Inspection on 19/03/07 for 1 Old Station Close

This inspection was carried out on 19th March 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

1 Old Station Close 26/02/08

1 Old Station Close 12/12/05

1 Old Station Close 08/08/05

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 Old Station Close Shepshed Leicestershire LE12 9NJ Lead Inspector Andrew Sales Key Unannounced Inspection 19th March 2007 10:00 1 Old Station Close DS0000062107.V333330.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 1 Old Station Close DS0000062107.V333330.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. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Old Station Close Address Shepshed Leicestershire LE12 9NJ 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) 01509 506218 01509 506441 Prime Life Ltd Miss Carmen Rosende Care Home 21 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (21) of places 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within category LD to be admitted to the home unless that person also falls within the category of MD - i.e. dual disability. No person to be admitted to the home in the category MD/LD when 7 persons in total in this category are already accommodated in the home. 12th December 2005 Date of last inspection Brief Description of the Service: 1 Old Station Close is a residential care home for a maximum of 21 people who have either mental health illnesses or learning disabilities. The home is purpose built and is separated into three smaller units named Peach Abbey, Strawberry Manor and Cherry Lodge, all linked by an adjoining corridor, with the main office located off the corridor. Each unit has it’s own garden area. The home is located in Shepshed, Leicestershire and is close to the town centre and local amenities. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by A. J. Sales on 19 March 2007. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they receive, through review of their records, discussions with them and care staff. During the course of the inspection some residents were out at colleges, day support services and shopping. About nine others were at home. We also spoke with three more residents and three members of staff. We spent part of the day with the manager discussing policies, procedures and records. What the service does well: Old Station Close provides a range of activities to meet the needs of the residents. This may include assisting residents out for pub meals, some attend colleges and day care services. There is s minibus, which residents can use for organised trips or for spontaneous outings. Some residents are able to access community facilities independently, using public transport to get nearby facilities. All residents have key workers and feel confident to discuss any issues with them. The residents spoken with during the inspection were complimentary about the standard of care provided. Routines are very flexible in the home and residents are able to prepare meals with the assistance from staff. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 6 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. 1 Old Station Close DS0000062107.V333330.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 1 Old Station Close DS0000062107.V333330.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): 2,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully assessed prior to moving into the home and the residents are confident that the home is suitable for them. EVIDENCE: We looked at three care plans. We saw evidence that professional assessments are obtained regarding residents needs prior to their being admitted. The manager develops with each resident a plan based on the assessment that details any restrictions on freedom, services or facilities balanced with their needs. Staff told us that plans are discussed with residents and attempts are made to ensure that they are in agreement with their plans. We saw evidence that where possible residents are asked to sign the plan ensuring that they are involved in the plan. The manager and staff showed us how the home obtains specialist advise from health care professionals. This was supported by documentation in care plans. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 9 Residents also told us about visiting community health services, such as Community Psychiatric Nurses and doctor services. The induction program and training schedule was observed and this will help to ensure that staff are able to meet the needs of residents admitted. The staff commented that the induction to the homes procedures and following training equipped them to provide a good standard of care. 1 Old Station Close DS0000062107.V333330.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): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assured that their needs are assessed and changing needs are reflected in their plan. Residents are supported to take risks and have an active independent lifestyle. EVIDENCE: We looked at three care plans. These plans enable staff to work appropriately with residents. This helps them to meet their needs and ensure they maintain an independent lifestyle. Support plans cover all aspects of the resident’s daily life and provide clear information on how the resident prefers to receive their care. There are risk assessments to ensure the safe participation of chosen activities 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 11 We saw evidence that support plans are reviewed regularly by senior staff. We observed risk assessments in relation to maintaining independence and risks for all areas of daily living. Staff who spoke with us demonstrated a good understanding of the care planning process and the management of risk. The inspector spoke with three of these residents who were able to describe what they were supported with and how the staff approached this. We made observations throughout the day. Residents were seen coming and going from the building, preparing meals with staff and going about general day to day tasks. During the day one resident became agitated and was in danger of placing other individuals at risk. We observed staff working together to resolve this situation with good outcomes for this resident and others. We believe staff are professional and use a variety of positive methods to interact with residents. 1 Old Station Close DS0000062107.V333330.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): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in age appropriate activities, are part of the community and are able to maintain personal relationships with family and friends. Residents’ rights are respected and responsibilities recognised. EVIDENCE: We saw evidence where assessment plans identified what domestic responsibilities the resident had. This went on to show and what staff support was required to help them do this, ensuring that the resident was actively involved in the day to day running of the home. One resident was able to describe how she is supported with daily tasks within her accommodation and staff confirmed how they draw up a plan of assistance centred around the individuals capabilities. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 13 The staff and residents described how residents meetings take place fairly frequently, where issues such as social activities are discussed. All of three of the residents spoken with, told us they were happy with the level of activities within the home and outside. Resident’s commented that the philosophy of the home and the attitude of the staff enabled them to make choices and felt they were generally well respected. The staff reported that they encourage residents to participate in events and outings. Residents told us this may include assisting them when out for pub meals, shopping, going to colleges or day care services. They told there is a minibus which they use regularly for organised trips or for spontaneous outings. Some residents told us they do this without the help of staff. Support plans showed us how staff promote and maintain residents privacy and dignity. Staff spoken with clearly understood the importance of promoting this with residents. We spoke with staff who showed us how residents were involved in choosing the menu for the week. We saw that residents were given a wide choice. We observed residents preparing food with staff assistance, this is a flexible arrangement, residents said they can eat whenever they want to. 1 Old Station Close DS0000062107.V333330.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): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s policies and procedures for dealing with medicines and receive their personal support as they prefer and require. EVIDENCE: We looked at three assessment plans. These show that residents are able to receive their support as they prefer to. Staff spoken with understood the different needs and preferences of residents and understood the importance of supporting residents this way. There was evidence in support plans and diary notes of residents attending GP appointments and other health care visits as well as GP advice being sought regarding residents’ behaviour and medication. We were able to track information from the diary notes and support plan to the Medication Administration Records (MAR) sheets to show that appropriate action had been taken, following incidents or reviews. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 15 We looked at one residents medication records seen. These reflected what was recorded and what was left in administration packs. We saw new risk assessments for each medication this individual was taking. These were very detailed and provided clear guidance for staff. This will contribute greatly to the effective management of medication and help reduce risks for residents and staff. 1 Old Station Close DS0000062107.V333330.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): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make complaints. Residents are protected against abuse. EVIDENCE: Staff spoken with had a good understanding of the importance of enabling residents to voice their complaints. We spoke with three residents who said that they would speak to the manager if they were not happy with something. One resident told us that last year, she had experienced problems with a member of staff. She described how she spoke with the manager and that this problem was resolved. We have received no complaints regarding this service and have no concerns in this area. There are clear policies and procedures for staff to follow in the event of a complaint. Staff spoken with had a clear understanding of what constituted abuse and what responsibilities they had to ensure residents remained safe. Residents spoken with said that they felt safe in the home and staff were pleasant to them. 1 Old Station Close DS0000062107.V333330.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is suitable for its stated purpose; accessible, safe and well maintained. Old Station Close provides residents with a comfortable and spacious environment. EVIDENCE: We looked at all of the communal areas and found them to be well furnished and maintained. Three residents told us they liked the homes décor and furnishings. We looked at bathrooms, bedrooms and communal areas including lounges and the kitchen. These are all well kept, clean and free from any odours. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 18 Bedrooms are personalised and provide residents with a pleasant space to relax in. We spoke with one resident in the garden, who told us how much he enjoyed sitting outside. The garden is a pleasant environment for residents to relax in. 1 Old Station Close DS0000062107.V333330.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who are competent and qualified. Residents are safeguarded by the homes recruitment and training procedures. EVIDENCE: We looked at three staff files. They contained all relevant recruitment documents and were very well maintained. Interviews are recorded and kept on file. All of the personnel files that were examined revealed that thorough pre-employment checks are carried out. Staff told us that all these recruitment procedures had taken place. The manager and staff told us that suitable inductions to their work are conducted for staff and a regular program of training is in place. We were shown a comprehensive training program that is provided by Prime Life. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 20 One staff member told us that she had attended a foundation course specific to Learning Disability and Mental Health and she had been on numerous health and safety courses. She told us she was a relief member of staff and said it was quite normal for everyone to attend all these courses. We saw evidence on files that showed staff had attended training in Control Of Substances Hazardous To Health (C.O.S.H.H), fire safety, food hygiene and the Safer Handling Of Medicines. Prime Life also runs frequent Protection Of Vulnerable Adults training, to ensure all staff are aware of procedures. 1 Old Station Close DS0000062107.V333330.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a home which is well managed. Resident’s benefit from the systems that are used for monitoring and reviewing the quality of care. The health, safety and welfare of residents are promoted and protected. EVIDENCE: All of the residents spoken with said they felt the home was well run and the management team and staff were always on hand for support and advice. 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 22 We spoke with three staff members who confirmed that they felt supported by the manager and senior staff and that they are approachable to discuss any issues. All of the residents spoken with, stated that they felt they were consulted about day to day issues. We saw evidence of reviews, residents meetings and consultation carried out with individual residents. We observed a system Prime Life uses for assessing the quality of it’s services and the views of residents. This is a valuable tool and is designed to reflect the outcomes for service users based around the current National Minimum Standards (NMS). A relevant policy with regards to the safe keeping of resident’s personal allowances is in place and followed. We saw records of resident’s cash accounts and one resident’s cash balance was checked and found to be satisfactory. The staff who spoke with the inspector, confirmed they receive regular supervision and attend regular team meetings. We observed three staff files, which contained records of supervision and appraisal. Staff confirmed that this is part of a supportive management style provided by the manager. All of the staff files showed us that staff have undertaken training in mandatory health and safety subjects. Staff spoken with, were aware of health and safety procedures and commented positively on the training provided. Risk assessments were observed on individual files and are in place for the building and individual residents. Records for Health and Safety monitoring and the servicing of systems and appliances were inspected on this occasion and were found to be up to date. 1 Old Station Close DS0000062107.V333330.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 3 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 x 3 x 3 X X 3 X 1 Old Station Close DS0000062107.V333330.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1 Old Station Close DS0000062107.V333330.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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