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

Also see our care home review for St Peters (Flat 24) 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 13 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. There is a consistent team of staff who know residents 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 layout of the shared room had been reviewed to maximise the space and ensure the residents safety. The single bedroom had been painted. Health declarations were available on staff files. The files sampled met the required standard. The provider was undertaking regulation 26 visits as required and reports are being forwarded to CSCI.

What the care home could do better:

The home does not meet the needs of the three people who live at flat 24 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. Some further development of residents care plans and risk assessments was required.

CARE HOME ADULTS 18-65 St Peters (Flat 24) College Road Saltley Birmingham West Midlands B8 3TF Lead Inspector Donna Ahern Unannounced Inspection 24th January 2006 09:00 St Peters (Flat 24) DS0000017137.V279870.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 24) DS0000017137.V279870.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 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Peters (Flat 24) Address College Road Saltley Birmingham West Midlands B8 3TF 0121 327 4613 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 Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places St Peters (Flat 24) DS0000017137.V279870.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 11th July 2005 Brief Description of the Service: Flat 24 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 two bedrooms and a lounge. There is a kitchen/dining room and bathroom with 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 1 and 3. Each is registered as a separate home and there is two managers to oversee the 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. St Peters (Flat 24) DS0000017137.V279870.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 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 and two staff. This report must be read in conjunction with the report of the visit of 11th 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 layout of the shared room had been reviewed to maximise the space and ensure the residents safety. The single bedroom had been painted. Health declarations were available on staff files. The files sampled met the required standard. The provider was undertaking regulation 26 visits as required and reports are being forwarded to CSCI. St Peters (Flat 24) DS0000017137.V279870.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 24) DS0000017137.V279870.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 24) DS0000017137.V279870.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 24) DS0000017137.V279870.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, 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: The care plan structure was clear and had been produced in a format that was more resident focused. Some cross-referencing of the care plan to relevant risk assessments was required (resident (R) making a cup of tea). There was evidence of further work and development of the care plans. Some updating was required to reflect residents changing needs. 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. The risk assessments sampled required some further development so that the risks and the required action by staff to manage the risks are clear. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 16 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: All three residents attend a day centre four days a week. Conversations with residents and staff and sampling of the records indicated that residents go out to the shops, out for meals and to a local club. Occasional trips out to places of interest are also arranged. Residents are encouraged to take part in household tasks making drinks wiping the tables and washing up. At the time of the visit all three residents were going to do the weekly shop and were going out for a meal. The limitations on the residents remain as reported in previous inspections reports; the environment does not provide opportunities for two residents to have a single bedroom for privacy. There is evidence that this causes difficulties for both men. Interactions between residents and staff were friendly and relaxed. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 11 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, 20 Some additional information was required on residents care plans so that residents receive support from staff in the way they prefer and meets their assessed needs. EVIDENCE: Some clarification was required regarding resident’s personal care needs and what people’s preferences are. Clarification and a review of risks assessments were required as these indicated that the resident was not able to have a bath due to the risk of drowning. The manager confirmed that there was no medical reason for the person not to have a bath. Health Action plans are in place and there was evidence that residents receive input from a number of health professionals. The outcome of appointments was documented. The recording required some cross-referencing so that health information could be tracked. Sampled medication administration sheets had gaps on. Staff must sign to say that medication has been administered. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 12 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, 23 The Complaint Procedure was available in different formats. The Adult Protection Procedure required some further development so that residents are fully safeguarded. EVIDENCE: The complaint procedure was available in different formats. The provider had received one complaint, which had been investigated appropriately. The Adult protection Policy required some amendments as raised at previous inspections. 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. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 13 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, 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 some maintenance matters required attention. EVIDENCE: In previous inspection reports Flat 24 has been deemed as not fit for purpose. The organisation had stated that they were in the process of seeking more suitable accommodation for the three residents based on their assessed needs. In the interim the organisation had put forward proposals to reduce the registered numbers from three to two and plan to upgrade the physical environment. It was disappointing that no progress has been made on this matter over the last two years. The plans are linked to other developments within the St Peters project, which have been delayed and have had an impact on developments at Flat 24. CSCI must be formally notified of what the organisations intentions are for this service. The hot water tap in the bathroom had a very slow flow of water and the temperature was tepid. The kitchen required painting. These matters must be addressed. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 14 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, 33, 34, 35, 36 Some mandatory training required updating so that an effective staff team supports residents. EVIDENCE: The staff rota examined indicated that there was one staff on duty in the morning one or two staff in the afternoon and one person doing a sleep in shift. There was one vacant post for 30 care hours. Two staff files were examined and had a copy of the application form, two written references, evidence of CRB checks and identification; health declaration and the manager was in the process of ensuring all files had a photograph. Staff spoken with confirmed that they receive regular supervision and this was evidenced when assessing staff files. Staff training records indicated that some mandatory training required updating. The manager stated that this would be addressed through the organisations rolling training programme. Staff had also taken part in Autism training and Challenging Behaviour since the last inspection. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 15 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, 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 for flat 24 also manages flat 3 and works closely with the manager of flat 1. 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. 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. A number of required records were examined and indicated that on the whole Health and safety matters are well managed. The West Midland Fire Risk assessment required dating. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 16 Recording and reporting procedures for incidents reportable via a regulation 37 incidents were in place. A requirement from the previous inspection was that the manager had agreed to contact West Midland Fire regarding interim fire safety training. This had been actioned. A Fire drill had taken place, staff names must be recorded so that the manager can monitor which staff has participated. The flat has a panic alarm system installed which links into the other two registered flats at St Peters. This will provide back up and support for residents and staff. Regulation 26 visits by the provider have taken place as required and copies of reports have been sent to CSCI. St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 17 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 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X X X X 2 3 St Peters (Flat 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 4 5 6 Standard YA6 YA9 YA18 YA19 YA20 YA23 Regulation 15 (1)(2) 13 (4abc) 15 (2) 17(1a) Sch3(m) 17(1)a sch3(m) 13 (6) Requirement Residents care plans required further development. Risk assessments required further development. Resident’s personal care needs and preferences must be clearly documented. The recording required some cross-referencing so that health information could be tracked Medication Record sheets must be signed when medication is administered. The Adult Protection Policy and Procedure required some development. Previous requirement September 2004. The organisation must provide regular updates on progress of identifying suitable accommodation for residents. The kithchen required painting. The flow of water and the temperature from the wash hand basin in the bathroom required immediate attention. Some mandatory training updates were required. One staff member must DS0000017137.V279870.R01.S.doc Timescale for action 28/02/06 28/02/06 28/02/06 28/02/06 25/01/06 31/03/06 7 YA24 14 (1)(2) 23 (2) 23 (2)(d) 23 (2)(b) 31/03/06 8 9 YA24 YA24 28/02/06 25/01/06 10 11 YA35 YA35 18 (1)(c) 18 (1)(c) 31/03/06 31/03/06 Page 19 St Peters (Flat 24) Version 5.1 12 YA37 13 YA42 complete advanced first Aid training. 8(1)(a,b) The organisation must confirm 31/03/06 (i) what its intentions are for the registered manager position of the home. 23(4)(d,e) Records of fire drills must include 31/03/06 staff names. 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 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 20 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 24) DS0000017137.V279870.R01.S.doc Version 5.1 Page 21 - 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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