Inspection on 11/12/05 for St Bonaventures

This inspection was carried out on 11th 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 found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Bonaventures 26/09/07

St Bonaventures 17/06/06

St Bonaventures 19/02/06

St Bonaventures 15/12/04

St Bonaventures 19/05/04

St Bonaventures 26/03/04

St Bonaventures 14/10/03

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

Hudson Road

Whitewalls

Home Farm

Griffin Lodge

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

CARE HOME ADULTS 18-65 St Bonaventures 62 Kenworthy Lane Northenden Manchester M22 4EJ Lead Inspector Kath Oldham Unannounced Inspection 11th December 2005 08.45a St Bonaventures DS0000021625.V271454.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 Bonaventures DS0000021625.V271454.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 Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Bonaventures Address 62 Kenworthy Lane Northenden Manchester M22 4EJ 0161 945 6265 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 Bonaventures Trust Ms Patricia Mitchell Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2004 Brief Description of the Service: St Bonaventure’s is a care home providing personal care only for a maximum of six adults with a learning disability. A homely environment is provided and strong emphasis is placed on providing residents with the necessary support to develop through participation is structured activities, education, occupation and ordinary life experiences/ opportunities. The home is situated in the Northenden area of Manchester, within easy reach of shops and community amenities. It blends well with neighbouring properties, having been converted from a domestic property. There are gardens to the front and rear of the property and car parking within the grounds. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day on 11th December 2005. The inspector spent time in conversation with residents and staff, in addition to speaking to the manager. Observations of staff practice and routines were undertaken, as was the examination of a sample of documents and files, which need to be maintained in line with regulation. A tour of the premises was also undertaken. Verbal feedback of the findings of the inspection was given to the manager at the end of the inspection. What the service does well: The atmosphere in the home is warm and friendly. Staff take a pride in their work and work as part of a team; all staff members assisting one another in differing tasks. Residents’ activities were said to be enjoyed and residents were occupied in everyday occupations, as they would be in their own home. They appear happy in the home. The manager continues the development of the home by keeping in touch with changes in care practices and routines. The manager was described as easy to approach. The atmosphere in the dining room was sociable with residents catching up with one another and sharing what they had done in the day and what they intended to do. Staff were patient, friendly and sensitive, and spent time with individual residents. Training is provided to staff and updates are scheduled on the yearly planner, which ensures training doesn’t get forgotten. Over 50 of staff have obtained NVQ training. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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 Bonaventures DS0000021625.V271454.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 Bonaventures DS0000021625.V271454.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): EVIDENCE: These standards were not assessed as part of this inspection. St Bonaventures DS0000021625.V271454.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 Residents’ needs and personal goals were identified and met. EVIDENCE: Examination of the care files identified the specifics of the care the residents are able to provide for themselves or areas where support is needed from others. Aims are identified within the records and include the staff support to meet the aims. Risk assessments were in place and a record was maintained of their review. The care files contained a record of health care and other professional appointments and the outcome of those visits or appointments. Examination of the daily reports identified that, on some occasions, only one entry had been made each day. This does not give an indication of how residents spent the remainder of their day. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 10 Staff were observed to support residents to make decisions as to how they spend their day and what they wanted to do. The care plans detail how individual choices have been made and record instances when others make decisions. The manager said that limitations on residents’ choice or human rights to promote individuality and safety are only made in the residents’ best interest and involve and include everyone who has an interest and involvement in their care. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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): 11, 12, 13, 14, 15 & 17 Residents were in the main able to make their own choices and decisions. Dignity and individuality were respected by staff. EVIDENCE: Many of the aims and objectives of the care plans were to be met by encouraging the use of community settings. These included shopping, use of public transport, college, work placements, pub meals, community groups and clubs. The residents also go on holiday together, with the support of the staff. Residents commented on attending college, day centres and going out to places of interest. One resident commented on their visit to see Father Christmas at the Saturday club and of the enjoyment of the event. Another was assisted to attend church on the inspection and was reminded to ensure they arrived on time. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 12 Staff were supportive of such activities and have helped residents to access a range of options, dependent upon their abilities and wishes. Person centred planning had been introduced to provide a formal process for setting goals and opportunities in occupation, education and training. The majority of residents have lived at the home for many years and were aware of the local facilities and amenities and supported, when necessary, to access them. Staff had knowledge of the local community and supported residents in leisure activities, such as visits to the local pub, bowling and cinema trips. Some of the occupational and leisure activities the residents take part in are provided by other learning disability services and voluntary groups, but others took place in the local community. The staff and residents also had an annual holiday abroad together. One resident was going abroad with staff for Christmas. Residents were entered on the electoral register. One resident said they they voted in the last election and the person they voted for was elected. A menu book is maintained and details the food served at the home for each of the meals taken at the home. One resident is provided with a diet which is appropriate to their religion and beliefs. Another resident’s cholesterol levels are monitored and certain foods are provided. An individual record of food served is not currently maintained so a judgement cannot be made as to whether individual diets are satisfactory. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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): 18 & 20 Systems are in place to ensure, as far as possible that residents receive the care they need. Procedures for recording of medication need to be developed. EVIDENCE: Reseidents receive their preferred bath or shower daily, some are able to undertake this task themselves or with minimal assistance. Residents were observed getting up and going to the bathroom as was their usual routine. One resident said they enjoyed their bath each morning. Residents who had personal needs were attended appropriately, in a manner that respected their dignity. to discreetly and Residents are routinely weighed, a record of this is kept and any weight loss or gain is addressed, through the review of the individual’s diet and lifestyle or through health care support. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 14 Examination of the medication records found the medication was signed as administered at the frequency of the prescription. The quantity of medication and the date it was received at the home was also recorded in the medication administration records. The return of medication to the pharmacy was reported to be written on the medication records. A separate record would assist staff to audit trail medication when necessary. There was one handwritten entry in the medication records which should be verified by another member of staff to safeguard residents. In the medication storage cupboard there were three tablets within a plastic bag, which were described by staff as ‘spare’. Photographs accompanying the medication records would further assist in the identification of residents. Specimen signatures and initials of staff who have the responsibility of administering medication were in place. The record needed updating to reflect the current staff group. A number of residents have homely remedies for minor ailments. The use of homely remedies had been authorised by the GP. The doctor did stipulate that these homely remedies could be given for a period of up to 48 hours. Some residents were having these medications for longer periods. All staff with the responsibility of administering medication were reported to have received training. However, some staff have not had updates to this training in recent years. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The lack of recording in the complaints record does not confirm the effectiveness of the complaints procedures. Some staff did not have training to protect residents from abuse. EVIDENCE: The staff on duty said they were able to tell when residents were not happy with something or someone, either through their change in mood or by letting staff know their views or opinions. The home had a complaints policy and a pictorial, user-friendly version of the procedure had been developed for service users, who have a copy. Examination of the complaints record identified there were no recorded complaints. The home needs to record the comments and complaints mentioned to staff to demonstrate that they take the views and opinions of residents, their relatives or staff seriously. Two residents contribute to pay for mobility allowance towards transport, for one resident this has not been approved or discussed with the placing local authority. The majority of staff have attended adult protection training and are aware of what constitutes abuse. The two newly appointed staff are to attend this training when it is next available. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 27, 28 & 30 St Bonaventure’s is a safe, well maintained, homely and clean home EVIDENCE: Residents’ bedrooms were bright and cheerful with lots of personal touches and items that made the bedrooms very individual. They had been personalised with their own ornaments, photographs, posters and entertainment equipment. The furniture and fittings of each bedroom was of a good standard and well maintained. There were sufficient numbers of toilets and bathrooms, both on the ground and first floors, that would meet the needs of the service users and offered sufficient personal privacy. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 17 The lounge is positioned at the front of the house and the dining room is opposite. A hatch in the kitchen enables meals to be passed through to residents in the dining room. A lot of residents have most of their meals in the dining room. They are able, if they choose, to have meals in the lounge or in their bedrooms. The residents also had access to the kitchen at a level identified by their risk assessment and care plan. Residents were observed to help at mealtimes in tidying the table and drying crockery after the meal. Residents chose to spend varying degrees of time in their own rooms. The garden at the rear of the property was spacious and fully enclosed. The home was clean, tidy and free from offensive odours. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The procedures for the recruitment and training of staff provide the safeguards to offer protection to residents living at the home. The deployment and number of staff on duty is sufficient to meet the needs of residents. EVIDENCE: Examination of the staff duty roster identified two staff on duty throughout the day from 7:00am until 10:00pm. A night care assistant is on duty from 10:00pm who is on sleep-in duty. There are no dedicated domestic or cooking staff; this is done by the staff on duty, supported by residents, when appropriate and within a risk management framework. Staff meetings are arranged which are used as an opportunity for staff to input into how the home is running. The meeting is also used by the manager to reinforce practice issues. The last meeting was undertaken in August 2005. Previous to this, meetings have been arranged more regularly. Examination of the two most recently appointed staff’s files found that both had completed a job application form, two written references were in place and there were copies of supervision records. One staff file did not have any proof of identification. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 19 New staff have commenced induction training and, as part of the home’s induction, specific training has been arranged. New staff are to commence NVQ training in the New Year. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41 & 42 The management of the home are approachable and focus on meeting the needs of residents. EVIDENCE: The manager has been in post for a number of years and is well respected by both residents and staff. Staff ask for guidance and assistance from the manager to assist in their own development. Staff and residents were complimentary about the managers’ skills, willingness to help and her management of the home. The manager has NVQ level 4 qualification and keeps up to date with techniques and development of care through the attendance to additional training and through research. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 21 Examination of the fire safety records identified that the checks to the means of escape, the emergency lighting, fire alarms and other associated fire safety checks had been undertaken regularly and these checks were recorded. The fire drill training/practice records identified all but one staff member having had training; the staff member’s previous training had been over 12 months ago. Staff do not currently sign next to their printed name to confirm receipt of the training. The actual date of the training is not indicated within the record. An outside contractor recorded the examination of the alarm panel and sounders to have taken place on 10th March 2005, when it was reported that the equipment was in order. The report of the fire authority’s inspection, undertaken on 4th May 2005, indicated that ‘on that visit it was considered that at the time of the visit, the requirements of the Workplace Fire Precautions legislation were being complied with’. A record of accidents, incidents and occurrences are maintained in an accident book, which are maintained within individual residents files. An examination of these records was not undertaken at this inspection. The admission and discharge book details residents entering and leaving the home to stay with friends or relatives or when they go away on holiday. Each resident has an individual record. An individual record is kept of purchases made on behalf of residents. Receipts were held on file, which were numbered for easy reference. Staff sign the records. Monies kept on behalf of service users are checked daily by staff on handover. One of the board of trustees looks at these records weekly and the accountant audits the accounts annually. Residents sign a petty cash slip on receipt of their monies. Examination of two residents’ monies identified the balances as being correct. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 2 3 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 X X 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 2 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Bonaventures Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 3 2 X DS0000021625.V271454.R01.S.doc Version 5.0 Page 23 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 YA6 Regulation 17(3)(a) Requirement Timescale for action 31/01/06 2 YA15 3 YA20 The registered person must arrange for the daily reports to be completed at a minimum of twice daily to give a clear picture of the care and support to residents Schedule The registered person must 4 maintain an individual record of food served to individual residents, so that anyone examining the records can assess whether the individual’s diet is satisfactory in terms of nutrition. 13(2) The registered person must 18(1)(c)(i) ensure that all staff members employed by the home, with responsibility for medication administration have received appropriate training. The training must include; basic knowledge of how medicines are used and how to recognise and deal with problems in use; the principles behind all aspects of the home’s policy on medicines handling and records. The training must also include a formal assessment of competency. DS0000021625.V271454.R01.S.doc 31/01/06 28/02/06 St Bonaventures Version 5.0 Page 24 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. 4 Standard YA22 Regulation 22 Requirement The registered person must further develop the staff team to support the recording of the complaints and comments made by residents in the complaints book. The registered person must ensure that medication that is returned to the supplying pharmacy is recorded. The registered person must ensure that handwritten medication details on the medication administration records are signed and dated and an additional member of staff validates the details. The registered person must ensure that the home retains an up to date list of staff members authorised to administer medicines, which includes a record of their signature and approved initials Timescale for action 28/02/06 5 YA20 13 31/12/05 6 YA20 13 31/12/05 7 YA20 13 31/12/05 St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 25 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 Refer to Standard YA20 YA23 YA42 Good Practice Recommendations The registered person should ensure that a formal system is in place to identify residents prior to medication administration. The registered person should refer to individual resident’s funding local authority for authorisation for their contribution to transport payments. The registered person should arrange for staff to sign next to their printed name to confirm receipt of fire drill training/practice and the record must include the actual date the training took place. St Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Bonaventures DS0000021625.V271454.R01.S.doc Version 5.0 Page 27 - 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!