Inspection on 11/10/06 for St Peters Hall

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Peters Hall 03/01/08

St Peters Hall 14/09/05

St Peters Hall 11/03/05

St Peters Hall 17/08/04

St Peters Hall 04/03/04

St Peters Hall 16/12/03

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 St Peters Hall 52 St Peters Road Handsworth Birmingham West Midlands B20 3RP Lead Inspector Brenda O’Neill Unannounced Inspection 11th October 2006 09:00 St Peters Hall DS0000016875.V315414.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 Hall DS0000016875.V315414.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 Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peters Hall Address 52 St Peters Road Handsworth Birmingham West Midlands B20 3RP 0121 523 4123 F/P 0121 523 4123 kamey@blueyonder.co.uk 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) Mr Raymond Jackson Ms Pearline Jackson Ms Pearline Jackson Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 14th September 2005 Brief Description of the Service: St Peter’s Hall is a large terraced property with an extension; it is situated in the Handsworth area of Birmingham. The home is conveniently positioned for local community facilities such as places of worship and local health services. The home is also close to public transport routes. It provides accommodation for 12 adults with mental disorder, excluding learning disabilities or dementia. The description of the property can best be given in two parts. First the main building has been converted into six ‘flatlets’, which can accommodate up to six residents. The flat-lets are self-contained and consist of a bedroom/lounge area and kitchenette. Two of the flat-lets have shower/WC en-suite facilities. Other occupants of the other flat-lets have communal bathrooms and toilet facilities. There is a communal lounge on the ground floor for service users’ to use. The main building is linked to an extension which is purpose built with six flat lets that also accommodate six service users. The flat-lets are similar to those in the main building with the exception that they have telephone points and they all have en-suite toilet and shower facilities. Windows in the extension are UPVC double-glazed. On the ground floor is a lounge and communal WC facility. A covered corridor that is wide and well lit links the main building and extension. There is space for someone to sit down to relax and the garden can be accessed via the corridor. The garden is large and spacious. The corridor leads on to an additional lounge. The manager’s office is situated between the main building and the extension. Residents who smoke use two of the lounges. Non-smokers can access the lounge off the corridor. The home has a laundry facility. All lounges have TV/video and stereo systems. There are flat-lets on the ground floor in the main building and extension. However, the home would not be suitable for those with mobility difficulties, as access to the other flats is via the stairs. There is no off road parking along St Peter’s Road. The fees at the home range from £343.40 to £540.33. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that was carried out over one day in October 2006 by one CSCI inspector. Jean Haldane (expert by experience) was there for part of the inspection. As a service user Jean had an expert opinion on what it was like to receive services for people who have a mental illness. Jeans comments are included throughout this report where she is referred to as ‘the expert’. During the course of the inspection a tour of the premises was carried out, three resident and two staff files were sampled as well as other care and health and safety documentation. The manager and deputy manager, who are also the homeowners, one staff member and eight of the eleven residents were spoken with. Prior to the inspection the manager had forwarded a completed pre inspection questionnaire to the CSCI which included information about the home. The inspector had also received completed comment cards from five relatives/visiting professionals and ten from residents. The vast majority of the comments received about the service were very positive. Some minor issues were raised about the availability of the complaints procedure to relatives however this was on display in the home and all residents received a copy of this. What the service does well: This is a well established service that consistently offers a good level of support to the residents living there. Numerous positive comments were received about the service by the inspector and the expert these included: ‘I have always found them (staff) to be very competent, polite and thorough in any task they perform’ ‘A very warm, welcoming environment which provides a safe place for service users in an atmosphere which respects the dignity of the individual.’ ‘….. treats everyone particularly well.’ ‘I have a lot to say in what I do.’ ‘I know I can get help if I need it.’ One of the residents commented to the expert ‘if I didn’t like it here I don’t think I would have stayed this long.’ There were comprehensive systems in place for assessing the needs of the residents, care planning and risk assessments. This ensured that staff knew St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 6 the support that was to be offered to the residents and how any risks were to be minimised. The residents were involved in decision making about the home and helped to exercise choice and control over their lives helping promote and maintain their independence. The expert commented in her report: ‘The management hold regular meetings with the residents which are used as a method of sharing information and involving clients in decision making. Everyone said if they disagree with decisions they feel able to raise any objections freely.’ And: ‘Clients said they are also able to exercise choice in all other aspects of living in the unit and in their life in general, including where to go on holiday, what to cook for their meals etc.’ Residents were given a good budget to purchase their own food and staff supported them where necessary with shopping and cooking. Residents had access to all the appropriate health care professionals ensuring their physical and emotional health care needs were met. Staff were very aware of the indicators of any deterioration in the residents’ mental health and of how to manage this. Residents felt they were listened to and could raise any issues. The expert commented ‘ all residents said they would have no difficulty with making a complaint or raising any issues with the management if necessary.’ There was a core group of well trained staff at the home that had worked there for a considerable amount of time which was good for the continuity of the support offered to the residents. When new staff were recruited the recruitment procedures at the home were robust and protected the residents. Health and safety in the home were well managed and the environment met with the needs of the residents giving them the benefits of both private and communal space. The expert said of the environment: ‘Everyone spoken to said they were happy with the environment, that they like their rooms and the general atmosphere of the unit. Several mentioned the extension of the premises and how much extra space and accommodation this has provided.’ What has improved since the last inspection? No particular improvements were asked for following the last inspection as all the required standards were met. Discussions with the management and residents demonstrated that there was a commitment to independence and rehabilitation. Evidence of this St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 7 commitment was apparent when one of the residents told the inspector they were to move to independent living in the near future. The management team were also able to demonstrate how they had improved the lives of several of the residents by helping and supporting them through relapses in their mental health. The manager was looking at ways of restructuring the induction procedure for new staff to ensure they complied with the specifications laid down by Skills for Care. Residents had been consulted about the smoking areas in the home and an agreement had been met to designate one lounge as no smoking. It was planned for the smoking lounge to have new flooring and the seating was to be reupholstered. 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 Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The assessment procedure at the home ensures that resident’s needs are known to the staff prior to admission. EVIDENCE: There had been no new admissions to the home since the last inspection. The files sampled evidenced that comprehensive assessments were carried out prior to the admission of a new resident to ensure the home could meet their needs. Community mental health teams were also very involved in the assessment of prospective residents ensuring the support that was needed and the risks involved were known to the staff at the home. St Peters Hall DS0000016875.V315414.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents assessed needs and goals were reflected in their care plans so that staff knew how to support them. Risk management was comprehensively detailed ensuring the residents were safeguarded. The systems in place encouraged residents to make decisions and promoted an independent and individual lifestyle. EVIDENCE: Three care plans were sampled and these were generally very comprehensive and the residents had been consulted on these. The care plans included the support needs for the residents in areas such as, personal appearance, diet, relationships, family contact, medication, general and mental health. Details of how staff were to support the residents were also included. It was noted that any cultural needs the residents may have were not reflected in the care plans. This was discussed with the managers and it was evident they were aware of the differing cultural needs in the home however these needed to be reflected in the care plans. All the care plans were being reviewed on a monthly basis and where any changes had occurred in the needs of the residents this was clearly detailed. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 11 It was evident throughout the course of the inspection that residents were able to make decisions about their lives and were consulted on the running of the home. The expert spoke to the residents about making choices and decisions about their lives and involvement in the home stated: ‘The management hold regular meetings with the residents which are used as a method of sharing information and involving clients in decision making. All the residents said this works well and they feel involved in what is happening in the unit.’ An example was given of where residents had been involved in making a decision about a no smoking area in the home. The expert also stated: ‘Clients said they were able to exercise choice in all aspects of living in the unit and their life in general, including where to go on holiday, what to cook for their meals etc.’ This was evidenced throughout the inspection with residents coming and going from the home as they pleased, within the bounds of their risk assessments, choosing what they were going to cook, how they were going to spend their day and so on. There were comprehensive risk assessments in place on all the files sampled. Risk assessments in relation to the residents’ mental health were very well detailed and included the indicators that staff should been aware of in case of relapse and how to respond to this. Emergency contact numbers were also included for the appropriate professionals if this was necessary. There were also physical health and general risk assessments and which included detail of such things as one residents reluctance to see a doctor and how this had been followed up on an ongoing basis, another detailed a residents difficulty with mobility. All the risk assessments were regularly reviewed and updated as the risks changed. St Peters Hall DS0000016875.V315414.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were supported to have an independent lifestyle which the home encourages and supports them to achieve without undue pressure. Their rights and responsibilities were recognised in their every day lives. EVIDENCE: The training and educational needs of residents are fully assessed as part of the core assessments. Residents are assisted within the home to develop and maintain life skills such as budgeting, shopping, domestic skills and cooking. The ethos of the home was very much one of rehabilitation for the residents with a view that wherever possible residents would move to more independent living. One of the residents spoke to the inspector about their intentions to move to a flat quite soon as they were now well enough to live more independently. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 13 Residents were assisted to have a structured day, this does not mean there were restrictions or limitations but that some residents needed a planner to encourage and focus them on have a fulfilling day. The residents at the home were offered a range of activities and were able to attend colleges and day centres if they wished. The home employed an activities coordinator and the residents were very positive about the range of activities offered to them. The expert stated; ‘The employment of an activities officer has made a difference to residents who now feel more motivated to join activities such as swimming, bowling, cycling, going to the cinema, playing bingo etc. At the same time, they said they felt no pressure to join in and that they enjoy a good measure of personal choice and freedom to come and go as they please.’ One of the residents spoke to both the inspector and the expert about taking driving lessons and that they hoped to pass their test soon. Another spoke of his ‘addiction’ to computer games and how the staff at the home were helping him to overcome this ‘for his own good’. Another spoke of being very keen on playing his guitar. Personal and family relationships were clearly detailed in the residents care plans. There was ample evidence that residents had contact with their families on a regular basis wherever possible and staff supported them with this where necessary. Residents spoke to the inspector about visiting their families and staying over night. Where residents were at risk when developing friendships this was clearly detailed in their risk assessments. The managers at the home demonstrated their awareness of how vulnerable some of the residents were and how they supported them with this. All the residents at the home cooked their own meals. They explained to the inspector how they were given money on a fortnightly basis and went shopping with staff to buy food. The dietary needs of the residents and the risks involved in them self catering were detailed in their care plans, for example, the need to ensure they ate healthily, the need to ensure food was defrosted and cooked appropriately. The support needed by the residents varied considerably, for example, some needed support budgeting their money, some had support to plan their weekly menus and some had support in the preparation and cooking of their meals. Evidence of the residents needs being met were seen throughout the inspection with staff asking what they were going to eat, had they taken food out to defrost and how long food had been cooking for. St Peters Hall DS0000016875.V315414.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 at least once during a 12 month period. 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 the service. The personal and healthcare support offered and provided to residents met their diverse needs. The medication system was well managed and safeguarded the residents. EVIDENCE: The assistance with personal care needed by the residents was minimal it was mainly prompting by staff to ensure their personal hygiene was to an acceptable standard. Any encouragement and prompting needed was clearly detailed in the care plans. The residents’ files sampled included detailed recordings of any health care appointments or contact with health care professionals. There was ample evidence of input from the appropriate professionals in relation to the residents’ mental health, for example, visits from community psychiatric nurses, medication reviews and visits to G.Ps. There was also evidence that where a resident refused to see a G.P. and this was ongoing it had been followed up with the appropriate mental health team as the staff at the home had no way of knowing the physical condition of the individual. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 15 The medication system in the home was well managed. Staff were not allowed to administer any medication until they had received the appropriate training. At the time of the inspection the deputy manager was going into the home early to administer medication, as one of the night staff had not been trained. Some of the residents administered their own medication and risk assessments had been undertaken for these individuals and agreed with the appropriate health care professionals. The amounts of medication issued to residents to self administer were recorded and compliance checks were carried out twice a week. There were clear risk assessments in place where there was a risk if the resident was given their own medication. Where the staff administered medication copies of prescriptions were kept, medication was acknowledged when it came into the home and appropriately signed for when administered. St Peters Hall DS0000016875.V315414.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s views were listened to and acted on appropriately. The systems in place in the home ensured the residents were protected. EVIDENCE: There was an appropriate complaints procedure on display in the home. No complaints had been raised with the home and none had been lodged with CSCI. The residents were comfortable in the presence of the managers and told the expert they would have no difficulty with making a complaint or raising any issues with the management if necessary. An example of this was given when a resident felt that a staff member had spoken inappropriately to her, she felt able to complain to the manager and this was dealt with promptly and appropriately. The home had appropriate policies and procedures in place for adult protection and staff had received training in the topic. Residents were provided with support to help manage their money where necessary. The records of transactions sampled were appropriate and the balances were correct. Residents were signing their records when they received any money. The managers were very aware of how vulnerable some of the residents were and how easily they could be exploited. An example of the possibility of this was related to the inspector and the steps the managers had taken to avoid it, which were entirely appropriate and ensured the resident was protected. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 17 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, 25, 26, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provided residents with a safe, well maintained and comfortable home that enabled them to have private accommodation and well as communal areas and enjoy the benefits of both. EVIDENCE: The home was found to be safe, comfortable and well maintained. One of the lounge carpets did have cigarette burns in it but the managers had already spoken to the residents about this and were to have the furniture recovered and laminate flooring put down, as this was to be the only internal smoking area. The other lounge in the home was going to be re designated as a no smoking area. There was also a covered external area where residents could sit and smoke and several were seen using this area throughout the day. All the residents had single bedrooms that varied in size, a kitchenette and eight of the rooms had an en-suite toilet and shower. The residents who did not have en-suite facilities had access to a communal bathroom, shower and toilets. The residents were happy to show the inspector their rooms and it was very evident this was their space and they had individualised them to their choosing. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 18 The laundry area was sited well away from any food storage and preparation areas. Residents did their own laundry on allocated days with support from staff as necessary. Sluicing of laundry is not a facility currently needed at the home. Residents spoken with were satisfied that the environment met their needs and this was reiterated to the expert: ‘Everyone spoken to said they were happy with the environment, that they like their rooms and the general atmosphere of the unit.’ St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 19 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 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Appropriate staffing levels were being maintained by a stable staff team. Staff had received the appropriate training to meet the needs of the residents but training records needed to be updated to reflect this. Recruitment procedures were generally robust and safeguarded the residents. EVIDENCE: Staffing levels at the home were appropriate for the needs of the residents. The management team were on duty throughout the day and this consisted of three staff. Two staff came on duty during the evening and there was one waking staff member on duty every night. The home also employed an activities coordinator but he was on holiday at the time of the inspection and a cleaner. Staff turnover at the home was relatively low. Residents were very positive in their comments about staff and the expert stated ‘ residents value the caring and supportive nature of the management and staff.’ It was evident throughout the course of the inspection that there were good relationships between the residents and the staff team. The recruitment records for two staff were sampled and the vast majority of the required documentation was in place including completed application forms, two written references and a current CRB check. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 20 It was noted that there was no documentation for one of the staff that evidenced they were eligible to work in this country. The home had quite a comprehensive induction procedure for new staff which the manager facilitated with them. The manager was in the process of cross referencing the training to the new induction standards from Skills for Care and had purchased some sample training booklets to assess which would be the best for the home to use. The pre inspection questionnaire detailed that ninety percent of staff were qualified to NVQ level 2 which is well in excess of the required fifty percent. Staff had received training in a variety of topics including, health and safety, adult protection, food hygiene, fire safety and manual handling. It was not possible to ascertain if all the training was up to date as the training records had not been updated. The manager stated staff had received all the required training and she would up date the records. It was also recommended that a training matrix for the staff team was developed so that it was easy to identify who had had what training and when. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 21 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): 37,38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager ensured the smooth running of the home in a competent manner. The home was run in the best interests of the residents. The health and safety of the staff and residents were well managed. EVIDENCE: The manager of the home had many years experience of supporting people with a mental health need. She was appropriately qualified. All the management team demonstrated a very good knowledge of the residents in their care and their needs. The home supported people with quite complex and fluctuating needs very efficiently and effectively. It was evident throughout the inspection that residents were satisfied with the service they were receiving and very appreciative of the support they received from the whole staff team. Relationships within the home were good. The expert commented ‘everyone appears to value the relaxed atmosphere and would recommend the unit if they were in a position to do so.’ St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 22 There was a quality monitoring system in place at the home with audits being undertaken on such things as the documentation in the home, care and maintenance and the deputy manager did analyse the results of the audits. There were also resident satisfaction questionnaires and resident meetings. Based on the findings of the audits, the questionnaires and the outcomes of residents’ meetings the home needed to have a yearly development plan that detailed how the service was to be further developed. Health and safety were well maintained. Staff had received training in safe working practices. The details on the pre inspection questionnaire evidenced that all the required servicing had been undertaken on the equipment in the home. The details for the last fire drill were given as 6th March 2006 and as this needed to be undertaken every six months was out of date. The home was contacted about this and it was addressed immediately and evidence was forwarded to the CSCI that the fire drill had been undertaken. There were numerous risk assessments in place for both the residents and the premises. The recording and reporting of incidents in the home were appropriate. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 23 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 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 3 X St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 24 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 YA34 Regulation 15(1) Requirement Timescale for action 01/12/06 01/12/06 3 4 YA35 YA39 Care plans must reflect any cultural needs the residents have. 19(1) The registered manager must ensure they have evidence that staff are eligible to work in this country prior to their commencing their employment. Evidence was forwarded to CSCI. 18(1)(c)(i) The registered manager must ensure staff training records are up to date. 24(2) The home must have in place a yearly development plan that details how the service is to be further developed. A development plan for 2006/2007 was forwarded to CSCI. 01/12/06 01/01/07 St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 25 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 YA35 Good Practice Recommendations It is recommended that the home have a staff training matrix to enable easy tracking of the training undertaken and the training required by staff. St Peters Hall DS0000016875.V315414.R01.S.doc Version 5.2 Page 26 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. 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