Inspection on 13/01/06 for 124 Pasley Street

This inspection was carried out on 13th January 2006.

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

The inspector 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

124 Pasley Street 21/02/07

124 Pasley Street 10/08/05

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 Devon PL2 1DS Lead Inspector Antonia Reynolds Unannounced Inspection 12:45 13 January 2006 th Pasley Street DS0000003456.V249635.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 Pasley Street DS0000003456.V249635.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. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pasley Street Address 124 Pasley Street Stoke Plymouth Devon PL2 1DS 01752 319370 01752 310530 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) 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 DS0000003456.V249635.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Learning disabled adults some of whom may have a mental disorder Age 18-50yrs Date of last inspection 10th August 2005 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 DS0000003456.V249635.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 1245 and 1300 on Friday, 13th January 2006 and between 1000 and 1130 on Monday, 23rd January 2006. The Registered Manager, Mark West, was present on both days. A tour of the premises took place and records relating to care and the home were inspected. One of the two residents (the home had one vacancy), 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: 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 DS0000003456.V249635.R01.S.doc Version 5.0 Page 6 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 Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 7 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 and 3 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: One service user has been admitted to the home since the last inspection but this person was already a service user within the organisation. However the organisation’s processes ensure that prospective service users are assessed prior to admission and a detailed assessment tool has been devised. Introductory visits are arranged for prospective and existing service users to meet each other and become familiar with the home and the staff prior to admission. Each service user has been provided with a guide to the home, produced in the form of individual leaflets with photographs and symbols, reflecting what is important to each service user. Discussion with a service user confirmed that they were clear about the services and facilities available in the home. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 The service users are enabled to participate in, and make decisions about, all aspects of their lives. EVIDENCE: Discussion with a service user showed that they participate in all aspects of life in the home and are consulted and supported to make their own choices and decisions. Discussion with the Registered Manager showed that the attitude and approach of the staff team promotes independence and personal responsibility, empowering service users to make decisions about lifestyle and daily routines, demonstrating excellent practice. Any restrictions on choice or freedom were documented and had been agreed with the service user and other people involved in the person’s care. Each service user has a care plan, risk assessments, behavioural guidelines and personal agreements that are regularly reviewed. Records relating to the administration of service users’ money were satisfactory and the organisation provides additional money for clothing and leisure activities. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 9 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, 12, 13, 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: Discussions with a service user and the Registered Manager 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 confirmed that they have a choice of meals, help to choose the menu and alternatives and snacks are always available. Contact with relatives and friends is encouraged and there are no limitations in place regarding visitors to the home. The Registered Manager confirmed that, wherever possible, service users would be enabled to go on holiday this year. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 10 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 and 19 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. Through observation it was clear that timings were flexible and the choice of the service users. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 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 service users explained how they would make a complaint and whom they would talk to. Regular house meetings are held where any issues can be raised and dealt with immediately, although it was also clear from discussion that service users can raise any issue at any time. The Registered Manager was aware of adult protection issues and procedures. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 The standard of the environment is improving and the home was comfortable, safe and clean. Bathroom and toilet facilities were adequate for the present service users. EVIDENCE: The home was comfortable, safe and clean with refurbishment and redecoration ongoing or planned. The home’s lounge room has recently been redecorated to a good standard and was comfortably furnished. Redecoration of the dining room is planned and work has commenced in the kitchen. All the bedrooms are single rooms on the 1st floor, none of which have en suite facilities or wash hand basins. Discussion with a service user confirmed that they do not wish to have wash hand basins in the bedrooms. One of the bedroom doors was fitted with an appropriate lock. The service user who had a bedroom without a lock confirmed that he can have a lock fitted if he wishes it but does not want one at this time. The service users were using the spare bedroom as a games room. The home has a bathroom on the 1st floor with a separate toilet. The doors to these are lockable using a star key. A bolt lock has been removed from the toilet door, as 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. Kitchen and laundry facilities are Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 13 satisfactory and infection control practices are in place. A separate cupboard has been constructed in the kitchen to house the washing machine. There is no sleeping accommodation for staff as this is not required. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 14 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): 33, 34 and 36 Recruitment procedures are robust and service users benefit from high staffing levels. EVIDENCE: Discussion with the Registered Manager confirmed that the organisation has robust recruitment procedures and that regular, documented individual supervision sessions take place with each staff member. Discussion with the Registered Manager and a service user confirmed that there are two staff members on duty during the day and evening and one waking staff member at night. The organisation operates an ‘on call’ system whereby members of the management team are available both in and out of office hours. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 15 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 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 fifteen months and is also the Registered Manager for another care home within the organisation. He is undertaking a level 4 National Vocational Qualification and the Registered Manager’s Award. The service user spoken with confirmed that service users are consulted and included in decisions regarding the running of the home and find the management approach open and positive. Lines of accountability are clear and the organisation provides an effective ‘on call’ system to support staff. Both a service user and the Registered Manager confirmed that all staff and service users have received training in fire safety awareness. A list has been compiled of all the portable electrical appliances that have been checked in the home. No health and safety issues were identified during the visit. The Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 16 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. Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 17 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 3 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 N/A 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pasley Street Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000003456.V249635.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Pasley Street DS0000003456.V249635.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Ashburton Office 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. 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