Inspection on 04/01/06 for 130 Station Road

This inspection was carried out on 4th 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

130 Station Road 18/03/09

130 Station Road 14/03/07

130 Station Road 07/09/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 130 Station Road 130 Station Road Sheffield South Yorkshire S13 7RB Lead Inspector Marina Warwicker Unannounced Inspection 4th January 2006 13:30 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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.V275986.R01.S.doc Version 5.1 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.V275986.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 130 Station Road Address 130 Station Road Sheffield South Yorkshire S13 7RB 0114 293 9081 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) londonroad@tiscali.co.uk Milbury Care Services Limited Mrs Rachel Chovil McGarry 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.V275986.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 problems. 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 and the private garden at the rear of the house. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspection of this service took place on 4th January 2006. The inspector visited the home around 1.30pm and met the staff and the service users. The inspector checked records and with the help of the manager checked the progress made from the last inspection requirements. This is the second inspection since the opening of the service. To obtain a balanced view of the service the reader is encouraged to read both the previous report and this. What the service does well: What has improved since the last inspection? What they could do better: The manager and the staff need a suitable office space to carry out the administration work. The sleeping in staff need a comfortable area to sleep in. All staff need to receive service specific training. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 6 The new staff need to complete induction prior to commencing work without supervision. They also need to receive mandatory training as part of induction. The staff need to sign and date all documentation so that the information could be clarified and the person who recorded the data will be responsible for it. This must be checked during monthly audits. 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. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home has information for the prospective service users and their representatives to help them make the suitable decision. EVIDENCE: There was up to date information for prospective service users about the facilities at the home. This was in the form of statement of a purpose and a service user guide. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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 the following standard(s): These individual standards were not checked on this inspection. EVIDENCE: The staff at the home continue to help the three service users to develop independent life skills with the assistance of the outside multidisciplinary agencies. The inspector established this by a) observing the support the service users were given by care staff b) reading the service users’ records and c) through speaking to the staff on duty. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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 the following standard(s): These individual standards were not checked on this inspection. EVIDENCE: The three service users were found to have a fulfilling lifestyle in and outside the home. The Inspector met two of the service users when they returned to the home after different activities. The service users looked happy and seem to have good rapport with the supporting staff. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20&21 The staff provide personal care and facilitate service users to maximise independence and control over their lives. The health care needs of the service users are assessed by the staff at the home and appropriate professionals from outside the organisation are involved in fulfilling their needs. There were policies and procedures for the safe handling of medication. The present policy needs updating. The medication training is not formalised. The supplying pharmacist has still not undertaken a medication audit. The home had policies on death and dying so that the staff are able to handle such situations. EVIDENCE: The manager said that they had recruited care staff and that the new staff were in the process of going through induction. Once this training is completed the manager assured the inspector that there would be adequate staff on duty to support the three service users. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 12 The service users’ care records indicated that they had access to GP, dentist, psychologists and other outpatient appointments. The manager said that none of the service users were able to self-medicate. The manager and some of the care assistants have had training on medication management. On questioning the staff, it was evident that the training needs to be formalised and all staff need to receive training. The manager said that a new training co-ordinator had come into post and that she had been made aware of this. The medication administration sheets of the three service users were checked. There were no gaps in them. However, an instruction on the Medication Administration Sheet was not clear. For example an instruction stated that a PRN (as required) medication was to be given when required by the service user. But the criteria for the requirement was not documented anywhere in the service user’s documentation. The inspector discussed this example with the senior carer and the others on duty during the evening. It was then agreed that if each service user had a list of medication they are prescribed, the reason for the prescription and the side effects as part of the medication record such issues could be avoided. The manager said that a pharmacy audit had not been carried out since the opening of the home and that the company was dealing with this issue. The care staff had not received formal training on palliative care or dealing with death and dying of service users. The manager said that they had access to the relevant professionals who would be able to give advice and support and that the home’s policy covered the basic actions the staff need to take in such situations. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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 the following standard(s): 22&23 The home had a complaints policy. By recruiting and training suitable staff the service users are safeguarded from abuse or neglect. EVIDENCE: The inspector viewed the complaints, comment and compliments file. The recordings were positive and complimentary to the staff at the home. Not all staff had received training on vulnerable adult protection. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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 the following standard(s): 24,25,26,27,28&30 The home is accessible, safe and well maintained. Each service user is provided with adequate living/bedroom space. The shared space provided for the service users is comfortable, accessible and safe. The premise is kept clean, hygienic and free from offensive odour. There were systems in place to control the spread of infection. EVIDENCE: Following the last inspection, discussions took place between the responsible individual, operations manager and the inspector regarding the staff sleeping arrangements and the lack of office space for staff. The manager told the inspector that work has been scheduled to be commenced in the next few months to make the necessary arrangement. The CSCI is awaiting an up to date plan of the layout of the home, since the original plan does not have sleeping room for staff. The home was clean and comfortable. The service user’s rooms were individualised. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35&36 The majority of the staff are competent and have the required qualities to meet the needs of the service users. The staff team work efficiently and help each other. Therefore the service users benefit from the caring and consistent approach. The manager operates a thorough recruitment procedure, so that suitable staff are working at the home. The induction training of new staff needs to be formalised. The staff receive supervision from the manager. EVIDENCE: The staff were enthusiastic and committed to delivering high standards of care. The manager said that the training co-ordinator was organising care staff to be trained to Learning Disability Award Framework levels. One of the staff told the Inspector that she was very happy with this decision. The Inspector requested to check new staff files. However, the manager informed her that the recruitment files of new employees were forwarded to 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 16 the home from the human resource department only on completion of the required information. Those staff who had been recruited after the opening of the home had not received formal induction and mandatory training before commencing work. The Inspector noted gaps in the mandatory training. The manager was aware of this. The new staff were given supernumerary status to get familiar with the service and the service users. However, they did not have induction focused on the category of service users and their special needs. The staff supervision has been carried out. The staff explained that they value the time of supervision. The manager said that since the last inspection she had made extra time available to carryout management duties. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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 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): 37,38,39,40,41&43 The home creates an open, positive and comfortable atmosphere. The home does not have adequate space for the administration and staff facilities. Therefore there are plans to rectify this. The manager ensures as far as is possible the health, safety and welfare of the service users and staff. EVIDENCE: The manager said that the financial management of the home was carried out at the head office. The manager is to commence RMA (registered managers award) this year. Not all staff had received training on moving and handling and health and hygiene. However the manager said that all staff had received fire safety instructions. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 18 The inspector found several documents had not been signed and dated by the staff. The staff were informed of this and the staff on duty were informed that such documents were legal documents and that the staff must sign and take responsibility. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 N/A 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 3 2 3 3 3 2 X 3 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes` 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 YA20 Regulation 13,18 Requirement The manager must ensure that all care staff who handle medication receive accredited formal training. 1/11/05, ongoing. Medication Administration Sheet must have accurate instruction. The manager with the help of the pharmacist must monitor this. Immediate. All staff must receive formal training on adult protection and recognising abuse and neglect. 1/11/05, ongoing. Staff must be provided with facilities including a safe place to store personal belongings and sleeping facilities when sleepingin. Work to commence shortly. The care staff must receive suitable assistance, including time off for the purpose of obtaining further qualifications (Such as LDAF training, eating disorders, mental health) appropriate to the work. The manager must obtain the appropriate management qualification. Timescale for action 06/04/06 2. YA20 17 04/01/06 3. YA23 18 06/04/06 4. YA28 23 06/04/06 5. YA32 18 06/04/06 6. YA37 9 04/01/07 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 21 7. YA41 17 8 YA28 23 Staff must sign and date all documentation/ records at the home. (e.g. care plan, risk assessments, additional information on the service user). The management must supply the CSCI with an up to date plan of the home. 06/02/06 04/02/06 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. 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 130 Station Road DS0000062845.V275986.R01.S.doc Version 5.1 Page 23 - 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!