CARE HOME ADULTS 18-65
130 Station Road 130 Station Road Sheffield South Yorkshire S13 7RB Lead Inspector
Marina Warwicker Key Unannounced Inspection 14th March 2007 09:00 130 Station Road DS0000062845.V325853.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 130 Station Road DS0000062845.V325853.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. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 130 Station Road Address 130 Station Road Sheffield South Yorkshire S13 7RB 0114 293 9081 0114 293 9082 none londonroad@tiscali.co.uk Milbury Care Services Limited 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) Vacant Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: 130 station road is a house converted to meet the needs of three service users with learning difficulties and some mental health needs. The house is situated in the Woodhouse area of Sheffield. There is a regular bus service from outside the home and there is also easy access to the tram service. There are some shops within walking distance. The staff have access to the homes transport. The bedrooms are on two floors. The residents have access to all the shared areas of the home. There is a well-maintained private garden at the rear of the house. The fees range from £1,650 to £1,850 per week. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection of 130, Station road was carried out on 14th March 2007 between 9:00am and 12 midday. Time was spent observing the support received by the service users and the daily routines of the young people. Three staff were interviewed. Relatives were consulted with regards to the service provided by the staff at the home. Eight staff and seven health and social services professional were contacted through surveys. Their comments are included in the report. During the day of the site visit service user plans, medication records, complaint records, staff files and other relevant records were checked. The inspector wishes to thank the service users, relatives, staff and the management for their co-operation and contribution throughout the inspection process. What the service does well:
Prospective service users are able to access information about the home so that they can make an informed decision about the service available to them. The service users have their needs assessed and a contract offered to them which clearly tells them about the service they will be receiving. There is documentary evidence to support that the service users visit the home on an introductory basis before moving in permanently. This process helps the other service users and the staff in finding out about the suitability of the prospective service user. The service users have individual care plans, which are person centred. These plans include treatment and rehabilitation. Also, how the staff at the home are planning on helping the service users meet their current needs and aspirations in achieving their individual goals. The staff respected the service users’ rights and helped them make decisions. Limitations are introduced only as a result of risk assessments and the service users and their representatives are involved in the decisions. These limitations are regularly reviewed with the view to reducing the restrictions. The staff help service users take responsible risks; action is taken by staff to minimise the identified hazards so that unnecessary limitation on the preferred activities and choices for service users are avoided.
130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 6 The staff are aware of the importance of maintaining confidentiality and keeping accurate account of any incidents. The service users said that they spoke to their key workers in confidence. One said, “I know that X will not tell the others but she might tell the manager if X was not sure what to do.” and the other said, “I don’t mind my key worker knowing my business because she is very good in helping me.” The people who use the service are able to make choices about their life style. They are supported by the staff and helped to develop their life skills. Social, educational, cultural and recreational activities are organised so that they meet individual service user’s expectations. The health and personal care the people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff working at the home. The young people who use the service are able to express their concerns and have access to a complaints procedure. The service users are protected from abuse, and they have their rights protected by the staff and the home’s policies. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The service users are able to bring their own personal possessions into the home so that their rooms are personalised. The home was kept clean and hygienic and free from offensive odours There are trained, skilled staff in sufficient numbers to support the people who use the service. This is in line with the terms and conditions of the service users. The adequate staffing levels enable the smooth running of the service. The management and administration of the home is based on openness and respect. The home has an effective quality assurance system, which helps the home to maintain a good quality of care and give adequate support to those who live there. The annual services and checks are taken care of by the head office and records maintained. What has improved since the last inspection?
130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 7 The care staff who handle medication have had training on the management and administration of medication. The recordings on the Medication Administration Sheets were accurate. The staff had also received training on protection of vulnerable adults. The staff facilities and sleeping arrangements have improved. 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. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 8 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 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 9 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, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including what the people who use the service said and a visit to this service. Prospective service users are able to access information about the home so that they can make an informed decision about the service available to them. The service users have their needs assessed and a contract is offered to them which clearly tells them about the service they will be receiving. EVIDENCE: There was a statement of purpose setting out the aims, objectives and facilities available at the home. The three young people occupying the home have had their placement planned with the help of their assessed needs. The plans included the support and the assistance the service users would receive to enable them successfully move on to adulthood. Arrangements had been made for education, training and employment for the service users. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 10 There was documentary evidence to support that the three service users had visited the home on an introductory basis before moving in permanently. This process had helped the other service users and the staff in finding out about the compatibility of the prospective service user. All three service users had written and costed Terms & Conditions which had been agreed by the management of the home and the representatives of the service users. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 11 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 excellent. This judgement has been made using what the people who use the service said and available evidence including a visit to this service. The three service users are involved in the decisions about their daily lives, and they play an active role in planning the care and support they receive. EVIDENCE: Each service user had an individual care plan which was person centred. These plans included treatment and rehabilitation. Also how the staff at the home were to help the service users meet their current needs and aspirations in achieving their individual goals. Through consulting relatives, checking the care plans and observing the support given to the service users it was established that staff respected the service users’ rights and helped them make decisions. However, limitations were introduced only as a result of risk assessments and the service users and
130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 12 their representatives were involved in the decisions. These limitations were reviewed regularly with the view to reducing the restrictions. The service users influenced the arrangements of furniture, the décor, who they like supporting them and what they want to do each day. The staff helped service users take responsible risks; action was taken by staff to minimise the identified hazards so that unnecessary limitations on the preferred activities and choices for service users were avoided. Two service users said that they spoke to their key workers in confidence. One said, “I know that X will not tell the others but she might tell the manager if X was not sure what to do.” and the other said, “I don’t mind my key worker knowing my business because she is very good in helping me.” Staff verbalised the importance of maintaining confidentiality and keeping accurate account of any incidents. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17. Quality in this outcome area is Good. This judgement has been made using the information given to us by those who are using the service and the available evidence including a visit to this service. The three service users who use service are able to make choices about their life style. They are supported by the staff, so that they could develop their life skills. Social, educational, cultural and recreational activities meet individual service user’s expectations. EVIDENCE: All three service users said that the staff supported them to maintain and develop social, emotional and communication skills. The relatives and the staff confirmed this. It was noted during the site visit that service users had been helped to continue education and training and take part in part-time jobs.
130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 14 The service users were supported in a rage of activities by staff. These activities were flexible and the service users were able to choose and change their minds at the last minute if they so wished. The staff were very understanding and flexible but firm when required so that service users achieve their best potential. The comments from the relatives and other visiting professionals confirmed that visitors to the home were welcome by the staff. Families and friends were encouraged by staff to get involved in the service user’s daily life and activities. The care staff said that service users had been away on holiday and they shared photographs taken during the vacation. One of the service users shared her experience and said that she enjoyed it. The service users were able to use their own bedrooms if they wished to speak with people in private. However, the following comments were received from the surveys. “The communal area is too small and too busy if I want to chat to my daughter”. “How many of us want to take visitors to our bedroom to get privacy. This is a problem for two of the girls at the home”. “One of the residents charges into the common room and demands attention. This causes a lot of problems with the others. They too want that attention.” On the day of the site visit it was observed that each service user had their own menu for the week and they did shopping for their meals. Staff promoted the health and wellbeing of the service users by encouraging them to eat wellbalanced healthy food. Mealtime was relaxed, flexible and arranged to suit the individuals. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 15 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 the comments from those who use the service, those who are involved in providing the professional support and the available evidence including a visit to this service. The health and personal care the three people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff working at the home. EVIDENCE: The relatives and the service users said that the staff gave support with personal care and always respected the young peoples’ privacy and dignity. This was noted on the site visit. One relative said, “Its good they have younger and older carers. My daughter is able to relate to the younger carers and they understand when they are little awkward; but the older ones are like second mothers to them.” 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 16 It was ascertained from the daily records and the comments from the professional surveys that service user’s health was monitored by staff and potential complications and problems were identified and dealt with at an early stage by prompt referral to the appropriate health specialist. The present clients were unable to self-medicate. A record of current medication for each service user was maintained. The staff on administering the medication signed the Medication Administration Sheets. Those staff who have had training on medication administer and manage medication at the home. Supplying pharmacist had not carried out audits on medication. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 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. 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 comments from the people who use the service and a visit to this service. The young people who use the service are able to express their concerns and have access to a complaints procedure. The service users are protected from abuse, and they have their rights protected by the staff and the home’s policies. EVIDENCE: The feedback from the surveys confirmed that the staff and the manager listened to and acted on the views and concerns of the service users and their representatives. There were no records of formal complaints. Four staff files were checked and all four staff had attended training on protection of vulnerable adults. The relatives said that the staff handled physical and verbal aggression of the service users appropriately. One of the comments from the survey said, “Sometimes the girls can be unpredictable and it takes staff with skills to manage the situation.” 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 18 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, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including surveys, comments from the people using the service and a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. However, the service users who have not got their own private living room have problems with receiving visitors in private. EVIDENCE: It was noted on the day of the site visit that home was accessible, safe, and well maintained. It met the needs of the individuals in a comfortable and homely manner. However, there was a comment about a lack of communal area for two service users. -“The communal area is too small and too busy if I want to chat to my daughter”- (Please see for more evidence under lifestyle). The home was in keeping with the local community and maintains the style and ambiance of the neighbourhood.
130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 19 The three young people were provided with bedrooms with furniture and fittings suitable to meet their needs. The service users had brought their own personal possessions so that their rooms were personalised. The home was kept clean and hygienic and free from offensive odours. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 20 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, 34, 35 and 36. Quality in this outcome area is good. Using the comments from those who use the service and their representatives and also the available evidence including a visit to this service has enabled us to make this judgement. There are trained, skilled staff in sufficient numbers to support the people who use the service. This is in line with the terms and conditions agreed with the service users before entering the home. The adequate staffing levels enable the smooth running of the service. EVIDENCE: The relatives and other professionals were consulted. They said that the staff at the home had a clear job role and that they all took their responsibilities seriously. During direct observation it was evident that the care staff had the experience and skill to support the service users. Four care staff recruitment files were checked. The information required by the care standards regulations was complied with.
130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 21 The manager had a training and development plan for the staff. This included mandatory training and service specific training. However, out of four care staff training records checked only 50 had attended training. All four staff checked have had regular supervision and the manager maintained records of the supervision. The staff commented that the manager was very supportive and that they work well as a team. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good, This judgement has been made from the comments made by the people who use the service and also using the available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The home has an effective quality assurance system which helps the home to maintain a good quality of care and give adequate support to those who live there. The annual services and checks are taken care of by the head office and records maintained. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager had the overall responsibility of the running of the home and she had worked towards meeting the stated purpose and the objectives of the home. This was confirmed through the feedback from the surveys. The manager had copies of the minutes of the staff meetings. The manager said that relatives and service users were consulted regularly and in an informal way. The responsible individual for the home carried out monthly monitoring and continues to forward copies of the reports to the Commission for Social Care Inspection. The manager continues to take reasonable steps to maintain the health and welfare of the service users and the staff. This was confirmed by the information provided in the pre-inspection questionnaire and checks made on the day of the site visit. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 24 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 3 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 X 28 2 29 N/A 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 4 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA28 Regulation 23 Requirement The communal area must be suitable for the individual and collective needs of service users. Timescale for action 17/07/07 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. Refer to Standard YA20 Good Practice Recommendations Pharmacy audit should be carried out as part of support to the service. Previous recommendation not achieved. 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Extracts may not be used or reproduced without the express permission of CSCI 130 Station Road DS0000062845.V325853.R01.S.doc Version 5.2 Page 27 - 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!
