Inspection on 21/06/07 for St Judes House

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Judes House 20/05/08

St Judes House 05/10/06

St Judes House 24/02/06

St Judes House 10/10/05

St Judes House 02/03/05

St Judes House 11/08/04

St Judes House 26/03/04

Similar services:

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Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Delrose House Ltd

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

CARE HOME ADULTS 18-65 St Judes House 14 Canadian Avenue Catford London SE6 3AS Lead Inspector Lisa Wilde Unannounced Inspection 21 June & 9th July 2007 11:00 st St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Judes House Address 14 Canadian Avenue Catford London SE6 3AS 0208 6904493 0208 690 4501 stjudes@hotmail.com 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) Elizabeth Peters Care Home Limited Mrs Priscilla Kagijo Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0), Physical disability (0), Physical disability over 65 years of age (0) St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 10 persons aged 40 years and above with a past or present mental disorder, 2 of whom can have a physical disability service users can be over 65 years To include one named person aged 39 years, until May 2006 2. Date of last inspection 5th October 2006 Brief Description of the Service: St Judes is a large Victorian property offering care and accommodation to ten adults with past or present mental health problems, some of who may be over 65 years of age. The home is one of four owned and managed by a local provider, Elizabeth Peters Care Homes Ltd. The home is on a main road and is a short walking distance of shops and facilities of Catford town centre. This provides the home with good transport links as the town centre has two train stations and is well served by buses. The house is unobtrusive and blends in with the surrounding properties. The home offers single bedroom accommodation and communal space including a large rear garden. There were no vacancies on the day of the inspection. The range of fees for a place at the home was not available at the time of writing the draft report. The home makes the reports of the Commission’s inspections available to service users in the hallway of the home. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2007 and the inspector then waited for the managers to send on further written information. The inspector met with residents, staff and the Registered Manager. The inspector toured the building, looked through records and checked the medication stocks. The inspector found that again this home provides a high standard of care and residents said they were happy at the home with no problems. Most of the requirements made at the last inspection had been met although a few more were made during this inspection. What the service does well: What has improved since the last inspection? • • • Staff now check often enough that they are still doing things right for residents. The organisation does not check people properly before they start working at the home. The organisation does not make sure staff can do their job properly before they start working at the home. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 6 • The organisation does not make sure that things get better residents every year. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff make sure that they can meet the needs of residents before they are offered a place at the home which take account of what the resident thinks their needs are. Residents are given contracts when they move to the home but not all details are completed which means that they are not given all the information they need. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that they gather the resident’s views on their needs and the placement when they complete an assessment. If the service user does not wish to contribute to the assessment this should be stated on the form. A detailed assessment including this information was seen. There was a previous requirement that the Registered Manager should ensure that all required details are completed in residents’ contracts. This is not yet being done. (See Requirement 1) St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff write care plans that describe what they will do to make sure that all residents’ needs are met. Risks are assessed and plans put in place to make sure that any risks are managed which means that residents are kept safe. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that all care plans are reviewed as required i.e. at least every six months for residents under 65 years of age and at least monthly for residents over 65 years of age. This is now done. There was a previous requirement that the Registered Manager must ensure that all care plans are useful to service users and agreed by them and that St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 10 agreed actions are carried out as identified in the care plans and risk assessments. This is now the case. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported to do what they want to do and go out when they want to. Residents choose what they want to eat and staff cook for them. EVIDENCE: Staff talked about the difficulties in getting some residents to go out but that other residents regularly go out. Records showed that some service users have reasonably full weekly plans. Although this is technically a younger adults home, several of the residents are over 65 years of age and as such do not want to do as much as some younger people. Staff cook for residents and records are kept of what they eat each day. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 12 Residents said that they liked the food a lot and they get to eat what they want. The menus are varied but perhaps not quite as healthy as they could be. (See Recommendation 1) St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff support residents in different ways and residents are encouraged to attend regular appointments to make sure they stay healthy. Some medication systems are operated effectively but recording of medication in the home and of medication changes must be more accurate to make sure that residents are getting their medication properly. EVIDENCE: Staff discussed how it was difficult to get some residents to attend regular GP or other healthcare appointments but generally these issues are monitored effectively. There was a previous requirement that the Registered Manager must ensure that all medication brought into the home is recorded. It was not possible to accurately stock check medication as the dates when medication starts being used and the amount carried forward are not recorded on the administration sheets. (See Requirement 2) St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 14 There was a previous requirement that the Registered Manager must ensure that all changes to medication administration are recorded on the medication administration charts. This is now done. There was no record of which staff have been deemed competent to administer medication. (See Requirement 3) St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents know how to complain but their day-to-day concerns should be taken more seriously so that action can be taken to make things better for them. Residents are protected from harm by staff receiving training and understanding what to do if they think a resident is being abused. EVIDENCE: There is a complaints procedure although there have been no formal complaints since the last inspection, the last complaint being recorded in 2004. There was a previous requirement that the Registered Manager must ensure that all informal concerns and comments on the service are recorded along with action taken to address the issues. This is not yet being done. (See Requirement 4) Staff could describe the procedures in place to protect residents and what staff should do if they thought a resident was being abused. There was a previous requirement that the Registered Manager must ensure that there is a written policy that staff are aware of, that describes the procedures and requirements for allowing staff visitors into the home (as this relates to staff who live in the flat at the top of the home). This is now done. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 16 The Registered Manager and staff do not yet have an awareness of the new Mental Capacity Act and its effect on assessing resident’s capacity to make decisions. (See Requirement 5) St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and homely throughout. Residents have their own rooms that they have decorated how they choose and the communal areas are large enough. EVIDENCE: On the day of the inspection the home was clean and hygienic throughout. There is a large lounge/dining room and a separate kitchen. Residents have their own rooms that have been decorated as they choose. Residents said they were happy with their rooms. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet the needs of residents and they hold the right qualifications and get enough training which means that service users are cared for by people who know what they are doing. Recruitment procedures are now effective enough which means that the organisation is doing enough to check up on the people who work in the home and to make sure that it is employing staff who can do the job. EVIDENCE: There was a previous requirement that the Registered Individual must ensure that all staff who offer supervision have received training and been judged as competent to do so. This is now the case. There was a previous requirement that the Registered Individuals must ensure that the induction and foundation programme being used is the most up-todate version of the Skills For Care (and not TOPSS) programme. This is now done. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 19 There are usually four staff on duty. All staff hold or are undertaking the NVQ Level 2 in Care. There were several previous requirements about the recruitment procedures. All of which were met although no reference had been gained from the most recent employer and there was no explanation in the recruitment pack as to why. (See Requirement 6) Each member of staff has an individual training plan and these are drawn together into an overall annual training plan for the home. This plan showed that staff receive the basic training required. Although the staff team has recently had some mental health training from another manager within the organisation who is a registered nurse, there may be more opportunities for the Registered Manager to offer in-house training to staff during team meetings or to access external training. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Registered Manager has been at the home for several years and holds or is undertaking the required qualifications, which means that she has the skills to run the home well. There is now a thorough system that looks at developing the home and planning to make things better for residents each year. Record keeping is not effective enough. Residents are protected from harm by the effective operation of all health and safety procedures. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 21 EVIDENCE: There was a previous requirement that the Registered Individual must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI. These are being done and now no longer need to be sent through to the Commission each month but they are not being kept at the home. (See Requirement 7) Notification of incidents have not been sent within 24 hours to the Commission. (See Requirement 8) There was a previous requirement that the Registered Individual must ensure that there is an annual development plan for the home that is based on a systemic cycle of planning, action and review and reflecting aims and outcomes for service users. This is now being done. There has been a lot of work over the past year on drawing up a quality assurance programme for the home that covers all the areas of the service. It now meets the standard although it hasn’t yet been fully used and the information is still as it was last year, although work is being done to collate and start to transfer the information. There was a previous requirement that the Registered Manager must ensure that action is taken to address all issues raised in service user meetings and that this is fed back in the next meeting and recorded in the minutes. This is not ye being done. (See Requirement 9) Many of the records required to be kept in the home were being held at the Registered Managers house and it too two weeks for the required information to be sent to the Commission. (See Requirement 10) All health and safety documentation is as required and no problems were noted during the tour of the building. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 3 X St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 23 YES 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 YA5 Regulation 5 Requirement The Registered Manager should ensure that all required details are completed in service users’ contracts. Previous requirement: Unmet timescale 30/11/06 The Registered Manager must ensure that all medication brought into the home is recorded. Previous requirement: Unmet timescale 05/10/06 The Registered Manager must ensure that there is a list kept of all staff trained and deemed competent to administer medication along with a sample of the signature they use to sign medication administration charts. The Registered Manager must ensure that all informal concerns and comments on the service are recorded along with action taken to address the issues. Previous requirement: Unmet timescale 30/11/06 The Registered Individuals must ensure that an appropriate policy and procedure is drawn up regarding the mental capacity act, that staff are aware of the DS0000025643.V343171.R01.S.doc Timescale for action 31/07/07 2. YA20 13 (2) 31/07/07 3. YA20 13 (2) 31/07/07 4. YA22 22 31/08/07 5. YA23 18 (1) (c) (i) 30/09/07 St Judes House Version 5.2 Page 24 6. YA34 19 (1) & (4) 7. 8. YA39 YA39 26 (3) 37 9. YA39 12 (3) 10. YA41 17 effect of this and that effective assessments of capacity are conducted when necessary. The Registered Individuals must ensure that a reference is gained from the most recent employer where possible or an explanation as to why this is not done is kept on file. The Registered Individual must keep records in the home of the monthly unannounced visits. The Registered Manager must ensure that notification of incidents are sent as required to the Commission. The Registered Manager must ensure that action is taken to address all issues raised in service user meetings and that this is fed back in the next meeting and recorded in the minutes. Previous requirement: Unmet timescale 30/11/06 The Registered Manager must ensure that all records required to be maintained in the home are so maintained. 31/08/07 31/07/07 31/07/07 31/08/07 31/07/07 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 YA10 Good Practice Recommendations The home should produce a statement on confidentiality for partner agencies, setting out the principles for governing the sharing of information. Previous recommendation. The Registered Manager should ensure that staff think about creative ways to introduce more fruit and vegetables into meals. The Registered Manager should consider ways in which inhouse training can be offered to staff around mental health DS0000025643.V343171.R01.S.doc Version 5.2 Page 25 2. 3. YA17 YA35 St Judes House 4. YA35 issues and should look into accessing more external training for staff in this area. Previous recommendation. The Registered Manager should ensure that she attends additional training on supervision and appraisal, recruitment and sickness management. Previous recommendation. St Judes House DS0000025643.V343171.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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