Inspection on 18/10/05 for St James` Care Home (12)

This inspection was carried out on 18th October 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 found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St James` Care Home (12) 31/10/06

St James` Care Home (12) 23/05/05

St James` Care Home (12) 23/09/04

St James` Care Home (12) 03/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St James` Care Home (12) 12 Old Hospital Close, St James`s Drive London SW12 8SS Lead Inspector Janet Pitt Unannounced Inspection 18th October 2005 10:00 St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 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 James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 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 James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St James` Care Home (12) Address 12 Old Hospital Close, St James`s Drive London SW12 8SS 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) 020-8767-7937 0000 Threshold Housing and Support Care Home 5 Category(ies) of Learning disability (5), Physical disability (1) registration, with number of places St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23/05/05 Brief Description of the Service: St James Care Home, 12 Old Hospital Close is a semi-detached house, providing a service for persons with learning disabilities. The home can accommodate up to five tenants in single rooms. One of the rooms has ensuite facilities. The accommodation is provided over two floors, with one room being wheelchair accessible. There is a communal lounge and a dining area situated near the kitchen. The aim of the home is to promote independent living skills within a safe environment. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection. Commencing at 10:00hrs and concluding at 11:45hrs. Two staff members were spoken with. All five tenants were out at the time of inspection. The inspection focused on requirements from the previous inspection, which covered mandatory training, abuse policies, medicines, supervision and training of staff and sleep in facilities for staff. A further visit will be made later in the inspection year to address Standards which have not been covered at this inspection. At the time of the inspection a new manager had been in post for one month. What the service does well: What has improved since the last inspection? What they could do better: The home need to make sure that policies and procedures reflect practice within the home, to protect tenants. Training of staff must be planned to ensure mandatory training is carried out and individual training needs are met, thus ensuring there are competent staff available to care for tenants. Staff need to be refreshed for work the following day, therefore appropriate sleep in facilities for staff must be available. To make sure that tenants are protected from harm, there must be an auditable trail of medicines within the home. The dining and kitchen area floor must be repaired or replaced to ensure everyone’s safety within the home. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 6 A letter was sent to the provider after the inspection, regarding the high number of unmet Requirements from the previous inspection, requesting what action is to be taken. 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 James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 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 James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Suitable assessments of tenants identify their care needs and there is appropriate involvement of other professionals. To make sure that tenant views are represented, they must be fully involved in the process of assessment. EVIDENCE: Tenants assessments gave detailed information the care required and individual views were sought during the process. The acting manager said that tenants were asked their views, but this information is not consistently documented to evidence that these discussions have occurred. On the two care support plans viewed, one tenant had signed to indicate their involvement in the process, but the other plan had been signed on behalf of the tenant by a member of staff. This action is not appropriate and was discussed with the acting manager, if a tenant is unable to sign the home must indicate this within the documentation as this practice places tenants at risk of not having their views properly heard. There was good evidence within the support plans of other professionals involvement on how care needs were to be met, indicating that advice is sought to make sure tenants needs are addressed. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Tenants are protected from harm by use of individualised risk assessments. Support plans relating to tenants care are appropriately evaluated and reviewed. EVIDENCE: Tenants support plans are reviewed initially after six weeks, the acting manager stated that tenants are involved in the process. Tenants are protected from harm by the implementation of risk assessments. These assessments are audited six monthly to ensure that information held is current. The risk assessments cover areas such as absconding, violence and aggression and skin condition. The risk assessments were individualised to each tenant’s needs. The acting manager has implemented set dates for evaluations of support plans as required at the previous inspection. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were assessed at this inspection. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 11 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 Tenants medicines are appropriately stored, however there needs to be an auditable trail of medicines within the home and improved recording of the administration of medicines, to ensure tenants receive the correct medication. EVIDENCE: Tenants are not consistently protected from harm by the procedures in place for administering medicines. Of the five tenants only two had any allergies recorded on the medication administration record (MAR). Medicines and creams were not consistently recorded when received into the home, however there was no overstocking of medicines. Care must be taken when recording administration of medicines, as this was not always consistent. One medicine had not been given and there was no reason recorded for its omission. The MAR sheets contained good information on when to give as required medicines and there was a record in place for medicines that were returned to the pharmacist for destruction. Medicines were observed to be stored appropriately. The above issues were discussed with the acting manager and it was agreed that a weekly stock balance check of medicines would be implemented, which will achieve a clear audit trail. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 12 St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 13 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 and 23 Tenants must be protected from harm by suitable policies and procedures relating to complaint and adult protection issues. EVIDENCE: Tenants are not protected from harm due to the lack of a complaints policy and adult protection policies. These requirements are longstanding and must be rectified. Both policies are in draft form, and require the process of what role the CSCI takes and contact details. The adult protection policy must reflect what occurs within the home at a local level, so staff can quickly action the procedure. Both policies must contain current information, which underpins practice within the home. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 14 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, 25,26,28 and 30 Tenants live in a homely environment and are able to choose furniture and furnishings for their private space. Attention must be paid to making sure that communal areas are maintained. Tenants must be supported by staff that have suitable sleep in facilities to make sure that staff are able to undertake their duties competently. EVIDENCE: Tenants are able to personalised their own space and have suitable communal areas to share. All five tenants rooms were seen and noted to be individual in décor and style of furniture. Each tenant has easy access to toilet and bathing facilities, the new shower room enables one tenant to maintain their independence. The home was clean and tidy at the time of inspection. One issue remains outstanding, which is the dining room and kitchen flooring requiring replacement, this detracts from the rest of the home. Staff do not have adequate sleep in provision, which is an ongoing issue. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 15 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, 32, 34, 35 and 36 Tenants are supported by staff who are recruited in a safe manner, however staff must be trained appropriately to make sure that suitable care is given and tenants are protected from harm. EVIDENCE: Tenants are supported by staff that have guidance on their role and responsibilities. Two staff files contained evidence of a good recruitment procedure and copies of job descriptions. Appropriate checks on made on potential employees. The acting manager informed the inspector that plans for supervision six times a year had been implemented as required at the previous inspection. Tenants must be supported by staff who are appropriately trained to protect them from harm. The records relating to training did not evidence that mandatory training was carried out as required, in particular fire, first aid, food hygiene and moving and handling. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 16 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 and 40 Tenants are supported by a manager who is aware of their role and responsibilities. Policies and procedures within the home should reflect the practice carried out. EVIDENCE: The acting manager is currently in the process of applying for registration with the CSCI. The acting manager demonstrated awareness of the role and the importance of the service benefiting tenants and meeting their needs. There is still an outstanding requirement in relation to policies and procedures, which must reflect the practice within the home. It is of concern to the CSCI that this issue has not been addressed in a timely manner, however due to a merger between Threshold and Open Door the timescale will be extended. St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 17 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 N/A 2 N/A N/A N/A Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 N/A N/A 3 N/A Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 N/A 1 N/A 3 LIFESTYLES Standard No Score 11 N/A 12 N/A 13 N/A 14 N/A 15 N/A 16 N/A 17 Standard No 31 32 33 34 35 36 Score 3 1 N/A 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME N/A PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St James` Care Home (12) Score N/A N/A 2 N/A Standard No 37 38 39 40 41 42 43 Score 3 N/A N/A 1 N/A N/A N/A DS0000010228.V263860.R01.S.doc Version 5.0 Page 18 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 YA2 Regulation 12 (2) & (3) Requirement The registered person must ensure that if tenants unable to sign to indicate that they have been involved in the assessment process, then this must be documented. The registered person must ensure that there is a clear auditable trail of medicines in the home and allergies of tenants are recorded. All medicines must be signed for when given. The registered person must ensure that the complaints policy has details of the current regulatory authority (previous timescale of 30/08/05 not met). The registered person must ensure that the Adult Protection policy reflects what occurs at local level and contains details of the current regulatory authority (previous timescale of 30/08/05 not met). The registered person must ensure that the kitchen and dining area floor is repaired or replaced. (previous timescale of 30/08/05 not met) DS0000010228.V263860.R01.S.doc Timescale for action 30/01/06 2 YA20 13 (2) 30/01/05 3 YA22 22 30/01/06 4. YA23 13 (6) 30/01/06 5. YA24 23 (2) (b) 30/01/06 St James` Care Home (12) Version 5.0 Page 19 6. YA28 23 (3) 7. YA32 18 (1) (c) 8. YA40 12 The registered person must 30/01/06 ensure that staff have adequate sleep in provision. (previous timescale of 30/08/05 not met). The registered person must 30/01/06 ensure that mandatory training; in particular fire training is carried out (previous timescale of 30/08/05 not met). The registered person must 30/03/06 ensure that policies and procedures reflect practice within the home (previous timescale of 30/08/05 not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St James` Care Home (12) DS0000010228.V263860.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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