Inspection on 26/09/07 for St Bonaventures

This inspection was carried out on 26th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Bonaventures 17/06/06

St Bonaventures 19/02/06

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 Joe Kenny Unannounced Inspection 26th September 2007 10:00 St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 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.V342480.R01.S.doc Version 5.2 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.V342480.R01.S.doc Version 5.2 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 Bonaventure’s Trust Ms Patricia Mitchell Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th June 2006 Brief Description of the Service: St Bonaventures 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 and 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.V342480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as an unannounced inspection of the home on the 26 September 2007. The inspector first visited the home on the 25 September, but staff and people living in the home had gone out for the day. The inspection began at 10:00 hours and ended at 17:30, enabling the inspector to meet all the residents. The inspection looked at key national minimum standards for Care Homes for Adults. The home’s deputy manager was present throughout the inspection. This inspection included examination of records, discussions with staff and people living in the home. Five people lived at the home at the time of the inspection. Comment cards were left to be completed by people, all were returned to the Commission. Comments from the cards and those made by residents on the inspection are included in this report. The home completed and provided the Commission with a self assessment of how the home perceived the service it offered. A requirements made at the last inspection had been addressed and one recommendation had also been actioned. What the service does well: The experiences of people living at the home were positive with a clear commitment to enable people to be actively involved in the day to day running of the home. In addition people were encouraged and supported on a range of community based activities relating to personal development, education and independent living. An established and committed staff team supported people living there, in a way which respected and met peoples needs. The design, lay out and location of the home provides people with a homely environment, immediate access to local resources and to be part of their local community. An established management team supports staff. Training programmes and support structures ensure care is delivered in a way which meets people’s needs. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 6 Observation on the day and from information gathered as part of the inspection process indicates the home is run in the best interest of people. 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. The summary of this inspection report can be made available in other formats on request. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 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.V342480.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People considering moving to the home, or their representatives, are provided with the necessary information to make an informed choice. EVIDENCE: Since the last inspection no new admission had taken place. The procedures described by the deputy manager in relation to referral and admission procedures ensure people’s needs are assessed, care and support plans are developed and people are offered the opportunity to visit the home prior to making a decision about moving there. During informal discussion with people living in the home they all indicated they were happy with the care and support offered by staff. The home had developed its Statement of Purpose and Service Users Guide in a format appropriate to the abilities of people living there. All residents are provided with a statement in relation to the terms and conditions of their placement. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 9 The home’s Statement of Purpose clearly stated that the activities and resources people access are based on their interests and preferences and they are supported to live in accordance with their cultural and religious wishes. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are consulted on, and participate in all aspects of life in the home and their local community. EVIDENCE: Each person living in the home has a named key worker to support them where assessed as required. Information in care plans and from discussions with staff were that the home encourages people to live as independent a life style as possible. All care plans were found to be written in a very person centered manner, to ensure they reflected choices and preferences of people. People were observed to actively be involved in daily routines and were encouraged to develop daily living skills. A number of people are involved in educational, leisure and work experience programmes and attend community resources throughout the week. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 11 This inspection took place unannounced on the 26 September 2007 and it was encouraging to note that on a visit to the home on the 25 September (with the intention to carry out the unannounced visit) all residents and staff were out on a planned activity involving shopping for the week and concluded with a visit and meal to another home managed by the trust. People confirmed they got up and went to bed when they choose and could freely plan how they spent their time throughout the day. People are encouraged to maintain contact with their relatives and one resident goes home at the weekend. Staff spoke about the positive outcomes for one person who lived at the home as the person had now moved to a more independent setting but continues to maintain contact with staff and people at the home. Records maintained by staff were detailed and informative, with up to two written entries per day on each person’s daily progress notes. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The lifestyle of people is relaxed and reflects people’s rights to be responsible for their daily living arrangements. Meal arrangements are very homely and relaxed. EVIDENCE: Residents live in a very relaxed and homely environment and are encouraged to retain responsibility for their personal and domestic routines of the day. This included domestic arrangements for cleaning their own rooms and assisting with support in the planning and preparation of meals. All rooms were pleasantly decorated, personalised and accessible to the named person who is provided with a key to their own room and provided with a key to the front door of the home. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 13 Staff were observed to be very supportive to people and had clearly developed a very caring whilst professional relationship with the people they supported. This was particularly evident in the one to one support offered to individuals who required greater input from staff. People were observed to relax and participate in activities of interest, before their evening meal. People also stated they were free to access their own rooms and relax how they wished in the evenings. A member of staff spoke about weekend arrangements where people came together to watch a particular weekly music show, and used this opportunity as a social event. The arrangements for accessing and supporting service users in meal arrangements continues to be restricted access to the kitchen area for some people due to assessed risks. Meal arrangements reflect the preferences of each individual and this is reflected in the shopping. There was evidence of a wide range of provisions purchased weekly, with all residents involved in this activity. Provisions also reflected dietary and cultural needs of people living in the home. Records are maintained of meal and menu arrangements to evidence the range of choices offered to people. The menu plans were varied with differing meals served each day. All residents said they liked their meals. One person commented ‘very happy here and enjoy the food’. Three people have access to motability cars, to support them on planned activities and outings/trips out. The home has a designated staff car for additional trips and use of a mini bus. Each person had a plan of activities for the week and this included access to day resources, trips out, craft courses and support with computer skills provided by staff in the home. Each year a holiday is planned and people can regularly access a caravan, owned by the trust, located in Wales, for weekends away. The Commission received five completed comment cards. In each case the person’s key worker had supported individuals to complete the comment card and three were signed by the named individual. All said they had received information about the home and had been involved directly or with their representative in the move to the home. One person commented ‘I am very happy here, the staff always listen to my views and support me in anything I wish to do’. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are met by the home. Procedures relating to medication protected people. EVIDENCE: People are encouraged and supported to access health care resources and their general practitioners. People are registered with general practitioners at a local health practice and with other health professionals at a local health clinic. The records relating to individuals and discussions with staff on their knowledge of the people they supported, demonstrated that systems were in place to respond appropriately to health care needs. Most people will plan or arrange their appointments and where necessary are supported by staff. The home maintains records of health care needs and visits to health professionals for dental, optical and chiropody appointments. The deputy manger stated access to the above health professionals was good. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 15 At the time of the inspection only two people were prescribed medication and no one self administered. Medication when inspected on the day was in order, well recorded and held securely. The senior on duty is responsible for administering medication. Prescriptions and medication are checked into the home and internal recording procedures support medication administrant records as an additional audit of how medication is administered. Procedures are also in place to record medication returned to the pharmacist. Medication was signed in and the quantity received was indicated on the medication administration record. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People said they knew who to speak to if they had any concerns or complaints. Procedures were in place to protect people from abuse or neglect. EVIDENCE: During discussion with staff and feed back from people completing the comment cards, systems were in place to ensure people knew who to speak to if they had any concern about any aspect of the care they received or issues relating to living in the home. The home keeps a register of complaints it may receive. None were received by the home or by the Commission in the period since the last inspection. Five completed comment cards were received by the Commission stating the person knew whom to speak to if they were not happy or wanted to make a complaint. Staff had received up to date training in adult protection procedures and demonstrated a clear understanding of what they would do to protect people from abuse. All full time staff had attended adult protection training at the Local Authority training section and the topic is also discussed with all staff during one to one supervision. All staff had signed up to the local authority guidelines. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 17 There were detailed procedures in place to protect people’s finances. This included checks conducted by the registered manager, weekly audits carried out by the deputy manager and additional checks carried out by the Chief Executive for the Trust and the Trust’s accountants. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home was well maintained, comfortable and offers people a safe, homely environment to live in. EVIDENCE: The grounds to the front offer parking space for up to three vehicles, one being the minibus used for trips out. There is a well maintained garden area to the rear of the home. There is a seating area and garden sheds used to store garden equipment and outdoor games. This area is well maintained and offers a secure, external recreational area. The lay out of the interior offers people ample communal space and private space in single bedrooms. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 19 The building is well maintained and domestic arrangements remain the responsibility of staff and people living there. People are supported and encouraged to take the lead in maintaining these standards and this helps people develop their daily living skills. All bedrooms were personalised and homely. The home is considering development an office area, on the first floor, in to a single room. The development of this area will enable the home to offer all single room accommodation, as there is currently one double room. The floor covering in bathrooms and toilet facilities would benefit from a programme of renewal. The five people completing comment cards said they found to home to be clean. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements were appropriate to meeting and responding to people’s assessed needs. EVIDENCE: The home has an established and stable staff team, consisting of a registered manager, deputy manager, four full time support workers and three bank staff. The staffing arrangements at the time of the inspection were appropriate to meeting peoples needs. Staff are deployed to ensure two staff are on duty during the day and one person available on site during the night, on sleep in duty. Staff are responsible for all domestic and catering arrangements. People living in the home are encouraged and supported to be involved in day to day routines in the home. Staff files contained their completed application form, job description, reference checks including Criminal Record Bureau checks, certificates of training achieved and records of supervision sessions. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 21 Staff meetings are held every three months and records are maintained of topics discussed. The five people completing comment cards said staff listened to them and acted upon their requests. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration procedures ensure the home is run in the best interest of people. Health and safety procedures protected people and staff. EVIDENCE: The manager and deputy manager held the necessary qualifications and had the experience to manage the home, and all full time staff had achieved NVQ level III. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 23 Procedures relating to the management and administration of the home ensure a homely environment is maintained. Legislation governing care homes was complied with whilst promoting best outcomes for people living there. Procedures were in place to ensure regular reviews of care and review of the service were conducted to ensure the home was meeting its objectives. Internal procedures also ensure relatives and people living in the home are consulted about the care they receive. People are encouraged to maintain contact with family and a number of people are supported on home visits. Staff confirmed they receive regular support through one to one supervision and through staff meetings. Programmes of training are planned based on identified personal development needs and to ensure refresher courses are available to staff. Documents were available to evidence regular tests and checks were conducted in relation to fire safety procedures and fire drills were held on a regular basis. All electrical appliances had been checked in January 2007. Extinguishers had been serviced in November 2006 Appropriate insurance liability was also in place. The home also conducted quality assurance survey, seeking the views of people living in the home; this was completed in March 2007. No requirements or recommendations were made in relation to this inspection. St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 24 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 4 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 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 X 4 X X 4 x St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 25 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. Refer to Standard Good Practice Recommendations St Bonaventures DS0000021625.V342480.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V342480.R01.S.doc Version 5.2 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. 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