Inspection on 01/11/05 for 10A & 10B Station Road

This inspection was carried out on 1st November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10A & 10B Station Road 11/04/07

10A & 10B Station Road 24/11/04

10A & 10B Station Road 26/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 10A & 10B Station Road Hatfield Doncaster DN7 6QB Lead Inspector Mike Hamstead Unannounced Inspection 1st November 2005 08:00 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 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 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 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. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 10A & 10B Station Road Address Hatfield Doncaster DN7 6QB 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) 01302 351965 01302 351886 carol10a@fsmail.net Doncaster & South Humber Healthcare NHS Trust Mrs Carol A Hayes Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user over the age of 65, named on variation dated 26th January 2005, may reside at the home. 26th April 2005 Date of last inspection Brief Description of the Service: Station Road Hatfield Doncaster, comprises of 2 purpose built bungalows accommodating 3 service users in each and is a joint venture between Doncaster and Humberside Healthcare Trust, who provide the staffing resources, and Sanctuary Housing who own the building and are responsible for the majority of the repairs and maintenance. The home provides care to 6 younger adults with learning disabilities. Each bungalow home comprises of 3 single bedrooms, a bathroom and wc, and a separate wc, and has a kitchen and dining room, separate lounges, and separate laundries. One of the bungalows (10A has a sleeping-in – room/office, and also has an en-suite bedroom.) Externally both bungalows have a sizeable rear garden, with seating facilities for residents. The accommodation is at the rear of a row of local shops, and access can be restricted if deliveries are being made, but this happens very infrequently. The home is close to shops, bus stop post office, bank, hairdressers, general store and public house, and most of these shops are used by residents and staff on a regular basis. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager and all staff on duty, and an examination of the homes records. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection commenced at 08:00 and finished at 15:30 and included talking to 5 members of staff, and those residents able to communicate in a meaningful way. What the service does well: What has improved since the last inspection? New furniture has been purchased, and there have been some repairs to the window sills. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 6 There has been an examination of the homes water services to make sure they comply with the required regulations. Arrangements have been made for all residents to receive an annual health check. More signposting aids are being prepared to enable residents to find their way about the home. 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. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 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 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. Potential residents/representatives would have all the information about the home available to them to enable them to understand and decide whether the services the home provides meets their needs. EVIDENCE: There is a Statement of Purpose that meets the requirements of this standard and this was submitted to the CSCI when the home was registered in March 2004. There is also a Service User Guide that includes both a standard version and also a user - friendly version, which is an excellent example of what is required for this resident group. Extra charges include hairdressing, extra newspapers and periodicals, dry cleaning, chiropody and transport. The majority of the current resident group transferred from the former Balfour Road and Asquith Road accommodation at Bentley to Station Road on the 1st April 2004, and all the residents were originally admitted following an assessment of need. A further review and reassessment is due to take place for all 6 residents before the end of 2005. One resident moved to supported living accommodation in February 2005 where it his felt he would be more suitably placed and be more able to achieve his full potential, and another resident was admitted in July 2005 and is settling in well following her request to live with more residents of her own age. This resident visited Station Road 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 9 for an overnight stay to familiarise herself with the other residents, the building, and the staff. A placement review has been held, attended by the social worker and an advocate from Doncaster Advocacy service, who had prepared an excellent pictorial transition plan for the resident that was available to see. Staff update the Trust’s assessment documentation, to reinforce that received from the placing authorities (which is generally DMBC) and make amendments based upon their own experience of the resident in their new environment. The behaviours of one resident who had a history of displaying aggressive and stubborn behaviour have reduced since the last inspection, although the resident has been assessed as needing psychiatric support. Staff are familiar with using ABC charts to monitor her behavioural patterns, but a proposed move to an assessment bed away from Station Road for a more thorough assessment of her needs to be undertaken, has been postponed because of a learned medical problem that is receiving medical attention. The resident is also not attending her usual day care placement pending her receiving medical attention in her own interests. The needs and preferences of specific minority ethnic residents continues to be met for one resident, in terms of maintaining her hair in an appropriate and cultural style, and by ensuring that she receives culturally appropriate food. None of the residents attend church at the present time, but staff would enable them to attend if they wished to do so and support their spiritual needs. Four of the residents have changed bedrooms with their agreement where possible, following the care manager and staff’s assessment of the most appropriate accommodation for them, and this has been amended in the homes Contract/Statement of Terms and Conditions, which meets the requirements of this standard. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 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, 9 & 10. Plans of care are comprehensive, but the residents care files still remain large and unwieldy, and it is difficult to find information quickly. It is also evident that some information is duplicated, wasting staff time, and causing unnecessary effort that could be better utilised working with residents. Staff consult and assist residents to make decisions wherever possible, and ensure their safety by assessing all risks involved in their daily activities. EVIDENCE: 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 11 Plans of care are developed from both the assessment of need and the homes own assessment, but are still unfortunately unable to be agreed with the majority of the resident group because of their limited understanding of the process, but the care manager is optimistic about involving the most recent admission in her own care plan. The care manager requests the relatives involvement in drawing up plans of care, but interest is variable depending upon attendance. The residents files are bulky and need reviewing for evidence of duplicated effort which the registered person has agreed is a planned task that needs attention. There is a statement in the plan of care to the effect that the majority of the residents are unable to give consent generally, and also that they are unable to consent to treatment, and can only make simple choices about their life in the home. The home operates a special interest worker/key -worker system to ensure that personal information such as birthdays, visits and appointments are not forgotten. Work is continuing to consider ways of making the plans of care available in a format that the residents may understand and a good example of this is the health action plan currently being trialled by staff. There is a procedure in place to record any physical interventions that take place by staff that are recorded in a specific restraint record maintained in the residents file. This includes a full description of the technique of intervention used, details of the staff involved, date time and location, and the duration of the restraint, and all staff have received training in these techniques. There has been a reduction in the number of interventions taking place, and the care manager is of the opinion that this may be linked to the departure of a resident earlier this year to alternative accommodation, and the effect that he had on residents during his accommodation at Station Road. Any incidents of selfharming which are infrequent, are recorded, to ensure that residents receive the necessary specialist help required. Plans of care are reviewed twice a year, and families are requested to attend along with the social worker if available, and the next reviews are in November/December 2005. Choices of activities undertaken such as going out socially, or about food and drinks are recorded in working notes. None of the residents can manage their own finances and they are assisted by staff to ensure that they are not taken advantage of, and are not abused financially. Risk assessments are maintained for all residents and the outcomes are recorded and amended as necessary. Risk assessments have been prepared for fire practices and evacuations, and there is a user - friendly diagram available which staff explain to all residents to ensure their safety. Residents are given training about their personal safety, particularly road safety, and are 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 12 supported to take appropriate risks as part of an independent lifestyle. Staff at Station Road endeavour to enable residents to participate in the running of the home, limited only by their abilities and understanding. Residents still do certain tasks in the home designed to improve independent living skills, such as emptying the bin and taking it to the wheelie-bin, mopping the bathroom floor, and setting the tables and emptying them after eating. The inspector saw one resident cleaning and putting the place mats away in a drawer after a meal. The care manager has introduced a training day to involve residents in cleaning their own rooms once a week. The majority of residents can communicate by speech, and another has a basic knowledge of Makaton learned at a day centre, and can indicate her desires in terms of food and drink, via symbols on display in the home. Staff continue to increase communication skills overall, by using posters placed on cupboards and doors, with drawings on them to indicate the contents. There are residents meetings on a two monthly basis, soon to be monthly, in which they are encouraged to mention any issues they are not happy with, and any aspect of their lifestyle they wish to improve. The home also has a “client satisfaction questionnaire” of the smiley/sad face type as part of their quality assurance system, and staff assist residents to understand and fill this in. The home still subscribes to the CHAD Support Group, “ Choice for all Doncaster” that supports adults with learning disabilities in centres/groups, and pursues the interests of people with learning difficulties. The home receives copies of the minutes from these meetings and staff read out items they feel residents will be interested in. The resident newly admitted to Station Road has been invited on to a task group for the CHAD forum, that will discuss communication issues at their next meeting on the 29th November 2005. The home also still obtains the Community Homes newsletter called “Chatterbox” which is recorded onto tape, and makes this available for homes/centres etc to use in their residents meetings. The tape contains useful information on the birthdays of residents in other trust homes, any day trips or holidays undertaken, reviews of videos and DVD’s and residents enjoy hearing about these items/events. There is a missing persons policy and procedure available to protect residents if required, and staff handovers ensure that all residents are discussed and their welfare is safeguarded. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 13 Documentation and records are securely stored, and the home has a confidentiality policy. Within the limitations of the resident groups understanding, staff respond to any questions from them about their private affairs in a discrete manner to ensure their privacy, and staff handovers take place after every shift, with briefings given in private. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 14 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): 11 & 14. Residents have opportunities for personal development and day care opportunities are provided for all the residents. There are also regular communal and leisure activities and an annual holiday that enables residents to broaden their horizons. EVIDENCE: Staff are trained to foster the personal development of each resident, and interpersonal skills are taught within the home setting, and also as part of the wider day care centre network where residents have opportunity to meet their peers on a regular basis. All the residents attend day centres at either Bentley, Thorne or Hayfields, or the Eclipse and Solar Centre’s at St Catherine’s hospital, and one resident was clearly happy and showed staff and the inspector that she had had her hair done and her nails manicured. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 15 The staff seek specialised psychiatric services for 4 residents, that involves medication reviews to safeguard their health and well – being. The staff provide access to a range of leisure activities, which as a result of experience varies between residents based upon their different interests and also their capacity to tolerate different events. Residents have other individual interests, one likes music and videos, and another likes watching cowboy films on television. Others simply like colouring or drawing, and the home provides ample opportunity for this interest. The most popular in-house entertainment is television, videos, and DVD’s. The majority of residents have been on holiday this year, two went to Otterburn Hall in Northumberland for a week in chalet type accommodation, one in June 2005, and the other in August this year. Three other residents went for a weeks holiday to Blackpool in July 2005. The remaining resident has had an overnight stay in Blackpool this year, and this situation will be discussed at her forthcoming review. Residents enjoy regular trips out to Meadowhall, the social club at St Catherines hospital, Sandall park and Thrybergh park and many other places as requested by residents. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19. Personal and healthcare support to residents continues to be promoted by obtaining the necessary advice and assistance when required, and now includes the facility of an annual health check. EVIDENCE: Personal support and guidance is provided to all residents in a sensitive and dignified way on a daily basis, because of their primary assessed need of “learning disability.” All residents receive assistance with bathing, and personal hygiene and a new hoist has been purchased for one resident. Staff also provide help and suggestions with a choice of clothes on occasions, and all the residents were clean and well dressed before setting off to their respective day care placements. Staff are aware of the most common forms of infection and health related problems associated with the respective residents condition, and all residents are registered with a GP practice in Dunsville, where they attend as and when required, and staff are happy with the level of service provided. There is also access to the other primary care services when required. The care manager has managed to arrange for all residents to receive an annual health check from the local GP practice, and letters were on file asking that appointments be made for them to visit the surgery. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Residents are made aware of the complaints procedure, but it is suspected that some resident discontentment is not being recorded because of the difficulties staff face in understanding such concerns. Staff are aware of how to deal with Adult Protection issues to promote the protection of residents. EVIDENCE: The DHT complaints policy and procedure is available, in an appropriate format for residents and includes information for referring a complaint to the CSCI at any stage of the process. No complaints have been recorded since the last inspection. A continuing discussion from previous inspections is still the difficulties staff face in actually recognising when legitimate complaints are being made by residents with a learning difficulty. It is possible that because of the communication difficulties experienced by residents that although they may be unhappy about certain aspects of their life at Station Road, their concerns are not being recognised by staff and consequently not being recorded. The newly admitted resident is able to communicate her concerns and the care manager is hopeful that she will be able to give feedback about her experiences at the home. The care manager has introduced a comments section within the complaints record, and continues to reinforce the need for staff to be constantly aware of this problem. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 18 There is a policy and procedure on Adult Protection, and also a whistle blowing policy, and staff are aware of what to do in the event of such an occurrence. All staff have attended an Adult Abuse workshop at St Catherines Hospital. There is a policy on how to deal with physical and verbal aggression by residents, and also a policy on residents money and financial affairs, both promoting the protection of residents in the home. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 19 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): 24,25,26,27,28,29 & 30. Continuing investment has maintained the appearance of this home creating a homely and comfortable environment for residents visitors and staff. Externally no progress has been made to repair/resurface the tarmac drive that presents a potential hazard to residents and staff. Staff should ensure that 2 fire drills are carried out before the end of 2005 to comply with the Fire Officer’s requirements. EVIDENCE: Station Road comprises of two purpose built bungalows, which provide safe secure and comfortable accommodation for all residents. All residents have a single bedroom, one with an en suite facility, and all the rooms are decorated to a high standard. Since the last inspection a new 3 piece suite has been purchased for the 10B lounge, and their suite has been transferred to 10A. Each bungalow comprises of a separate kitchen and lounge, a communal bathroom and wc including a shower attachment, and a separate wc. There is a separate laundry room and storage room in each bungalow, and the only differences between the two bungalows are that 10A has an extra room, comprising of an office in the daytime, and the sleeping – in room at night, and 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 20 an en – suite bedroom. Dor- guards have been fitted to those communal area doors deemed necessary to be kept ajar for ease of access and general service user observation, and these comply with the requirements of the Fire Service. The communal space in the home is adequately furnished with armchairs and settees, and suitable domestic carpeting. Residents eat in the kitchen/dining room, but could eat in the lounges if they wanted to. Visitors are accommodated in the lounges or the residents own rooms if required. The bathroom and toilet facilities provided are domestic in scale and meet the requirements of this standard because of a dispensation at the registration stage that en-suite facilities were not required for all bedrooms. None of the service users smoke, and staff smoke outside the home, to protect the residents health. Because the home does not have a staff room, staff are provided with adequate facilities including a safe place to store personal belongings and sleeping facilities when sleeping in. Two of the residents have physical disabilities, and one has a walking stick, and safe working practices are followed at all times. Thermostatic valves are fitted to control the temperature of the water supply, and the home has a call alarm system installed, which links the two buildings, which is not formally in use and is not a requirement of registration. There were no odours found on this inspection, and the home currently has one incontinent resident. Each bungalow has its own separate laundry facilities, and has a washing machine with a combined sluice programme to meet disinfection standards. There is a policy on the control of infection. The care manager has obtained the materials to make more signposting aids for residents, like pictures of a bathroom on the bathroom door and wc etc, but also to show the contents of cupboards and the fridge etc, so that some residents can work in the kitchen, and be able to find things more easily. There are sizeable gardens at the rear of both homes, which also includes a patio with seating and barbeque facilities. Externally, a requirement at the last two inspections about the uneven surface on the access road to, and adjacent to Station Road, used by delivery vehicles to get to the rear of the shops has still not been resolved, and there were sizeable potholes that could affect both residents and staff at Station Road. Risk assessments are in place for these hazards to protect the residents safety, but an Immediate Requirement notice was issued to the care manager because of the potential and continuing danger to residents and staff. It was also observed that the external lighting may be inadequate to illuminate the danger 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 21 area sufficiently well and this should also receive attention. The matter is currently with Sanctuary Housing who have determined that responsibility for the repairs lies with the company that owns the shop premises but they are still having difficulties getting the landlord to undertake the work. Another issue identified is that part of the window sill at the front of 10B bungalow is rotten and requires urgent attention, and the Fire Officer requirements are generally met, which offers a protection for both residents and staff, but the home must undertake 2 fire drills before the end of 2005. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 & 36. Staffing numbers were satisfactory to meet the needs of residents, and the recruitment and selection procedures ensure residents are protected, as does staff training. Further attention still needs to be paid to the supervision process to ensure that the overall interests of residents are maintained. EVIDENCE: All staff have job descriptions, that relates their role to the assessed needs of service users, at 10A and 10B Station road, and staff can alternate between both units. There has been one new staff member employed since the last inspection (An internal transfer from Howbeck Close) and the recruitment and selection process was checked and found to be satisfactory safeguarding the interests of residents. The home does not employ volunteers. The home is aware of the requirements of the GSCC, and the care manager has obtained copies of the standards of conduct and practice in different formats such as Makaton and tape as advertised to share with residents. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 23 The home has over 78 of care staff who have achieved NVQ Level 2, and a number who have also achieved NVQ Level 3. The home employs staff in accordance with the dependency levels of residents, but there is always at least one member of staff on duty at all times in each bungalow, 24 hours a day x 7 days per week. Additional staff are also brought in to provide extra cover when residents go to day centres or other events The home operates a sleeping - in system that is judged appropriate to safeguard the residents interests. The home currently employs 11 staff, who operate between 10A and 10B Station Road, providing care tasks, and also undertaking the ancillary tasks such as laundry, cooking, and cleaning. The home generally has a good staff attendance record although a qualified nurse and a member of care staff are on long term sickness absence at the present time, and the staff team reflects the cultural/gender composition of residents. Regular staff meetings take place, the last one being on the 15th September 2005. The home has access to specialised services, and some staff know basic Makaton, and can communicate with residents via this method. Three residents can make their needs known to staff using this form of communication. The supervision process has improved in terms of content, but still needs to be carried out at least 6 times per year. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 41, 42 & 43. Residents benefit from a home run well and in their best interests where their health and safety is promoted. The dual responsibilities of the care manager should be reviewed to ensure the welfare and safety of residents at Station Road. EVIDENCE: 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 25 The care manager is qualified, competent and experienced to run the home, and there was plenty of evidence to support this assertion. The care manager also has a line management responsibility for two other homes, Larch Avenue and Sandringham Road that takes her away from her main responsibilities at Station Road on occasions and may be a reason why some of her work like supervision and fire drills is falling behind at Station Road and this must be reviewed. The care manager is already qualified to the equivalent of NVQ level 4 in management and care, and continues to keep herself updated in all relevant aspects of care practice. The care manager was on duty at this inspection, and all staff were comfortable with her management approach which was one of openess and inclusiveness and there were plenty of examples of this approach in evidence. It was clear that she was able to foster an atmosphere of respect and togetherness directed towards providing the best possible care for residents. Staff meetings are held, and all staff on duty said that they received guidance and supervision from her, and felt able to approach her with ease at all times. The new member of staff was able to read the residents files at her own pace to familiarise herself with their needs. All the homes policies and procedures are developed centrally by DHT, and made available to all homes. Staff have some input to them from suggestions made at staff meetings, or at other times, and these are passed to Girton Lodge for consideration. All policies and procedures are signed and dated by, and monitored and amended by the Trust, not the registered care manager. Many of the policies and procedures have been produced in appropriate formats for the understanding of residents which is commendable. Accurate and comprehensive records are maintained, but there is still a variable interest shown by residents in wanting to see their files. There is a policy and procedure for maintaining safe working practices for residents and staff, and risk assessments for all safe working practice topics have been done including one from the danger of delivery vehicles visiting the shops adjacent to the home. Staff receive planned training in moving and handling, fire procedures, food hygiene and infection control training, and staff have been on a managing violence and aggression course since the last inspection. The gas boiler was serviced by a CORGI registered person, employed by 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 26 Sanctuary Housing, on the 29th March 2005, and the home had an electrical wiring check on the 22nd November 2004. There is a monthly Health & Safety checklist, which covers risk assessments on residents and window restrictors are fitted, and the care manager has been informed that the home does not require a Legionella test to be carried out. The care manager has sought advice from DHT and been informed that the home complies with all the relevant legislation contained in this standard because of the risk assessments and policies and procedures that are in operation. There is a poster produced by the home in an appropriate format understandable to residents which explains the procedure to be followed in the event of a fire that is clearly protecting their safety. The weekly fire tests are being carried out, but staff need to carry out two fire drills before the end of the year to maintain the residents safety. There is a business and financial plan for the home, and home also has public liability insurance. Residents are unable to be involved in the business and financial aspects of the homes operations because of their limited understanding of this process. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 27 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 4 4 4 4 Standard No 22 23 Score 3 4 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 4 4 4 LIFESTYLES Standard No Score 11 4 12 x 13 x 14 4 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 4 4 x x 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 10A & 10B Station Road Score 4 4 x x Standard No 37 38 39 40 41 42 43 Score 2 4 x 3 3 3 3 DS0000060649.V259727.R01.S.doc Version 5.0 Page 28 Yes 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 Standard YA24 Regulation 23 Requirement Timescale for action 30/11/05 2 YA24 23 3 YA36 18 4 YA37 9 The registered person must ensure that service users live in a safe environment with reference to the potential hazard and uneven surface on the driveway adjacent to Station Road. The registered person must 30/11/05 ensure that the premised are well maintained with regard to the window sill at the front of the home. The registered person must 30/11/05 ensure that all staff receive supervision in accordance with the requirements of this standard. The registered person must 30/11/05 review the dual role of the care manager that may have implications for the welfare of residents at Station Road. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 29 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 2 Refer to Standard YA6 YA24 Good Practice Recommendations The registered person should ensure that a review of the residents case files are undertaken to streamline the content, and eliminate duplication of effort. The registered person should ensure that two fire drills are carried out before the end of 2005 to comply with the Fire Officer’s requirements. 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 10A & 10B Station Road DS0000060649.V259727.R01.S.doc Version 5.0 Page 31 - 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. 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