Inspection on 17/04/05 for St James` Care Home (21)

This inspection was carried out on 17th April 2005.

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 (21) 10/11/06

St James` Care Home (21) 28/09/05

St James` Care Home (21) 20/09/04

St James` Care Home (21) 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 21 21 Old Hospital Close St Jamess Drive London SW112 8SS Lead Inspector Janet Pitt Unannounced 17 April 2005 10:00 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 21 Version 1.10 Page 3 SERVICE INFORMATION Name of service St James Care Home 21 Address 21 Old Hospital Close, St Jamess Drive, London SW12 8SS 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) 020 8672 7149 Threshold Housing & Support Phillip Burden Care Home (CRH) 5 Category(ies) of Learning Disability (LD) 5 registration, with number Physical Disability (PD) 1 of places St James Care Home 21 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th September 2005 Brief Description of the Service: St James Care Home, 21 Old Hospital Close is owned and managed by Threshold Housing and Support, providing accomodation for up to five persons with learning disabilities. The accomodation is provided in a semi-detatched house, situated on a housing estate within walking distance of Tooting and Balham. All service users have their own room and one room has ensuite facilities. St James Care Home 21 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken unannounced by one inspector and commenced at 09:00 hrs and concluded at 11:00 hrs. Three service users were home on the day of inspection, two of whom talked to the inspector. Service user plans, medication records and staff files were examined. A tour of the premises was undertaken. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St James Care Home 21 Version 1.10 Page 6 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 21 Version 1.10 Page 7 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 and 4 Assessments of service users are comprehensive and identify care needs. There are appropriate individualised risk assessments in place to ensure service users are protected. EVIDENCE: Service users are assessed prior to admission and on admission. Service users care needs are appropriately identified through the assessment process of collating comprehensive and specific details. These assessments are fully reviewed every six months, with the involvement of the service user, their representative and other health professionals, ensuring that care needs continue to be met and new issues are identified. Service users are protected from undue harm by the use of risk assessments relating to areas such as absconding and cooking, which detail what actions are required by staff to maintain safety. There have not been any new admissions to the home since the previous inspection. The manager explained that prospective service users would be able to make an informed choice about the home, by being able to visit the home to meet other service users and staff. St James Care Home 21 Version 1.10 Page 8 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, 9 and 10 Service user plans evidence that care needs are being met and they are involved in the process. EVIDENCE: Service users plans examined evidenced individual care needs of service users and reflected service users involvement in the reviews of the plans. Service users are consulted about the running of the home, dietary preferences and how they spend their leisure time through one to one sessions, which are recorded and signed by a staff member. One of the three service users present on the day of inspection said that they could chose what activities they participated in, this was reflected in the recorded one to one sessions. As detailed under the previous section individualised risk assessments are in place, which enable service users to be as independent as possible. Information relating to service users was noted to be kept securely and the manager stated that service users are able to access information within their own files. St James Care Home 21 Version 1.10 Page 9 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) 12,13, 14,15, and 16 The home has appropriate activities in place, which reflect service user choice and promote independence. EVIDENCE: Three of the service users attend day centres during the week and activities they choose to undertake outside of this time were evidenced in the one to one sessions and their care plans. These records indicated that the service users visit pubs, go out for lunch, or participate in activities such as bowling in the evenings and weekends. On the day of inspection one service user was enjoying watching the London Marathon and said that they enjoyed sport on television. The manager explained that one service user was awaiting a visit from their parents and was also enabled to visit them from time to time. Staff were observed encouraging two service users to participate in meal and drink preparation during the inspection in a calm and supportive manner. The manager explained that service users are supported to manage their own financial affairs and undertake daily living skills by staff. St James Care Home 21 Version 1.10 Page 10 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) 18,20 and 21 The privacy and dignity of service users is protected and appropriate procedures are in place for handling medication. EVIDENCE: A member of staff was assisting one service user with personal care at the time of inspection. The member of staff ensured that the bedroom door was shut and the other staff member was aware of what was happening, in order to maintain privacy and dignity of the service user. The receipt, storage and handling of medication reflected the policy that is in place in the home ensuring that medicines are handled safely and given appropriately. Examination of five medicine records indicated that there were clear directions for as required medications, no gaps in administration and the amount of medicines received into the home were recorded accurately. The manager explained that the issue of ageing, illness and death is handled sensitively with service users and at the time of inspection the issues had not been raised with one service user, due to their belief that it could not happen to them. The service users wishes were noted to be recorded in their individual files. St James Care Home 21 Version 1.10 Page 11 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 The complaints procedure indicates that service users concerns are heard, but there must be a local Adult Protection procedure in place to protect service users from harm. EVIDENCE: The home has not received any complaints since the previous inspection, which indicates that service users are confident their views are listened to and acted upon. This was also evident in the choice of lunch for the day of inspection, which was chicken, rice and vegetables, a particular service user’s favourite meal. The complaints policy details actions to be taken and was consistent with the requirements of the Standard. The home have a copy of the Local Authority’s Adult Protection guidance, but this should be supplemented with a local policy to demonstrate that service users are protected from harm. St James Care Home 21 Version 1.10 Page 12 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) 24,28 and 30 Improvements have been made to service users areas of the home, but this needs to be followed through with improvements to staff arrangements, to ensure staff have suitable sleep in facilities. EVIDENCE: The home has made improvements to the décor of the home since the previous inspection. The dining area has been repainted dnad carpeting has been replaced with hard flooring, which provides a more homely environment for service users. The home was clean and tidy on the day of inspection. The lounge had a television and music equipment for service users and provided comfortable seating. Arrangements for staff have not improved and there is still a lack of suitable sleep in facilities, which the manager said were being addressed by the provision of a dormer window in a room on the second floor with a predicted timescale of June 2005. Carpeting in the office has been replaced as required at the previous inspection. St James Care Home 21 Version 1.10 Page 13 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) 34,35 and 36 Information in staff files has improved since the previous inspection indicating that service users are protected by the recruitment process. However, the home need to evidence that staff are appropriately supervised and trained to undertake their duties. EVIDENCE: Improvements have been made on the information contained within staff files and all three files examined contained photographs of staff members and job descriptions as required at the previous inspection. Appropriate checks are made on staff members. This demonstrates that the home’s recruitment policy and practices are followed, which protects service users from harm. Records of staff supervision sessions were contained within staff files, but the home need to ensure that this section of the file is maintain and evidence of supervision is filed in a timely manner, to demonstrate that staff are supported and supervised. Improvement is needed in relation to training needs of staff to ensure that there are competent members of staff caring for service users. Training records examined indicated that mandatory training is not consistently undertaken. St James Care Home 21 Version 1.10 Page 14 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) 37,41 and 42 There has been an improvement in supernumery time for the manager, which is reflected in requirements from the previous inspection being met and enabling him to run the home more effectively. EVIDENCE: The manager stated that he has more supernumery time as required at the previous inspection, which is evidenced by the improvements in maintaining staff records and amendments to policies. This enables the home to demonstrate that service users rights and best interests are safeguarded. However, lack of mandatory training, in particular fire training, does not ensure that service users health safety and welfare are always promoted and protected. St James Care Home 21 Version 1.10 Page 15 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x 3 x 3 Standard No 11 12 13 14 15 St James Care Home 21 x 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 2 Version 1.10 Page 16 16 17 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 3 x St James Care Home 21 Version 1.10 Page 17 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 23 Regulation 13 (6) Requirement The registered person must ensure that there is a local Adult Protection Policy in place. (the previous timescale of 30/11/05 has been extended.) The registered person must esure that there are suitable sleep-in facilities for staff. (the previous timescale of 30/11/04 has been extended) The registered person must ensure that staff are supervised six weekly and this is planned in advance and recorded. The registered person must ensure that manadatory training for all staff members is undertaken. Timescale for action 30th June 2005 2. 24 23 (3) (b) 30th July 2005 3. 36 18 (2) 30th June 2005 30th July 2005 4. 36 18 (1) (c) 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 21 Version 1.10 Page 18 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon 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 21 Version 1.10 Page 19 - 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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