Inspection on 13/05/08 for St Peters (Flat 1)

This inspection was carried out on 13th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

St Peters (Flat 1) 30/04/07

St Peters (Flat 1) 25/07/06

St Peters (Flat 1) 24/01/06

St Peters (Flat 1) 12/07/05

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 28/09/2008.

CARE HOME ADULTS 18-65 St Peters (Flat 1) College Road Saltley Birmingham West Midlands B8 3TF Lead Inspector Donna Ahern Key Unannounced Inspection 13 and 22nd May 2008 16:15p th St Peters (Flat 1) DS0000017140.V366543.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 Peters (Flat 1) DS0000017140.V366543.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 Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peters (Flat 1) Address College Road Saltley Birmingham West Midlands B8 3TF 0121 328 4054 0121 328 2867 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) www.mencap.org.uk Royal Mencap Society Miss Yvonne Mae Thomas Care Home 3 Category(ies) of Learning disability (3) registration, with number of places St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 30th April 2007 Brief Description of the Service: Flat 1 St Peters is registered for three adults who have learning disabilities. Mencap are the Registered 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. Space is very limited throughout the home and doorways are difficult to access for people who use a wheelchair. The bathroom has a specialist bath but again space is very restrictive with no turning room for wheelchairs. The home does not have a private garden area; there are communal grounds that are shared with other properties. We (CSCI) have previously discussed with the providers the Homes lack of fitness for purpose. As a result of these discussions the home had given a commitment to identify alternative premises more suited to the needs of people living at St Peters. However at the time of the visit we had not been informed of any future plans. Each of the people living at the Home had a copy of the service users guide however this did not state the current scale of charges. A copy of the last inspection report is available in the home for visitors to read if they wish to. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The visit was carried out over two days; the home did not know we were going to visit. This was the homes key inspection for the inspection year 2008 to 2009. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. The people who live at the home, the manager and two staff on duty were spoken to. Due to peoples communication needs discussions with people about the home and the care they receive was limited. Information about this was gained from observing support from staff, observing support given to people at a meal time and gaining information from reading care records and talking to staff. A tour of the premises took place. Care, staff and health and safety records were looked at. All information looked at was used to determine whether peoples varied needs are being effectively met. Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Prior to the fieldwork the manager completed an AQAA (annual quality assurance assessment), which tells us about how well the Home thinks it is performing and achieving good outcomes for the people who live in the Home. It also provides some factual information about the Home. Information from the AQAA was used to help inform the inspection process. The AQAA was completed and returned to CSCI within the required timescale. Reports of any accidents, complaints or incidents reported to us involving people using the service were also looked at, as part of the planning of the inspection. What the service does well: People living in the Home are supported to maintain contact with their family and friends and staff recognise the importance of personal relationships. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 6 The people living in the home receive attention from health care professionals as needed to help with meeting their health care needs. The interactions between people living in the home and staff were positive. Staff knew about peoples care needs. The home is clean and bedrooms have been personalised so they are comfortable and individual for each of the people to relax in. What has improved since the last inspection? What they could do better: When new staff are recruited thorough checks must be done to make sure they are the right staff and people living in the home are not put at risk of having unsuitable staff working with them. Risk assessments must be in place for the use of bedrails so that these are only used in a way that promotes the safety and well-being of people. The service users guide needs further development so that people are fully aware of the services the home offers and how much it costs to live there. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 7 Risk assessment for the support people require at night should be developed further to include information about how, why and when support should be given so that people are safe and their privacy is respected. 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 Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 8 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 Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 9 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): 1 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have most of the information they need to make a choice of whether or not they want to live there. EVIDENCE: The statement of purpose included the relevant and required information so that prospective service users are able to make a choice of whether or not they want to live in the Home. The service user guide needed to be up-dated as it did not include information about the range of fees charged or any additional charges. The manager said that the guide was already in the process of being updated and details of fees will be included. People living in the home had a copy of the service user guide which had been produced using some photographs and pictures in an easy read format so that it was more meaningful to people living there. It was not possible to assess standard 2 relating to assessment of service users before they move into the Home as the last admission was several years ago. The provider has an assessment procedure that if followed should ensure that prospective peoples needs would be assessed prior to admission. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff have detailed information in care plans as to how support each person so that their individual needs are met. Risk assessments are written in a way to enable people to undertake activities safely and maintain their independence. EVIDENCE: The records of two of the people living there were looked at. These included peoples individual care plans. These tell staff how to support a person so their assessed needs are met. Progress had been made on these since the last inspection. The care plans were generally detailed documents that included information about healthcare, communication, personal care, and personal development. It was positive that pictures and photographs were included throughout the care plan so that they were meaningful and personal to the individual. People had signed their care plan, which was further evidence of St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 11 their involvement. There was some really good detail especially about meeting people’s personal care needs. Information was written in a way that reflected personalised care and included comments such as “ask what I want to do first” and “do things in my own time”. If followed this would ensure that people receive support in a way that they prefer. Care plans had been kept under review so that up to date information is provided to inform staff on how to meet people needs. Risk assessments were looked at. These detail the support people need to be kept safe whilst still being enabled to be independent. These included assessments about bathing, showering, fire safety and support during the night. Daily records seen lacked detail and do not always reflect response to care and how choices are made and if they are in the best interest of the individual. During the visit staff were observed giving people choices about what they wanted to drink, how they wanted to spend their time, what activities they wanted to do, where they wanted to sit. The previous inspection recommended that the way service user meetings were organised was improved so that they were meaningful for the people living there. Individual Key worker meetings now take place monthly and replace the meetings. Minutes seen of the outcome of the meetings indicated that information is generally repeated each month and again lacked detail about how decisions were arrived at. It is therefore recommended that daily records and key worker meeting minutes be improved so that there is evidence that people are consulted on and do participate in all aspects of life in the home and that records reflect the good practice seen during the visit. These records will also help inform and plan future care needs and is particularly important when people have limited verbal communication and cannot always inform staff of what has taken place and what they have been involved in. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. People are offered a healthy diet that meets their dietary needs. EVIDENCE: All service users attend a day centre and have one day a week at Home when they are supported on a 1:1 to do their personal banking and their own food shopping. People were observed in day-to-day tasks such as taking cups and plates to the kitchen, washing up and wiping the tables and generally helping out St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 13 around the home. Staff were observed prompting and encouraging people to do this. When people came in from the day centre they relaxed in the lounge. One person wanted to watch T.V and was engrossed in a quiz that was on, another listened to music on their headphones. The other person occupied themselves with a puzzles which they selected from their bedroom and staff sat with them to help work on the puzzle Staffing levels had been improved since the last inspection, which has provided more time for people to be supported to take part in community activities such as going out for meals, walks and doing personal shopping. The home has shared communal grounds, which include grassed area and sitting areas. Staff said that people do make use of the grounds and on one of the visits they had just returned from sitting outside. People seemed relaxed and freely accessed all areas of the home choosing to go to their own bedroom, the kitchen or sitting in the communal lounge. Care plans seen indicated that routines have some flexibility and were individual in how people wanted to be supported indicating that staff try to provide an individualised service. Although when only one staff member is on duty they will have to consider the overall needs and safety of people. Two of the people go to stay with their family each weekend and staff said they maintain close links and speak regularly to people’s family. One person stays from Friday to Sunday and the other spends all day Saturday with their relative returning on the evening, which leaves one person at the Home who receives one to one staff support. Advocates have worked alongside individual service users and a referral has been made to a befriender service so that people with limited family contact get independent support. A holiday abroad has been planned again for two of the people following the success of the previous holiday. Staff said people would be staying in a hotel with facilities that meet their assessed needs and is accessible throughout. Service users indicated during the visit that they are looking forward to going. The arrangements in place for meal planning had greatly improved so that people are far more involved with this process. Each person is supported to prepare a weekly shopping list and to do their own food shopping with one to one support from staff, which should ensure that skills are promoted and personal food preferences are catered for. On the day of the visit each person had a different meal paella, spaghetti bolognas and faggots. Fresh fruit was readily available in a fruit bowl in the lounge and some fresh vegetables were in store. The manager said that people are supported with choices that they make including monitoring the use of ready-made meals to ensure that they St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 14 eat a well balanced diet to maintain their health and well being. A menu board in the lounge had on display what each person had chosen for tea, using pictures and photographs. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home receive personal support in the way they prefer and require and their health needs are generally met. Improvement must be made to the management of changing needs so people are safe. EVIDENCE: Care plans seen had good detail about how personal care should be given so that people receive the support they require in a way that meets their needs and preference. People who live in the home were observed to be well groomed and dressed according to age, gender and culture. Health action plans were looked at, these are personal plans about what a person needs to stay healthy and what healthcare services they need to access. People are referred to health professionals where appropriate and records seen indicated input from physiotherapy, speech and language and occupational therapy services. People are also supported to have check ups St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 16 with the dentist and optician. Records of all appointments were kept including the outcome with any action that staff need to take to ensure the individuals health needs are met. People have been supported to attend Well Men clinic, which will help identify small concerns before they become big health problems. Where there has been a change in peoples care need then this was recorded on the care plan and health action plan so that staff have the information to support people safely. Where people have specific health needs such as Epilepsy some additional information was required to be added to the care plan so that it is clear what type of seizures people have. There was clear information about how people should be supported by staff if they had a seizure and what further action should be taken to ensure people are safe. One of the people had a new bed with bed rails in place. There were no bed rail assessments in place or a record of safety checks for the bedrail. These safety assessments must be in place so that the rails are only used in the best interest and safety of the person and any risk of entrapments or other injury is minimised. Some further information was needed to the nighttime risk assessments so that it is clear how and why night staff do checks so that people are supported safely; their privacy respected and support is given in accordance with peoples assessed needs. Weight monitoring of people living at the home is undertaken monthly to ensure they are a healthy weight. Storage of medication was satisfactory; the cabinet was clean and well organised and wall mounted. No controlled medication was being used. The medication administration chart (MAR) were looked at these were seen to have been satisfactorily completed but correction fluid had been used on one entry. The manager was aware that this should not of been used and was addressing the matter with the staff member concerned. We had not been informed of any medication errors occurring since the home’s last inspection. All staff are trained to administer medication. Information was recorded about how medication should be given to individuals. Medication reviews have taken place, which have resulted in the reduction of medication for some people and staff reported on the positive effect noted for individuals. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place for dealing with complaints if followed would ensure that people are listened to. Arrangements are in place to protect people from the risk of harm and the arrangements for managing peoples finances are robust. EVIDENCE: The complaints procedure was available and on display on the notice board and people who live in the home have a copy in their bedroom. The complaints log was looked at and no complaints had been received. We have received any complaints about this Home in the last twelve months. An easy read complaint format was available however people who live in the Home would require significant support from staff to raise a concern. Therefore staff training and awareness in this area is essential. Multi agency procedures advising staff what to do and who to contact were available on display on the notice board in the office and there was a local protocol for staff to follow in the event of an incident occurring, displayed on the office notice board. A minor amendment to update contact numbers was advised. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 18 A staff member on duty was briefly spoken with regarding their understanding of emergency procedures and Protection procedures and they demonstrated a general awareness. They were able to identify where they would be able to access further information and guidance should this be needed and said that on call support from a manager in the organisation is provided at all times. All staff had received fresher training on safeguarding in February 2008, which address issues around the protection of vulnerable people. The training matrix looked at confirmed when this training had taken place. The Home has a system in place for the logging and recording of regulation 37 incidents, which are reportable to us. This ensures the regulatory body is informed of significant events involving people living in the Home and action taken by the Home to ensure peoples welfare and safety is protected. The arrangements in place to support two of the people with managing their finances were sampled. There was a financial risk assessment in place, which should ensure that people receive the support they require and staff follow the organisations financial procedures. Individual financial record sheets with details of transactions are audited, receipts were available that cross-reference to purchased items. Details of personal money, savings, benefits and how these are received were recorded as well as arrangements for paying any fees. Systems were robust and should ensure people’s finances are safeguarded. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home is not suitable to meet the needs of the people living in the Home. Improvements have been made to the physical environment so that it is a nicer, more comfortable and homely place for people to live. EVIDENCE: Flat 1 St Peters is a ground floor flat. Previous reports have highlighted the physical limitations of the Home and how this negatively impacts on people living there. The provider had indicated some time ago that alternative living accommodation would be provided however to date we have not been informed of any development plans. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 20 The bathroom is domestic in layout with limited space for people to move about and is restrictive especially for the people with limited mobility. Some cosmetic improvements such as painting had been made to the bathroom to make it a more pleasant environment for people living there. The combined lounge dining room has limited space. People are continually moving around each other and the space restricts people who have limited mobility or use a wheelchair. There is some difficulty getting wheelchairs through doorways. The kitchen door opens out from the lounge area and noise and cooking smells cause a disruption to the lounge /dining area. If the kitchen door is closed then staff cannot safely supervise people or check on the meal they are preparing whilst also supporting people. The kitchen is an enclosed room with no window and limited ventilation making it an uncomfortable area when cooking is taking place. There is limited storage in the kitchen for food items. There is no separate laundry area. There have been lots of decorating and painting in the flat to make it clean and comfortable for people. Bedrooms have been painted and new furniture provided and these rooms have been personalised and made very homely for people. Lamps, cushions, picture and a variety of lighting has been incorporated to make peoples rooms comfortable and individual. There are no wash hand basins in people’s bedrooms. Staff said people were involved with choosing items. People indicated that they were pleased with their bedroom. Previous reports have raised concerns about infection control practice, which could place people at harm. During the visit there were no concerns regarding this. Staff worked well with the limited facilities available to them and demonstrated that they understood the need to practice good standards of infection control so that people are not put at risk. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home benefit from a well trained staff team that can support them to meet their individual needs and achieve their goals. The recruitment procedures have not been robust in some cases and so have not fully safeguarded people who live in the home. EVIDENCE: There was good interaction between people living in the home and care staff. Staff spoken to indicate they had a good understanding of peoples support needs. The Home is staffed by a small staff team who frequently lone work. Staffing hours have been increased since the last visit following reassessments by Social Services. This allows two staff on at specific times to support with community-based activities. One staff member had just recently left the service, which had some temporary impact on staffing levels with some shifts dropping again to one staff on duty. The manager said this post was in the St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 22 process of being recruited to. The AQAA states that agency or relief staff have not been used since October 2007. The Staff files of the two most recently appointed staff were looked at. A staff member had resigned from the position as a support worker to work for another organisation but remained as a casual staff member working some regular shifts. The person after three months reapplied for a permanent position and was transferred back onto a permanent contract. However security checks were not followed up including references from their previous employer or a CRB (Criminal Records Bureau check). The manager said that senior managers advised her that these checks did not need to be repeated as the person remained in their employment. References should have been sought from the person employer and a new CRB check should have been completed. The need to complete risk assessments on staff suitability to remain in employment when information shows up on CRB was also discussed. The recruitment procedures are not being consistently followed to ensure that people living in the home are safeguarded. Staff spoken with said they received the training they need. Training records and discussions with staff show that staff receive training in first aid, health and safety, food hygiene, fire safety, epilepsy, challenging behaviour, signing, autism, health and safety and the mental capacity act. The AQAA states that 90 of staff have completed a National Vocational Qualification (NVQ) level 2 in care. Staff spoken with said they are being supported to register for NVQ level 3. This should ensure that a knowledgeable and skilled staff team can meet people’s needs individually and collectively. Minutes of staff meetings indicate that regular monthly meetings take place and there was evidence of discussions about health and safety in the home, training updates and communicating effectively with service users. The frequency of staff supervision was looked at across three staff files. These are one to one sessions when staff can discuss work related issues and personal development issues with their manager. Supervision records seen indicated that sessions take place every one to two months and notes of the supervision sessions were on staff files. Which this indicates that staff are given the support to do their job and training and development needs are met. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements generally ensure that people benefit from a service that is run in their best interests. The health and safety of people who live at the home is generally promoted and protected. EVIDENCE: The manager was registered with CSCI in May 2006 and oversees Flat 1 and 24 St Peters. Both are separate registrations with CSCI. A deputy manager was appointed in February 2007 and is mainly based in Flat 24. Which means both Homes have direct management support. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 24 The general administration of the Home has improved. Health and safety records were easy to find and generally well maintained. Progress had been made on previous requirements. However, the recruitment procedures are not being consistently followed to ensure that people living in the home are safeguarded. This remains an outstanding requirement from the previous inspection and must be addressed. Risk management in relation to peoples changing need and personal care support must be improved so that people are safe. A service manager supports the registered manager. Regular 26 visits are carried out thus ensuring that the provider does take responsibility for monitoring the Home. Copies of these reports were in the Home at the time of the visit. The continuous improvement plan was looked at. This is an improvement plan for the service developed by the manager. Information is gathered from a variety of sources including CSCI inspection reports and information from people who use the service and is then put into action points. Safety checks were looked at including hot water checks, general risk assessments, gas safety and Fire records. These were all up to date which ensure regular testing and service of equipment take place as required, to protect the safety and well being of people living at the Home. Systems are in place to monitor incidents and accidents in the home so people’s well-being is promoted. Discussions with staff at the home indicate that the manager is approachable and listens to what people have to say. Staff said the manager spends time working with people “hands on” on shift so that she knows and understands what peoples care needs are and staff said this is positive. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 25 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 2 2 N/A 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 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 32 33 34 35 36 3 3 1 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 x 3 X X 3 X St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 26 Yes number 2 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 YA18 Regulation 13 (4) Requirement Timescale for action 30/06/08 2 YA34 19 The use of bed rails must be risk assessed and kept under regular review so that people are not put at risk. Recruitment procedures must be 30/06/08 thorough, robust and consistently followed so that people living in the Home are protected from harm. Previous requirement. Unmet timescale 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The statement of purpose and service user guide should state what the fees charged to live at the home are. This will give prospective service users all the information they need so they can make a choice as to whether or not they want to live there. St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 27 2 3 YA7 YA18 Daily records should be developed so that peoples needs can be properly monitored. Risk assessment for the support people require at night should be developed further to include information about how, why and when support should be given. This protects people living in the home. The provider should keep the commission informed about the development of the service so that there is a plan about how shortfalls in the environment will be addressed and how peoples future needs will be planned for. 4 YA24 St Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Peters (Flat 1) DS0000017140.V366543.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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