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Inspection on 18/07/05 for 155-157 Upperton Road

Also see our care home review for 155-157 Upperton Road for more information

This inspection was carried out on 18th July 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There are excellent outcomes for service users at Upperton Road. Service users are clearly encouraged and supported to make decisions and take an active role in the running of the home. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. The staff team are well trained and supported ensuring an excellent service for service users.

What has improved since the last inspection?

Work is currently being completed to ensure the home complies with the recommendations made by a fire officer at the beginning of the year.

What the care home could do better:

The Registered Manager should ensure that all staff complete training for epilepsy.

CARE HOME ADULTS 18-65 155-157 Upperton Road Leicester Leicestershire LE3 0HF Lead Inspector Jo Vyas Unannounced 18 July 2005 at 12:30pm th 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. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 155-157 Upperton Road Address Leicester Leicestershire LE3 0HF 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) 0116 2547706 H2043@mencap.org.uk Royal Mencap Society Mrs Sharon Mary Brealey Care Home 8 Category(ies) of LD Learning disability (8) registration, with number of places 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 11th January 2005 Brief Description of the Service: The home is located in two connected terraced houses in a popular residential area in Leicester. The home can accomodate up to eight service users with a learning disability. The home is pleasantly decorated throughout and service users’ rooms are extensively personalised with belongings and décor. Service users benefit from easy access to a range of local facilities such as parks, pubs and shops. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the CSCI is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion with them, and their relatives, care staff and observation of care practices. This unannounced inspection took place between 12:30pm and 3:30pm and was carried out as part of the annual plan of inspection. Planning for this inspection included reviewing the previous inspection report. During the inspection, residents showed the inspector their bedrooms and care records were inspected. Two care files were viewed. The inspector spoke to and observed the practice of staff and spoke to most of the residents living in the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) none These standards were not inspected on this occasion. EVIDENCE: 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 Good systems are in place to ensure service users are consulted in all aspects of their lives, enabled and supported by staff and advocates, to meet their individual needs and choices in order for them to achieve independent lifestyles. EVIDENCE: • Service users have comprehensive Person Centred Plans although these do not offer enough detail for one service user with a serious health problem. Staff the inspector spoke to were competent in their knowledge of all the care needs for service users living in the home. Staff were competent in their knowledge and understanding about how each person communicates. One member of staff was observed using the British Sign Language with a service user who is deaf. Another was observed giving time to a service user who has a stammer to enable them to communicate effectively. Service users had comprehensive risk assessments most of which were regularly reviewed. C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 9 • • 155-157 Upperton Road 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 Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: • • • Service users attend day services and colleges. One service user very proudly spoke about the work he does at the day service he goes to. Staff were observed interacting with residents positively, with respect and upholding their dignity. Service users had free access to the kitchen and helped themselves to drinks if they were able. Meals were varied and planned by service users a week in advance. A member of staff explained that service users take it in turns to do the weeks shopping. Evidence was seen of service users accessing the local community i.e. shops and the park also visiting the theatre, the cinema and the church. At home service users watch TV, listen to music and relax. Staff encourage and facilitate family/friends contact. At the time of inspection, two service users were on holiday and two service users were on a day trip to Skegness. C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 10 • • • 155-157 Upperton Road 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 There are excellent levels of personal and healthcare support for service users. EVIDENCE: • • • Personal support is detailed in the Person Centred Plans. Service users are registered with a GP and have access to the appropriate healthcare professionals as required. Healthcare monitoring sheets are used to record all healthcare visits. Medication was received, stored, handled and disposed of appropriately. Staff have received medication and first aid training. Staff were competent in their knowledge of the medication they were dispensing. A member of staff stated that they are moving medication into service user rooms to enable supported self-medication. The inspector thought this was a positive move and should be commended. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The inspector was satisfied that the home responds to complaints and concerns effectively and that residents are safe from abuse or neglect. EVIDENCE: • • • The complaints procedure is posted on service user notice boards and staff stated that all service users have received a booklet on how to complain. A member of staff the inspector spoke to was competent in their knowledge of adult protection procedures. A member of staff explained the service user financial procedures which were robust. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 Upperton Road provides service users with a safe and comfortable place to live. EVIDENCE: • • • • • The home was clean and well maintained. All bedrooms are single and are highly personalised. There are sufficient toilets and bathrooms. Communal areas are bright and homely. The home is well maintained and decorated. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 13 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) 33, 35, 36 The deployment, number, support and training of staff is sufficient to meet the needs of the service users. EVIDENCE: • • • There are normally two staff on each shift during the day, one person in each house, and one staff who sleeps over night but is available if service users need them. Staff stated that they receive a comprehensive induction package called the Mencap Learning Programme, which staff are expected to complete in their first six months of employment. Currently, four staff are working towards a National Vocational Qualification level two. Staff receive a comprehensive training package, however, a member of staff stated that staff had not received any training on epilepsy, although this member of staff was competent in her knowledge. A member of staff stated that she receives one to one supervision with the Registered Manager every month and a staff meeting is also held monthly. • 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 14 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, 39, 41, 42 The staff team benefits from good management, leadership and direction from the Registered Manager, which ensures service users receive consistent, quality care. Service users are protected by good health and safety procedures. EVIDENCE: • • • • The management approach of the home is open and positive. The inspector noted that there were good relationships between service users, staff and the Registered Manager. Health and safety records were accurate and up to date. Service user records are organised, well presented and up to date. Regulation 26 monitoring visits are carried out by the Responsible Individual monthly and reports are submitted to the Commission for Social Care Inspection. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 15 • It was evident at this Inspection, through conversations with residents and staff that feedback about how the home is operating is sought and discussed on a regular basis. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 16 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 x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 4 4 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 4 4 4 4 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 2 4 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 155-157 Upperton Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x 3 3 x C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 17 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. 1. Standard Regulation none 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. 1. Refer to Standard 35 Good Practice Recommendations It is recomended that all staff receive training on epilepsy. 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX 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 155-157 Upperton Road C51 C01 S6367 155-157 Upperton Rd V239923 180705 Stage 4.doc Version 1.40 Page 19 - 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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