Inspection on 03/01/08 for St Peters Hall

This inspection was carried out on 3rd January 2008.

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

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

Other inspections for this house

St Peters Hall 11/10/06

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 Key Unannounced Inspection 3rd January 2008 09:30 St Peters Hall DS0000016875.V357153.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.V357153.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.V357153.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 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places St Peters Hall DS0000016875.V357153.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 11th October 2006 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 11 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 people. 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. Occupants of the other flat-lets have communal bathrooms and toilet facilities. There is a communal lounge on the ground floor for the people who live in the home to use. The main building is linked to an extension which is purpose built with five flat lets that also accommodate up to five people. 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. The people who live in the home who smoke use the lounge in the extension. 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 range of fees at the home range was not included in the service user guide at the time of this inspection. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is 2 star. This means the people who use this service experience good quality outcomes. One inspector carried out this key inspection over one day in January 2008. During the course of the inspection a tour of the home was undertaken and the care for two of the people living in the home was tracked. The inspector also sampled documentation in relation to care, staff training and maintenance in the home. The inspector spoke with the owners of the home, one of whom is also the registered manager, and five of the people living in the home. Prior to the inspection the owners had returned to the commission a completed annual quality assurance assessment (AQAA) which gave some additional information about the home. Questionnaires were sent out to six of the people living in the home, two health care professionals and three relatives. With the exception of two of the relatives all were returned. One of the relatives who did not return the their questionnaire spoke to the inspector on the telephone. All the comments received were very positive about the service offered at the home. The home had not had any complaints or adult protection issues raised with them since the last key inspection and none had been lodged with the commission. What the service does well: The home has consistently demonstrated that it offers a good service. Comments received from the people living in the home, health care professionals and relatives agreed that the home offered a good service. These included: ‘They are very good people.’ ‘A good holistic service is offered to residents.’ ‘St. Peters is a very well managed and caring environment for any client to be in they maintain a professional service at all times.’ ‘Out of all the nursing homes I have been in I find St. Peters to be best in the Birmingham and Coventry areas.’ ‘The residents seem happy and content so they must be doing something right.’ The management held regular meetings with the people living in the home which were used as a method of sharing information and involving them in decision making. Clearly the people living in the home were encouraged to make decisions on a daily basis. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 6 The people living in the home had access to all the appropriate health care professionals ensuring their physical and emotional health care needs were met. The people living in the home were assisted within the home to develop and maintain life skills such as budgeting, shopping, domestic skills and cooking. The home had an activities co-ordinator to arrange such things as swimming, bowling, going out for meals and such like. People were not pressured into joining these activities if they did not want to. Comments received from one of the visiting health care professionals and a relative about the lifestyle of the people living in the home included: ‘Particularly good that St. Peters has an activity co-ordinator to pursue sporting/leisure interests.’ ‘Staff encourage residents to develop to their full potential and pursue interests/training/future plans in a realistic manner.’ ‘‘……. is supervised and assisted with her shopping and is encouraged to eat healthy. Activities such as swimming, walks, and interactive gatherings are in place. Transport is provided every Sunday to take her to church.’ The views of the people living in the home were listened to and acted on appropriately. Comments received included: ‘I don’t have much to complain about’ ‘They are receptive and respond appropriately to our concerns.’ ‘Staff group are receptive to hearing concerns and willing to work together to resolve any issues.’ There had been little staff turnover since the last inspection which was very good for the continuity of care of the people living in the home. Staffing levels were appropriate for the needs of the people living in the home at the time of the inspection. Staff were friendly and seen to have good relationships with the people living in the home. They told the inspector they were satisfied with their relationships with the staff. The home provided the people living there with a safe, well maintained and comfortable home that enabled them to have private accommodation as well as communal areas and enjoy the benefits of both. The health and safety of the staff and the people living in the home were well managed. The manager ensured the smooth running of the home in a competent manner and the home was run in the best interests of the people living there. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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 Hall DS0000016875.V357153.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.V357153.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information available for people wanting to move into the home needed to be updated to ensure it included all the current information about the service offered at the home. The assessment procedure at the home ensured that the needs of the people wanting to move into the home were known to the staff prior to admission. EVIDENCE: The statement of purpose and service users guide for the home was a combined document. There was also a brochure available giving some details of the service available at the home. The service users guide had not been updated for a considerable amount of time. It was strongly recommended that the information for people wanting to move into the home was updated and that the range of fees charged at the home was included. This would ensure people have all the relevant information to enable them to decide if the home can meet their needs. The files for two people admitted to the home since the last inspection were sampled. The home had not had the opportunity to undertake their own assessments as the individuals had to move into the home quickly. However St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 10 there was evidence that social workers had been involved in the admissions and care plans had been drawn up them that detailed the individuals’ mental health needs. There was also evidence that information had been obtained about the individuals from their previous placements which gave staff a good insight into the needs of the individuals. Both placements had been reviewed quite quickly after admission to ensure they were suitable. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessed needs and goals of the people living in the home were generally reflected in their care plans so that staff knew how to support them. Risk management was not always clearly documented leaving people potentially at risk. The systems in place encouraged individuals to make decisions and promoted an independent and individual lifestyle. EVIDENCE: Both of the files sampled during the inspection included care plans. These were generally well detailed and had been improved since the last inspection to include cultural and religious needs. However cultural needs were not always clearly detailed. Speaking to the manager of the home one of the people living in the home had hair and skin needs due to her culture. Clearly staff knew and were meeting these needs and a member of the family was also involved in this. These needs and how staff are to support the individual to meet them needed to be detailed in the care plan for any new staff that may start at the home. It was also evident from the daily records and some of the meetings St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 12 that had been held at the home that staff were offering a lot more support for personal hygiene needs than was detailed in the care plans. Again these needed to be detailed for any new staff that may start at the home. Clearly the owners, who both worked at the home, and the current staff group at the home were very well aware of the needs of the people living in the home. Although these were not always fully documented it was very clear from the discussions during the inspection and the daily records that these needs were being met. It was not evident from the care plans that the people living in the home had been involved in drawing them up. There was evidence in the records that individuals were involved in reviews with social workers and community psychiatric nurses and if any issues arose they were addressed and strategies put in place to manage these. For example, there had clearly been an issue with one of the people living in the home and the way he spoke to staff and conducted himself in the home. A meeting had been held and some house rules had been put in place with the individual’s agreement for him to follow. The home were trying to introduce a key worker system and it was strongly recommended that this be pursued so that the people living in the home had a named worker who was overseeing their care plan. Key workers should hold regular reviews/meetings with the people living in the home to discuss what has been achieved in relation to the aims in their care plans and highlight any areas that are not being achieved and to establish why. The management held regular meetings with the people living in the home which were used as a method of sharing information and involving them in decision making. Clearly the people living in the home were encouraged to make decisions on a daily basis. This was evidenced throughout the inspection with individuals 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, having friends visit them in the home and so on. Both files sampled had comprehensive risk assessments in place in relation to mental health. These 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. One of the files also included risk assessments for physical health and general risks. These included such issues as the risk of exploitation, isolation and anti social behaviour. These were well detailed and included information for staff as to how these risks were to be managed. One of the files sampled did not include any general risk assessments. Clearly from the records this individual spent a lot of his time out of the home and there had been an incident where he had been assaulted and was therefore quite vulnerable when out. There needed to be a management plan in place for this and any other risks the individual may be exposed to. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. The people living in the home 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 the people living in the home were part of the care plans. Care plans also detailed where the people living in the home needed support with budgeting, shopping, laundry and so on. The people living in the home were 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 people living there with a view that wherever possible they would move to more independent living. The home was clearly achieving this as three of the people St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 14 that had been living in the home at the time of the last inspection had moved on. There was a recognition at the home that most of the people living there needed a structured day to encourage and focus them on having a fulfilling day rather than staying in bed for the most part. Daily planners were in place for this and these detailed the hygiene, laundry, cleaning and cooking routines for individuals. The home had an activities co-ordinator to arrange such things as swimming, bowling, going out for meals and such like. People were not pressured into joining these activities if they did not want to. Some of the people living in the home had gone and stayed with relatives over the Christmas period others had stayed at the home all appeared to have enjoyed themselves. One of the people living in the home spoke about going out and buying presents for other people living in the home and how she enjoyed doing this. Others spoke of how they enjoyed Christmas day at the home and that the owners cooked Christmas lunch for them. Comments received from one of the visiting health care professionals about the lifestyle of the people living in the home were: ‘Particularly good that St. peters has an activity co-ordinator to pursue sporting/leisure interests.’ ‘Staff encourage residents to develop to their full potential and pursue interests/training/future plans in a realistic manner.’ ‘One of the things the home does well ‘promotion of independent living through acquisition of skills.’ One of the relatives commented: ‘‘……. is supervised and assisted with her shopping and is encouraged to eat healthy. Activities such as swimming, walks, and interactive gatherings are in place. Transport is provided every Sunday to take her to church.’ One of the people living in the home spoke about going on holiday to Wales, going to daycentres, college and church every week. Personal and family relationships were clearly detailed in the individuals care plans. There was ample evidence that the people living in the home had contact with their families on a regular basis wherever possible and staff supported them with this where necessary. They spoke to the inspector about visiting their families and staying over night. One of the people living in the home spoke about seeing his girlfriend and that she visited him at the home also. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 15 All the people living in the home cooked their own meals. They were given money on a fortnightly basis and went shopping with staff to buy food. Their dietary needs and the risks involved in them self catering were detailed in their care plans, for example, ‘diet is poor will eat high fat and sugar foods. Will microwave everything. Staff to examine contents of shopping basket and offer advice as to a balanced choice of foods.’ The support needed by the people living in the home 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. Staff were not always recording what the people living in the home were eating. It was strongly recommended that this was done to evidence that people’s nutritional needs were being met. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 16 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. The personal and healthcare support offered and provided to the people living in the home met their diverse needs. The medication system was generally well managed and ensured the people living in the home received their medication as prescribed. EVIDENCE: Care plans detailed the personal care needs of the people living in the home. However as previously mentioned some were having much more support than was detailed. Clearly staff were very aware of the personal care needs of the individuals and the support they needed and there was evidence of their needs being met on the daily records. Health care needs were being met and these were recorded separately from daily records making them easy to track. There was evidence that people received visits from CPN’s, visited the G.P. when necessary and saw other health care professionals such as dentists when necessary. There was also evidence of more specialised health care input as necessary for example drug counsellors. There was also evidence that when issues were not followed up by St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 17 hospitals that the manager pursued these and that when people were in hospital the manager kept in close contact with them. The people living in the home were encouraged to follow healthy lifestyles with input from staff on healthy diets and being encouraged to take regular exercise such as swimming and walking. One of the people living in the home spoke to the inspector about having stopped smoking since last year. She attended a clinic to obtain aids to help her and did this with the encouragement of staff. Medication was being administered mainly via a seven day monitored dosage system. Staff were not allowed to administer medication until they had received adequate training. The medication records were sampled. Some minor discrepancies were found however these did not indicate that people had not received their medication they were mainly in relation to how the medication had been booked into the home. For example, the numbers of one lot of medication received in the home had not been booked onto the medication administration record (MAR) and the new supply for another medication had been entered twice. One tablet that was a controlled tablet was not being recorded as controlled medication in a controlled medication register only on the MAR chart however this was being reduced gradually and was due to be stopped shortly. The manager was reminded that any future controlled medication must be entered in a controlled drug register as well as on the MAR chart. Wherever possible the people living in the home were encouraged to self administer their medication in preparation for more independent living. At the time of this inspection the only person who was self administering was in hospital. A comment received form a health care professional indicated that the home managed medication well: ‘Medication management is particularly good at St. Peters and staff discuss self medication programmes with ourselves.’ St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the people living in the home were listened to and acted on appropriately. The systems in place in the home ensured the people living there were protected. EVIDENCE: There was a complaints procedure on display in the home and the manager stated this was discussed with people when they were admitted to the home and in meetings with them. The completed questionnaires that were returned to the Commission before the inspection indicated that the people living in the home knew who to speak to if they were not happy and that they knew how to make a complaint. One of them commented ‘I don’t have much to complain about’ A relative commented: ‘They are receptive and respond appropriately to our concerns.’ A health care professional commented: ‘Staff group are receptive to hearing concerns and willing to work together to resolve any issues.’ The home had not logged any complaints since the last inspection and none had been lodged with the commission. No adult protection issues have been raised at the home since the last inspection. The adult protection procedures have been viewed at previous St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 19 inspections therefore were not viewed on this occasion. There was evidence on site that staff receive training in adult protection issues on an ongoing basis. The people living in the home were helped to manage their money where necessary. There was a safe keeping facility in the home. The records for this were sampled. All money deposited by the people living in the home was recorded and receipts were available for expenditure. The people living in the home signed their own records when depositing or withdrawing money from the balances held in the home. All the balances checked were correct. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 20 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, 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 this service. The home provided the people living there with a safe, well maintained and comfortable home that enabled them to have private accommodation as well as communal areas and enjoy the benefits of both. EVIDENCE: There had been no changes to the layout of the home since the last inspection and it was suitable for its stated purpose. The home was found to be safe, comfortable, clean and well maintained. The only issues raised with the owners were that one bedroom carpet needed to be replaced and one of the kitchenettes was showing signs of wear and tear. The owners were well aware of these and they were to be addressed. The owners are very proactive in trying to ensure the home is well maintained but the owner described it as the ‘forth bridge’ there was always something that needed doing. Since the last inspection they had employed a dedicated person for maintenance and refurbishment. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 21 The home had two comfortable lounges one of these was the designated smoking area. The flooring had been replaced in this lounge to try and lessen the damage from cigarette burns. There was also a smaller covered external area where the people living in the home could go and smoke. All the people living in the home had single bedrooms that varied in size, a kitchenette and eight of the rooms had an en-suite toilet and shower. Those that did not have en-suite facilities had access to a communal bathroom, shower and toilets. The people living in the home 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. One of the people living in the home told the inspector she had moved to a larger room and was very happy with this. The laundry area was sited well away from any food storage and preparation areas. The people living in the home did their own laundry with support from staff as necessary. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 22 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate staffing levels were being maintained by a stable staff team. Staff had received the appropriate training to meet the needs of the people living in the home. Recruitment procedures were robust and safeguarded the people living in the home. EVIDENCE: There had been little staff turnover since the last inspection which was very good for the continuity of care of the people living in the home. Many of the staff had worked at the home for a considerable amount of time. The manager was in the process of recruiting a member of staff for weekends and informed the inspector that other than this no new staff had been recruited. The staff and the owners of the home were friendly and seen to have good relationships with the people living in the home. The people living in the home told the inspector they were satisfied with their relationships with the staff. The completed questionnaires that had been returned to the commission indicated that staff were available when needed by the people living in the home. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 23 Comments received from a health care professional in relation to staffing included: ‘Staff encourage residents to develop to their full potential and pursue interests/training/future plans in a realistic manner.’ ‘Service users are treated with respect and this encourages an atmosphere of respect and dignity within the unit.’ At the time of the last inspection the staff recruitment procedures in the home were robust and safeguarded the people there. Only one issue was raised that one of the files sampled at that time did not include documentation that evidenced the person was eligible to work in this country. This was addressed and evidence was forwarded to the commission within days of the inspection. It was recommended at the last inspection that the home developed a training matrix to enable easy tracking of the training undertaken and the training required by staff. This had been done and was quite comprehensive however it did show some shortfalls in the regulatory training for staff. The manager stated the training matrix was not fully up to date and was able to produce other evidence that staff had undertaken a range of training since the last inspection. As well as the required training other topics had also been undertaken, for example, equal opportunities and valuing diversity. It was recommended that the training matrix was updated so that it was a true reflection of the training undertaken by staff and that dates were entered so that it was easy to identify when a refresher was needed. The home employed ten staff and the inspector was informed that seven of these had NVQ level 2 or above which is in excess of the fifty percent required. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. The home was run in the best interests of the people living there. The health and safety of the staff and the people living in the home were well managed. EVIDENCE: Both the proprietors of the home worked there full time and one of them was the registered manager. Both were present for the inspection and clearly have a lot of experience of working with people with mental health needs and the running of a residential home. Both demonstrated throughout the inspection that they have a very good knowledge of the needs of the people living in the home. Any requirements made following inspections are quickly addressed and the home has consistently evidenced that it offers a good service. Comments St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 25 received from the people living in the home, health care professionals and relatives agreed that the home offered a good service. These included: ‘They are very good people.’ ‘A good holistic service is offered to residents.’ ‘St. Peters is a very well managed and caring environment for any client to be in they maintain a professional service at all times.’ ‘Out of all the nursing homes I have been in I find St. Peters to be best in the Birmingham and Coventry areas.’ ‘The residents seem happy and content so they must be doing something right.’ At the time of the last inspection 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 had analysed the results of the audits. There were also satisfaction questionnaires completed by the people living in the home and meetings held with them. At the time of this inspection the system remained in place but the audits were quite out of date and the development plan for the home was the one that was produced after the last inspection. It was strongly recommended that the quality audits were recommenced and that a new development plan was drawn up to indicate how the owners proposed to improve the service throughout the coming year. The health and safety of the people living in the home and the staff was well were managed. Staff received training in safe working practices. The AQAA indicated that all the required servicing on the equipment in the home was up to date. The documentation for the in house checks on the fire system were sampled and found to be up to date and also indicated that regular fire drills were taking place. Records were also kept of the temperature checks undertaken on the radiators and the hot water in the home. St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 26 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 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 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No. 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 YA9 Regulation 134(c) Requirement There must be management plans in place for any risks that have been identified for the people living in the home. This will ensure that the people living in the home are not exposed to unnecessary risks. All medication must be correctly acknowledged as received into the home. Any controlled medication administered in the future by the home must be recorded in a controlled drug register. This will ensure that there is full audit trail for all the medicines received into the home. Timescale for action 14/02/08 2. YA20 13(2) 14/02/08 St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 28 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 It was strongly recommended that the information for people wanting to move into the home was updated and that the range of fees charged at the home was included. This would ensure people have all the relevant information to enable them to decide if the home can meet their needs. It was recommended that the care plans specifically reflected how staff were to meet the cultural and personal care needs of the people living in the home. This will ensure that any new staff have all the information they need to care for the people living in the home appropriately. Key workers should hold regular reviews/meetings with the people living in the home to discuss what has been achieved in relation to the aims in their care plans and highlight any areas that are not being achieved and to establish why. It is recommended that the training matrix is updated so that it is a true reflection of the training undertaken by staff and that dates are entered so that it is easy to identify when a refresher is needed. This will evidence that staff have all the appropriate training to care for the people living in the home. It is strongly recommended that the quality audits are recommenced and that a new development plan is drawn up to indicate how the owners propose to improve the service throughout the coming year. This will ensure the service is being continuously for the people living in the home. 2. YA6 3. YA6 4. YA35 5. YA39 St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI St Peters Hall DS0000016875.V357153.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!