Inspection on 10/08/05 for 124 Pasley Street

This inspection was carried out on 10th August 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

124 Pasley Street 21/02/07

124 Pasley Street 13/01/06

124 Pasley Street 05/10/04

124 Pasley Street 20/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Pasley Street 124 Pasley Street Stoke Plymouth PL2 1DS Lead Inspector Antonia Reynolds Unannounced 10 August 2005 th 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 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 Stationary 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. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pasley Street Address 124 Pasley Street, Stoke, Plymouth, Devon, PL2 1DS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 319370 01752 310530 Michael Batt Foundation (Valued Life Projects) Mr Mark John West Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Learning disabled adults some of whom may have a mental disorder Age 18-50yrs Date of last inspection 5th October 2004 Brief Description of the Service: 124 Pasley Street is a care home providing personal care (if required) and accommodation for three people, aged 18 - 50, with learning disabilities, who may also have mental health issues. It is owned by the Michael Batt Foundation (Valued Life Projects) which is a not for profit organisation providing services for people with a range of needs who require support and care to live in the community. The home was opened in 2000 and is a two storey terraced house located in the residential area of Stoke in Plymouth. It is close to local shops and amenities. All the homes bedrooms are single and are on the 1st floor. None of these have en suite facilities or wash hand basins. There are separate lounge and dining rooms and the home has a small front garden and back yard. All areas are accessible to the service users and on street parking is available outside the home. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 1130am and 1.15pm. The Registered Manager, Mark West, and the Senior Support, Simon Cook, were present. A tour of the premises took place and records relating to care and the home were inspected. The one resident (the home had two vacancies), as well as staff on duty, were spoken with and observed during the visit. What the service does well: What has improved since the last inspection? What they could do better: There are still areas that need redecoration/refurbishment and the Registered Manager confirmed that these will be done. All staff members must receive more frequent fire safety training. It is recommended that a list of the portable electrical appliances checked is kept on the premises and reviewed regularly. Consideration should be given to removing the bolt lock on the inside of the 1st floor toilet to enable easier access in an emergency. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 6 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. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 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 standard(s) 2 and 4 The home’s Statement of Purpose and Service User Guide provide service users and prospective service users with details of the services the home provides, enabling an informed decision about admission to the home. EVIDENCE: No new service users have been admitted to the home recently. However, the organisation has a procedure where all prospective service users are assessed prior to admission and a detailed assessment tool has been devised. As much information as possible is obtained from the service user, relatives and representatives, as well as other professionals involved in the person’s care and this is documented. Introductory visits are arranged for prospective and existing service users to meet each other and become familiar with the home prior to admission. Individual records are kept for each service user and these contain assessments, care plans, risk assessments and behavioural guidelines, which are regularly reviewed. Ongoing evaluation is recorded daily. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 6, 7, 8, and 9 The service uses are enabled to participate in, and make decisions about, all aspects of their lives. EVIDENCE: Each service user has a care plan, risk assessments and behavioural guidelines that are regularly reviewed. The staff are fully aware of the needs of each person. The attitude and approach of the staff team promotes independence and empowers service users to make decisions about lifestyles and daily routines, demonstrating excellent practice. Service users are encouraged and enabled to participate in all aspects of life in the home and personal agreements about domestic tasks are drawn up in consultation with service users. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11, 12, 13, 14, 14, 15, 16 and 17 Service users can learn life skills, attend work placements, participate in any community and leisure activities, choose their own daily routines and enjoy a healthy diet of their choice. EVIDENCE: Information in care plans, as well as talking with staff and the service user, showed that service users are enabled to live as full a life as they wish to and have opportunities for personal development. Service users are encouraged to participate in all the domestic activities in the home and to take part in leisure activities of their choice. The home does not provide transport as service users are encouraged to use public transport wherever possible. However, occasionally staff cars are used, for which service users are expected to make a contribution towards the cost of petrol. Service users participate in household shopping and preparing meals, drinks and snacks. Service users have a choice of meals, help to choose the menu, alternatives and snacks are always available and records are kept of meals provided. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 11 Contact with relatives and friends is encouraged and there are no limitations in place regarding visitors to the home. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 18, 19 and 20 Service users can be confident that personal support is provided in the way, and at the time, that service users want and need. Health care needs are addressed as soon as they are identified. EVIDENCE: Service user plans provide information about personal, emotional and health care needs. External professional advice and guidance is sought when necessary from local health care professionals or social services. The staff are commended for the high level of support they provide to service users to enable dietary issues to be addressed and adhered to. Through observation it was clear that timings were flexible and the choice of the service user. Medication is locked away safely, a monitored dosage system is used, and records pertaining to its administration are up to date and accurate. A discussion took place about the best way of handing medication to the service user. Medication prescribed to be taken ‘as required’ is only administered by staff following consultation with a senior manager. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 22 and 23 Service users are protected from abuse, neglect and self-harm. Service users can be confident that the Registered Provider always deals with complaints seriously and any concerns from service users are listened to and acted upon immediately. EVIDENCE: Neither the home nor the Commission for Social Care Inspection have received any complaints regarding the service since the last inspection. The home has a complaints procedure and regular house meetings are held where any issues can be raised and dealt with immediately, although it is also clear from discussion that service users can raise any issue at any time. The management and staff team are aware of adult protection issues. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24, 27, 28, 29 and 30 The home has recently been refurbished and redecorated in places, which is a significant improvement, and it was comfortable, safe and clean. Bathroom and toilet facilities were adequate for the present service user. EVIDENCE: All the bedrooms are single rooms on the 1st floor, none of which have en suite facilities or wash hand basins. The Registered Provider has confirmed that the service user does not wish to have a wash hand basin in the bedroom. The Registered Manager confirmed that service users are consulted and involved in the redecoration process. The home has a bathroom on the 1st floor with a separate toilet. The doors to these are lockable using a star key but the toilet door also has a bolt lock and this would be difficult to open in an emergency. There is a shower room and toilet on the ground floor. The Registered Provider should consider more appropriate locks as part of the overall improvement programme. The shared rooms on the ground floor consist of a kitchen, dining room and lounge room, which has recently been redecorated to a good standard. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 15 The Registered Manager confirmed that there are plans to redecorate/refurbish the hallway, stairs, dining room, kitchen and bathrooms/toilets. Kitchen and laundry facilities are satisfactory and infection control practices are in place. A discussion took place about the moving the washing machine to a more suitable location during the refurbishment of the kitchen. The home does not have a call alarm system or any specific aids and adaptations, apart from hand rails, as these are not required for the service users. There is no sleeping accommodation for staff as this is not required. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 and 35 The staff have a good understanding of the service users’ support needs and service users benefit from high staffing levels. EVIDENCE: Discussion with the Registered Manager and staff confirmed that there is a waking staff member on duty at all times. The organisation operates an ‘on call’ system whereby members of the management team are available both in and out of office hours. The organisation has a designated staff member to coordinate and arrange training to maintain an overview of what the organisation requires, as well as ensuring that individual staff members receive the training they need. Staff confirmed that they are expected to attend relevant training including person centred planning, social role valorisation, human development, epilepsy awareness, health and safety, emergency first aid, food hygiene and medication awareness. The organisation does not tend to enrol staff on National Vocational Qualifications but have devised their own training, in consultation with the local College of Further Education, as this reflects the needs of the service users they support. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41 and 42 The management approach is open, inclusive and positive, providing clear leadership and guidance. Empowerment and enablement of service users is the focus of the organisation. Service users’ rights, health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager has been in post for approximately ten months and is undertaking a level 4 National Vocational Qualification and the Registered Manager’s Award. Documentation relating to service users is up to date and accurate. Records relating to health and safety issues, such as risk assessments, the accident book and fire log book are available. However, the fire log showed that some staff are out of date for fire safety training. Staff on duty confirmed that all Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 18 tests and checks of fire safety equipment are carried out as required. The documentation was not available on the day of inspection but the Registered Provider confirmed that all fire safety checks and tests were recorded. All staff complete training in emergency first aid. The use of hot water is risk assessed and none of the hot water is regulated as the Registered Provider does not consider this is necessary for the service users. The Registered Manager confirmed that health and safety checks, including the checking of portable electrical appliances, are carried out during the monthly provider visits. The organisation has devised a quality assurance system which will be implemented in due course. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 19 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 x 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pasley Street Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 x D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA42 Regulation 23 Requirement All staff must be trained in fire safety awareness at least every 6 months. Timescale for action 9/11/05 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. 3. 4. Refer to Standard YA27 YA42 Good Practice Recommendations Consideration should be given to removing the bolt lock on the 1st floor toilet door. A list should be compiled of all the portable electrical appliances that have been checked/tested in the home. Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Pasley Street D52-D04 S3456 124 Pasley Street V240015 100805 Stage 4.doc Version 1.40 Page 22 - 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!