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Inspection on 30/04/07 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 30th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

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

St Peters is a comfortable domestic style home. There was a relaxed and welcoming atmosphere. It was pleasing that on arrival to the Home one of the people living in the Home answered the door to the inspector and checked the photograph identification and then said, "Come in". The men seemed relaxed during the fieldwork and interactions between service users and staff were observed to be friendly and relaxed.

What has improved since the last inspection?

The manager had made good progress on actioning outstanding requirements indicating compliance with requirements and ensuring the home improved for the benefit of the people living there. The general administration of the Home has improved. Health and safety records were easy to find and generally well maintained and ensure the safety of the people living in the Home. Vacant posts have been appointed to and a deputy had been appointed so that people benefit from a more consistent staff team. Staff are now receiving regular supervision and staff training has improved so staff have the skills and knowledge to support people.

What the care home could do better:

There is one thing that must be done. There must be an up to date support plan in place for each of the three people living in the Home so that staff know how peoples individual assessed needs will be met. There are lots of other things that the Home should really think about making better this would really improve things for people living in the Home. People who live in the Home should be involved in putting their support plan together. There should also be individual person centred plans that are in a format that the person can understand and follow. This could be in picture format or on an audiotape. Risk assessments should be reviewed to make sure that people get the support they need to manage things that might be difficult. When people living in the Home meet to talk about things in the Home there must be a way of checking out that things have been done and that people have been listened too. The manager needs to make sure that there is enough staff on duty supporting people so they can go out if they want to especially at weekends. MENCAP who are the Home owners need to talk to people about what they plan to do with the Home so that people know what is happening and where they maybe living in the future.

CARE HOME ADULTS 18-65 St Peters (Flat 24) College Road Saltley Birmingham West Midlands B8 3TF Lead Inspector Donna Ahern Unannounced Inspection 30th April & 11th May 2007 11:45 St Peters (Flat 24) DS0000017137.V335798.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 24) DS0000017137.V335798.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 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peters (Flat 24) Address College Road Saltley Birmingham West Midlands B8 3TF 0121 327 4613 F/P 0121 327 4613 yvonne.thomas@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Miss Yvonne Mae Thomas Care Home 3 Category(ies) of Learning disability (3) registration, with number of places St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years, with the exception of one named existing service user of the age of 65 years. 25th July 2006 Date of last inspection 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. A manager is registered with CSCI for all three Homes. 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 fieldwork visit limited progress had been made on the development plans for this service. The Fee level for the Home is £114.05 Per week. CSCI inspection reports were available in the Home for people to read. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one long day returning on a second evening to complete the fieldwork. The inspector met all three people living at the Home, spent time observing support and interactions from staff, had a tour of the premises including peoples bedrooms, looked at care records and health care records and medication management. Health and safety records and staffing records were also assessed. All information looked at was used to determine whether peoples varied needs are being effectively met. Due to peoples communication needs discussions were limited. However the inspector was able to use have some brief discussions and spent time sitting in the lounge observing interactions and support given to people through the afternoon and evening. What the service does well: What has improved since the last inspection? The manager had made good progress on actioning outstanding requirements indicating compliance with requirements and ensuring the home improved for the benefit of the people living there. The general administration of the Home has improved. Health and safety records were easy to find and generally well maintained and ensure the safety of the people living in the Home. Vacant posts have been appointed to and a deputy had been appointed so that people benefit from a more consistent staff team. Staff are now receiving regular supervision and staff training has improved so staff have the skills and knowledge to support people. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 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.V335798.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. These standards could not be fully assessed due to the Home having a stable group of service users and no new admissions will be made. Information is available to inform people who live in the home and their relatives about Flat 24. EVIDENCE: The statement of purpose and service user guide was looked at and describes the services and facilities provided. The service user guide was available in an easy read and picture format so it is more accessible to the people who live at St Peters. It would be good if these documents were further developed so that the information is more meaningful and interesting and includes the comments and experience of people who live at the Home. Some updating and review of the information is required so that staff and management information reflects the current arrangements. Flat 24 had been judged by CSCI at previous inspections as not fit for purpose. CSCI was informed that the organisation is in the process of seeking more suitable accommodation. An interim plan was to reduce registered numbers in flat 24 from three to two. No progress had been made on this since the previous inspection July 2006. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 9 The inspector spoke to the Manager and staff about the future plans for the Home. The manager said that reassessments had been completed by Social Care and Health in October 2006 however the outcome of these were disappointing with less care hours identified for people than the provider expected. The manager said she has been trying to follow this up with Social Care and Health since she received the outcome of the assessments but to date had not had a reply to a number of emails and phone calls. There have been no new admissions since the previous inspection. The three people who live at St Peters Flat 24 have lived there for many years. It was not possible to assess the pre admission assessment process. However, the admission procedure seen dated 2002 if this was followed would ensure that a full assessment would be completed prior to admission to the Home. There are no plans by the provider to make admissions to the service but plans to move people within the St Peters complex. St Peters (Flat 24) DS0000017137.V335798.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, 8 and Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A comprehensive support plan must be implemented for each person living in the Home for staff to follow detailing how their assessed needs will be met. EVIDENCE: Some further progress had been made since the previous inspection on developing peoples support plans. These tell staff how to support a person so their assessed needs can be met. The support plans had been developed using information that the Home has collated on the person over a number of years there was no evidence of a formal assessment tool. The support plans for all three people were still under development with some sections incomplete. They were being produced on the Homes computer system. This had enabled digital photographs to be added so that the support plan was more meaningful to the person. Each plan had information about how people should be supported with their healthcare, communication, personal care and social needs. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 11 Lifestyle plans were seen and were dated January 2006 and had been completed in conjunction with the day centre that people attend during the week. It identified goals for the person these are personal things that the person had said they want to achieve. It was unclear how people would be supported to achieve these goals and these had not been kept under review. Risk assessments were in place including bathing, showering, safety in the event of a fire and making a cup of tea. These had a corresponding action sheet and were due for to be reviewed so that any control factors in place were still relevant. The risk assessments in place for peoples needs during the night should be developed to include how people seek assistance from the person sleeping in and how they would be supported to follow the home evacuation procedure so that any health and safety concerns are identified and planned for. Daily records were looked at these were generally repetitive and do not always include response to care or how decisions are made. It is advised that these should be developed so that people’s care needs can be fully monitored through their care records. Service users meeting minutes were looked at and are held weekly. Minutes of the meeting held on 29/04/07 were read and indicate that items are discussed each week around what people want to eat and where they want to go. It is unclear how things raised by people living in the Home are followed up in practice. People were being asked what they want to do but it was unclear what had happened with the information and if things were followed through. It is recommended that the minutes are developed to include this information as evidence that people have been listened to. Communication system and how people living in the home are supported to make choices and decisions would benefit from some further development. Staff spoken with during the fieldwork said there are plans in place to develop a board for menu choices and planning which would enable pictures to be used to enhance peoples communication. The staff team are in the process of collocating a range of photographs taken with the digital camera to assist with communication within the Home and these were shown to the inspector during the fieldwork. A large board has been positioned in the kitchen in preparation for the photographs. St Peters (Flat 24) DS0000017137.V335798.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, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples varied and individual lifestyles are not being fully met. Communication systems must be developed so that people can make more meaningful choices about their lifestyle. EVIDENCE: All three people attend a day centre four days a week. Sampling of the records indicated that people go out to the shops, the barbers, go for occasional meals and trips out to places of interest are also arranged. Due to staffing levels these are planned in advance so that additional staff is on duty to support people the “shopping night” is a set night so that an extra member of staff is scheduled on duty to support. There is limited opportunity for spontaneous activities to take place unless this is within the local area, as the Home mainly has one staff member on duty and people require the support of staff if either staying in or to access facilities in the community, therefore if two people St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 13 wanted to go out and one didn’t then they would be unable to go out. Staffing levels must therefore be looked out to ensure there is adequate staff to enable people to take part in activities and opportunities to meet their individual and collective needs. This is of particular concern at weekends when people would most benefit from social and recreational opportunities. There is no garden directly linked to the Flat, however there is access to a large well-maintained grass area to the side of the Home. The men indicated they like to sit outside on the paved area in front of the Home and showed the inspector the garden chairs that they use to sit on. People are encouraged to take part in household tasks as observed during the fieldwork. One person was supported to make a hot drink for everyone and then cleared and laid the table for the evening meal. Staff said the men have only limited involvement in the preparation of food but are fully involved in the planning and purchasing of food items. The menu seen is varied and indicated that meals served are balanced and nutritional and cater for cultural and dietary needs of the people. It is advised that the menu is monitored to ensure that five fruit and vegetables are served daily in line with health eating advice, as this isn’t clear from reading the food records kept. As previously stated discussions with people was limited due to their communication needs. It was pleasing that on arrival to the Home one of the people living in the Home answered the door to the inspector and checked the photograph identification and then said, “Come in”. The men seemed relaxed during the fieldwork and freely accessed their own room and all communal areas of the Home. Two of the men showed the inspector their bedrooms and one person indicated that it was okay to look in their bedroom. The afternoon, evening was spent watching a DVD, that people living in a neighbouring Home had borrowed to them. The limitations of the current environment remain as reported in previous inspections reports; the environment does not provide opportunities for two people to have a single bedroom for privacy. There is evidence that this causes difficulties for both men due to their preference for different sleeping routines and the use of the bedroom for private space. It is pleasing to hear there are plans in place to enhance communication systems for the people who live in the Home so that they can be more involved in decision-making and in daily living opportunities. This will include staff training and developing people individual communication systems. People are supported to maintain contact with relatives and friends and staff spoken with demonstrated that they recognise the importance of personal relationships. It was positive to read on one of the peoples care plan that staff had liaised with their relatives so that a family tree could be developed providing important personal information. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. There are systems in place to ensure that people receive personal care and health care based on their individual needs. Medication is generally well managed ensuring people receive their medication as prescribed. EVIDENCE: People living in the Home are supported to access a range of health care professionals. Health action plans were seen and were being actively used for each person. Health Action Plans are a personal plan about what a person needs to stay healthy and what healthcare services they need to access. It was positive that people had been supported to attend well men check ups with their local doctor this should ensure the early detection of any health issues. Regular weighing of people was also taking place which again is a good was of detecting any potential health problems. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 15 Support plans had details of peoples health care needs however, as already highlighted these were in the process of being improved and updated so that a comprehensive plan is in place for staff to follow so they can support people in a way that meets their individual needs. Peoples personal appearance was good and indicated that they receive good support to attend to their personal care needs. There is a good ratio of male carers within the staff team, which is positive for the people who live in the Home who are all male so that on most shifts they receive support with personal care by a person of the same gender. There had been no changes to people’s manual handling needs. The bath has an overhead shower and al three men are able to access this without support. The medication is stored in the office in a metal cupboard that is usually secured to the wall but as it is only a stud wall the fittings had become unsecured and the cupboard was free standing. The manager said the cupboard would be secured. Policies for medication administration, selfadministration and the control and use of medicines were seen. There needs to be an audit of non blister pack medication so that full audits can take place to ensure that safe systems are established and any errors identified. Medication administration record sheets were looked at and the medication MAR sheet cross-referenced to what was on peoples care plan. There was a photograph of each person and details of their prescribed medication. Peoples support plans had detailed of the medication they take why they take it and any side effects that may occur. Staff who administer medication have received the Boots training so that they have an understanding of how to safely administer medication. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 16 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, adequate. This judgement has been made using available evidence including a visit to this service. The Complaints procedure if followed would ensure that people would be listened to. The systems in place to protect people from abuse should be further developed so that robust stems are in place to protect people from the risk of harm. 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. CSCI have received no 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. The organisations own policy on the protection of vulnerable people requires some minor amendments so that it makes it clear what the staff role is in reporting potential vulnerable adults issues. A copy of the whistle blowing policy was St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 17 forwarded to CSCI as requested and the manager said this has been made available to all staff that work in the Home. All but one staff member had received training in Respond and Respect which address issues around the protection of vulnerable people and in national training organised by Mencap. The training matrix looked at confirmed when this training had taken place. The training plan for the Home was seen and the staff member was booked on this for May 2007, the inspector was advised that they had missed previous training due to illness. The Home has a system in place for the logging and recording of regulation 37 incidents, which are reportable to CSCI. This ensures the regulatory body is informed of significant events involving people living in the Home and what action has been taken by the Home to ensure peoples welfare and safety is protected. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 18 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 at the Home. Further improvements are required to the physical environment so that it is a nicer, more comfortable and homely place for people to live. EVIDENCE: In previous inspection reports Flat 24 had been judged as not fit for purpose. The organisation had stated that they were in the process of seeking more suitable accommodation for the three people who live at St Peters 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 St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 19 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. As raised previously in this report two people share a bedroom and this does present some problems for the individuals and impacts on people’s privacy and dignity. A new leather sofa has been purchased for the lounge since the last inspection this is now a comfortable and homely room for the people to relax in. The manager said that there are plans to improve the general environment for the people living in the home and this will include painting and decorating in the hallway and to replace carpets in the communal areas of the Home. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 20 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 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels should be reviewed so that there is adequate staff on duty to meet peoples assessed needs. EVIDENCE: Previous reports have highlighted that the home has had an unsettled period with staff changes. This has been particularly problematic as the Home is staffed by a small staff team who frequently lone work. The staff rota was examined and this indicated that there was one staff on at core times of the day when people are at home. Two staff have recently been recruited and are currently on the rota to work alongside an established staff member in either Flat 24 or one of the other neighbouring registered homes (Flat 1). The manager said the recent appointments means there are no vacant posts. At weekends there is one staff member on duty across the working day and occasionally a second person is on duty to enable the men to go out on an activity. At night there continues to be one staff member on duty sleeping in. Although now fully staffed the rota only provides minimum staffing levels. It is St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 21 positive that there is some flexibility with the rota and the manager does schedule days when there is additional staff on so that people can go out. However the current staffing levels does limit people’s opportunity to go out especially if it is a spontaneous request. A revised staffing rota and staffing assignment details should be sent to CSCI to indicate how staff resources will be utilised to best meet peoples needs. The Staff files of the most recently appointed staff were looked at. Checks of the person’s suitability to work in the home had been made; including satisfactory Criminal Records Bureau checks, completed application form, references and proof of identification indicating that the recruitment procedures ensure the safety of the people who live in the Home. 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 the frequency had increased with sessions taking place every one to two months and notes of the supervision sessions were on staff files. The training matrix and records were looked at and had been improved since the last inspection. All mandatory training was detailed and completed dates of training and dates for updates were recorded and copies of certificates were on file. It was easy to track the details of the staff member who had missed adult protection training and could evidence that this had been scheduled for May 2007. Training is clearly required on Makaton so that staff have the skills to communicate effectively with people living in the Home. The manager had identified this need in the Pre Inspection questionnaire completed and returned to CSCI prior to the fieldwork and also stated that risk assessment training and updates of mandatory training will be provided as required. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 22 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, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Homes systems ensure that the safety and wellbeing of people living in the Home is promoted and protected. Opportunities for people to contribute their views in the running of the Home should be further developed. EVIDENCE: The manager was registered in May 2006 and oversees Flat 1,3 and 24. All are separate registrations with CSCI. A deputy manager was appointed in February 2007 and is mainly based in Flat 24. The general administration of the Home has improved. Health and safety records were easy to find and generally well maintained. Some risk St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 23 assessments were due to be reviewed so that the risks people face are well managed. Documentation relating to people who live in the home was under major review so that comprehensive support plans will be implemented for each person. A service manager supports the registered manager. Regular 26 visits are carried out and a summary of these reports is sent to CSCI office 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 fieldwork. 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. However, the future plans for this Home have not been progressed since the previous inspection and it is advised that the provider informs CSCI of what its intentions are. The Provider undertook a comprehensive service review on 15th and 16th of January 2007 and a detailed report has been produced detailing what the Home is doing well and what needs to be developed. This was on display in the office and made available to the inspector. A number of quality of life, choice and autonomy issues were identified as requiring development. Safety checks were looked at including hot water checks, general risk assessments, shower cleaning, monthly safety audits (April, March, Feb, and January 2007) and Fire records 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. A number of policies and procedures are available and were seen in the staff office. The review date of these was discussed with the manager as many are dated 2002. The provider is a large organisation and policies and procedures are reviewed at a senior level. There must be evidence that policies and procedures are kept under review and reflect changing legislation and good practice. The review of the adult protection policy has remained outstanding for over two years. The general feel of the Home is that things are more organised however, the manager and staff team must look at how the Home can be further developed for the benefit of the people who live in the home in terms of quality of life opportunities, how choices are made and the involvement of people who use the service in the day to day running of their Home such as improving communication opportunities for people. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 24 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 X 3 X St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 25 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. Standard YA6 Regulation 15 (1) (2) Requirement A comprehensive support plan must be in place for each person living in the Home detailing how his or her assessed needs will be met. Outstanding from previous inspection July 2006. Timescale for action 31/07/07 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 be updated so that information about the current service is clear to the people who live in the Home. It would be good if they were made even more accessible to the people who live in the Home and alternative formats considered. People who live in the Home should be supported to be involved in the development of their support plan. Person centred plans should be implemented in a format suitable for the individual so that it is meaningful and DS0000017137.V335798.R01.S.doc Version 5.2 Page 26 2 3 YA6 YA6 St Peters (Flat 24) 4 5 6 7 8 9 10 11 12 YA6 YA7 YA8 YA8 YA9 YA16 YA20 YA23 YA24 13 14 15 16 YA33 YA12 YA37 YA39 YA40 personal to them. Daily records should be developed so that peoples needs can be properly monitored. Communication systems within the Home must be developed so that people living in the Home receive the support and assistance they need. There should be evidence that peoples goals and aspirations have been followed through so that the Home can demonstrate that people have been listened to. Meetings with people who live in the home must be developed so that there is evidence that requests made have been listened to and acted upon. Risk assessments were due to be reviewed so that the risk people face are well managed. The shared room impacts on people’s routine, privacy and dignity and this arrangement should be reviewed as part of the development plans for the Home. A record on non blister pack medication should be kept so that there are good auditing systems in place to minimise errors. The policy on the protection of vulnerable people requires some minor amendments so that it makes it clear what the staff role is in reporting potential vulnerable adults issues. 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 future needs will be planned for. A review of staffing levels should take place to ensure resources will be utilised to best meet peoples needs. The manager must ensure that the home is further developed for the benefit of the people who live in the home. The quality assurance system must include the views and wishes of people living in the Home and how these will be acted upon. There must be evidence that policies and procedures are kept under review and reflect changing legislation and good practice. St Peters (Flat 24) DS0000017137.V335798.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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