Inspection on 10/11/05 for St James House

This inspection was carried out on 10th November 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St James House 03/05/07

St James House 26/06/06

St James House 28/02/06

St James House 17/11/04

St James House 15/06/04

St James House 08/12/03

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 St James` House Danes Road Rusholme Manchester M14 5JT Lead Inspector John Oliver Unannounced Inspection 10:00 10 November 2005 St James` House DS0000021626.V260430.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` House DS0000021626.V260430.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` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St James` House Address Danes Road Rusholme Manchester M14 5JT 0161 225 6999 0161 224 9355 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) Standwalk Limited Wendy Nield Care Home 14 Category(ies) of Learning disability (14) registration, with number of places St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home will not accommodate:(i) people who have a criminal conviction, (ii) those people whose risk assessment inidcates that they are likely to pose a risk to the general public (iii) sexual Offenders, (iv) people with a history of sexualised behaviour, unless a full risk assessment has been carried out and it is clear that the behaviour is either situation speficic or can be controlled in other ways Staffing levels must be commensurate with the needs of the services users and must be sufficient to allow for them to be escorted outside the building on a one:one or two:two:one basis, as per their assessment. A manager with qualifications, agreed as appropriate by the Commission for Social Care Inspection, will be employed to manage the day to day running of the home at all times. In the absence of the manager, day to day running of the home will be the responsibility of a senior member of staff who has substantial experience at a senior level and/or qualifications relating to care of people with a learning disability and associated challenging behaviour. Night care provision will consist of a member of staff on waking duty per unit. A maximum of 14 service users will be accommodated. The home will only provide a service to people whose primary need for care arises from a learning disability with associated challenging behaviour. Accommodation will be provided in three separate units. 2. 3. 4. 5. 6. 7. Date of last inspection 17th November 2004 St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 5 Brief Description of the Service: St James House is a registered home providing 24-hour care and accommodation for 14 persons with a learning disability and associated challenging behaviours. The home is situated in the Rusholme area of South Manchester, close to local amenities and transport routes. The home is a converted church sited in a residential area within its own grounds. It is accessed directly from a residential street and has adequate parking and an extensive and wellmanaged garden. The home is divided into three separate areas, offering a range of facilities to cater for people with varying levels of support needs. Bedroom accommodation is provided on the ground, first and second floors. The ground and second floor bedrooms are single with en-suite facilities and a self-contained flat. The first floor contains three self-contained flats and three single rooms. The building is fully accessible and there is lift access to all floors. There are a variety of communal areas on each floor including lounges, kitchens, laundry facilities, a well-equipped sensory room, hydrotherapy pool and gym room. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 10 November 2005 over a five hour period. The inspection involved spending time talking with the deputy manager, staff on duty and one particular resident who was comfortable speaking with the inspector. Some time was spent looking at files and records. Time was also spent looking around the inside of the home and observing the interaction between residents and staff. No improvements were identified as being required at the last inspection conducted in November 2004. Not all standards were assessed at this inspection and it is strongly advised that this report should be read together with the last inspection report and any future inspection reports to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? No requirements were made at the last inspection carried out in November 2004. However, it was evident from the work being carried out to the premises at the time of this inspection that on going maintenance and improvements to the environment were being made. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 7 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. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 8 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` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 9 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): Information about the service was available to people and their needs are assessed before they come to live at the home. EVIDENCE: The home had in place a Statement of Purpose and a Service User’s Guide. Both documents had been reviewed and updated in October 2005 and contained all the information required from the National Minimum Standards and Regulations. One of the most recent people to come to live in the home had a full and detailed assessment provided by the purchasing local authority. Along with this, the manager of the home had carried out a full and detailed preadmission assessment. Trial visits to the home had taken place prior to ‘formal’ admission. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8 and 9 The home had developed a care planning system that included regular reviews of those plans. The home had identified the risks residents may come across in their day-to-day lives and the support needed to address those risks. EVIDENCE: Care plans had been developed for each resident using information collated from care manager and in-house assessments of need. Care plans examined indicated that they had been subject to regular review and updating (where required). Care plans detailed how a persons needs would be met and covered all aspects of personal, social and healthcare needs. Any restrictions on choice and freedom were included and there was evidence that residents had been consulted prior to any restrictions being imposed. Examination of care plans and observation of interactions during the inspection provided evidence that the right of residents to make decisions was respected by staff. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 11 All information relating to residents was recorded in the ‘first person’, which demonstrated that communication processes had been undertaken with the full involvement of the resident(s). Each resident had been provided with a copy of his or her care plan, which was included in a file of information in his or her bedroom. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 The home was able to show that it had offered people opportunities to participate in appropriate social, leisure and community based activities as set down in its Statement of Purpose. EVIDENCE: Of the care plans seen during the inspection and the diary notes being maintained on each individual resident it was evident that residents living in the home had access to a variety of appropriate and stimulating activities. These included visits to places of interest, such as a railway museum, art galleries, bowling, a trip to Blackpool and a holiday in Southport. During the inspection numerous residents were seen to be supported to access the local community. This included shopping, visits to the library and, on other occasions, visits to the cinema and local pubs. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 13 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): 18 and 19 The home supports people’s personal and healthcare needs. EVIDENCE: Resident’s personal care and healthcare needs and support were identified in the individual care plan. Guidance was available to staff on how to meet those needs in the most appropriate way according to the resident’s wishes and needs and in accordance with a risk management strategy for the individual. Throughout the inspection staff were observed to be providing personal support that maximised residents privacy and dignity. Care plans indicated that appointments with opticians, chiropodists, psychologists, district nurses and other health care professionals had been kept. District nurses regularly supervised the care of stoma sites and catheters for individual residents. Three members of the staff team had also attended a four-day ‘stoma care’ training course at a local hospital in order to be able to support one particular resident appropriately. The deputy manager and another member of the staff team had recently attended “Health Action Planning” training. Following this, the manager wrote to individual GP’s and other health care professionals to arrange health checks St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 14 for all residents living in the home. The Community Learning Disability Nurse attended the home and met with each resident to assess any particular health care needs. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 15 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 Residents living in the home are protected from abuse, neglect and self-harm. EVIDENCE: The home has adopted Manchester’s Multi-Agency policy on the Protection of Vulnerable Adults. Discussion with the deputy manager confirmed that she had a thorough knowledge and understanding of the procedure to follow should any allegation of abuse be made. All staff had received relevant training for the Quality Manager of the organisation in relation to the subject of protecting vulnerable adults. training linked directly with the Local Authority guidance. This St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 16 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): 24,29 and 30 The home provided people with a safe environment to live and had systems in place to minimise the risk of cross infection. EVIDENCE: At the time of the inspection a team of builders were in the home carrying out general repairs and refurbishment work. Observation of the builders indicated that they had considered the environment they were working in and took necessary steps to safeguard both residents and staff during this work. A tour of the premises found the home to be generally well maintained, clean, hygienic and free from any unpleasant odours. Lighting, heating and ventilation was suitable to the assessed needs of the residents. Fixtures and fittings were domestic in nature. Carpets on the first floor corridor were showing signs of wear and tear and must be replaced once all building work is fully completed. It was noted that suitable adaptations had been made to the home to meet the assessed physical needs of residents. It is commended that the home provides therapies which include a gym, sensory room and hydrotherapy pool. The St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 17 sensory room also contained a waterbed, massage aid and audio/visual stimulation. Laundry facilities were provided on site and adequate facilities were in place to control and minimise the risk from infection. Facilities were sited away from food preparation and eating areas. Policies and procedures for the control of infection were also in place. Protective aprons, gloves antibacterial soaps and paper towels were in place. It is commendable that each resident has their clothes washed separately. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: During the inspection the file of one of the latest staff to be recruited to the staff team was examined. This file contained all the required employment checks for the protection of residents. The member of staff had completed induction training and the induction schedules were also held of the file along with their interview notes. The home had implemented a training and development programme that met the Skills for Care criteria. All staff had recently received a two day in-house training programme that had included working through documents such as the statement of purpose and service user guide. Staff had also been included in discussions regarding the business plan for the organisation, which is considered good practice. The Quality Manager for the organisation is primarily responsible for arranging all training for staff and was in the process of compiling an updated training schedule at the time of the inspection. Each member of staff had an individual file that contained information relating to the specific training they had received. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 19 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): 42 The health, safety and welfare of residents are promoted and protected by the systems in place. EVIDENCE: Records were maintained of the servicing and maintenance of equipment used by both residents and staff in the home. All the required health and safety checks were up to date. Environmental risk assessments had been undertaken and these were found to be clear and easy to understand. Hazard sheets for the control of substances hazardous to health were in place. St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 20 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 3 3 3 3 X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St James` House Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000021626.V260430.R01.S.doc Version 5.0 Page 21 0 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 OP24 Regulation 23 Requirement The carpets to the upstairs corridor (identified to the deputy manager) must be replaced. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 0 Refer to Standard 0 Good Practice Recommendations No recommendations have been made as a result of this inspection St James` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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` House DS0000021626.V260430.R01.S.doc Version 5.0 Page 23 - 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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