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

This inspection was carried out on 28th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St James` Care Home (21) 10/11/06

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

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 James`s Drive London SW12 8SS Lead Inspector Janet Pitt Unannounced Inspection 28th September 2005 10:25 St James` Care Home (21) DS0000010229.V255783.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 (21) DS0000010229.V255783.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 (21) DS0000010229.V255783.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St James` Care Home (21) Address 21 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 8672 7149 0000 Threshold Housing & Support Phillip Burden Care Home 5 Category(ies) of Learning disability (5), Physical disability (1) registration, with number of places St James` Care Home (21) DS0000010229.V255783.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2005 Brief Description of the Service: St James Care Home, 21 Old Hospital Close is owned and managed by Threshold Housing and Support, providing accommodation for up to five persons with learning disabilities. The accommodation is provided in a semidetached 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) DS0000010229.V255783.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector. Commencing at 10:25hrs and concluding at 12:20hrs. Two residents and three members of staff were spoken with. The inspection focused on requirements from the previous inspection, which covered mandatory training, abuse policies, supervision 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: 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 service users. To ensure staff are refreshed for work the following day, appropriate sleep in facilities for staff must be available. 21 St James must ensure that sleep-in arrangements are satisfactory and do not impact on tenants care within the home. Staff must be able to access a local policy on Adult Protection, to ensure that tenants are protected from harm. A letter was sent to the Provider addressing the concerns of CSCI regarding non-compliance with requirements from the previous inspection; the CSCI is awaiting a response at the time of writing this report. St James` Care Home (21) DS0000010229.V255783.R01.S.doc Version 5.0 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 (21) DS0000010229.V255783.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 (21) DS0000010229.V255783.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): None of these Standards were assessed on this inspection, but will be during the inspection year. EVIDENCE: St James` Care Home (21) DS0000010229.V255783.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, 7 and 9 Tenants benefit from having their care needs addressed on admission. Tenants are consulted about the running of the home indicating that their views are listened to. EVIDENCE: Tenants are assessed on admission and these assessments are reviewed regularly. The assessment process informs the care plan drawn up for each tenant. There was evidence that tenants are involved in the process. However, the inspector had concerns regarding the change of care needs of one tenant, and discussed this with the new manager of the home. The new manager explained that further assessments by health professionals were being made regarding treatment of this particular tenant. Assessments of tenants were noted to be comprehensive and contained relevant contacts for particular aspects of tenants care needs, such as social workers and psychiatrists specialising in learning disabilities. Tenants are able to attend day centres and are supported to undertake activities of their choosing. Tenants 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. Individualised risk assessments are in St James` Care Home (21) DS0000010229.V255783.R01.S.doc Version 5.0 Page 10 place, which enable service users to be as independent as possible, and covered areas such as absconding and cooking. St James` Care Home (21) DS0000010229.V255783.R01.S.doc Version 5.0 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 the following standard(s): 17 Tenants are able to choose what food they eat and are encouraged by staff to have a balanced diet. EVIDENCE: One of the tenant’s spoken with said that the food was ‘good’ and they were able to chose what to eat. The manager said that tenants meet and plan what meals to have for the week ahead and menu is then drawn up. Tenants are encouraged to participate in shopping for the planned menu. The menu for the week that the inspection took place in had a variety of food, including fresh fruit and vegetables. A record of food served in the home is maintained. The inspector noted that for the end of the week the tenants had chosen to have a take away meal. Tenants that attend day centres have lunch at the centre. Tenants who chose to remain at home are supported to prepare their lunch. St James` Care Home (21) DS0000010229.V255783.R01.S.doc Version 5.0 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 the following standard(s): 19 Tenants health and emotional needs are appropriately addressed. EVIDENCE: Tenants physical and emotional health needs are identified on admission and there are appropriate procedures in place to make sure that health professionals are involved in the review process. Regular health checks are maintained and documented in the care record. As mentioned in the Individual Needs and Choices section, the inspector had concerns about the changing care needs of one tenant and review of their care file indicated that appropriate measures were being taken. However, the home must be aware that if the conclusion of the review being undertaken highlighted that the tenant had more predominate mental health needs than learning disabilities then a variation of category would not be appropriate as the tenants behaviour is impacting negatively on other tenants and staff within the home. St James` Care Home (21) DS0000010229.V255783.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): 23 Tenants are not protected from harm, due to the lack of a local Adult Protection policy. EVIDENCE: 21 St James has a copy of the local authority’s Adult Protection policy, but has yet to develop a local procedure to inform staff of what must be done. This places tenants at risk of harm, if staff are not correctly informed of the procedure to be under taken. St James` Care Home (21) DS0000010229.V255783.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 Tenants should be supported by staff that have suitable sleep in facilities to make sure that staff are able to undertake their duties competently. EVIDENCE: Arrangements for staff have not improved and there is still a lack of suitable sleep in facilities, this does not ensure that staff are well rested for duty the following morning. This concern was subject to a requirement at the previous two inspections and the home must take action to comply. St James` Care Home (21) DS0000010229.V255783.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): 32,33, 35 and 36 Improvements have been made to supervision of staff, however mandatory training must be in place to make sure that tenants are supported by competent, trained staff. EVIDENCE: Records of staff supervision sessions were contained within staff files and noted to be undertaken at regular intervals, demonstrating 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. This is an area of concern as a requirement was made at the previous two inspections and compliance has not been achieved, which places tenants at risk of not being supported by competent training trained staff. The manager stated that there is one member of staff who sleeps in, but is also required to cover another home nearby. The home must demonstrate that this issue does not have a detrimental effect on either home. St James` Care Home (21) DS0000010229.V255783.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): None of these Standards were assessed on this inspection, but will be during the inspection year. EVIDENCE: St James` Care Home (21) DS0000010229.V255783.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 X X X X X Standard No 22 23 Score X 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 x 3 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St James` Care Home (21) Score X 3 X X Standard No 37 38 39 40 41 42 43 Score X X X X X X x DS0000010229.V255783.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 YA23 Regulation 13 (6) Requirement The registered person must ensure that there is a local Adult Protection Policy in place. (the previous timescale of 30/07/05 has been extended.) The registered person must ensure that there are suitable sleep-in facilities for staff. (the previous timescale of 30/07/05 has been extended) The registered person must ensure that mandatory training for all staff members is undertaken. The registered person must demonstrate that a shared sleep in person does not have a detrimental effect on the home; by maintaining a record of the times the sleep-in person is woken. Timescale for action 30/11/05 2. YA24 23 (3) (b) 30/11/05 3. YA36 18 (1) (c) 30/11/05 4. YA36 18 (1) (a) 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. St James` Care Home (21) DS0000010229.V255783.R01.S.doc Version 5.0 Page 19 No. Refer to Standard Good Practice Recommendations St James` Care Home (21) DS0000010229.V255783.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. Extracts may not be used or reproduced without the express permission of CSCI St James` Care Home (21) DS0000010229.V255783.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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