Inspection on 19/02/06 for St Bonaventures

This inspection was carried out on 19th 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 found no outstanding requirements from the previous inspection report, but made 3 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 11/12/05

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 19 February 2006 9:10 th St Bonaventures DS0000021625.V278854.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 Bonaventures DS0000021625.V278854.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 Bonaventures DS0000021625.V278854.R01.S.doc Version 5.1 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.V278854.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th December 2005 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.V278854.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on Sunday 19th February 2006 commencing shortly after 9.00am. The majority of the key national minimum standards were looked at on the last inspection in December 2005. Readers are referred to that inspection report where a fuller picture of the service provided at the home was reported on. The manager is registered with CSCI and was present throughout the inspection. Time was spent examining records, in discussion with the manager, staff and residents. Four residents were at the home and two were spending time with their relatives. Of the seven requirements made on the last inspection six were complied with. The outstanding requirement is repeated in this report. Three recommendations were made on the last inspection two had been fully addressed. Comment cards were left at the home for residents and their relatives and visitors. Comments from the cards and those made by residents on the inspection are included in this report. What the service does well: The manager is supported by a committed team. The carers are respectful towards the residents, their families and each other. The staff are loyal to the home and want to give a high standard of care. Residents were complimentary about the staff and about the food provided in the home. Staff training is provided in line with the residents needs. Staff have training in mandatory aspects of health and safety Quality assurance questionnaires are sent out and the results assist the home to develop the service they provide. St Bonaventures DS0000021625.V278854.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 Bonaventures DS0000021625.V278854.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 Bonaventures DS0000021625.V278854.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&4 Residents’ care needs were assessed before admission and they were satisfied with the care provided. EVIDENCE: There have been no new admissions since the last inspection. The manager said that the home has an assessment procedure, which includes the prospective resident, their family or key relative and the local authority. When the initial assessment is undertaken by the local authority this is presented to the home, who will offer a short visit to the prospective resident. If all goes well a second visit over a weekend is arranged to give the resident an opportunity to see what they think of the home. The home’s assessment is undertaken and after discussions a decision is made whether the prospective resident will fit in at the home and get on with the residents that already live there. St Bonaventures DS0000021625.V278854.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): These standards were not assessed as part of this inspection. Readers are referred to the inspection report dated 11th December 2005, where these standards were reported on. EVIDENCE: St Bonaventures DS0000021625.V278854.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 The day-to-day routine of the home including mealtimes was relaxed and informal and met residents’ needs. EVIDENCE: Residents are offered a key to their bedroom, which can be, locked from inside and outside, some of the residents use their keys others don’t want the bother or are prompted or supported by staff. All residents have a key to the front door with some residents being supported by staff to remember their key or to use it. Staff were observed to talk and interact with residents and good relationships were apparent. Residents have the opportunity of spending time alone when they wish or having the company of others in their room or in the lounge. Residents said they can go where they want within the home. Residents are able to spend time in any of the rooms of the house within a risk management framework. St Bonaventures DS0000021625.V278854.R01.S.doc Version 5.1 Page 11 The kitchen is an area where restricted access is in place to specific residents at differing times. A record has been introduced of the food each resident eats at mealtimes; this enables an assessment to be made whether the diet the resident is having is nutritional. If a resident is loosing or gaining weight this record can be used to also check whether there have been any changes to the residents’ eating pattern. The diet appeared varied with differing meals served each day. Residents said they liked the food and enjoyed particular meals in the week. St Bonaventures DS0000021625.V278854.R01.S.doc Version 5.1 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): 19 & 20 Residents’ health care needs were identified and met. EVIDENCE: Residents are supported to take control of and manage their own health care needs as much as they are able. Some residents are able to let staff know if they are unwell, others due to their abilities are not and staff use their skills, knowledge and communication systems known to them to assess residents’ health care needs. Residents are able to choose their own doctor and make some decisions about their own health care and medical treatment, staff support residents to keep appointments and accompany them when this is needed. Routine appointments are made with chiropodist, dentist and optician. The majority of residents are able to attend health appointments at the surgery. Examination of the medication administration records identified that medication received into the home was signed in and the quantity received was indicated, as is best practice. St Bonaventures DS0000021625.V278854.R01.S.doc Version 5.1 Page 13 New medication that has been prescribed after the printed record had been sent to the home, was handwritten and a second person had signed to say they had verified the detail, this was indicated as a requirement on the last inspection and has been complied with. The home has asked the pharmacist to supply them with a book to record medication that is returned to the chemist. This has not been received at the home. In the interim as a safeguard the home is using the medication administration records to detail any returns but confirmed that a central record would assist in their audit trail of medication. The medication records seen at the inspection were completed in line with pharmaceutical guidelines with no unexplained omissions in the recording. The medication policy has been amended since the last inspection and details the changes in practice that must be adhered to by staff. St Bonaventures DS0000021625.V278854.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): 22 &23 The complaints procedure ensured that all interested parties were aware of how to complain and the process that would be undertaken. Residents are protected from abuse and exploitation. EVIDENCE: A complaints book has been introduced which will be used to record residents, families, visitors and staffs comments and complaints about the service. It is envisaged that all complaints will be documented to show that the home takes peoples views seriously and attends to their complaints objectively. The recording of complaints is a new development and staff are to be assisted in how to use the record and what constitutes a complaint. The home has an adult protection policy, which informs of the actions to be taken if abuse is suspected. Staff have signed that they have seen and understood the policy. The policy was last reviewed in January 2006 when no revision was seen as necessary. Adult protection training has been requested from the local authority. At this time the home has not received confirmation that places have been allocated to them. In the mean time an external trainer has been contacted and places for all staff have been confirmed for April 2006. St Bonaventures DS0000021625.V278854.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 The home was well maintained and provided comfortable living accommodation for residents. EVIDENCE: The home was well maintained throughout and provided comfortable accommodation. The grounds of the home were well kept and attractive. The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours. Resident’s rooms are personalised and homely. Residents said that they were happy with their rooms and they had all they required. St Bonaventures DS0000021625.V278854.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): 33 Residents would benefit from increased numbers of staff on duty at particular times of the day. EVIDENCE: Examination of the staff duty roster found two staff to be on duty throughout the waking day with one staff on sleeping duty each night. The full names of staff need to be included on the duty roster in line with regulations. Comments received on the inspection suggested that at particular times of the day an additional staff member would be useful to enable all residents to take part in activity or attend events. Staff undertakes laundry, cleaning and cooking, with residents contributing dependent on their abilities. The care plan indicates for example the cleaning of residents’ bedrooms by the resident in some instances. St Bonaventures DS0000021625.V278854.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): 39 & 42 The health, safety and welfare of staff and residents were safeguarded. EVIDENCE: Annual reviews have been undertaken in December and January 2006, when the resident, their families or representative and the local authority meet with the home to discuss whether the home is meeting the residents needs. Minutes are made of the meeting and the local authority send a copy to the resident. Time is spent with the resident and key worker reading the minutes to make sure the resident understands what has been recorded and the implications of the meeting. The service user signs the minutes and these are placed within their file. A questionnaire is periodically sent to families asking for their views and opinions on the home and the care provided. Families have returned the most recent questionnaire and all the comments were positive. One visitor said, “ I am completely satisfied with all efforts of the management and staff to make St Bonaventures DS0000021625.V278854.R01.S.doc Version 5.1 Page 18 the home a friendly and happy residence”. A further comment made said, “ We are so happy we found St Bonaventure’s”. Residents’ meetings are arranged from time to time, when there are any issues or something that needs discussing with the group, or if there is something in particular to discuss. Records are made of the “get togethers”. These were not seen on the inspection. Policies and procedures are reviewed annually or more frequently through increased knowledge, practice issues or if legislation changes. A plan is in place to remind the manager of these timescales. Staff read the policies and procedures and sign to say they have read and understood them. Staff meetings are arranged periodically, which provides staff with an opportunity to comment on the development of the home and to be informed of any practices issues. The last meeting was held in January 2006. Staff sign the notes of the meeting as confirmation that the notes are accurate and they understand the content of the meeting. A staff member has been nominated to take responsibility to ensure all staff are familiar with what to do in the event of a fire, by making sure they all have fire drill practice every six months and training annually. The staff member is to attend Fire Marshall training on 20th March 2006 to further assist in there understanding of fire procedures. Examination of the fire safety records found that they were recorded as having been checked in keeping with the fire authority’s guidelines. All staff were reported to have received fire drill training, some staff having had the training the day before the inspection. The manager said staff had not had the opportunity to sign next to their printed name to confirm attendance to the drill. The servicing of the fire alarm was recorded as having been undertaken by a contactor on 10th March 2005. A fire inspection by the fire authority had not been undertaken in recent times, the last recorded inspection being in April 2004. St Bonaventures DS0000021625.V278854.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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X X X 3 X X 3 X St Bonaventures DS0000021625.V278854.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. 1 Standard YA20 Regulation 13 Requirement Timescale for action 2 YA23 13(6) 3 YA32 18 The registered person must 31/03/06 ensure that medication that is returned to the supplying pharmacy is recorded. (Previous timescale of 31/12/05 not met) The registered manager must 30/04/06 provide training in adult protection to all care staff employed at the home. The registered person must 30/04/06 review the numbers of staff on duty and increase those numbers at particular times of the day to provide all residents with the opportunity to take part in activity or attend appointments with ease. St Bonaventures DS0000021625.V278854.R01.S.doc Version 5.1 Page 21 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 YA33 YA39 YA42 Good Practice Recommendations The registered person should include on the staff duty roster the full names of staff on duty. The registered person should maintain a record of residents meetings, which should be made available for inspection. 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. 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