Inspection on 28/02/06 for St James House

This inspection was carried out on 28th February 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 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 10/11/05

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 28th February 2006 10:00 St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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.V278933.R01.S.doc Version 5.1 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.V278933.R01.S.doc Version 5.1 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.V278933.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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. 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 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. 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. Night care provision will consist of a member of staff on waking duty per unit. 10th November 2005 5. 6. 7. Date of last inspection 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 wellSt James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 5 managed 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.V278933.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 28 February 2006 over a three hour period. The inspection involved spending time talking with the registered manager, the quality manager, a senior carer and the owner of the home. Although a number of residents were seen during the inspection process there was only one who was comfortable speaking with the inspector. Some time was spent looking at files, records and a number of policies and procedures. Time was also spent looking around parts of the home and observing the interaction between residents and staff. Only one improvement was identified as being required at the last inspection, and, although this improvement had not been carried out it is acknowledged that the timescale for this improvement had not run out at the time of this inspection. What the service does well: The management and staff team of the home continue to work hard at developing good ways of helping and supporting residents and their families. A lot of time has been spent in making sure that individual residents get support in the way that is most important to them. One resident said, “I like my room”, “I like some staff”, and “the food is good”. This resident was a wheelchair user and was seen to have full access to all parts of the ground floor including her bedroom. Watching residents and staff in the home together showed that good supportive and understanding relationships had been developed. Care plans and risk assessments are regularly checked and updated to make sure that each resident living in the home receives the support they need in the best way possible. Residents are provided with good opportunities to develop their confidence and skills through being involved in life skills training. One resident has achieved a National Vocational Qualification at level 2 in ‘cleaning processes’. Talking with this resident confirmed that she was doing things that she enjoyed and that would help her to live as independently as possible. One area of really good support is in making sure other healthcare professionals such as G.P’s and district nurses are involved in supporting and assisting meeting the health needs of the individual resident. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 7 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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.V278933.R01.S.doc Version 5.1 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): None of these standards were inspected on this occasion. EVIDENCE: St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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): 7 People living in the home are able to make decisions about their lives with assistance where required in order to meet their individual needs. EVIDENCE: Each person living in the home had a care plan that had been developed from information collated from care manager and in-house assessments of need. Those plans seen indicated that the resident was treated very much as an individual with individual needs and wishes to be fully considered as part of their daily lifestyle. Evidence was available to show that other health care professionals such as a speech and language therapist and an appropriate advocacy service are used to enable individual residents to express their choice(s) about their lives. Discussion with the manager confirmed that an opportunity for resident’s to meet on a regular basis to discuss issues about the home is offered to all residents but the majority decline to attend. However, one resident attends every meeting and does express any concerns or opinions that have been made known to her by other residents living in the home. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 11 A copy of the minutes from the meeting held on 23 October 2005 was provided for examination. From these minutes it was seen that nine residents had attended this particular meeting and a variety of issues were raised including maintenance and repairs to individual residents’ bedrooms. A copy of these minutes was given to each resident living in the home or placed on their file. Each resident had a ‘Health Action Booklet’ that detailed any relevant information regarding the individuals health needs and wants. The information in these booklets had been completed with the full involvement of the individual resident. One resident manages her own personal allowance each week and decides how and what she spends her money on. She has been provided with a secure lockable space within her bedroom. The home has a ‘no restraint’ policy and any interventions that may be needed to prevent self-harm or self-neglect or abuse or harm to others is managed within a risk assessment/management framework. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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): 15,16 and 17 The home was able to show that it offered people opportunities to participate in appropriate personal relationships and that their rights are respected. A healthy diet is offered and provided to all residents. EVIDENCE: Evidence seen on a number of residents files indicated that links with family and friends have been maintained wherever possible and in accordance with the wishes of the individual resident. It was also seen where family members have been fully involved in personalising their relatives own accommodation and also in assisting with meeting their care needs where identified and requested by the individual resident. A number of residents have personal friends who visit them in the home and who they go to visit in the community. To ensure staff have an awareness of how to support an individual resident to maintain close personal relationships, the home has developed a ‘Interpersonal Relationship and Sexual St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 13 Development’ policy. This covers various personal matters that an individual resident may need support with. Information contained within this policy also clearly states the rights and responsibilities of the resident and staff. Each resident has a lock on his or her bedroom door. Any risks to a resident using a lock has been identified with a risk assessment and is linked to their individual care plan. Wherever possible, residents are given their mail to open. Where it has been identified that the home deals with an individual’s mail, the manager confirmed that this mail would be opened in front of the resident. Observation of staff during the inspection indicated that appropriate and positive working and supportive relationships had been developed. Residents appeared to be treated with respect and staff were clearly understanding to the behaviours of individual residents and how to respond to those behaviours, some of which, could be quite challenging. There are three ‘satellite’ kitchens based in the home, one on each floor. Staff with the responsibility for preparing meals have all completed Basic Food Hygiene training and have an awareness of residents likes, dislikes and any special dietary needs. Should a resident wish to take their meals somewhere other than in the dining room this would be identified within the individuals care plan. Menus seen offered a varied and nutritious diet and also included options for choice at mealtimes. One person planned her own menu and went to the local shops to purchase the ingredients (paid for by the home). St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Systems, including policies and procedures are in place to support and protect residents when administering medication. However, further work could be done to enhance this. EVIDENCE: Systems were in place for the receipt, recording, administration, storage and return of medication. This appeared to be well co-ordinated and managed. One resident was self-medicating and written confirmation from their GP confirmed that the individual was capable of doing so within a risk management framework. This resident was supported by the staff in the home to check their medication at the end of each month and to place a ‘re-order’ with the GP. Staff with the responsibility for the administration of medication had received training. Information was available about the safe administration of ‘as required’ medication. The home had also developed a ‘Drug Analysis File – 2005’ for staff to access information relating to each type of medication being used in the home and the effects of this medication on the individual for who it is prescribed. This is good practice. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 15 Medication Administration Records (MAR) appeared to be appropriately signed with no gaps apparent. Medication for each resident had been reviewed in October/November 2005 by the GP. It is recommended that a photograph of each resident be placed on the MAR file for staff to be further supported and enabled to clearly identify each resident who requires medication to be administered to them. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Residents’ views, opinions and concerns are listened to and taken seriously and necessary action is taken to address problems. EVIDENCE: A comprehensive and up dated ‘Complaints Procedure’ was available and was displayed throughout the home. Each resident had a copy provided in an information file in his or her room. The manager provided a copy of this policy to the Commission for Social Care Inspection for reference. Discussion with one particular resident confirmed that she knew that she was entitled to make a complaint and said “I would go to Wendy (manager) if I needed to”. A record was kept of any complaints made and the action taken in addressing these. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. However, a requirement made at the inspection carried out in November 2005 under Standard 24 was still outstanding. EVIDENCE: It is however, acknowledged that the timescale for the requirement to be addressed had not expired at the time of this inspection. The timescale has been reiterated again in this report. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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): 32 and 36 Residents are supported by staff that are well trained and received regular, formal supervision. EVIDENCE: During the inspection staff were observed to be approachable and effective in their communications and interactions with residents. Staff were consistent in demonstrating their skills and personal qualities when undertaking supporting tasks with residents. Staff all had individual training records on file and had attended various training courses throughout the year. The supervision of staff was carried out on a regular basis and supervision records were held on staff files. An annual appraisal system was also in place. Wherever required, staff would be offered support and supervision by various health care professionals such as speech and language therapist and psychologist in order to meet specific needs of an individual resident. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 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): 37, 38 and 39 People living in the home benefit from having a manager and management team with the skills to provide a quality service. EVIDENCE: The manager of the home has a number of years experience and has had relevant training to update her skills and knowledge. At the time of this inspection she was working towards completing the Registered Managers Award and other recent training has included ‘Person Centred Planning’ and ‘Health Action Planning’. The home has the support of a Quality Manager who has the responsibility for monitoring and appraising service delivery. The quality manager has done this through resident/staff/relatives surveys carried out on a 1 – 1 basis. A full health and safety audit of the premises is carried out approximately every 3 months and information collated is used to plan and develop an on going repairs and maintenance programme for the home. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 20 The owner of the home carries out regular monthly checks of the premises and holds regular meetings with the registered manager. Reports from these monthly checks are provided to the manager and a copy supplied to the Commission for Social Care Inspection. It is commendable that out of 29 care staff, 18 have achieved the National Vocational Qualification (NVQ) at level 2 and 2 staff have also completed NVQ level 3. St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 21 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 3 3 X X X X St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations St James` House DS0000021626.V278933.R01.S.doc Version 5.1 Page 23 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.V278933.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!