Inspection on 19/09/05 for St Catherines

This inspection was carried out on 19th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Catherines 31/10/06

St Catherines 15/02/06

St Catherines 17/01/05

St Catherines 23/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 St Catherines Coventry Road Coleshill Birmingham West Midlands B46 3EA Lead Inspector Maggie Arnold Unannounced Inspection 19th September 2005 4.00 St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 1 St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 2 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.V251460.R01.S.doc Version 5.0 Page 3 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.V251460.R01.S.doc Version 5.0 Page 4 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.V251460.R01.S.doc Version 5.0 Page 5 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 disablty The home may only provide care for service users who have a learning disability. However, service users may also have a physical and/or sensory disability. 17th January 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.V251460.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 4.00pm and 7.45 pm on Monday 19th of September. The acting deputy manager was on duty for the duration of the inspection. Two residents’ files and two staff files were looked at on this occasion. A number of residents were spoken to throughout the inspection process. Due to the busy time of the day no residents and only one staff member were interviewed in private. What the service does well: What has improved since the last inspection? What they could do better: Overall the home is well organised and managed in an accountable manner. Three requirements arose from this inspection. In order to reduce the risk of St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 7 abuse towards residents the home must ensure that all staff working in the home receive Protection of Vulnerable Adults (POVA) awareness training. The home must also maintain a record of all visitors to the home. In order to reduce the risk of fire or accidents, safety directions on doors must be followed. Directions on doors must not be removed or changed without the authority of the Local Fire Safety Officer. 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.V251460.R01.S.doc Version 5.0 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.V251460.R01.S.doc Version 5.0 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): 2 New residents are only admitted following a full assessment that takes into account their individual needs and aspirations. EVIDENCE: Records looked at contained initial referrals and assessments from the placing agencies. The assessments of needs covered all aspects of care as well as including preferences and aspirations. The initial assessments included methods of communication, physical and mental care needs, finances and family contacts. The inspector was also advised that, where appropriate, other specialists such as psychologists, physiotherapists and occupational therapists are also involved in the initial assessment process. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 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): 6, 9 &10 Each resident has an individual plan of care and accompanying risk assessments, which helps to ensure that individual care needs and personal goals are met. Staff handle confidential information in accordance with the home’s written policies and procedures and the Data Protection Act 1998. This helps to protect the privacy and dignity of the residents. EVIDENCE: The home has a comprehensive care planning and recording documentation process, which covers all aspects of care, as well as personal aspirations and changing needs. For example, care plans seen included details of daily routines, likes and dislikes as well as support plans for communication, mobility, behaviour as well as the management of medication. Individual risk assessments and risk management strategies are in place and there was evidence that these were routinely reviewed. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 11 The inspector had the opportunity to have a telephone conversation with a parent of a resident. The parent confirmed that any changes in care needs or risk assessments were promptly addressed and that they had been consulted and updated as necessary. In order to involve and keep the residents informed, the care staff help residents to develop detailed life story books. The life story book covers both past and present and are in a format to suit the needs of the individual resident. It is pleasing to note that the life story books are the property of the resident and are kept in their bedrooms. The books are also updated as required. Records of a confidential nature are securely stored when not in use. Although some records are held in the bungalows the bulk of confidential information is held in the main office. The office is locked when not in use. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 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): 15, 17 The residents’ sense of identity and feelings of well being are promoted by appropriate personal and family relationships and from a varied and healthy diet. In order to improve accountability the home is required to maintain a record of visitors to the home. EVIDENCE: Nine relatives completed the Commission’s comment cards. The comment cards ask ten questions covering all aspects of the service and allow space for additional comments. Questions asked covered issues such as how welcoming is the home, privacy, consultation, general satisfaction and staffing levels. All nine respondents expressed an overall satisfaction with the home. Seven of the nine respondents expressed complete satisfaction with the service. Some of the comments, many of which were glowing, clearly indicated that the parents and next of kin felt that St. Catherines was the correct home for their relative. Comments included “I could not find a better home for my …”, “Regarding staff, care and home comforts- a wonderful home.” “Cannot fault the care...a very high standard”,”…is so happy,” and “Excellent staff…always St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 13 receive a warm and friendly welcome.” Although they had not made a complaint, two respondents noted that they had commented on occasional staff shortages. One of the respondent commented that the home quickly addressed the particular concern. The inspector had the opportunity to have a telephone conversation with a relative of one of the residents. The inspector was advised that the staff were always very pleasant and accommodating and that any comments they had made regarding how they felt the care of their relative might be improved were taken seriously and addressed. It was also confirmed that the home updated the family as appropriately and that they felt the home was meeting the needs of their relative. Discussions with staff evidenced that one resident receives regular visits from an advocate. However, this is not always recorded in the plan of care. In accordance with the Care Homes Regulations 2001: Regulation 17(2): Schedule 4 (17) records must be kept of all visitors to the care home. The residents’ care plans noted any particular dietary or support needs that the residents had and guidance as to how these needs were to be met. Records show that staff complete a basic food hygiene course. Records also evidenced that one of the staff had also undertaken training in Healthy Eating and Menu Planning. A tour of the open plan kitchen found it to be clean, well ordered and well stocked with a variety of foodstuffs. Specialist aids and equipment is available for residents who have swallowing or motor difficulties. Staff were observed to assist the residents in an appropriate and discrete manner. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 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): 19 Residents receive personal and emotional support in a way they prefer and require. EVIDENCE: Discussions with a relative and staff members combined with records seen demonstrated that residents’ physical and emotional needs are met. As necessary, the residents are supported by a number of different healthcare specialists. In addition to routine healthcare providers such as GPs, Dentists and Opticians, there may also be support from specialist Learning Disabilities providers such as Community Psychiatric Nurses, Psychologists, dieticians and Speech and Language Therapists. Records also evidenced that residents’ health is monitored and preventative care practice is in place to reduce the risk complications such as pressure sores developing. Working in cooperation with the Primary Care Trust (PCT) the home has recently introduced a recording document titled ‘My Health’. All residents have their own copy which covers all aspects of care including eyes, ears, diet, exercise and so on. The document, which has pictorial prompts and guidance, forms the basis of an ongoing record of care. St Catherines DS0000004299.V251460.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 &23 Systems are in place that helps to ensure that the views of residents and family members are heard and acted on. All staff members should receive Vulnerable Adult Awareness Training. This would help to safeguard residents against the risk of abuse and neglect. EVIDENCE: The home adheres to Father Hudson’s Society corporate complaints policies and procedures. No complaints regarding the service received were received by the home or the Commission in the last twelve months. The home has adopted the good practice of providing relatives or guardians with a copy of the complaints procedures. As noted in the section titled ‘Lifestyle’, feedback from family members, the overall feedback from relatives was very complimentary regarding the care and support offered by the home. All of the respondents said that they were aware of the complaints procedures and that they were also made aware of forthcoming inspections and had access to the resulting inspection reports. It is pleasing to note that the staffing training matrix evidenced that the thirty nine of the forty two staff had received training in the last twelve months in the protection of vulnerable adults (POVA) policies and procedures. All staff, including domestic staff, who work in the home should receive training to reduce the risk of abuse or neglect of residents. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 16 St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 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): 24, 25, 27, 30. The premises are suitable, comfortable and safe the present residents. The clean and hygienic premises helps to control the spread of infection. EVIDENCE: Only one of the three bungalows was visited on this occasion. The kitchen, dining area and lounge lead onto each other in an open plan design. This large communal area was homely and comfortable and the furniture set out in order to accommodate the needs of any residents mobilizing with the use of wheelchairs. A few of the residents were relaxing in their bedrooms or receiving personal care. Consequently not all the bedrooms were seen. In respect of the residents’ rights to privacy and dignity whilst resting or receiving care, the inspector only had a very brief view of a couple of the vacant bedrooms. The bedrooms seen, which were of a good size, were personalised, furnished and arranged to suit the needs and preferences of the occupants. Various aids and equipment were seen throughout the home. Some of the equipment is for communal use, whilst other equipment and aids such as wheelchairs and specialist hoists are for the sole use of a particular person. All St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 18 bedrooms have an en-suite facility. One bedroom in each bungalow is fitted with a Parker bath that is for the sole use of the occupant of the room and the remaining residents may access a Parker bath in the bungalow’s communal bathroom. There is levelled access into the bungalows and gardens. Each bungalow has a small open plan garden to the rear of the property all of which are slightly different. All of the areas seen, both internally and externally were clean and hygienic and maintained to a good standard. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 19 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): 31-36 Residents’ safety and well-being are protected by the home’s recruitment policy and practices. A competent and qualified staff team who receive regular supervision meet the residents’ needs. EVIDENCE: In addition to the Acting deputy manager, five staff were on duty to meet the needs of the residents. Discussions with the staff and Acting deputy manager demonstrated that the staff were clear regarding their roles and responsibilities and were very well informed about the needs and preferences of the residents. Staff were observed to be friendly, polite and respectful when supporting and chatting with residents. It was nice to hear the sound of laughter from both staff and residents during the course of the inspection. Two staff files were seen on this occasion. The files were well ordered and complied with the Care Standards Act 2000: Care Homes Regulations 2001: Regulation 19:Schedule 2. The inspector had the opportunity for a short interview with a member of staff. The staff member confirmed that she had undertaken an induction process and received core training. In addition to becoming familiar with the home’s daily St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 20 routine and procedures, the staff member said that, when first working in the home, she always worked alongside another member of staff. All staff receive core training compromising of Basic Food Hygiene, Fire Safety, Safe Management of Medication, and Emergency First Aid and Safe Moving and Handling. A copy of the training matrix showed that other training courses completed by some of the staff included healthy eating, diabetic awareness and epilepsy. It is particularly pleasing to note that twenty of the care staff hold a National Vocational Qualification (NVQ) Level 2 in Care. It has been noted in the sectioned headed ‘Complaints and Concerns’ that the majority of staff have received Vulnerable Adult Awareness training. Discussions with the manager and staff member also confirmed that supervision and staff meetings take place on a regular basis. On this occasion, documentary evidence was not seen to confirm this to be the case. As noted in the section titled ‘Complaints and Concerns’ of this report, the home is required to ensure that all staff receive Vulnerable Adult Awareness training. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 With one exception the home’s policies and practices promote and protect the health and safety of residents. The failure to lock some doors in accordance with instructions has the potential to put the residents’ safety at risk. EVIDENCE: As noted in the section headed ‘ Staffing’ records seen demonstrated that the staff receive training in core training such as Moving and Handling, Fire Safety, Emergency First Aid and Food Hygiene. This helps to ensure that the health, safety and welfare of residents is protected and promoted. A tour of the home found it to be clean and well ordered with no potential trip hazards such as worn flooring or excess clutter and furniture. Fire safety equipment was in place and designated emergency exits were clear of obstacles. Potentially harmful cleaning items were securely stored in locked St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 22 cupboards in accordance with the Control of Substances Hazardous to Health (COSSH) Regulations 1999. The kitchen, laundry area, bathrooms and toilets, which are all high risk areas with regards to the possibility of infection, were clean and stocked with basic essentials such as liquid soap, disposable towels, and as, appropriate toilet paper. It was noted that doors labelled ‘Keep Locked shut’ were left open. The home is required to liaise with the Fire Safety officer regarding whether the doors in question are required to be locked. In the meantime the home is to adhere to the notices on the doors. It is strongly recommended that the home request written confirmation of the Fire Safety Officer’s advice. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 23 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 3 x x x x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 2 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Catherines Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000004299.V251460.R01.S.doc Version 5.0 Page 24 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. 1 2 3 Standard 15 23 42 Regulation 17(2) Sch 4(17) 13(6) 23(4)(a) Requirement Records must be kept of all visitors to the home. All staff should receive Vulnerable Adult Awareness training. Staff must adhere to directives such as ‘Keep Locked Shut’ on doors. Timescale for action 31/12/05 31/01/06 30/11/05 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 42 Good Practice Recommendations Regarding telephone discussions as to whether directives on some of the doors in the home may be changed, it is strongly recommended that the home request written confirmation of the Fire Safety Officer’s advice. St Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 25 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 © 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 Catherines DS0000004299.V251460.R01.S.doc Version 5.0 Page 26 - 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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