Inspection on 22/07/05 for St Mary`s Home

This inspection was carried out on 22nd July 2005.

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 1 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 11/01/06

St Mary`s Home 28/02/05

St Mary`s Home 17/08/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 St Marys Home Roehampton High Street London SW15 4HJ Lead Inspector Jon Fry Unannounced 22 July 2005 11:55 am nd 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 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 Stationary 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 Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Marys Home Address Roehampton High Street London SW15 4HJ Telephone number Fax number Email 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 The Frances Taylor Foundation Ms Lisa Dowling CRH Care Home 42 Category(ies) of DE (E) Dementia - Over 65 (13) registration, with number LD Learning Disability (42) of places St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/02/05. Brief Description of the Service: St Mary’s is a care home providing personal care and accommodation for 42 adults with a learning disability. It is owned by The Poor Servants of the Mother of God which is a voluntary organisation and is managed by The Frances Taylor Foundation. The home is located on the High Street in Roehampton, attached to St Mary’s Convent with residents being able to access its Chapel and grounds. The home is close to shops, pubs, the post office and other amenities. The home consists of a four-storey building. Accommodation is divided into seven ‘flats’. 24 of the home’s bedrooms are single, 1 of which is en-suite, and 9 bedrooms are shared. There is a passenger lift between all floors. There is a backyard and a larger garden to the side of the building. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulatory inspector on the 22nd July and 19th August 2005. The inspector spent approximately seven hours in total at the home. The inspection included the examination of records, a tour of the premises and individual conversation with ten residents, the registered manager, deputy manager and four members of staff. What the service does well: What has improved since the last inspection? What they could do better: St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 6 The bathroom provision on the ground floor should be fully reviewed and a larger area with suitable adaptations provided for residents. The current provision lacks space and hinders the personal care provision by staff. It is recommended that the monthly unannounced visits made by representatives of the organisation focuses on the views of residents and staff rather than assessing National Minimum Standards. The minutes of residents meetings should include actions required and by whom. Matters arising should be discussed within the staff meetings to ensure follow through for individuals. 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 Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 standard(s) 2. Satisfactory procedures are in place to ensure that the individual aspirations and needs of prospective residents are assessed prior to admission. EVIDENCE: The inspector identified that an appropriate assessment procedure is in place at the home to ensure that it can fully meet individual needs of residents once they are admitted. This was evidenced by care documentation as examined for three residents. Ten residents were spoken to individually at the time of inspection and all reported that they enjoyed living at the home. Comments included ‘its lovely living here’ and ‘its like a five star hotel’. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 standard(s) 6, 7 and 9. Care plans in place for residents are being improved and updated to ensure that all individual needs of residents are fully addressed on an on-going basis. Risk assessment documentation is in place as part of the process to allow residents to be as independent as possible. EVIDENCE: The inspector was informed that the care plans in place for all residents were being fully reviewed and updated. Care documentation was examined for three residents at the time of this inspection and good information was presented regarding areas such as daily routine, personal care and mobility. The registered manager stated that each care plan will include the current goals for each resident once they are completed. Accessible Person Centred Planning books are additionally being introduced for each resident to complete with their key worker. These books include information about the people and things that are important to each individual resident and should allow for increased individual involvement in the planning process. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 10 Assessments were observed to be in place for individual residents with regard to identified areas of potential risk such as pressure areas and the use of hoisting equipment. These were seen to be dated with a specified review date additionally indicated. Ten residents were spoken to individually and each person reported that they were satisfied with the overall service provided to them. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 16 and 17. Residents are provided with opportunities to participate in activities both internally at the home and externally in the local community on a regular basis. Residents are treated with respect. Individual dietary needs are well catered for. Residents were seen to enjoy the meals on offer at the time of this inspection. EVIDENCE: The home has its own Day Centre located on the ground floor of the building. This is supplemented by additional activities provided within the home by external tutors and therapists. A number of residents spoken to stated that they also went to local colleges to attend classes such as art and keep fit. Weekly schedules for individual residents were observed to be displayed within each flat and these included scheduled activities such as pub night, music, cooking and dance class. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 12 One resident reported that they had been out recently to attend a movie convention and another person stated that they were having a massage session later that day. A number of residents spoke about their recent holiday to Portugal and other individuals reported that they were due to go to Lanzarote in October 2005. The inspector observed meals being served in all the individual flats during the inspection process. Meals were seen to be unhurried with residents receiving appropriate individual support as required. Comments from residents included ‘the food is good’, ‘the food is lovely’, ‘I like the food’ and ‘I help choose the menu’. The displayed menus were observed to include dishes such as savoury mince, pork chops and fish and chips. Three residents spoken to stated that they regularly helped staff with the shopping. Other residents were seen to help with household chores at the time of inspection. Four members of staff spoken to individually reported that they felt the quality of care provided at the home was good. Observations included ‘brilliant care’, ‘staff respect residents’ and ‘good’. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 standard(s) 18, 19 , 20 and 21. Residents benefit from good access to health practitioners as required. Personal and health care needs are appropriately recorded and monitored to ensure positive outcomes for individuals. Full and accurate records are maintained to ensure the safe administration of medication to residents. The current arrangements for storage of medication on each unit should be reviewed to ensure best practice. The home aims to ensure that personal wishes for arrangements following death are obtained from each resident or their representative. EVIDENCE: All residents are registered with local GPs. The Community Team for Learning Disabilities and other health care professionals offer support and training to staff and work directly with some of the residents. Care documentation was examined for three residents at the time of this inspection and these were observed to include full records of health appointments attended by individuals. Health Action Plans were in place for each of the three residents at the time of inspection. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 14 The health and welfare of residents was seen to be protected by the appropriate management of medication in the home. A full record of all medication given to each resident is maintained. All care staff responsible for administering medication have received appropriate training. The inspector identified that changes were being made to the ordering and subsequent storage of stocks of medication for each flat. These changes will serve to further improve the medication systems in place at the home. The actual medication in use was still observed to be stored within large plastic storage boxes in a locked cupboard within each flat. It is recommended that dedicated storage facilities be provided for each flat in line with guidelines as issued by the Royal Pharmaceutical Society. The home has an appropriate system in place to sensitively and confidentially obtain the individual wishes of residents for arrangements following death. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 standard(s) 22. Appropriate policies and procedures are in place to deal with complaints. Information is made available to residents in an accessible format to ensure they know how to make a complaint. EVIDENCE: A complaints procedure is in place and this was observed to be on display at the time of inspection. An accessible version in a symbol format is made available to residents living at the home. No complaints have been received by the home or by the CSCI since the previous inspection. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 27, 28, 29 and 30. Residents are provided with a comfortable well maintained environment. The home is kept clean and hygienic. EVIDENCE: Available communal space within each flat includes a dedicated kitchen and lounge / dining room. Residents accommodated are provided with comfortable domestic style furnishings of good quality. The majority of rooms provided are single and the bedrooms seen at the time of inspection were observed to be well maintained and personalised to each individual. One resident showed the inspector their room that had computer, television and music equipment for their personal use. Comments from residents regarding the accommodation provided included ‘I like my room’, ‘I like sharing my room’, ‘it’s a nice room’ and ‘comfortable’. The registered manager reported that eight bedrooms were due to be redecorated within the next two months while individual residents were away on holiday. One issue was identified regarding the ground floor bathroom provision. The existing adapted bathroom was observed to provide a poor amount of space St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 17 for residents and staff to utilise and a recommendation has been included for the home to consider the adaptation of the treatment room into a larger bathroom space. The home was found to be clean, tidy and free from offensive odours. The levels of cleanliness throughout the home seen at this visit were good. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 35. Residents were seen to be supported by sufficient staff to meet their needs at the time of this inspection. A programme of training is in place that serves to ensure the health and welfare of residents accommodated. EVIDENCE: Staffing levels vary on each floor according to the individual needs of residents accommodated. These were seen to be satisfactory at the time of this inspection visit. ‘I like the staff’, ‘nice and kind’, ‘obliging’, ‘lovely’ and ‘very kind’ were all comments made by residents during the inspection. All four members of staff spoken to reported that they felt that the staffing levels were satisfactory but two individuals stated that weekend staffing could be improved to allow for more activity provision. An organisational training programme is in place and the staff members spoken to reported positively on the availability of training at the home. Course recently attended by care staff included manual handling, infection control, food hygiene and abuse awareness. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 19 The deputy manager reported that specialist training around epilepsy was due to be provided shortly by a nurse from the local community team. The competency of staff members is further ensured through access to NVQ training provided via a local college. Two of the four members of staff spoken to reported that they were studying for the NVQ Level Two award. Records provided to the inspector evidenced that the provision of NVQ training is well advanced at the home. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42. Good systems are in place to ensure the health and safety of residents. One shortfall was observed regarding the security of a boiler room on the first day of inspection. This does not fully promote the health, safety and welfare of residents. An organisational quality assurance system is in place at the home. This ensures that the views of residents, their representatives and other stakeholders are formally obtained. Systems in place to record and act on information obtained at monthly residents meetings could be further improved. EVIDENCE: To ensure the health and safety of residents, staff carry out regular checks on equipment, keep a record of any accidents and of the maintenance checks carried out within the home. The records of fire testing, fire drills, hot water temperatures, accidents and fridge and freezer temperatures were seen at the time of this inspection. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 21 The inspector identified that formal questionnaires were in place to obtain the views of those using / involved with the service. A number of completed questionnaires were examined at the time of inspection – comments from relatives of individual residents were observed to be very positive. The home should now ensure that this feedback is collated and used to inform the annual development plan / residents guide in place. Resident meetings take place on a monthly basis and this allows for discussion and forward planning regarding areas such as holidays and activities. It is recommended that the minutes of these meetings clearly specify actions required and are formally discussed within the staff meetings that also take place at the home. Monthly unannounced visits take place by a representative of the organisation. The written reports now include an assessment of a number of National Minimum Standards. The inspector is of the opinion that these assessment duties may detract from individual discussion with residents and staff on duty. The organisation must also ensure that the report includes all information as required by the Care Homes Regulations 2001. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Marys Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 23 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 YA42 Regulation 13 (4) Requirement The Registered Persons must ensure that the boiler room of the home is kept locked at all times. This room must not be used for the storage of equipment. 2. YA 39 26 (4) The Registered Persons must ensure that the reports of the monthly unannounced visits fully address all areas as specified within this Regulation. 01.10.05 Timescale for action 01.09.05 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 YA 20 Good Practice Recommendations It is recommended that dedicated medication storage facilities be provided on each floor. These should be of 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 further consideration be given to the provision of a larger suitably adapted bathroom for use by residents on the ground floor. G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 24 2. YA 27 St Marys Home 3. YA 39 4. YA 39 It is recommended that the minutes of resident meetings include actions required and by whom. Matters arising should be discussed within the staff meetings to ensure follow through. Responses obtained via the formal questionnaire process should be collated and then utilised to inform the annual development plan / residents guide for the service. St Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon 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 Marys Home G54-G04 S10230 St Marys Home V244741 220705 Stage 4.doc Version 1.40 Page 26 - 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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