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Inspection on 24/01/06 for St Peters (Flat 1)

Also see our care home review for St Peters (Flat 1) for more information

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Resident`s personal care needs are well met. The Flat is comfortable, homely and domestic in style and layout.

What has improved since the last inspection?

The manager has continued to develop care plans and risk assessments and has worked hard on making this information resident focused and clear and straightforward for support staff to follow. Staff training had been provided on autism and Challenging behaviour so that the staff team have a greater understanding of the needs of residents. Interim training on fire safety had also been provided. The residents enjoyed a holiday to Spain.

What the care home could do better:

Some further development of residents care plans and risk assessments were required. Risk assessments must be undertaken on resident`s wheelchairs and the use of lap belts/ posture belts. The mealtime seating arrangements must be reviewed so that resident`s safety and wellbeing is protected and guidelines are fully implemented. Staff must follow the medication procedure they must sign the MAR (Medication Administration Record) sheets when medication has been administered. The home does not meet the needs of the three people who live at flat 1 and as reported in previous inspection reports there are plans in place for the residents to move on to a home that is appropriate for their needs. The organisation had made no progress on its development plans for this home.

CARE HOME ADULTS 18-65 St Peters (Flat 1) College Road Saltley Birmingham West Midlands B8 3TF Lead Inspector Donna Ahern Unannounced Inspection 24th January 2006 15.15p St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 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 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 12th July 2005 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. 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) DS0000017140.V279867.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one afternoon and evening. Time was spent talking with residents and observing interactions between residents and staff. A partial inspection of the physical standards of the Flat 1 was undertaken. Residents care plans and risk assessments were inspected. Some Health and Safety records were inspected. The inspector had the opportunity to talk to one support worker. This report must be read in conjunction with the report of the visit of 12th July 2005. What the service does well: What has improved since the last inspection? The manager has continued to develop care plans and risk assessments and has worked hard on making this information resident focused and clear and straightforward for support staff to follow. Staff training had been provided on autism and Challenging behaviour so that the staff team have a greater understanding of the needs of residents. Interim training on fire safety had also been provided. The residents enjoyed a holiday to Spain. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 6 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) DS0000017140.V279867.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed at this inspection. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 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. 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. The care plan must be further developed so that it includes details of resident’s goals, aspirations and activities. Staff must sign to say they have read and will follow residents care plans and risk assessments and will bring to the attention of the manager any concerns they may have. Guidelines developed by speech and language therapy had been reviewed as required at the previous inspection. The risk assessments in place regarding mealtime support must cross reference to the guidelines. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 10 At the previous inspection there was evidence of ongoing work to risk assessments as they were reviewed to ensure that they are specific to the individual resident. When risk assessments are reviewed the review must include evidence that the control factors are fully reviewed. Risk assessments were not available on one of the sampled care plan. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 Residents are respected. They receive a healthy diet. The support residents receive at mealtimes must be reviewed so that resident’s safety and wellbeing is protected. EVIDENCE: Residents were observed having their evening meal of pizza salad and beans. Interactions between the staff member and residents were very positive. Residents received good support. One of the residents requires support to eat their meal and was sitting on a comfy chair for their evening meal. These arrangements must be reviewed to ensure the seating arrangements are adequate and don’t compromise the eating guidelines that are in place. Residents were seen relaxing after their meal. One resident helped with some household tasks another residents watched some television programmes in the lounge and the other resident relaxed in their own room listening to some music with headphones on. The staff member ensured that each resident received appropriate level of support and supervision and also allowed each resident the freedom to choose where they wanted to go and how they wanted to spend their evening. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 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 the following standard(s): 18,19 and 20 The medication procedures must be reviewed. The current arrangements do not protect residents. EVIDENCE: Residents are supported to access a range of health care professionals. The home had commenced Health Action Plans and was in the process of completing the required documentation. The chiropodist had visited at the time of the inspection. Risk assessments must be implemented for resident’s wheelchairs and the use of lap belts. The homes arrangements for storing and administering medication were examined. Sampled medication administration sheets had several gaps on different dates (15/01/06 and 18/01/06). In addition the morning medication for all residents had not been signed for (24/01/06). Staff must sign the medication record sheet when the medication has been administered to each resident. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 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 the following 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: The complaint procedure was available in different formats. The home had received no complaints. The home had an abuse policy, which required some amendments as raised at the 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 home 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) DS0000017140.V279867.R01.S.doc Version 5.1 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 the following standard(s): 24 and 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 safe and comfortable for residents. 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. No progress on development plans has been made since the previous inspection July2005. The organisation must inform CSCI of it plans for this service. A number of tiles required replacing in the bathroom. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 33, Residents receive good support from staff. Vacant post must be appointed to so that there is a effective team with sufficient numbers to meet residents needs at all times. EVIDENCE: There was good interaction between residents and the support worker. The Staff member 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. 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 the home use no agency staff and staff sickness levels had greatly reduced. It was not possible to assess staff files and training as this information is kept secured and the manager was not on duty to give access. The previous requirement to review its recruitment practice and ensure CRB dates and numbers are recordeded on staff files, was carried over to the next inspection. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 and 43 Health and Safety matters in the home were generally well managed. Some matters required attention so that the home can ensure that residents are not put at risk. EVIDENCE: The manager of flat 1 St Peters works closely with the manager of flat 3 and 24 St Peters. CSCI must be informed of what the organisations intentions are for the future management of the homes as neither of the managers are registered with CSCI. A number of required records were examined and indicated that on the whole Health and Safety matters are well managed. Workplace Fire Risk assessment required review. The weekly check of the fire alarm system was slightly overdue. (Last recoded 11/01/06) At the previous St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 17 inspection the manager agreed to contact West Midland Fire regarding interim fire safety training for staff this had been actioned. 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 whom lone work. Regulation 26 visits by the provider had taken place as required and copies of reports have been sent to CSCI. St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X X X X 2 3 St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 19 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 2 3 Standard YA6 YA9 YA17 Regulation 15 (1) (2) Requirement Timescale for action 28/02/06 28/02/06 10/02/06 4 5 6 YA18 YA20 YA23 7 8 YA24 YA24 9 10 YA33 YA34 Residents care plans required further development. 13 (4) abc Risk assessments required further development. 12 (1)a,b The mealtime arrangements for one resident required review. They must not conflict with the guidelines in place by Speech and Language Therapist. 13 (4) Resident’s wheelchairs and lap belts/posture belts must be risk assessed. 17 (1) a Staff must sign the Medication Sch3 (i) Administration Record when medication is administered. 13 (6) The Adult Protection Policy and Procedure required some development (Previous requirement september 2004). 23 (2) d Broken tiles in the bathroom must be replaced. 23(1)a,b The organisation must provide 14(1) regular updates on progress of identifying suitable accommodation for residents 18 (1) a Vacant post for support workers must be appointed to. 7,9,19 The organisation must review its Sch2 recruitment practice and inform CSCI of the outcome. CRB dates DS0000017140.V279867.R01.S.doc 10/02/06 25/01/06 31/03/06 28/02/06 31/03/06 30/04/06 31/03/06 St Peters (Flat 1) Version 5.1 Page 20 11 YA35 18 (1) c 12 YA37 8 (1) (a) (b) (i) 13 (4) 23 (4) 23 (4) c (v) 13 14 YA42 YA42 and numbers must be recordeded on staff files. Not assessed requiremnnt carried over. Staff training must be arranged on Fire Safety and Health and Safety. Not assessed requirement carried over. The organisation must confirm what its intentions are for the registered manager position of the home. Workplace Fire Risk assessment required review. The weekly check of the Fire alarm system was required. 30/04/06 31/03/06 28/02/06 27/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Peters (Flat 1) DS0000017140.V279867.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Birmingham 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) DS0000017140.V279867.R01.S.doc Version 5.1 Page 22 - 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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