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

This inspection was carried out on 31st October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 James` Care Home (12) 18/10/05

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 31st October and 6th November 2006 10:00 St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 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.V317864.R01.S.doc Version 5.2 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.V317864.R01.S.doc Version 5.2 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 www.thresholdsupport.org.uk 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.V317864.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 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. The fees charged are £1084-64 per week. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection. The site visit was carried out over two days and lasted a total of four and a quarter hours. Ten surveys were sent to staff and one was received. Tenants were unable to complete surveys; CSCI surveys are not conducive to this. The tenants families live a distance from the home and were not able to support them to complete surveys. An evening visit was made to enable the inspector to meet with tenants. Staff files, medications, duty rotas, financial information and care documentation were examined. Discussion also took place with three members of staff. What the service does well: What has improved since the last inspection? Stable management of the home has meant requirements made at the previous inspection have been met. There is now a clear audit trail of medication within the home. Work is being undertaken on reviewing policies and procedures. Significant improvements have been made to the kitchen and sleep in room for staff. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 6 The acting manager is working on making sure all mandatory training is carried out in a timely manner. What they could do better: 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. The summary of this inspection report can be made available in other formats on request. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 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.V317864.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until full needs assessment has been made. Prospective tenants are given the opportunity to spend time in the home. New tenants are provided with appropriate information on the running of the home. EVIDENCE: Tenants are assessed by the support staff prior to moving into 12 St James. They are able to visit for meals and meet other people living in the home before making a decision about whether they want to live there. Tenants are able to stay the night if they chose. Full assessments are carried out once the tenant has made a decision to live at 12 St James. Information is gathered on personal and social history, health needs and religious needs. It was noted that the tenants’ views were sought during the process and fully documented. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 9 Support plans are drawn up from assessments and detail how needs are to be met, involving other health professionals as needed. Support is given by staff to enable tenants to make choices and achieve personal goals. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong belief that it is essential to involve residents in the planning of the care that affects their lifestyle and quality of life. Management and staff understand the importance of tenants being supported to take control of their own lives, and to encourage and enable them to exercise their rights and make their own decisions. EVIDENCE: Tenants support plans are routinely reviewed and they are active in this process. Tenants are able to make decisions and take reasonable risks, in order that they can maintain or develop independent living skills. Risk assessments are reviewed six monthly to make sure that information held is current. Risk assessments cover areas such as absconding, travel outside St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 11 the home, challenging behaviour, sexual risks and medical treatment. Tenants have individualised risk assessments according to their needs. The acting manager stated that at present none of the tenants have a regular relationship, but if this occurs as has happened previously, then support is given and privacy is respected. Support plans are routinely reviewed and changes are noted. Tenants are encouraged to participate in these reviews and it was evidenced that they had taken part. All tenants attend a day centre and it was noted that holidays are organised with appropriate support. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling tenants to develop their skills, including social, emotional, communication and independent living skills. Individuals are supported to identify their goals, and work to achieve them. EVIDENCE: Tenants are supported to attend a disco once a month and attend day centres. Other activities that the tenants have taken part in are bowling, holidays, shopping and going to the pub. Records of discussions with tenants evidence that they are able to make choices and take part in appropriate activities. Tenants have an individualised programme of activities for the week and staff said that they make sure that there is time for individual activities, such as St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 13 shopping, paying rent or having a meal out. This helps tenants to have a positive relationship with their support worker. Support is given with medical and other health appointments when needed. Tenants are able to maintain contact with their friends and family. This is achieved either by the tenant visiting or visitors coming to the home. On Sundays all tenants decide the menu for the week, this normally includes a take away meal on one night. Lunch is taken at the day centre during the week. Suppertime was observed during the evening visit. All tenants have their preferred places and assistance was given discreetly if needed. The use of specialist cutlery and plate guards allowed some tenants to eat independently. Portion sizes were noted to be good and there was a plentiful supply of beverages. Alternative meals can be provided if a tenant decides they would like something different. All tenants were requested to wash their hands before the meal and take their plates and cutlery out after they had finished eating and drinking. Support was given to the tenants to put dirty dishes in the dishwasher ready for washing. All tenants have time set aside to do their laundry and ironing. One member of staff was doing some ironing for a tenant, who was unable to do complicated items of clothing. Throughout the site visits staff, were observed to be good role models for tenants and treated all tenants with respect. Tenants are consulted about any religious or spiritual needs they may have. Staff said that one tenant had specific needs and the staff are trying to access facilities to enable the tenant to practice. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants have access to health and remedial services, staff make sure those tenants who are fit and well enough are encouraged to be independent. The home has an effective medication policy supported by procedures and practice guidance. EVIDENCE: Tenants records evidence that physical and emotional health needs are met. Staff confirmed that assistance is given with personal hygiene and privacy is respected. Staff are able to make sure that the key worker system is effective and tenants have time to express any concerns. Other health professionals such as psychologists are involved when needed. Tenants are protected from harm by clear guidance and procedures that are in place for medications. The medication policy has recently been updated and was noted to include guidance on administration, storage and handling of medication. Medication records examined had no gaps in recording of St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 15 administration of medicines. Medicine reviews are evidenced as being carried out. Daily stock checks are taken; there were no issues of concern. Each medication record had a current photograph of the tenant and details of any allergies. There were clear instructions for when ‘as required’ medications were to be given and information leaflets on the medications that tenants have been prescribed. Staff said that the current tenants were unwilling to discuss death and dying, but staff are aware of the need to address this and will continue to use reviews to attempt to determine the tenants’ wishes. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture, which enables tenants to express their views and concerns. The complaints policy is accessible and explained to tenants. Tenants are protected by correct adherence to Protection of Vulnerable Adults procedures. EVIDENCE: Tenants are protected from harm by clear polices and procedures on adult protection. At the time of the inspection there was one ongoing adult protection investigation. The home had taken appropriate steps to make sure that tenants were not at risk. The complaints policy has been reviewed in March 2006. The procedure is clear and easy to read. The acting manager said that work was progressing on producing a picture format for the complaints policy, to make sure that tenants are aware of how to complain. The CSCI has not received any concerns about the service. It was noted that when tenants are consulted about the home, the complaints policy is explained to them. The consultation record and reviews of tenants indicate that their views are noted and acted upon. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Tenants are able to personalise their rooms. The shared areas of communal space are homely and provide areas for tenants to relax. EVIDENCE: 12 St James provides a homely environment for tenants. Communal areas are kept clean and tidy. Significant improvements have been made with the provision of a new kitchen and sleep in accommodation for staff. Staff spoken with during the site visit said that the sleep in provision enabled them to relax and rest in comfort. Tenants are able to personalise their rooms and staff support them to choose accessories, such as light shades, lamps and bed covers. Tenants chose what colour theme they wish for their room. Appropriate toilet and bathing facilities are available for tenants use. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained to care for tenants. Rotas show well thought out and creative ways of making sure that the home is staffed effectively. The recruitment process protects individuals from harm and appropriate checks are carried out on staff prior to commencing employment. EVIDENCE: Tenants are supported by adequate numbers of staff. The published duty rota indicated that staff are deployed effectively to make sure that tenants needs are met. Staff spoken with said that when agency staff are used, generally the same people work in the home to make sure there is consistency. This makes sure that tenants are appropriately supported. No new staff have been recruited since the previous inspection when the recruitment procedure was found to be satisfactory. Staff confirmed that they receive supervision regularly. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 19 One member of staff said that they had just commenced their NVQ Level 2 and have been receiving support to undertake this qualification. The one staff survey received indicated that the support worker was satisfied with the amount and appropriateness of training given. The acting manager said that she was working on making sure all staff receive mandatory training. Suitable training is in place for medication handling. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The acting manager has provided stability at the home, which has benefited both staff and residents. The management style is proactive and open. Attention is given to making sure that the health, safety and welfare of tenants is promoted and maintained. EVIDENCE: Tenants benefit from a home, which is run in their best interests. Improvements have been made to make sure policies and procedures reflect current practice. Staff are able to access policies and procedures on Threshold’s Intranet. The acting manager said that Threshold is in the process of reviewing all policies and procedures. Records were noted to be well maintained and up to date. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 21 There were no issues with health and safety identified on the site visit. Tenants are able to make their views known through one to one sessions, and staff respect their views. Consideration is given to making sure that tenants are able to make decisions within a risk-assessed framework. St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X St James` Care Home (12) DS0000010228.V317864.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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.V317864.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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) DS0000010228.V317864.R01.S.doc Version 5.2 Page 25 - 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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