CARE HOME ADULTS 18-65
St Catherines Coventry Road Coleshill Birmingham West Midlands B46 3EA Lead Inspector
Maggie Arnold Unannounced Inspection 15th February 2006 15:00 St Catherines DS0000004299.V284044.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 Catherines DS0000004299.V284044.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 Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Catherines Address Coventry Road Coleshill Birmingham West Midlands B46 3EA 01675 434050 01675 434050 carolwilliams@fatherhurdsons.org.uk 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) Father Hudson`s Society Ms Carol Williams Care Home 16 Category(ies) of Learning disability (16), Physical disability (16), registration, with number Sensory impairment (16) of places St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may only provide care for service users who have a learning disability. However, service users may also have a physical &/or sensory disability 19th September 2005 Date of last inspection Brief Description of the Service: St Catherines is a registered care home for 16 younger adults with learning and physical disabilities. The care home consists of 3 interlinking purpose-built bungalows and the provision of management facilities. The Father Hudson’s Society provides 24 hour care and support for the people living in the home. The home is situated within the Father Hudson’s Society main complex, which is situated in the small town of Coleshill, North Warwickshire and close to all local amenities and services the town, has to offer. Each bungalow can provide shared accommodation of an open planned lounge and dining/kitchen area, a fully adapted bathroom to meet disability needs and a light sensory room. Service users each have their own bedroom with ensuite facilities. There is a well-equipped laundry room and small office in each bungalow. There are separate garden areas for each bungalow, which are well maintained and easily accessible. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between the hours of 3:00pm and 7:15pm. Eight of the forty-three standards were assessed on this occasion. What the service does well:
St. Catherine’s provides a relaxed and homely service for the residents. The purpose built home is decorated and furnished to a good standard. All of the documents seen were well ordered, up to date and easy to crossreference. The home is proactive in checking the quality of the service. This includes eliciting the views of the residents, visitors and other professionals. A sample of completed Service Satisfaction Questionnaires demonstrated that the home has received very positive feedback. The feedback included comments such as “Extremely professional”, “Staff easy to talk to”, “Management and staff are always willing to help” and “Excellent all round -very impressed with the standards of care”. The form gives the respondent the opportunity to make suggestions regarding any changes they would like to see. Other systems include an annual quality assurance audit process, regular Regulation 26 visits and ensuring that all residents have a full review meeting at least once a year, more of it there is a significant change of needs. Residents also have regular residents meetings in the individual bungalows. Additionally both the manager and staff team receive regular formal supervision and participate in an ongoing training and development programme. As on the previous inspection it was noted that there were high levels of interaction between the staff and residents. Residents were confident when approaching the manager and staff members. It was also obvious that some residents liked to spend time with the manager in her office for a general chat. The manager and staff were relaxed and respectful when talking and working with the residents. It was noted that the manager always rang the bell when entering bungalows and introduced the inspector to the residents. Time was taken to explain the reason for the inspection and permission asked to entering to look around the home. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
With the exception of some poor medication practice there were no concerns regarding the service. It is pleasing to note that most of the medication shortfalls were actioned within twenty-four hours. The registered person is required to ensure that: A) Handwritten changes to medication administration record (MAR) sheets are signed and dated by the person making the changes. B) Details of who authorised the changes and reason why are to be recorded on the resident’s file. C) The MAR sheets are routinely updated to reflect the residents’ current medication. D) Unless it is absolutely necessary secondary dispensing should not take place. Reasons for secondary dispensing should be clearly recorded on the resident’s file. The home must ensure that appropriate risk assessments and Secondary Dispensing policies and procedures are in place. Such documents must be routinely reviewed, more often in the even of any changes. E) Professional medication tablet cutters must be provided for each bungalow. Appropriate policies and procedures are to be in place to ensure that such practice is undertaken in a safe and hygienic manner. F) The home must not maintain excess amounts of medication. It is also recommended that: A) The registered person seek guidance from the home’s pharmacist regarding guidance to be followed in the even of the home having to cut tablets in half. Guidance should also be sought from a pharmacist with regards to procedures for dispensing tablets that are not suitable for storage in a
DS0000004299.V284044.R01.S.doc Version 5.1 Page 7 B) St Catherines monitored dosage system. This is particularly important in the event of a resident having two or more of such types medication. C) D) It is recommended, where possible, the review documents are signed and dated by the resident and or their parent/advocate. It is recommended that care plans include details of any agreements for the staff to open mail on the residents’ behalf. 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 Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 8 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 Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 9 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): No assessed on this inspection. EVIDENCE: St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Residents are encouraged to make decisions about their lives. This promotes self determination and self confident. EVIDENCE: As noted in the previous inspection report, the residents have an individual care plan that identifies the individual’s assessed needs and preferences. Records seen evidenced that the care plans and accompanying risk assessments are subject to regular reviews. Three residents’ records of recent review meetings were scrutinised. The records evidenced that, where possible, in addition to the home’s staff, key people such as relatives, Social Services reviewing officers/ social workers and day service staff also attend the reviews. The document includes a photograph of the resident and pictorial prompts accompany the various sections. The reviews cover aspects of the resident’s activities, likes, health and money. The document also includes a section headed ‘Things I would like to change’. If necessary the document concludes with any agreed actions to be taken.
St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 11 At present the home’s manager is the only person who signs the document. It is recommended, where possible, the document is signed and dated by the resident and or their parent/advocate. All of the residents require help in managing their finances. The review notes advises who is the appointee. Financial records were not checked on this occasion. Refer also to the section headed Conduct and management of the home. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 16 The home supports residents to maintain family links and friendships outside the home. Residents’ rights and responsibilities are respected. This works towards a promoting a positive self-image and identity. EVIDENCE: Discussions with some of the residents, staff and manager combined with records seen evidenced that the residents are supported to undertake valued and fulfilling activities. Most of the residents attend a day care provision. The number of days attendance will vary according to the needs and preferences of the resident. The home is proactive in supporting the residents to access activities of their choice within the home and local and wider community. These may be one to one or small group activities. Recent activities, which also take place in the evenings and at weekends, have included trips to the cinema, meals out, a car show and visit to a safari park. A number of the residents also enjoy regular aromatherapy massages.
St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 13 One to one activities include, personal shopping, time in the sensory room, watching television, listening to music, beauty activities such as skin care, hand massages and having fingernails painted. The home also has computers and software for the use of the residents. As noted in previous section, residents’ individual choice and freedom of movement is only restricted subject to risk assessments. Within the restrictions of group living, the home is run in a manner that encourages individual choice and self-determination. Throughout the inspection process residents were observed to move around the bungalows choosing whether they wished to spend time in their own bedrooms or communal areas. Discussions with the manager combined with review notes, demonstrated that the residents’ personal post is usually delivered to the home’s office. Residents either collect their own post or the staff take it to the resident. Staff open the post in the presence of the resident and read the contents to the resident. It is recommended that the home record this agreement between the home and resident on the residents’ care plans. The Commission received one completed relatives/visitors comment card. The comment card, which is produced by the Commission, asks questions about the service such as “Do the staff/owners make you welcome and have you ever made a complaint?” The feedback form advised that there were no concerns regarding the service and that the home was very friendly and good for their relative. The respondent also particularly noted that the overall care provided was “Very good” The respondent also indicated that they were appropriately involved in their relative’s care. It was observed throughout the inspection process that the staff constantly talked to and interacted with the residents. It is also pleasing to note staff did not talk exclusively with each other but involved the resident in more general conversations. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The failure to adhere to the home’s medication policies and procedures compromises the residents’ health and welfare. EVIDENCE: The home has policies and procedures in place for the safe management of medication. The documents are reviewed on an annual basis. Only suitably trained staff are responsible for the handling of medication. At the time of the inspection medication and accompanying records were securely stored. The home has a monitored dosage system and accompanying daily administration record sheets (MARS) for the management and recording of medication. Three residents’ medication and accompanying MAR sheets were selected for scrutiny. A number of discrepancies and evidence of poor practice were noted. For example, there were a number of handwritten changes to some of the MAR sheets. In addition to details of medication being crossed out there were also handwritten changes to the dosage of medication. Although the staff were well informed regarding the changes there was no documentary evidence recording why and by whom the changes had been authorised. There was an excess of some medication, in particular items such as tinned or bottled medication such as lactlulose.
St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 15 There was also evidence of secondary medication. Medication, that isn’t suitable for storage in the monitored dosage system, had been dispensed from the original containers or foil wrapping into a dispensing container. It was also noted that some tablets of the tablets had, as required, been cut in half without using the appropriate aid. At the time of writing this report, the manager has confirmed in writing the steps that had been taken to correct the discrepancies and poor practice. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 17 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): Not assessed on this occasion. EVIDENCE: The core standards were met in full at the time of the last inspection, which took place in September 2005. Areas seen by the inspector were warm, homely, clean and comfortable. The environment, which continues to be maintained to a high standard, was free from excess clutter and offensive odours. One resident showed the inspector her bedroom. The good-sized bedroom and en-suite facility was decorated and furnished to suit the needs, preferences and interests of the resident. It was also pleasing to note that the resident had her own telephone in her bedroom. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 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): This section was fully assessed at the time of the previous inspection. EVIDENCE: Staff members spoken to were well informed and cooperated fully in the inspection process. It was noted that the staff members worked in a relaxed but polite and respectful manner with the residents. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The registered manager is suitably qualified, competent and experience to run the home. This helps to ensure that the meets its stated purpose, aims and objectives. EVIDENCE: The registered manager has thirteen years management experience, three of which were as a deputy manager. In addition to the Registered Managers Award (2005) the manager has completed the Advanced Management in Care Award (1996) and a Diploma in Welfare Studies (1996). At present the manager is undertaking a course, which covers the various aspects of the roles and responsibilities of the manager. Areas covered include performance management, leadership styles, and skills for care. The home has a number quality assurance and monitoring systems in place. The home has Service Satisfaction forms for relatives, visitors and other professionals who visit the home. Residents receive regular reviews of their packages of care and are offered the opportunity to attend residents meetings. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 20 In accordance with the Care Homes Regulations 2001: Regulation 26 a representative of the Charity makes regular unannounced visits to the home. A copy of the findings of the Regulation 26 visit is forwarded to the Commission and Responsible Individual for the home. The home is also subject to an annual performance review. The manager receives regular formal supervision and an annual appraisal from the Chief Executive of the Company. An annual performance review helps to monitor the standard of the service over the previous twelve months and agree on development plans for the forthcoming year. The meetings and visits help to ensure the accountability of the manager and staff and that the service is run in a manner that takes into account the views of the residents. St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 21 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 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x 3 x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 2 x 3 x 3 x x x x St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 22 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 St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 23 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 YA7 Good Practice Recommendations It is recommended, where possible, the review documents are signed and dated by the resident and or their parent/advocate. It is recommended that care plans include details of any agreements for the staff to open mail on the residents’ behalf. It is recommended that the registered person seek guidance from the home’s pharmacist regarding guidance to be followed in the even of the home having to cut tablets in half. Guidance should also be sought from a pharmacist with regards to procedures for dispensing tablets that are not suitable for storage in a monitored dosage system. This is particularly important in the event of a resident having two or more of such types medication. 2 YA16 3 YA20 St Catherines DS0000004299.V284044.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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