Duty rotas checked for the month of November and December confirmed that there was one member of staff on duty at all time, occasionally there were two staff during the day. The manager informed the inspector that there were still vacancies for staff but that she had managed to fill one of the posts recently. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 Page 17 At the moment there are no service users who have any behavioural problems therefore one member of staff appears to be sufficient in meeting the current service users needs. Extra staff is available from its sister home Temple road which is situated a few miles from Birkdale road. Should the needs of the current service users change then it would be advisable for another member of staff to be on duty during the day. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 Page 18 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 The health, safety and welfare of service users are protected. EVIDENCE: Records regarding health and safety matters were in good order. There was evidence in the records that the required checks and maintenance of safety and specialist equipment is carried out. Evidence that regular fire drills are carried out to ensure that service users and staff are aware of the procedure was seen in the records. All staff receives training in health and safety. No unsafe practices were observed at the time of inspection. Inspectors noted that service users at Temple road are allowed to smoke in their rooms. This has been the cause of some fire alarms in recent times resulting in the fire brigade being called out. This needs to be clearly written into fire risk assessments, where this has been a problem relating to individuals. St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 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 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 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Anne`s (Dewsbury 2) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000026352.V271580.R01.S.doc Version 5.0 Page 20 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. 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 YA24 Good Practice Recommendations The items stored in the payphone kiosk at Temple Rd should be removed for the safety of service users. The back garden should be cleared of unwanted items. The reception area in temple road requires redecoration. The kitchen floor at Birkdale Rd needs to be cleaned. Individual fire risk assessments should be in place relating to service users who smoke in their rooms. Individuals should be identified on the fire risk assessment. 2 3 4 YA28 YA30 YA42 St Anne`s (Dewsbury 2) DS0000026352.V271580.R01.S.doc Version 5.0 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.V271580.R01.S.doc Version 5.0 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. 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!