Inspection on 24/11/09 for St Erme

This inspection was carried out on 24th November 2009.

CQC found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Erme 02/12/08

St Erme 08/07/08

St Erme 12/12/07

St Erme 14/08/07

St Erme 07/03/07

St Erme 24/07/06

St Erme 16/02/06

St Erme 27/09/05

St Erme 11/11/04

St Erme 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 St Erme Trispen Truro Cornwall TR4 9BW Lead Inspector Ian Wright Key Unannounced Inspection 24 November 2009 to 27th November 2009 09:45 th St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service St Erme Address Trispen Truro Cornwall TR4 9BW 01872 263355 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) Mail@dcact.org Spectrum Miss Siobhan Helen Sinnott Care Home 20 Category(ies) of Learning disability (20) registration, with number of places St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. St Erme House - up to 10 adults with a Learning Disability (LD) The Lodge - up to 9 adults with a Learning Disability (LD) St Michaels - up to 3 adults with a Learning Disability (LD) Total number of service users not to exceed a maximum of 20 Date of last inspection 2nd December 2008 Brief Description of the Service: St. Erme provides accommodation and personal care for up to 20 adults with a learning disability. The registered provider is Spectrum, which manages a number of services for people diagnosed as on the autistic spectrum. The service comprises of three separate, self-contained units: • St. Erme House provides accommodation currently for up to five adults. People have their own bedrooms, some of which are en suite and have their own lounge. There is also a communal lounge, dining area and kitchen. There is a secure garden. There is a self contained flat, for one person, attached to the house. • The Lodge currently accommodates four people. People have their own bedrooms. There are shared bathroom, lounge, dining, and kitchen facilities. There is a garden. • St. Michaels can accommodate up to three people. People have their own bedroom, and share lounge, dining, kitchen and bathroom facilities. One of the people accommodated has their own self-contained ‘flat’ within the home. There is a separate administrative block on the site. St Erme is set in its own extensive grounds, near the village of Trispen, which is close to the city of Truro. Current fees range from £846 per week to £4351. There are variable additional charges to individuals for personal items such as hairdressing, newspapers, confectionery, private chiropody and off-site entertainment. A copy of this report is available from the registered persons, or free of charge from the CQC website, or via our customer service centre. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. One inspector completed this key inspection in sixteen and a half hours over three days. All of the key standards were inspected. The methodology used for this inspection was: • To case track three people who use the service. This included, where possible, meeting and discussing with them their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other people who use the service and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. • Carrying out a confidential postal survey of stakeholders involved in the service. The survey included staff and external professionals working with the home. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 6 There are five statutory requirements. Action is required by law within the timescales set: • • • • • Some improvement is required to the management of monies belonging to people who use the service. Some improvement is required to record keeping regarding health care checks service user records. Some improvements are required to the delivery of staff training. The registered persons must ensure any untoward incidents are always reported to the commission without delay. Some improvement is required to health and safety precautions for example there is a record of testing of gas /oil appliances. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 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 Erme DS0000009149.V378100.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment information regarding people who use the service prior to admission, and information issued to people when they move in is good. This helps to ensure people’s needs are met, and suitable information is issued about people’s rights and responsibilities. EVIDENCE: The service has a satisfactory statement of purpose and service user guide. This outlines what facilities and services the home provides. A copy of the service user guide is provided to representatives of people who use the service. An easy to read / pictorial version of the service user guide is also available to people who live in the home. The organisation has a suitable pre admission assessment procedure. There have been no new admissions to the service since the last key inspection in December 2008 Copies of contracts of care / statement of terms of conditions of residency were present on the files of people we inspected. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the service appear to have their individual needs and choices met so they should be able to live a life style according to their wishes and needs. EVIDENCE: Each person has a care plan, and there is evidence these are reviewed appropriately. People who use the service seem to be encouraged to make decisions regarding their lives where possible. Suitable risk assessments are in place to assess any risks or actions to promote independence. The registered persons look after some people’s monies, for which records are maintained. There were some errors regarding some peoples’ money (i.e. between what is in the written records and the actual cash balance). Extra care needs to be taken by staff to avoid this occurring. For example it is important staff assisting people with expenditure reconcile cash spent as soon as they St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 10 return to the home, and cash is checked regularly-preferably daily, to ensure it agrees with records. The registered provider acts as an agent for financial benefits / saving accounts for some people’s monies. Personnel at Spectrum headquarters manage government benefits claimed on behalf of people who use the service. A concern was raised in one survey we received regarding representatives wanting more information regarding monies held on behalf of one person using the service. This matter was discussed with the registered manager, who said this information could be provided. We have informed the representative of this. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable opportunities for activities, educational opportunities and contact with the wider community are provided so people have the opportunity to live a varied lifestyle. Food provided appears to be to a good standard. EVIDENCE: According to care plans and daily records people who use the service have a suitable range of activities available to them, and that they participate in. The registered provider has several minibuses available to people living in the home. These enable people to move around the community and to go out on social trips. Some people raised concerns to us that the limited number of vehicles available to people living at St Erme house at times made it difficult for more St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 12 than one person to go out at one time. We discussed this matter with the registered manager. The registered manager said that due to individual needs of people using the service, users required a large ‘minibus’ type vehicle and the mobility component of their Disability Living Allowance is not sufficient to purchase /lease such a vehicle. The registered manager said the organisation was negotiating with funders to raise fees for certain individuals so more vehicles could be purchased. However, records show that all people using the service do have a wide range of activities available to them. For example, depending on individual needs and preferences, people go swimming, attend college, have massages, have voluntary jobs as well as opportunities to go to the shops and go on social trips. People who use the service can visit friends and relatives, and can also maintain contact via the telephone or post. Visiting arrangements are flexible, and there is suitable space for people to receive visitors privately. Times when people get up and go to bed are flexible, although there does need to be some fixed routines due to the nature of people’s diagnosis. We observed staff working in a manner, which was professional, and respected the privacy and dignity of people who use the service. Food provided appears to be to a good standard and suitable records are maintained regarding food provided. People who use the service have access to the kitchen, with varying degrees of staff support according to people’s needs. There are suitable laundry facilities. People using the service are encouraged to participate in doing their laundry with varying degrees of staff support. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and health care support is delivered to a good standard, and there are suitable links with medical professionals. The management of medication is satisfactory. People who use the service, and their representatives, therefore should be able to be assured personal and health care needs are suitably met although recording of medical support needs to be improved. EVIDENCE: The service provides support to people, some of whom can be very challenging. We observed people receiving good support from staff. Staff who we spoke to and survey responses we received from a variety of sources all said support provided is to a good standard. Any personal care needs are clearly documented in care plans, and staff seem clear regarding what assistance people require. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 14 Care plans show that people are registered with GP’s, dentists, chiropodists and other professionals (as required). We were told that people do see medical professionals when necessary. However, records of medical interventions does require some improvement. It should be possible to ascertain when somebody last saw the relevant medical professional e.g. ‘at a glance’. If the person does not wish to see a medical professional or it is deemed too traumatic for the person to attend for example a dentist, this should be agreed by the multidisciplinary team in a risk assessment and recorded in the person’s care plan. The operation of the medication system is to a good standard. Medication is stored securely in locked cabinets in each unit of the home. Medication is dispensed via a ‘monitored dosage system’. Medication records kept are satisfactory. There is a suitable medication returns system. Most staff have received suitable training regarding the handling of medication. Concerns were raised since the last inspection in December 2008 regarding the number of reported administration errors to GP’s. This matter was dealt with under Cornwall Council’s Adult Safeguarding procedures. Since this time improvement has occurred. However we noted in the last month, there have been at least two incidents of error (e.g. a person has missed a prescribed medication dose), but these errors were reported to management and suitable action occurred. Staff and management need to be constantly vigilant in ensuring medication is given, and ensuring suitable checks and reporting systems are maintained. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are suitable complaints and adult safeguarding procedures in place. Subsequently people who use the service, and their representatives can be assured there are appropriate procedures to deal with any concerns or bad practice. EVIDENCE: The registered provider has suitable complaints and adult safeguarding procedures. The registered manager said there has been one concern raised by a relative since the last inspection. This matter was dealt with appropriately by the registered persons. The commission received one complaint, which was referred to the registered provider, which was dealt with appropriately. There have been three concerns which were referred to Cornwall Council under their safeguarding procedures. 1. Concerns regarding medication errors outlined previously. This matter has been resolved satisfactorily. 2. Three concerns referred by the registered persons regarding staff conduct. Although these matters were dealt with under safeguarding procedures, they have been resolved to a satisfactory standard by the registered persons. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 16 Staff attend adult safeguarding training as part of their induction. All the staff records assessed contained a record that people had attended this training. Staff and people who use the service all said they had not witnessed any bad or abusive practices. No concerns regarding staff practices were raised in the surveys we received. All staff have Criminal Record Bureau check, and a Protection of Vulnerable Adults check (where applicable). St Erme DS0000009149.V378100.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Erme provides a suitable environment for people using the service. EVIDENCE: We inspected the three units on the St Erme campus: St Michaels. The accommodation is satisfactory. Some aspects of the accommodation are rather utilitarian, but this is due to the needs of the people in the home. Some fixtures and fittings have to be tailored to people’s needs to prevent harm and damage. However, as people’s skills develop more homely fixtures and fittings are replacing the current provision. One person has their own self-contained ‘apartment’ within the unit, which seems pleasant. The building was clean and appeared safe. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 18 The Lodge The accommodation is satisfactory. Again some aspects of the accommodation are rather utilitarian, for similar reasons to St Michael’s. This part of the home has been made as comfortable and clean as possible. St Erme House. This part of the service is satisfactory. The lounge has been extended in the last year so there is more communal space in this room. One person has a flat, in part of the building. This appears suitable for the person. The inspector did raise a concern that one of the fire exits was only accessible via the sleep in room on the first floor. The door to this room was locked. This was to prevent people using the service entering the room and causing themselves harm. The registered manager said all staff carry a key to the door, and in the event of a fire people using the service would need supervision to exit the building. The registered manager said the matter of locking the door had been discussed with the fire service, and they had agreed this was satisfactory. This matter however should be kept under review, and every effort made to ensure any risk is minimised. Toilet rolls, towels and soap were absent from some toilets and bathrooms in all units. The registered manager said it was not possible to keep these items in the toilets /bathrooms due to the behaviour of some of the people using the service. She said that people would either receive some level of supervision if they needed to go to the toilet /bathe, or people would ask for these items. Where possible toilet roll / soap / towels should be provided, for example in suitable receptacles. However the difficulties raised by the registered manager are acknowledged. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, recruitment checks and staff training appear to be to a generally suitable standard. Some improvement is required to the delivery of staff training. People who use the service should however receive appropriate staff support from suitably recruited and trained staff. EVIDENCE: From our observation people who use the service seem to receive professional and caring support from staff. The people who use the service can display behaviour which could be deemed difficult and challenging. Staff seem to support people in a positive manner. Staff we spoke to were positive about the service and the support people using it receive. Management were viewed as supportive and approachable. There were satisfactory numbers of staff on duty on the days of the inspection in each part of the service. However there have been two incidents at one of St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 20 the units where staff members have been victims of unprovoked attacks by a person using the service. Both incidents resulted in the staff members requiring hospital treatment. On both occasions the staff members were on duty alone. The registered provider has taken satisfactory action by increasing the level of support to this person to two staff for the one person at all times. We were told the local authority paying for the person’s care believes the person only requires one to one support. Currently the registered provider is in negotiation with the sponsoring authority to increase weekly payments for this person. It is appropriate that there remains satisfactory levels of staffing at all times for this person. This will ensure the person receives appropriate levels of support, and the risk of injury to staff and other people in the home is kept to an absolute minimum. Staff are currently not allowed to keep a mobile telephone on their person. It should be considered that staff are provided with attack alarms to assist with minimising the risk of injury in future. We checked staff recruitment records and these are maintained to a high standard. There was difficulty obtaining the information, via the home’s computer system, due to the internet connection. Subsequently the inspector had to go to the organisation’s offices to inspect personnel records. The system needs improvement so records are available for inspection at the home, as is required by the Care Homes Regulations 2001. However, when the records were inspected there was suitable evidence all staff receive a Protection of Vulnerable Adults ‘First’ check, a Criminal Records Bureau check, two written references etc. Staff training is to a good standard. The registered provider has a suitable approach to providing National Vocational Qualifications (NVQ). The minimum training we would expect to be delivered to all staff in this service is: • • • • • • • • • • Fire training-at least annually. Food hygiene / handling training- if staff handle food. First Aid training- in line with CQC and HSE (Health and Safety Executive) guidance for example at least a satisfactory number of staff on duty at all times trained to ‘appointed persons’ level. Manual handling training- in line with moving and handling regulations and the needs of people living in the home. Training regarding medication-if medication is handled. Infection control. Basic training regarding hand washing, use of protective clothing etc. Awareness of the needs of people on the Autistic Spectrum Training regarding handling aggressive behaviour including restraint techniques (if the latter is appropriate). Epilepsy-if people accommodated have this diagnosis. Record of induction when the person starts working at the service (e.g. orientation, how to work with individuals in the home, awareness of policies and procedures etc.) St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 21 Suitable induction records were available for all staff. Spectrum ensures new staff are shadowed, alongside more experienced staff, when they commence employment. Staff also complete a five day formal induction at the organisation’s training centre where most of the training required is delivered. Staff then receive follow up and more detailed training according to the needs of people accommodated in the service. Training records for the staff records assessed seemed generally comprehensive. However there were some gaps regarding some staff not having food handling and infection control training. The inspector had a discussion with the organisation’s training manager about the possibility that this training may be able to be part of the organisation’s induction week. The training manager is going to discuss legal requirements, and what training needs to be delivered, with Cornwall Council’s environmental health department. Some staff also need to receive medication training. However there were a suitable number of people on duty who had received training in this area, and staff also have to be internally assessed as ‘competent’ before they can administer medication. Particular vigilance is required in this area, particularly due to concerns raised in the past regarding problems with the operation of the medication system. Internal training in this area also covers epilepsy awareness. As there are several people who have epilepsy, who use this service, it is essential that all staff have knowledge of this diagnosis. A staff supervision system is in place. We did not assess records of this. However the staff we spoke to say the supervision they received was useful and supportive. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is generally good. The service has a competent management team including a registered manager. Quality assurance procedures are to a good standard. Some improvement is required to statutory reporting under the Care Homes Regulations 2001 and health and safety precautions. Improvement in these areas will give greater assurance that the service is managed to a good standard. EVIDENCE: The registered provider is Spectrum, a registered charity supporting people with autism / aspergers syndrome. The registered manager of the home is Ms Siobhan Sinnott. Ms Sinnott oversees two deputy managers at St Erme House and The Lodge. St Michael’s has a dedicated unit manager (who is currently not required to be registered by the commission). This manager is supervised by Ms Sinnott. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 23 The current management team appear to be positive, professional and organised. Management were viewed positively by the majority of people who we either spoke to or answered our survey. People were also pleased that the management team was more stable after a period of significant change up to the end of 2008. A representative of the registered provider carries out monthly visits (in line with regulation 26 of the Care Homes Regulations 2001). The reports of these visits are comprehensive. The managers of each unit have completed annual development plans and these are good. Despite procedures being very good regarding quality assurance, there is not a policy which outlines the organisation’s approach. This needs to be written detailing the current measures taken to maintain and improve quality standards. The Commission has received the Annual Quality Assurance Assessment (AQAA) (an annual dataset, and self assessment required by CQC). We have received some notifications, required by the commission (e.g. regarding untoward incidents) which are required according to the Care Home Regulations 2001. However we note that some incidents have not been reported to us as required by the regulations; for example where there has been an injury requiring hospital treatment as a result of the behaviour of people using the service. It is essential relevant incidents are reported to the commission, without delay. The registered provider has a suitable health and safety policy. Records kept of health and safety checks are mostly satisfactory. For example there are suitable records of the testing of fire equipment and portable electrical appliances. There is also a certificate to state the electrical hardwire circuit has been serviced. The registered manager said this has just been recompleted in all parts of the service, and any remedial work required was subsequently carried out. The home is waiting for the new certificate to be sent to them. A copy of this certificate should subsequently be forwarded to the commission. Gas safety certificates and certificates regarding the servicing of the oil central heating (in one part of the building) were out of date. This work needs to be completed and a copy of the certificates should be forwarded to the commission without delay. Accident and incident records are suitably maintained. Health and safety risk assessments are satisfactory. The registered persons have arranged for external testing to be completed to minimise the risk of Legionella. Any control measures to minimise this risk however do need to be outlined in the home’s health and safety risk assessment document. The Health and Safety Executive publishes information how to do this and the factors which need to be taken into consideration. This information is on their website. Suitable insurance cover for the buildings was available for inspection. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 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 3 2 3 3 X 4 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 X 3 X 2 2 X Version 5.3 Page 25 St Erme DS0000009149.V378100.R01.S.doc YES 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 YA7 Regulation 13 Requirement The registered persons need to ensure monies belonging to people using the service are managed to a satisfactory standard, and suitable records are kept. People using the service will subsequently be more assured that their monies are managed to a satisfactory standard. Improve records regarding when people using the service see medical practitioners such as a GP, dentist, optician, chiropodist etc. This will help to ensure there is a record of when a person last saw the relevant medical practitioner; and assist staff to monitor people’s health needs so the person concerned sees relevant practioners at regular intervals. All staff must receive training according to the law, and the needs of the people using the service (for example as outlined in the ‘Staffing’ section of the report.) This will ensure that people using the service and their representatives can be DS0000009149.V378100.R01.S.doc Timescale for action 01/01/10 2 YA19 12 01/01/10 3. YA35 18 01/04/10 St Erme Version 5.3 Page 26 4 YA41 37 5. YA38 13 assured that staff have suitable skills and knowledge to meet the needs of people using this service. Matters listed under this regulation, such as injuries or untoward incidents, must be reported to the commission without delay. This will ensure that the commission is made aware of any matters, required by law, regarding any incidents adversely affecting people using the service. The registered persons must ensure there are satisfactory health and safety precautions at the service. For example there is evidence gas and oil fuelled appliances and /or heating has been serviced. Copies of relevant certificates need to be forwarded to the Commission. (Previous timescale of 01/03/2009 only partly met Second Notification). 01/01/10 01/02/10 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. Refer to Standard YA13 YA42 Good Practice Recommendations Provide an additional vehicle for the people living at St Erme House to enable them to go out more. Provide staff with personal attack alarms if there is a risk of unprovoked attack from people using the service, who staff work with. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. St Erme DS0000009149.V378100.R01.S.doc Version 5.3 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!