Inspection on 11/01/06 for St Mary`s Home

This inspection was carried out on 11th January 2006.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Mary`s Home 31/08/06

St Mary`s Home 22/07/05

St Mary`s Home 28/02/05

St Mary`s Home 17/08/04

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 Mary`s Home Roehampton High Street London SW15 4HJ Lead Inspector Jon Fry Unannounced Inspection 11th January 2006 10:30 St Mary`s Home DS0000010230.V277999.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 Mary`s Home DS0000010230.V277999.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 Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mary`s Home Address Roehampton High Street London SW15 4HJ 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 8788 6186 020 8788 1054 fintan.oreilly@smg-ftf.org The Frances Taylor Foundation Ms Lisa Dowling Care Home 42 Category(ies) of Dementia - over 65 years of age (13), Learning registration, with number disability (42) of places St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd July 2005. Brief Description of the Service: St Marys is a care home for 42 adults with a learning disability. The home is located on the High Street in Roehampton, close to shops, pubs, the post office and other amenities. It is owned by The Poor Servants of the Mother of God, a voluntary organisation and is managed by The Frances Taylor Foundation. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 11th January 2006. The inspection took place over six hours. The inspector spoke with nine residents, the manager and five members of staff. A number of records were examined, as well as a tour of the communal areas of the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 6 contacting your local CSCI office. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 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 Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 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): 3 and 4. Prospective residents are able to visit and ‘test drive’ the home before admission. EVIDENCE: A satisfactory assessment and admission procedure clearly outlines the process for all prospective residents. The procedure includes opportunities for the new resident to make introductory visits to the home. There is a trial period of ninety days followed by a review meeting. A prospective resident was being shown round the home on the day of inspection. Feedback from residents about the care provided at the home was very positive. Comments included “I like living here”, “everything is fine” and “we get looked after well”. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 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 and 9. Care plans for residents have improved. Further development work is taking place to make sure that the care plans are person centred and address individual goals. Staff carry out individual risk assessments to promote the safety and independence of residents. EVIDENCE: The care plans for three residents were looked at during this inspection. The documents were well-organised and provided good clear information about the individual care and support required. The plan contains the resident’s usual daily routine and covers areas of need such as mobility, eating and drinking and relationships. Personal Planning books were about to be completed with each resident at the time of this inspection. These are accessible person centred documents that also contain the future goals for individual residents. It is recommended that the home look at the role of key workers and how they could be more involved in the care planning process. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 10 Full records of the six monthly reviews held for residents were seen at the time of inspection. Risk assessments address potential areas of risk such as moving and handling and the safe use of hot water. The assessments were satisfactorily reviewed as required. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 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): 12, 15 and 17. Residents are supported to take part in activities and to be part of the local community as required. Residents receive appropriate support to maintain contact with their family and friends. Staff support residents in making menu choices and encourage individuals to have a healthy and varied diet. EVIDENCE: Residents take part in a range of different activities with many individuals going to college for courses such as music, computing and cooking. The home has its own Day Service and visiting tutors and therapists provides additional in-house activities. Weekly activity planners are displayed in each flat for residents. These are completed each week and include numerous college sessions as well as tasks such as cooking and shopping. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 12 Care plans include details of residents contact with friends and family. One resident said that they had been to see their family over Christmas and another person reported that they had their own mobile phone to ring their family when they wanted. All the residents spoken to were positive regarding the food provided and comments included “it’s fine”, “I like the food” and “lovely”. Communal menus are on display in each flat and one resident was writing out their own individual menu on the day of inspection. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 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): 20. Overall good medication systems are in place for the protection of residents. Minor shortfalls were however observed at the time of this inspection. EVIDENCE: An organisational procedure for medication is available for reference by staff. Medication administration records are generally well maintained at the home. Two instances were seen where medication had not been administered as prescribed to individuals. Four instances were also found where the record has not been signed to show that a medication had been administered to individuals. The medication in use is stored within large plastic storage boxes in a locked cupboard within each flat. It is recommended that storage facilities used only for medication be provided in each flat in line with guidelines from the Royal Pharmaceutical Society. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 14 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 and 23. An appropriate complaints procedure is in place at the home. Satisfactory procedures are additionally in place for the protection of vulnerable adults. EVIDENCE: A satisfactory complaints procedure is in place. No complaints have been received by the home or by the CSCI since the previous inspection in July 2005. Two residents spoken to said that they would talk a senior or the manager if they had any problems or concerns. No complaints were raised by individual residents on the day of inspection. Clear procedures regarding abuse are available to make sure that staff have an understanding of their role and responsibility in reporting any concerns to the appropriate persons. Training is provided to new staff as part of their induction and further courses are available to individuals within the organisational training programme. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 15 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, 25, 27 and 30. The standard of accommodation is good providing residents with a comfortable and homely place to live. The home is kept clean and hygienic. EVIDENCE: The home is a large four-storey building with the accommodation divided into seven ‘flats’. There is a passenger lift between all floors. Residents are provided with comfortable and homely accommodation that is maintained to a high standard. Available communal space in each flat includes a lounge, kitchen and dining area. No maintenance issues were seen during this inspection and all areas of the home were kept clean and tidy. There are twenty-nine single bedrooms and five double bedrooms. Bedrooms seen at the time of inspection were personalised to the residents’ own preferences. Residents spoken to all said that they were satisfied with their bedroom accommodation. The acting manager reported that the ground floor treatment room is to be changed to a large adapted bathroom in 2006. This will benefit both residents and staff as the current bathroom in use offers limited space. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 16 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 34. An effective staff team meets the individual needs of residents. The homes’ recruitment checks assist in protecting residents. EVIDENCE: Staffing levels are different on each floor according to the individual needs of residents accommodated. These were satisfactory at the time of this inspection visit. Feedback was positive regarding the staff working at the home. Comments included “the staff are lovely”, “the staff are alright” and “I get on with everybody (staff)”. The home carries out appropriate checks including Criminal Records Bureau (CRB) checks on staff before they start work in the home. This process helps to ensure the protection of residents. Recruitment records examined for two members of care staff were well maintained and included application forms and identity documents. One newer member of staff spoke very positively about the induction training they had received. A well organised induction pack is given to new staff members that is mapped to current national standards. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 17 It is recommended that the home start to review this document to reflect the newer ‘common induction standards’ that must be used from September 2006. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 18 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, 39 and 42. Residents’ benefit from a well run home. The views of residents, their representatives and other stakeholders are obtained as part of the quality assurance system in place at the home. The Health and Safety of residents is protected by regular checks being carried out within the home. EVIDENCE: The registered manager has taken up a more senior role with the organisation and is no longer based at the home. The deputy manager has been at the home since 1995 and is now the acting manager of the service. A Requirement has been made for the acting manager to now register with the CSCI. A new Health and Safety guidance manual has been introduced by the organisation. Staff carry out regular checks on the building, furnishings and St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 19 equipment to ensure the Health and Safety of residents and visitors to the home. As recommended at the last inspection, the minutes of residents meetings now record any actions required and are discussed within the staff meetings that take place at the home. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 X 3 X X 3 X St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 21 No 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 YA20 Regulation 13 (2) Requirement The Registered Persons must ensure that medication records are fully and accurately maintained at all times. Items of medication must be administered as prescribed at all times. 2. YA37 8 (1) The Registered Persons must ensure that an application is submitted to the CSCI for registration of a manager for the home. 01/03/06 Timescale for action 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA20 Good Practice Recommendations It is recommended that the home look at the role of key workers and how they could be more involved in the care planning system. It is recommended that dedicated medication storage facilities be provided on each floor. These should be of DS0000010230.V277999.R01.S.doc Version 5.1 Page 22 St Mary`s Home 3. YA32 sufficient size to hold all medication for service users and the security of medication should not be compromised by the facility being used for non-clinical purposes. It is recommended that the home start to review the induction materials for care staff to reflect the new national ‘common induction standards’. St Mary`s Home DS0000010230.V277999.R01.S.doc Version 5.1 Page 23 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 Mary`s Home DS0000010230.V277999.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. 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