Inspection on 07/09/05 for 130 Station Road

This inspection was carried out on 7th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

130 Station Road 18/03/09

130 Station Road 14/03/07

130 Station Road 04/01/06

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 07 September 2005 10:15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 130 Station Road Address 130 Station Road, Sheffield, South Yorkshire, S13 7RB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01709 375355 paulconstable@milburycare.com Milbury Care Services Limited Rachel Mc Garry Care home for adults only 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding dementia (3) of places 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection None 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 and the well maintained private garden at the rear of the house. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection following registration of the care home. The inspection was unannounced and the inspector visited the home around 10am on 7th September 2005. The house was homely and clean. The rooms were inspected with the permission of the service users. Time was spent on speaking to the service users and staff whilst they were escorting service users on their daily activities. 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 of the home. The sleeping staff too need a comfortable area to sleep in. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 6 The home needs an up to date statement of purpose and a service user guide. All staff need to receive service specific training. The new staff need to complete induction prior to commencing work without supervision. The staff should be commended, encouraged and helped by the organisation for wanting to develop themselves in this specialist field. The staffing levels need to be reviewed and the manager needs adequate time to carryout the daily administrative duties, care audits, supervision and training of staff. 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 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 &5 This is a new home, which was opened early this year. There was no information available for prospective service users about the facilities. The service users are admitted on the basis of a full needs assessment undertaken by competent professionals, to ensure that placements of service users are appropriate. The manager and her staff demonstrate their capacity to meet the identified needs of the residents. Unplanned admissions are avoided and the manager invites prospective service users to spend time at the home on an introductory basis before moving in permanently. The service users or their representatives are given a statement of terms and conditions, which is costed. This is agreed and signed by the service user or representative and the manager making this a legally binding arrangement. EVIDENCE: The home did not have an up to date statement of purpose or a service user guide. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 9 Out of three, two residents had single care management assessment integrated with the care programme approach. The third service user had a care plan with care needs identified by the service user and staff. Through observation and whist speaking to staff and the service users the inspector ascertained that the staff had the commitment and experience to deliver the care and support. During discussions with staff and service users it was evident that the service users have had opportunities to have trial sessions at the home before moving in permanently. The inspector did not ask to see the signed contracts for the three service users on this occasion, but the manager said that all the service users had a contract each. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 &10 The service users have individual care plans. The staff set out with the help of the service users a care plan to include the facilities available at the home and in the community. The plan focuses on meeting the changing needs, aspirations and goals of the residents. The manager offers opportunities to service users and includes them in the day-to-day running of the home. The staff enable service users to take responsible risks. The staff maintain confidence regarding the information given to them by service users. EVIDENCE: The inspector saw examples of service users making individual choices. In some instances the staff were helping the service users to make appropriate decisions. One of the service users spoke to the manager about the staffing levels and the inspector witnessed a useful discussion between them. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 11 The staff told the inspector that any information given by the service users was handled according to the Date protection act and the home’s policy on confidentiality. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 &17 The home provides opportunities for the development and maintenance of social, emotional, communication and independent living skills. The staff ensure that the service users have access to a range of leisure activities and opportunities to become part of the community. Staff also support service users to maintain family links and develop new relationships. The daily routine of the home promotes individual choice and freedom. The service users are able to decide each day where and what they are going to eat. This gives them autonomy and choice. EVIDENCE: On the day of inspection it was noted that the three service users had separate routines and the staff assisted the service users when it was appropriate. All three service users went out of the home at different times to attend to their personal affairs. One service user attended skills centre, the other attended a 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 13 hospital appointment and then went shopping. The third went shopping for the home. Staff escorted all service users. The house is situated among the community and the staff had helped the service users integrate by forming links with the neighbours. The service users cooked with assistance and ate food they choose. This can be varied as to each individual service user’s choice. The staff maintained records of meals consumed by each resident to monitor whether they were having a good healthy diet. The staff said that they influence the service users to have a healthy diet if they were found to be eating unhealthy food. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 &21 The staff try to provide sensitive and flexible personal care and support to maximise independence and control over the service users lives. The health care needs of the service users are assessed and appropriate professionals outside the organisation are involved in fulfilling those needs. The manager said that there were policies and procedures for the safe handling of medication. The home had policies on death and dying so that the staff are trained to handle such situations. EVIDENCE: Through discussions it was established that sometimes due to the lack of care staff it was difficult to provide one-to-one care to service users. One of the service users raised this concern on the day of inspection. The service users had access to GP, dentist, psychologists and other outpatient appointments. Although the manager said that there were systems in place for service users to self-medicate none of the three service users wanted to be responsible for 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 15 medication management. The manager and some of the care assistants have had training on medication management. The medication administration sheets of the three service users were checked. There were no gaps. However, the allergies section of the MAR sheets was not completed. The manager said that a pharmacy audit was carried out recently but was unable to locate the report. The care staff had not received formal training on palliative care or dealing with death and dying of service users. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The manager said that there was a complaints policy, which included time scales and the people to be contacted. Service users are safeguarded from abuse, by training staff and recruiting suitable staff. EVIDENCE: The staff interviewed had a good understanding of the home’s complaints policy. The inspector witnessed the service users making comments and concerns to the staff and the action staff took to resolve them. Not all staff have had training on protecting vulnerable adults and they were not familiar with the procedures 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29&30 The home is small for its stated purpose. It 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. However there isn’t adequate space for the use of the service users. Since the service users are ambulant and do not have any physical disabilities the home did not have specialist equipment. The premise is kept clean, hygienic and free from offensive odour. There were systems in place to control the spread of infection. EVIDENCE: The home was newly opened in January 2005. It consists of a one bedroom flat on the ground floor and a two bedroom house with dining kitchen area. The shared space is not adequate for the service users. During summer months the service users are using the garden area as an extension. Discussions took 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 18 place between the staff and the manager regarding the lack of space. Further discussions took place between the Responsible Individual, Operations manager and the inspector regarding the staff sleeping arrangements and the office space for staff. The management have agreed to address this and forward an up to date plan of the layout of the home to the CSCI; Since the plan does not have sleeping room for staff. The bedroom within the flat is very small. However, the service user benefits by having a small sitting room to her/him self. The two bedrooms on the first floor had en-suite facilities and are of a good size. The service users have furnished their bedrooms to their liking. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 33.34.35&36 The core 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 staff receive induction training and support to maintain a good standard of care. Staff receive supervision from the manager. This enables the manager to establish her/his supervisory role and offer the staff support and guidance. EVIDENCE: This is a new staff team and the inspector observed good and efficient team working. The staff were enthusiastic and committed to delivering of high standard of care. The staff are committed to completing NVQ Level 2 and 3. The inspector was informed that the management are only committed to staff achieving NVQ level 2 and not NVQ level 3. As part of the speciality “Valuing 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 20 People A New Strategy For Learning Disability” the care staff are expected to be trained to Learning Disability Award Framework levels 2 or 3. This needs to be explored by the organisation. Four recruitment files were checked. The following were noted. Not all gaps in employment histories had been explored and reasons explained. The CBR clearance dates were not available. The staff said that the management had carried out a through induction programme for those staff who started at the beginning. However, the staff who had been recruited after the opening of the home had not received extensive training before commencing work. They explained that this was due to the lack of staff. The staff supervision was not carried out regularly. The staff explained that this was due to the lack of time available within each shift and the manager being involved with everyday hands-on care. The inspector witnessed this on the day of inspection. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,41,&42 The home creates an open, positive and inclusive atmosphere. The records required for the protection of service users and for the running of the business are stored in the same room as the staff sleep at night. The home does not have adequate space for the administration and staff facilities. The manager ensures as far as is possible the health, safety and welfare of the service users and staff. EVIDENCE: The manager communicates a clear sense of direction and the staff and the service users were able to relate to the purpose of the service. The manager’s office is not fit for its purpose. This is also used as the bedroom for sleeping-in night staff. It houses all administrative documents used at the home. Please see previous section for further clarification. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 22 The staff had received training on moving and handling, Fire safety and health and hygiene. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 23 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 1 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 1 N/A 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 x 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 130 Station Road Score 2 3 1 2 Standard No 37 38 39 40 41 42 43 Score x 3 x x 2 3 x 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 1 Regulation 4 Requirement The home must have a written statement of purpose which must include matters listed in Schedule 1. A copy must be available on request for CSCI inspection. The manager must ensure that all care staff who handle medication are formally trained in medication management. All medication administration sheets must indicate any allergies the service users may have. All records must be accessible to the manager i.e. Pharmacy audit. All records must be accessible to the manager i.e. Pharmacy audit. All staff must receive formal training on adult protection and recognising abuse and neglect. Staff must be provided with facilities including a safe place to store personal belongings and sleeping facilities when sleepingin. Staff must be provided with facilities including a safe place to store personal belongings and Timescale for action 01/11/05 2. 20 13, 18 01/11/05 3. 20 13 07/09/05 4. 5. 6. 7. 20 41 23 38 17 17 18 23 01/11/05 01/11/05 01/11/05 01/11/05 8. 28 23 01/11/05 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 25 9. 10. 11. 12. 13. 28 38 34 34 36 23 23 12,19 12,19 18,19 14. 18 31,18 15. 28 23 sleeping facilities when sleepingin. There must be a private area for visitors, consultations and case reviews available in the home. There must be a private area for visitors, consultations and case reviews available in the home. All gaps in employment histories must be explored and reasons explained. The CRB check records of the employees must have the date of the clearance. Regular supervision of staff must take place i.e. at least six times a year. Staff must be trained to supervise and the written supervision records must be maintained by the supervisor. Staffing levels must be reviewed to reflect the management role and the required service user support . The manager must have an office within the house to perform him/her duties. 12/12/05 12/12/05 23.08.05 01/11/05 01/11/05 01/11/05 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 21 35 Good Practice Recommendations Care staff should receive formal training on palliative care, death and dying. The care staff should be helped by the organisation to achieve LDAF training. Both levels,2&3. 130 Station Road 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 Page 26 Commission for Social Care Inspection Ground Floor Unit 3 waterside Court Bold Street Sheffield S9 2LR 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 20050823 130 Station road X00023 UI Stage 4 S62845 V243430 J55.doc Version 1.40 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. 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