Inspection on 23/05/05 for St James` Care Home (12)

This inspection was carried out on 23rd May 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

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

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 Drive London SW12 8SS Lead Inspector Janet Pitt Unannounced 23rd May 2005 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 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 Stationary 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) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St James Care Home (12) Address 12 Old Hospital Close St James Drive London SW12 8SS 020 8767 7937 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Threshold Housing and Support Care home only (PC) 5 Category(ies) of Physical disability (PD) registration, with number Learning disability (LD) of places St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22nd September 2004 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 accomodate up to five tenants in single rooms. One of the rooms has ensuite facilties. The accomodation 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) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook the inspection unannounced, which lasted for four hours. Two members of staff were spoken with and one tenant. Records relating to staff, tenants and training were examined. A brief tour of the premises was undertaken. 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 enable tenants to be protected from harm. Training of staff must be planned to ensure mandatory training is carried out and individual training needs are met, to ensure there are competent staff available to care for tenants. To ensure staff are refreshed for work the following day, appropriate sleep in facilities for staff must be available. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 6 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) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 standard(s) 2, 3 4 and 5 Tenants are able to make an informed choice on the type of service provided, but the home should ensure that there is full involvement of tenants in the assessment process. EVIDENCE: Tenants assessments are undertaken on admission and noted to identify care needs. The assessments included details of social interests and preferred activities. The assessments include information on specific risks such as mobility, swallowing and diet. Staff should ensure that the tenant signs the assessment to indicate involvement in the process, staff should also ensure that they sign care documentation. Tenants’ contracts detailed the service provided and give a clear indication of the room to be occupied and what is included in the fee. The manager stated that prospective tenants are invited to visit the home and spend time with current tenants, to see if they like 12 St James. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 8 and 9 Tenants are involved in the care planning process and are supported to lead independence lives within the context of a risk framework. EVIDENCE: Tenants individual plans were seen to be formatted from assessments undertaken. The plans were observed to be routinely reviewed six monthly with the involvement of the tenant and any changes in care needs documented. Tenants care plans were not consistently evaluated monthly. The care plans included detailed instructions on care needs, which indicates how a tenant prefers to be cared for. The home has a daily record sheet in place, which is used for recording of daily activities and care given; more detailed entries are made if significant events occur. Comprehensive individualised risk assessments are in place relating to safety when crossing roads, travel and carrying out household tasks. The risk assessments are formulated in conjunction with tenants and provide a structure within which tenants are enabled safely. However, staff should ensure that documentation is signed by the tenant and by staff. Staff are available to support tenants in daily living activities and when venturing into the community. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 10 Tenants are invited to attend weekly meetings regarding the service provided, menus and plan activities for the forthcoming week. The minutes showed outcomes and actions of meetings as required at the previous inspection. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14, 15 and 17 Tenants are enabled to participate in activities of their choosing and are able to maintain contact with significant others. EVIDENCE: Tenants are able to choose how they spend their day. Social activities that tenants chose to participate in include cinema, television, meals out and walks. These were noted to be recorded in their care documentation. The manager said that time is given for one to one activities such as shopping and paying rent. The majority of tenants attend day centres during the day. The tenants are enabled to maintain contact with significant others Care documentation details family and other contact with significant people in their lives and gives information on legal status of tenants. There was sufficient food in the home on the day of inspection and tenants choose their meals when in the home. Tenants are supported by staff in the preparation of meals; this ensures that tenants receive a healthy, balanced diet. Tenants are encouraged to participate in the weekly meetings and documented one to one sessions in order that their views are heard. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18,19, 20and 21. Tenants can be sure that their personal and health needs are identified and met. EVIDENCE: Tenants are supported to access health professional to meet their individual health needs. This was evidence in their individual records. One tenant had received a dietician’s advise for weight loss and there were entries relating to medical appointments attended. The manager said that the current tenants were unable to discuss their wishes in relation to ageing, illness and death, due to their health status. None of the current tenants are self-medicating. The home has a clear audit trail in place and there are detailed instructions for ‘as required’ medications and information on allergies. Only one medicine was not recorded when received into the home. Medicines were noted to be stored securely and appropriately. Tenants are protected from receiving incorrect medication and the medication they do receive is monitored correctly. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 standard(s) 22 and 23 Improvements could be made in relation to policies relating to complaints and Adult Protection, in order to ensure that tenants are protected from harm. EVIDENCE: Tenants have access to the complaints policy on admission and it is made available in an accessible format. There have been no complaints since the previous inspection. The policy should give details of the current regulatory authority. The timescales for responding to complaints were clear. Tenants are protected from harm, by procedures dealing with allegations of abuse and Adult Protection training is covered in the Learning Disabilities Award Framework, ‘Role as a Worker’ training, which all staff are due to complete in July 2005. The home has not had any Adult Protection issues since the previous inspection. The policy relating to Adult Protection should include details of the current regulatory authority and what action is to be taken at a local level. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29 and 30. Tenants live in a homely environment, which is kept clean and tidy. EVIDENCE: Tenants are able to access homely communal areas, which comprise a kitchen, dining area and lounge. The dining area has recently been redecorated, but the flooring in the kitchen and dining area requires renewing. Tenants have their own bedrooms, which they are able to personalise and it was observed that they have their own choice of paint colour. Tenants are encouraged to participate in household tasks and cooking as part of maintaining their independence. One shower room was being converted to a ‘wet room’ to allow a new tenant user to be accommodated. Tenants are able to access bathrooms and toilets easily and the ground floor room has ensuite facilities. Sleep in arrangements for staff do not enable the staff to wake refreshed in the morning to care for tenants. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 34, 35 and 36 Tenants are protected from harm by appropriate recruitment procedures and supervision of staff. EVIDENCE: Two of three staff files contained job descriptions, which indicate that staff are aware of their roles and responsibilities in relation to caring for tenants, but the home should make sure that all files contain job descriptions. Tenants are protected by clear recruitment procedures in place, which were noted to be followed when employing new staff. Appropriate references and checks were in place. Tenants benefit from staff that are routinely supervised according to the Standard. Tenants are supported by staff that are trained to undertake their job. Training is provided in medicines, fire and customer service. The home should ensure that fire training is undertaken for staff that have not received fire training in the past six months. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 and 41 Tenants personal information is held securely and maintained. Policies and procedures within the home should reflect the practice. EVIDENCE: Tenants can be confident that records containing personal information are kept securely. A requirement from the previous inspection relating to policies and procedures reflecting practice in the home needs to be met. St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 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 x 2 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 1 3 3 Standard No 11 12 13 14 15 16 17 x 3 x 3 3 x 3 Standard No 31 32 33 34 35 36 Score 2 1 x 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St James Care Home (12) Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score x x x 1 3 x x G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 18 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 2 Regulation 12 (2) & (3) Requirement The registered person must ensure that tenants are involved in the assessment process, and sign to indicate that they have been involved, if able. The registered person must ensure that care plans for tenants are reviewed monthly. The registered person must ensure that tenants are involved in the risk assessment process and sign to indicate they have been involved if able. The registered person must ensure that all medicines into the home are recorded. The registered person must ensure that the complaints policy has details of the current regulatory authority (previous timescale of 30/11/04 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 30/11/04 not met). The registered person must ensure that the kithchen and dining area floor is repaired or Timescale for action 30th August 2005 2. 3. 6 9 15 (2) (b) 12 (2) & (3) 30th August 2005 30th August 2005 30th August 2005 30th August 2005 30th August 2005 4. 5. 20 22 13 (2) 22 6. 23 13 (6) 7. 24 23 (2) (b) 30th August 2005 Page 19 St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 replaced. 8. 28 23 (3) The registered person must ensure that staff have adequate sleep in provision. (previous timescale of 30/11/04, not met). The registered person must ensure that all staff files contain a job description(previous timescale of 30/11/04 not met). The registered person must ensure that mandatory training, in particular fire traiing is carried out (previous timescale of 30/11/04 not met). The registered person must ensure that policies and procedures reflect practice within the home 9previous timescale of 30/11/04 not met). 30th August 2005 30th August 2005 30th August 2005 30th August 2005 9. 31 Schedule 2 and 4 18 (1) (c) 10. 32 11. 40 12 12. 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 Good Practice Recommendations St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road Wimbledon Lonond 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. Extracts may not be used or reproduced without the express permission of CSCI St James Care Home (12) G54-G04 S10228 St James 12 V211783 110505 Stage 4.doc Version 1.30 Page 21 - 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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