Inspection on 12/07/05 for St Peters (Flat 1)

This inspection was carried out on 12th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Peters (Flat 1) 13/05/08

St Peters (Flat 1) 30/04/07

St Peters (Flat 1) 25/07/06

St Peters (Flat 1) 24/01/06

St Peters (Flat 1) 12/01/05

St Peters (Flat 1) 03/09/04

St Peters (Flat 1) 26/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 St Peters, Flat 1 188 College Road Saltley Birmingham B8 3TF Lead Inspector Donna Ahern Announced 12 July 2005 th 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 Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Peters, Flat 1 Address 188 College Road Saltley Birmingham B8 3TF 0121 328 4054 0121 328 2867 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) Mencap Vacant Care Home 3 Category(ies) of Care Home registration, with number of places St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years.. Date of last inspection 12/01/05 Brief Description of the Service: Flat 1 St Peters is registerd for three adults who have learning disabilities. Mencap are the Registerd Providers. The home is situated within a listed building that was once a religious seminary college to train priests. There is level access into the property. The home has three bedrooms and a lounge that is also used as a dining room. There is a kithchen, bathroom with W.C and an additional W.C. The home does not have a private garden area, there are communal grounds that are shared with other properties. There are two other flats that are registered homes within St Peters college flat 3 and 24. Each is registered as a separate home and there is two managers to oversee all three homes only one of the managers is registered (August 2005). CSCI have discussed with the providers the homes lack of fitness for purpose. As a result of these discussions the home have given a commitment to identify alternative premises more suited to the needs of residents. The organisation had made limited progress on its development plans for this service. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one afternoon/evening. Time was spent talking with residents and observing interactions between residents and staff. A full inspection of the physical standards of the flat was undertaken. Residents care plans and risk assessments were inspected. Staff records were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the manager, two staff and one visiting professional. What the service does well: What has improved since the last inspection? Previous inspection reports June 2004, had raised concern about the management, staffing and up keep of required records. At this and the previous inspection January 2005, there was evidence that the manager had made really good progress on developing the service and actioning previous raised requirements. The manager had continued to develop care plans and risk assessments. The home had worked hard on making this information resident focused and clear and straightforward for staff to follow. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 6 The use of agency staff had reduced. The physical standards had been improved. The lounge and a bedroom had been painted, there was a new carpet in the hall and a new bath had been installed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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 Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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) 1, 2 and 3 Information was available about the home and had been produced in a suitable format for residents. The home was not fit for purpose; any proposed moves or changes for residents must be based on reassessments and evidence of a full consultation process with residents and their representatives. EVIDENCE: The home had a Statement Of Purpose and a Service User Guide, which had been updated to reflect staff and management changes. Both documents had been produced in a format suitable for residents. Flat 1 had been deemed by CSCI at previous inspections as not fit for purpose. The organisation was in the process of seeking more suitable accommodation for residents. The organisation must inform CSCI of it plans for this service. Any proposed moves or changes must be based on reassessments of resident’s needs and evidence of consultations with the residents and their representatives. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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 and 9 Further development of residents care plans was required so that an up to date plan of care is in place so that resident’s needs, aspirations and goals are clearly documented and monitored. Some further development of risk assessments was required so that the home can evidence that the risk residents face are well managed. EVIDENCE: There was evidence of ongoing work to residents care plans. One care plan was near completion and the other two care plans were still being updated into a more resident focussed format. The care plan structure was clear and had been produced in a format that was more resident focused. The care plan cross-referenced to risk assessments. Guidelines that have been developed by speech and language therapy required review. There was evidence of ongoing work to risk assessments to ensure that they are specific to the individual resident and state clearly what the risk are and the support required to reduce /manage the risks. Risk assessments required for residents support during the night from waking night staff were required. These must then inform the nighttime guidelines/care plan. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 10 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) 12,13,14 and15 Residents are given opportunities to take part in a range of relevant opportunities in the home and community, which were suitable to their needs. Residents are enabled to maintain contact with their family. EVIDENCE: Residents were involved in household tasks making drinks, wiping and setting the tables and washing up. All three residents attend a day centre four days a week. One of the residents had been supported to join a gym. The staff were also looking at opportunities that the residents could access at a local college. Previous inspection reports raised concern regarding staffing levels and how they impacted on the resident’s opportunity to go out especially for spontaneous request. Some improvements had been made to staffing levels although there remained some vacant posts. The manager had planned the rota so that the residents get one to one staff support the day they don’t attend the day centre and on three evenings a week there was an additional staff member on duty. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 11 The residents had been to Butlins in March 2005 when work to the bathroom had taken place. The main holiday had been booked for October 2005 when the three residents will go to Benidorm for a week. The men looked through the brochures and indicated where they wanted to go. The manager stated that the accommodation was wheelchair accessible and that they were in the process of compiling a holiday risk assessment. Residents were well supported to maintain links with their family. One of the residents goes home to their family every week from Friday night to Sunday and another resident had regular family contact. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 12 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 and 20 Resident’s health care needs are satisfactorily monitored. The ongoing development of Health Action Plans for all residents will ensure that their health care needs are fully monitored and kept under review. EVIDENCE: Residents are supported to access a range of health care professionals. The home had just commenced Health Action Plans and was in the process of completing the required documentation. Progress will be monitored at future inspection. A visiting professional made positive comment about the support residents received from staff. A comment card received from a health professional raised no concerns. The arrangements for storing and administering medication were examined and found to be satisfactory. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 13 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 and 23 The Complaints Procedure was available in different formats for residents. The Adult Protection Procedure required some further development so that residents are fully safeguarded. EVIDENCE: There was a complaint procedure in place. This was available in different formats. The provider had received no complaints. The Adult Protection policy required amendments, as raised at previous inspection. The policy must make it clear what the staff role is in the reporting of abuse (section C of the homes policy). The manager had the No Secrets document and the Multi Agency Guidelines in place. It was advised that contact numbers and details of Social Care and Health and the local police are available on display for staff reference in the event of an incident arising. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 14 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, 26 , 27and 30 The home is not fit for purpose alternative provision must be provide so that residents live in a home that meets their assessed needs. The home was clean and maintenance matters were well managed. EVIDENCE: Flat 1 had been deemed by CSCI at previous inspections as not fit for purpose. The organisation was in the process of seeking more suitable accommodation for residents. In the interim the organisation had plans to upgrade the current provision, which would include utilising an unoccupied adjacent flat known as flat 2. An application was received in April 2004 to register the flat. A number of requests were made to the responsible individual for information to enable CSCI to process the application. Eleven months later, CSCI took the decision to return the incomplete application to the registered individual. The organisation must inform CSCI of it plans for this service. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 15 There was evidence of much improvement to the environment. The lounge had been painted and the furniture rearranged to make it more comfortable and accessible for residents. The hallway had a new carpet. One of the residents mobilizes by moving along the carpet the manager stated that a carpetcleaning contract was in place. Residents rooms are small and do not have wash hand basins. One bedroom had been painted recently. Some repair work and painting of the ceiling was scheduled to be actioned by the housing association. A new bedside locker had been provided in the one residents room. A new mattress was required for one resident. A new specialist bath had been installed in the bathroom and the housing association had agreed to replace the flooring. It was really positive that progress had been made on providing specialist fire alert equipment in the one residents bedroom this included a flashing light and a vibrating pad. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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 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, 34, 35 and 36 The home must have an effective staff team in sufficient numbers to meet resident’s needs. The organisation must improve the recruitment practices so that they can evidence that resident’s are fully safeguarded. EVIDENCE: There was good interaction between residents and the support worker. Staff communicated well with residents and demonstrated that they knew their needs. Some improvements had been made to staffing levels however the home was still short staffed. There was fifty care hours vacant and one staff member was on long term sick. Staff recruitment was taking place with interviews scheduled for the end of July. The staff rota was examined and this indicated that there was one or two staff on at core times of the day when the residents are at home. At weekends there is one staff member on duty across the working day as one of the residents goes home to their family. At night there continues to be one waking night staff member on duty. It was positive to hear that no agency staff were being used and staff sickness levels had greatly reduced. One of the comment cards received from a professional stated “staff at this home do attempt to follow recommendations or work regarding residents St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 17 however the lack of staffing resources is often a reason they give when things haven’t been carried through”. Staff files were examined they had a copy of the application form, two written references, evidence of CRB checks and identification. Some matters regarding appointment practices prior to the current manager being in post were identified and required further exploration with the organisations Human resource department. CSCI must be informed of the outcome. Staff spoken with confirmed that they receive regular supervision and this was evidenced when inspecting staff files. Staff training on Fire safety matters and Health and Safety was scheduled to take place over the forthcoming months. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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 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) 37, 42 and 43 Health and Safety matters in the home were generally well managed. Some matters required attention so that the manager can ensure that residents are not put at risk. The organisation was failing in its duty to carry out monthly owners visits, which monitor that the home is being effectively managed. EVIDENCE: The manager of flat 1 St Peters works closely with the manager of flat 3 and 24, St Peters. CSCI had received an application to register the manager of flat 3 and 24 as the registered manager for all three flats and an interview has been arranged for August 2005. The manager of flat 1 will remain the homes day-to-day manager reporting to the registered manager. Throughout the inspection process the manager presented as open and positive and welcomed the inspection process. Almost all of the previous raised requirements had been actioned. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 19 A number of required records were examined and indicated that on the whole Health and Safety matters are well managed. Recording and reporting procedures for incidents reportable via a regulation 37 incidents were in place. Accident reporting and recording procedures were examined and found to be satisfactory. The manager agreed to contact West Midland Fire regarding interim fire safety training for staff. Residents risk assessments required some further development. The flat had a panic alarm system installed which links into the other two registered flats at St Peters. This will provide back up and support for staff when working alone. Reports of owner’s visits were examined and records indicated that visits were not undertaken monthly as required. St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 2 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 2 2 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 1 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Peters, Flat 1 Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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 1and 24 Regulation 14 (1) 2 23 (2) Requirement Timescale for action 30/09/05 2. 3. 4. 5. 6 9 9 23 6. 7. 8. 26 33 34 9. 10. 35 42 11. 43 The organisation must provide regular updates on progress of identifying suitable accommodation for residents. 15 (1) (2) Residents care plans required further development. 13 (4) abc Risk assessments required further development. 12 (1) ab The mealtime guidelines for one resident required review. 13 6 The Adult Protection Policy and Procedure required some development (Previous requirement september 2004). 16c A new mattress was required for one residents bedroom. 18 (1) a Vacant post for support workers must be appointed to. 7,9,19 The organisation must review its Schedule recruitment practice and inform 2 CSCI of the outcome. CRB dates and numbers must be recordeded on staff files. 18 (1) c Staff training must be arranged on Fire Safety and Health and Safety. 23 (4) (d) The manager agreed to seek advice from West Midland Fire regarding training provided in between annual fire training. 26 The Registered Provider must E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc 12/10/05 12/09/05 31/07/05 30/09/05 31/07/05 30/09/05 31/08/05 31/10/05 12/08/05 31/07/05 Page 22 St Peters, Flat 1 Version 1.30 visit the home on a monthly basis, unannounced, and produce a report of the visit . 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 Good Practice Recommendations St Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham B2 4UZ 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 Peters, Flat 1 E54_S17140_StPetersFlat1_V230438_110705 Stage 4.doc Version 1.30 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. 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