Inspection on 02/11/06 for St Maur

This inspection was carried out on 2nd November 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Maur 29/10/08

St Maur 12/10/05

St Maur 10/01/05

St Maur 16/11/04

St Maur 07/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 St Maur St Maur 8 Knowles Hill Road Newton Abbot Devon TQ12 2PW Lead Inspector Judy Cooper Unannounced Inspection 2 November 2006 10:00 nd St Maur DS0000003813.V307046.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 Maur DS0000003813.V307046.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 Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Maur Address St Maur 8 Knowles Hill Road Newton Abbot Devon TQ12 2PW 01626 335560 01626 363313 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) Community Care Trust (South Devon) Limited Mrs Jacqueline Taryn Murch Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2005 Brief Description of the Service: St. Maur is a detached house in a quiet residential area. It is less than half a mile from Newton Abbot town centre, therefore near to shops and the other usual town facilities. The house is located up a steep drive in a secluded position, and there is a large garden and a small car parking area. There is a lounge, separate dining room (which also has a small office facility sited within it) and a communal lounge. There are six single bedrooms and one double. The home caters for younger adults with a mental health problem, its main aim being to provide a needs-led, person centred care package, based on thorough assessment and care planning which is undertaken with the client. The care and support subsequently provided is a client self management and recovery programme. The home can also provide a small day care service for up to two clients on a daily basis, although this service is not used on a regular basis, but rather as needed. The weekly cost is £357.00. The inspection report issued from this Commission is prominently displayed on a central notice board within the home’s dining room. St Maur DS0000003813.V307046.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 on a Thursday between 10.00 a.m. and 3.00 p.m. There were seven clients in the home and one day care client. The clients at the home have varied routines, undertaking their individual programmes. However most clients were available at different times to talk with, which ensured that this inspection involved them as far as they wished to be involved however, some clients were not comfortable speaking openly whilst others were quite happy to do so. During the visit the opportunity was also taken to tour the home, examine appropriate records and policies and talk with the manager and home’s deputy manager and several staff members. A visiting community psychiatric nurse and a visiting student occupational therapist were also spoken with during the inspection. Other information about the home, including the receipt of questionnaires from some of the clients and staff, has provided further feedback as to how the home performs and all of this collated information has been used in the writing of this report. All required core standards were inspected during the course of this inspection. What the service does well: The management of the home undertakes a rigorous admission procedure to ensure that St maur will be the correct placement for each client. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 6 Once in the home, the management and staff work very closely with each client to allow them to work through, and understand their mental health problems/illness and how best it may be controlled. The manager and staff then ensure all care/support is delivered in a way that is acceptable and agreeable to the client. The home’s ultimate goal is a return to independent living with clients achieving their full potential and it was very pleasing to note that this has been the case for some past clients who were at the home at the last inspection and are now living independently. The home continues to provide a relaxed yet structured environment where clients have the time, support and the space, required to address their mental health problems. Clients’ individuality and a respect for their rights to privacy and confidentiality is upheld at all times by all staff which resulted in several clients confirming that they felt they could both trust and work with the staff at the home. The manager and staff ensure that an “open door” policy is in place, which allows clients, staff and others the ability to speak openly, and easily. This in turn helps all concerned provide/receive the required support/care. Both staff and clients are treated equally i.e. using the same facilities, eating at the same time, having a say in the running of the home etc. This helps break down any barriers that may exist between staff and clients, with all working toward one goal, which is the eventual rehabilitation of each client at the home. St Maur continues to facilitate a very broad range of activities for clients, which they are both encouraged and supported in undertaking. The home continues to use all local facilities in preparation for when a client moves back into independent living. However any past client is welcomed and encouraged to visit the home informally for a chat or support and as such the management and staff provide an excellent support system for past clients. What has improved since the last inspection? St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 7 The home has adopted a “no-smoking” policy within the building. This has ensured that the home remains free from smoke and has allowed there to be a more pleasant atmosphere. Smokers are still able to smoke, but outside of the building. Computer usage within the home has been enhanced with the installation of Broadband. This benefits both staff and clients who are all able to use this facility. The home’s fire precautions have been enhanced with the provision of additional fire notices and a recognised stay open device provided for the kitchen door which helps both clients and staff have easy access to what is a very busy central part of the home. Additional kitchen items have been provided including a new cooker, a new freezer, new microwave and a new kettle. Again all these additions benefit both staff and clients who all use the kitchen facilities. What they could do better: Further general upgrading within the home needs to continue to be undertaken to ensure all areas are presented and maintained to good and acceptable standard for the clients stating at the home. Medication records should be completed as required and updated medication training should be made available to all staff involved in this area of care. This is to ensure clients remain protected in respect of the medication administered to them. The registered provider must ensure that staff records are held at the home and made available for inspection purposes. This is to allow confirmation that all staff members employed are suitable to work with vulnerable adults and therefore that the clients remain protected. The registered manager should, as part of her continuing professional development, consider undertaking the Registered Manager’s Award to ensure she meets the requirements of this Commission in respect of required qualifications expected to be held by the registered manager. A written record of the Organisation’s senior manager’s visit should be undertaken and a copy given to the home’s manager for reference purposes to ensure that any issues arising form the visit are formally documented. This is St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 8 to allow the manager to be fully aware of any areas that may need attention and so consequently ensure standards remain high in the home. The home’s fire risk assessment needs to be reviewed and updated to ensure that clients remain cared for in a safe environment. 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 Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 9 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 Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 10 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): Standard 2. Quality in this outcome area is good. The individual needs and aspirations of any prospective client are assessed and well known by both the manager and staff prior to any client’s admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: By looking at the records for two clients, who have been admitted to the home since the last inspection, it was noted that a full and detailed admission procedure was undertaken in both cases, which had ensured that St Maur was an appropriate placement for the clients. Clients are made aware of the “house rules” prior to admission. These include such statements as: All residents are expected to conduct themselves in a manner that does not disrupt or disturb fellow residents. All residents are required to participate in the day to day cleaning of the home. Both clients were able to personally state that they felt their placements had been a positive and that they felt they were in the best place, whilst suffering with their current problems. Both were fully aware of the routines and boundaries that the home operated within and what was expected of them during their stay. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 11 The manager is very clear as to what care/support can be made available and in what instances a client may not be suitable for the home. This ensures that the home only accepts those clients that it is felt will benefit from the care and support made available. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 12 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): Standards 6,7,and 9. Quality in this outcome area is excellent. The manager and staff are skilled in planning for all aspects of the overall needs and personal goals of the clients. They show both sensitivity and awareness of each client’s current and changing needs. The staff promote person centred planning to ensure that clients are fully involved in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A written plan, named a “Recovery Action Plan”, was available for each client. It had been drawn up with each client and their key worker. The plan covers all daily aspects of daily living and is easy to understand and contained very realistic goals for each individual client. The client owns the plan and has daily input into it in the form of writing his or her own daily notes and any subsequent changes to the plan. In fact the manager consulted both of the clients, whose care was being looked at in detail, to confirm they were happy for their details to be made available St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 13 for the purposes of inspection. Both were agreeable and so it was possible to inspect their plans of care in detail. Incorporated within the plan are risk assessments and it was noted that risk taking, in various forms, is considered a big part of an individual client’s recovery programme. During the inspection the daily group meeting took place where staff meet with the clients, to discuss the day’s planning which includes usual domestic planning such as cooking the evening meal or cleaning chores as well as any specific appointments etc a client may have. The meeting also allows for a client to discuss any individual anxiety/ problem they may be having, which is then helped by offering group support and counselling. A weekly one to one meeting is also made available to each client, when personal issues may be discussed in a confidential setting. Each client has a key worker, who is an experienced member of staff. Clients spoken to expressed great confidence in their individual key worker. Clients spoken with were articulate as to their illness/needs. The clients again confirmed that the management and staff are able to meet these as well as provide support in every day living tasks. An example of what a client said was: I was terrified when I came but within my first day I began to feel at ease, they are so understanding and encouraging. It’s taken me a while to trust people and I do now. I feel I can talk to all staff and that I can trust them to keep my confidence”. Another client stated: “I feel better with the support, not so shut off or isolated. There are always people around. I have a good relationship with my key worker and I feel the daily diary I write is good as it allows others to know how I am feeling”. All clients were able to confirm that their individual choices were upheld, and that the staff respected them and treated them with dignity. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14,15,16 and 17 were inspected. Quality in this outcome area is excellent. The clients have as active a lifestyle as possible within the constraints of their abilities. Clients’ lives continue to be enhanced by being supported to participate in many varied activities and by making good use of the local, nearby community facilities. All aspects of daily living within the home continue to be determined, as far as possible, by client choice whilst healthy and well planned meals are provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 15 Clients continue to have the opportunity of a full recreational programme. Excellent use is made of the local community with clients using all local amenities including educational and work placements. Clients are supported as necessary to participate in any activity that they feel may benefit them, for example one client is undertaking a voluntary placement in a working environment that the client finds interesting and wishes to be involved in. During the inspection another client was going on a shopping trip to Exeter with a staff member, whilst another was going to prepare the evening meal, having been and shopped for the fresh ingredients needed in the morning. A client whose care had been inspected in detail had enjoyed a walk, in the morning, to a local park as it was a lovely day. Her outreach worker (support worker from outside of the home) had accompanied her on this. Equality and diversity remain an every day part of the care provided at the home. All clients have quite diverse needs and each client is treated with equal respect with an acceptance and understanding their very specific needs. For example some clients may find it difficult to go out alone, others may struggle with eating disorders whilst others with other forms of mental illness such as depression etc however all are treated with equal respect and tolerance. A comment received from a client stated: I have made more progress here than anywhere else I’ve been over nineteen years and I get treated with more respect here than anywhere else I’ve stayed”. The management encourage the use of negotiation skills within the home and one area where this is very evident is with meal preparation. All clients have a weekly input into what meals they wish to have and each client will then cook the meal they choose (with support if necessary). The result of this is that meals are varied, as clients wish and clients take a sense of pride in producing a meal that will be enjoyed by all. A comment received from a client during the inspection stated: “The food is lovely, it’s really nice, we get to try different things. I think it’s very important for mental well being to try and eat healthily”. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 16 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): Standards 18,19 and 20. Quality in this outcome area is good. Staff provide sensitive and flexible personal support and care to maximise the clients’ rights to privacy, dignity, independence and choice over their own life. Staff have an excellent awareness regarding the clients’ health and emotional needs which has allowed them to understand the clients’ illnesses and start to build up their feelings of self worth and esteem. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care provided continues to be tailored to each individual client’s needs. Clients’ written records contained full details of all care provided. Clients are encouraged and supported to manage their own health care and take personal responsibility for their own welfare as far as they are able. The home uses a recognised medication administration system and all records inspected were mostly in order. The home is not holding any controlled drugs at present. The supplying pharmacist last visited the home in May 2005. Experienced permanent staff undertake any required administration of medication and there are appropriate medication policies and procedures in place, including a client self medication risk assessment policy. For some St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 17 clients this is a very viable option and the management of the home encourages it as a necessary life skill. Previous written communication from the manager of the home has clearly demonstrated that the management, along with the individual clients, regularly review the client’s ability to self medicate and take steps to minimise any risk associated with this if needed. This helps ensure that clients are both protected and aware of their responsibilities when self medicating. There is a need, for the staff involved in medication allocation, to receive some updated training in this area to ensure that they remain fully aware of any new practices etc. as the last training provided in this was some time ago. Also all medications offered to clients must be recorded even if a client refuses to take the medication. This is to ensure that there is a record of any medication administered or of any reasons why they have not been. During the inspection a visiting psychiatric nurse was very happy to give verbal feedback as to how he feels the home delivers its care. He felt that the home fully supported and encouraged the client he was involved with, and worked at the client’s pace. He had seen a very good improvement in the both clients’ mental health and in the client’s acceptance of their problems since the client had come to stay at St Maurs. Other professionals are also involved with other clients and a visiting occupational therapy student who is undertaking some outreach work with a client at the home stated: “This home is brilliant. They are really supportive, have good routines, the staff get to know the clients. There are meaningful activities. It is a nice environment which is really important for these clients”. Another recent comment received by the home stated: “I would like to thank to express my appreciation of the help and support you gave X during her three weeks respite. She left you feeling much more positive and determined to manage her depression and get on with her life”. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 18 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): Standards 22 and 23. Quality in this outcome area is good. There is a satisfactory complaints procedure and arrangements for protecting residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an appropriate complaints procedure, which is available within every client’s own personal file to which they have daily, if not more regular, access. The home also has policies and procedures for adult protection, in line with the local multi-agency code of practice. All staff receive regular training in adult protection, which is documented in training records. Any incidents of any untoward nature are fully documented and a copy forwarded to the Commission to keep the Commission informed. General day to day risk assessments are in place and no form of restraint is used within the home. The home does not manage clients’ monies, but will hold small amounts in the home’s safe if required and records are kept of this (currently only one client is taking advantage of this facility). There are details of any monies held. All these measures continue to protect clients at the home. No complaints have been received by the home itself or through the Commission, within the last twelve months. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 19 St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 20 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): Standards 24 and 30. Quality in this outcome area is adequate. St Maur is comfortable, clean, and mostly well maintained, however, the environment could further be improved upon by general upgrading. It was warm, clean and hygienic and was not institutional in appearance in any aspect. Clients’ bedrooms were personalised as clients wished. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour of the home confirmed that some upgrading continues to take place with the provision of some new kitchen equipment. However there were still some areas of the home that need to be further upgraded, to ensure that clients benefit from a pleasant environment. This includes the downstairs and entrance carpet as well as the back stairs carpet both of which were stained and should be replaced whilst some general re-painting/re-decorating within the home should also be undertaken. Additionally some replacement of the furniture and fittings within the clients’ rooms would be beneficial. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 21 Since the last inspection it was noted that there was some damage to the skirting in the downstairs bathroom whilst the toilet seat in the first floor bathroom is loose and the surrounding cupboards of the home’s kitchen sink are also damaged. It was noted that the home’s fire precautions were being maintained with the kitchen door now being help open by a recognised device, rather than a wedge, and some new fire warning signs have been provided throughout the home. The home’s fire extinguishers, on the first floor, have been re-sited to a more safe and convenient area. The management mostly maintains other fire precautions in line with the requirements of the local fire and rescue service. (The home’s fire log book was inspected). There is, however, a need to record when fire drills were carried out and who attended to ensure that all staff do undertake this training. The home remains clean and hygienic. There is a pay phone on the first floor of the home for client use. The hot temperatures within the home have been risk assessed and the hot water within the home is regulated to a safe temperature. Overall the home was clean, comfortable and provided a homely, warm environment, with little touches such as a fish tank in the lounge, notice boards with useful relevant information in the communal areas, a nice large modern television and comfortable chairs and settees. All bedroom doors have a lock to enhance a client’s right to privacy. The home’s laundry room is equipped with adequate washing facilities and clients have open access to this area, with it being the expectation that clients undertake their own washing as required. The home’s garden is very pleasant and clients take advantage of it to smoke in or just enjoy the fresh air. Although the home is now officially a no smoking area the manager is looking at ways of providing a covered external area away from the home for those clients that do smoke. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 22 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): Standards 32,34 and 35. Quality in this outcome area is good. Clients are well supported by an appropriately experienced and trained staff group. It was not possible to confirm that all staff working at the home had undergone a robust recruitment procedure, which ensures that the clients are fully protected, as not all staff records were available within the home. There are sufficient designated staff on duty to meet the clients’ agreed needs at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were again fully maintained in sufficient numbers to ensure that clients’ needs could be met at all times. Staff were noted as interacting very positively with the clients. Training continues to be well planned and supports the staff in providing support for the clients. Induction training is provided with new staff undertaking a long period of day duties, (working under supervision), even if appointed as night time carer to ensure they are familiar with clients’ needs and the running of the home, before going onto night duty which automatically carries more responsibility due to there being less staff around. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 23 The management of the home takes new staff members through an in-depth induction training programme which ensures that they are fully aware of the expectations of their role and prepared to be able to deliver the required care. This ensures that any new staff are able to both understand and work well with clients suffering with mental health problems. All staff attend regular training sessions on ”Support, time and recovery” which builds on the therapeutic work already undertaken within the home and ensures staff remain confident in delivering this very specific model of care. Other statutory training is also regularly provided. Excellent feedback was received from clients in respect of the staff with all clients feeling the staff were supportive, available and understanding. The management of the home provide regular staff supervision and appraisals This helps ensure all staff are comfortable within their role and that any appropriate support and training etc is identified and made available, as required, to allow staff to be able to offer the most suitable care to the clients. Since the last inspection the home has employed three new members of staff (two of whom were spoken with during the inspection). They were able to confirm that their recruitment process had been thorough and that they had been/were being supported in their role. One of the staff members stated how much she enjoyed her job saying: “I wished I’d done it years ago”. Some staff recruitment records were available for inspection but they were not fully complete. This is because the full records are held at the Organisation’s head office rather than within the home. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 24 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): Standards 37,39 and 42. Quality in this outcome area is good. The home is managed efficiently and well. Management and staff endeavour to ensure that the home is run in the best interests of the clients. The home provides a safe, secure environment where clients’ safety and well being is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to be managed in such a way that clients’ needs are known and met by a supported and well informed staff group. The management of the home helps create a welcoming, open and positive place to stay and work. Clients were seen to be relaxed with the management and staff. The manager has worked at St Maur’s since it opened in 1986. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 25 She holds a Registered Mental Nurse qualification, which is current and has a certificate in management skills. She is currently considering undertaking the Registered Manager’s Award, as part of her continuing professional development. This would then ensure she has the required qualifications required by this Commission in relation to registered managers. Clients’ health and safety continues to be maintained within the home. A quality assurance system is in place, and questionnaires are sent out to various stakeholders including residents’ relatives, advocates and other professionals. The management is currently waiting for the results from this year’s annual audit. A director from the Organisation visits the home every six months and records from these visits were seen. It was pleasing to note that very honest comments were contained within the report (both positive and negative). In the case of St Maur the negative comments were only in relation to the physical environment of the building, whilst the care provided was very much praised. A senior manager from the Organisation also visits monthly to ensure standards continue to be met; however a written record of her visit is not provided for the manager at the home. Staff and client meetings are also held regularly with minutes from these meetings made available A new initiative has been set up by the Organisition to look at the efficency of the service given and to ensure that the home is delivering what they hope to deliver. Clients have been invloved in this audit. With regard to health and safety the manager has carried out risk assessments in respect of all issues within the home. The home’s accident recording was in order as was routine health and safety documetation seen. However the home’s fire risk assessment needed to be updated for this year to fully ensure that clients remain cared for in a safe environment. All records seen were being maintained in relation to the requirements of the Data protection Act 1998 and were noted as being up to date, concise and professionally maintained. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 26 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 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 2 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 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 x 3 x 3 x x 3 x St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 27 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 YA34 Regulation 19 Requirement The registered provider must ensure that staff records are made available for inspection purposes. (Previous timescale of 17/01/06 not yet met) Timescale for action 02/12/06 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 Refer to Standard YA20 Good Practice Recommendations The registered manager should ensure that updated medication training is provided to all staff involved in this area of practice. Medication records should fully record whether a client has had their medication or not and the reason why the medication was not taken. The registered provider should continue to upgrade the home’s accommodation as required. The management should record when fire drills are carried out and who attended. The registered manager should, as part of her continuing DS0000003813.V307046.R01.S.doc Version 5.2 Page 28 2 3 4 St Maur YA24 YA24 YA37 professional development, consider undertaking the Registered Manager’s Award. 5 5 YA39 YA42 The senior manager, from the Organisation, undertaking the required monthly visit to the home, should provide a written record of her visit for the manager of the home. The registered manager should ensure that the home’s fire risk assessment is updated. St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI St Maur DS0000003813.V307046.R01.S.doc Version 5.2 Page 30 - 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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