Inspection on 21/02/07 for 124 Pasley Street

This inspection was carried out on 21st February 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

124 Pasley Street 13/01/06

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 Jane Gurnell Unannounced Inspection 21st February 2007 10:45 Pasley Street DS0000003456.V321154.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 Pasley Street DS0000003456.V321154.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. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pasley Street Address 124 Pasley Street Stoke Plymouth Devon PL2 1DS 01752 319370 01752 310530 info@michaelbattfoundation.org 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.V321154.R01.S.doc Version 5.2 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 13th January 2006 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: one of the 3 bedrooms is used as an activity room. None of these have en suite facilities or wash hand basins. There is a shower room with a toilet on the ground floor and a separate toilet and bathroom on the first floor. 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. The weekly fees for this service are calculated on an individual basis depending upon the service user’s support needs. Information relating to the services provided by the Michael Batt Foundation can be obtained from their Head Office at Third Floor, Poseidon House, Neptune Business Park, Cattedown, Plymouth, PL4 OSJ, telephone number 01752 310531. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken during the morning of 21st February 2007. The Registered Manager, Mr Mark West, was present. The inspector spoke both service users, (the home has one vacancy), as well as the member of staff on duty. A tour of the building was made and documents relating to the support needs of the service users were examined. A visit was made to Michael Batt Foundation’s head office on 12th February 2007 to examine the confidential documents relating to the admission of newly referred service users and also staff recruitment. What the service does well: The house is comfortable, warm and very clean. There is plenty of good food. Residents have enough things to do to be happy. They are helped to find a job. There are always enough staff to help. The resident’s get all the help they need. Each resident can have their room just as they want it. The staff know how to help people and the staff do their best. If a resident has a problem it is easy to get help. The staff are safe to be with. If you want to live there the staff will tell you about what it is like. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 6 The staff are good at helping people to move in and be happy. 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. Pasley Street DS0000003456.V321154.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 Pasley Street DS0000003456.V321154.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): 1, 2, 3, and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s pre-admission processes ensure that prospective service users are provided with information about the home as well as having the opportunity to experience life in the home prior to admission, so enabling them to make a properly informed decision. EVIDENCE: There have been no admissions to the home since the last inspection. However, from examination of records relating to newly admitted service users in two other Michael Batt Foundation homes, it was evident that the preadmission process thoroughly explores the prospective service user’s support needs and that each person is enabled to visit the home on several occasions to meet with the other service users and staff. The Foundation provides a Service User Guide in different formats, such as pictorial and on audiotape, depending upon each prospective service user’s needs and abilities, thereby enabling them, with the support of visits and explanations to make an informed choice about the suitability of the home. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are enabled to participate in, and make decisions about, all aspects of their lives. Confidentiality is respected. EVIDENCE: Discussions with the service users and the staff confirmed that service users are actively consulted and enabled to make choices and decisions about their lives. Service users are supported to take risks that have been carefully assessed and these were clearly documented in each service user’s support plan ensuring that the support provided by staff is done so in a consistent manner. Any restrictions on choice or freedom had been agreed with the service user and other people involved in the person’s care: any restrictions in place were made to protect the service user’s health and safety and recognises the service user’s responsibility towards others. The attitude and approach of the staff team promotes independence and empowers service users to make decisions about lifestyles and daily routines. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 the service users 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. One service user confirmed that he has a part-time job. 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 Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 11 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 are enabled to go on holiday each year. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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: A service user confirmed that he is consulted about the level of personal support he needs and that he is being supported to live more independently. Both service users’ support plans were examined and these provided very clear descriptions of personal, emotional and health care needs. This clarity is important to ensure that the support team are fully aware of each service user’s specific needs and can respond in a consistent manner. Through observation it was clear that timings were flexible and the choice of the service users: each service user was able to plan their day independent of each other. Incidents of inappropriate behaviour as a result of service user anxiety were documented and monitored by the Team Leader, who is a member of the Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 13 senior management team, to identify if further support and guidance is necessary to overcome these difficulties. Service users are offered support from other healthcare professionals such as nurses and psychologists from the Community Learning Disability and Mental Health Teams, to enable them to express their concerns, to deal with situations that make them anxious and to develop more appropriate coping strategies. Medication is stored safely and records accurately maintained. One service user is being supported to take responsibility for his medication and his medication is put by staff into a weekly dispenser which he can manage independently. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 one of the service users said he knew how to make a complaint and whom he 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 and staff have received training ensuring they are aware of their responsibilities should they suspect a service user is at risk of abuse. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is satisfactory providing service users with a comfortable and homely place to live. EVIDENCE: The home was comfortable, safe and clean with refurbishment and redecoration ongoing or planned. The home’s shared areas are comfortably furnished. 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 at the previous inspection confirmed that they do not wish to have wash hand basins in the bedrooms. Both bedrooms used by service users were fitted with appropriate locks that provide both privacy and security: scaring to the doors where the previous locks were removed is required and the Registered Manager confirmed that this would be done shortly when the service users redecorate Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 16 their bedrooms. 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 and a shower room and toilet on the ground floor. Kitchen and laundry facilities are satisfactory and infection control practices are in place. A separate cupboard has been constructed in the kitchen to house the washing machine. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 17 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): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust. Staff are enthusiastic, have a good understanding of the service users’ needs and work positively with service users to improve their quality of life. EVIDENCE: The Foundation has a department that ensures recruitment practices are safe. A sample of staff files were examined and showed a robust recruitment procedure. All the required information was available, including Criminal Record Bureau checks and 2 written references, ensuring as far as possible only suitable staff are employed. Regular staff meetings and individual supervision sessions took place and addressed the principles and values of the Foundation, staff performance and training and development needs, as well as day-to-day support issues. The Foundation 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. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 18 The Registered Manager and staff members confirmed that staff were expected to attend relevant training on topics such as social role valorisation, person centred planning, human development, adult protection, conflict management and emergency first aid, ensuring they have the skills and confidence to support the service users on a day-to-day basis and also at times of crisis. The majority of staff are either enrolled in or have completed the Learning Disability Award Framework (LDAF), a nationally recognised qualification. The Registered Manager and staff member on duty confirmed there was normally one member of staff on duty until 2pm when another member of staff came on duty to facilitate community activities: one service user did not require supervision during the day but did to go out of the home and this arrangement had been made with his agreement. One waking staff member is on duty at night. There is an ‘on call’ system whereby members of the management team are available both in and out of office hours. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 19 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, 38, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 was competent and experienced to run the home, he is also the Registered Manager for another care home within the Foundation. He confirmed that he is nearing completion of the Registered Manager’s Award, a recognised management qualification. He has also completed the “Humanistic Approach to Support” Course, a LDAF course that follows a person-centred philosophy of care and support. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 20 Lines of accountability were clear and the organisation has a management structure that enables it to cover absences when required, and provide an effective ‘on call’ system to support staff. Staff have completed training in fire safety, first aid, food hygiene and health and safety ensuring they have the skills to deal with emergencies. The Foundation has a Quality Assurance Auditor who is responsible for assessing whether the services provided meets the service users’ needs to their satisfaction as well as ensuring their safety and that of the support staff. These assessments are detailed and include all aspects of a service user’s personal, health, emotional and social support needs. The results of these assessments are shared with the service user and their family or representative to plan future service support and personal goals. Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 21 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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 3 3 3 3 Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 22 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 Pasley Street DS0000003456.V321154.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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