Inspection on 03/06/05 for 16 Mansfield Road

This inspection was carried out on 3rd June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

16 Mansfield Road 09/07/07

16 Mansfield Road 29/06/06

16 Mansfield Road 01/11/05

16 Mansfield Road 27/05/04

16 Mansfield Road 13/05/03

Similar services:

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

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

CARE HOME ADULTS 18-65 16 Mansfield Road Heanor Derby DE75 7AJ Lead Inspector Tony Barker Unannounced 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. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 16 Mansfield Road Address Heanor Derby DE75 7AJ 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) 01773 711270 United Response CRH 4 Category(ies) of LD registration, with number of places 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23/11/2004 Brief Description of the Service: This service provides accommodation for four younger adults with severe learning disabilities and associated conditions including autism, sensory disability and challenging behaviour. Four single bedrooms are provided in a detached house situated on a bus route near to the town centre of Heanor. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 5.0 hours and was a routine unannounced inspection. The last inspection took place in November 2004 and was announced. This inspection was the inspector’s first visit to the Home. The Manager and one other staff member were spoken to and records were inspected. Service users’ disabilities were such that they were unable to speak except on a single word level. However, they had varying degrees of nonverbal communication with the inspector. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. There was no tour of the premises at this inspection. What the service does well: What has improved since the last inspection? What they could do better: The Home had a written Statement of Purpose and written care plans for each service user but these documents still needed improvement. Property maintenance issues were still outstanding from the last inspection and must now be prioritised. The registered provider must ensure that the Acting Manager is made aware of changes to the Regulations that apply to staffing matters and that staff receive formal supervision at appropriate intervals. Most importantly, the registered provider must put forward a prospective manager for registration. Finally, some Health and Safety matters required attention to ensure service users’ welfare was addressed. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 6 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. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 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 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 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 The Home had a useful guide and statement of the services it provided. Service users’ needs were being used as a basis for individualised care provided by an experienced and competent staff group. EVIDENCE: There was a Service Users’ Guide and Statement of Purpose. The latter had still not been amended to reflect the recent changes to the management arrangements in the Home or contact details with the Commission for Social Care Inspection. The copy seen was not personalised to the Home in a number of places – making it look like a draft copy. There was no mention of the Commission in the complaints procedure section of the Statement of Purpose. Both documents incorporated pictorial symbols to make them more understandable to service users. All four service users were admitted from Morley Manor nine years ago when that establishment closed. Documents reflecting the admission process were not available at this inspection but previous inspections had identified good quality documentation. Many of the staff members had been employed working with adults with learning disabilities for more than five years. As there had been no turnover of service users during the Home’s nine year history staff had built up a significant range of skills to meet the needs of this group - which had high levels of need including some difficult and challenging behaviours. In 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 9 particular, the communication techniques that had been developed by staff were varied and included verbal and Makaton – a sign language used by several of the service users. The Acting Manager said that staff were proficient in this sign language. One service user’s specific cultural needs were met through periodic Caribbean meals and monthly church services. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 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 & 9 Staff were able to plan services for service users based on personal goals recorded on individual care plans. Service users were being supported to take risks as part of an independent lifestyle. EVIDENCE: Each of the four individual care plans were examined. Care plan objectives for staff to follow were clearly and comprehensively recorded and regularly reviewed. However, on one file there were no minutes of any overall care plan review meetings although staff notes produced for two such meetings, in the last two years, were on file. The Acting Manager said that review meetings should be held twice a year. As already mentioned, service users’ religious and cultural needs were recognised and being met but these were not reflected in care plan records. Care plans were still not presented in a style appropriate for service users’ individual needs. However, two service users had a brief Makaton (sign language) pictorial care plan displayed in their bedroom. Service users’ files each had a ‘Service User Information Sheet’ although many sections of these had been left blank. There was only one file with a 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 11 photograph of the service user in it and none had a record of the date of admission to the Home, as required by the Regulations. Care plans now included the preferred name of the service user but not of the key worker. The encouragement of independence was a key part of the Home’s philosophy. Written care plans did much to guide and support staff in appropriate behaviour management programmes. They contained comprehensive risk assessments for a wide range of activities with potential risk attached. Each file had a missing persons form completed. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 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, 13, 16 & 17 Service users’ personal development was being encouraged by the Home and their involvement in household routines reinforced this as well as reflecting needs often associated with autism. Service users were encouraged to be part of the local community. They were offered a healthy diet and mealtimes were an enjoyable occasion. EVIDENCE: Evidence was seen in care records of a broad and varied range of opportunities being made available to service users. Each service user was receiving one-toone staff support on one day each week – their ‘one-to-one day’ at the Home. Additionally, each service user attended local day services provision. Daily trips and local walks showed that service users were encouraged to be part of the community. Two service users enjoyed regular church attendance. Records confirmed that the development of service users’ skills, and activities focussed on individual needs, were a priority at the Home. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 13 Routines in the Home were structured to reflect the needs of the service users who had varying degrees of autism. All service users were involved in household shopping in local stores on one-to-one days and to varying extents in food preparation - according to their ability. Each of them cleared up after their meal. The Home provided a nutritious and varied menu to service users. The dining room was used for meals and the evening meal was seen to be a relaxed occasion. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 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) 20 Service users were being protected by the Home’s policies and procedures for dealing with medicines. EVIDENCE: Medication was being prescribed to all the service users – none managed their own medication. The storage, administration and recording system was satisfactory. One member of care staff said that PRN (as and when required) medication was just occasionally used by two residents – a good written policy on the use of PRN medication was seen. It was also stated that all staff had received medicine training from the Home’s pharmacist but records were not available to confirm this, as the Acting Manager had to leave before the end of the inspection. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 15 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 Procedures were in place to enable service users to make known their views and to protect them from abuse. Staff had the skills to appropriately manage any aggressive behaviour displayed by the service users. EVIDENCE: The Home’s complaints procedure was displayed and was well worded, with the use of suitable symbols. Just one complaint, by a neighbour, had been recorded - in 2003. The action taken had not been recorded. Discussion took place with a member of care staff about strategies to enable service users to make complaints if staff felt they were unhappy about something or someone. Appropriate written policies and procedures, relating to the protection of service users from harm, were seen and provided staff with a good level of understanding. Staff were attending SCIP training annually: this provided staff with skills to appropriately manage aggressive behaviour in adults with learning disability. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 16 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 & 30 Matters were still outstanding from the previous inspection that meant the Home fell short of providing a comfortable and safe environment for service users. However, a generally positive assessment of the Home’s environment had been made at previous inspections. EVIDENCE: A full tour of the premises was not made at this inspection. However, the Acting Manager confirmed that window replacements were planned. The two bathrooms had not been redecorated, although the timescale of 30 June 2005 had not been reached at the time of this inspection. It was still unclear whether the Home was complying with the Water Supply (Water Fittings) Regulations, 1999. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 & 36 The Home was not fully protecting service users by means of staff recruitment practices. Service users were not, at the time of this inspection, benefiting from well-supported and supervised staff. EVIDENCE: The Home’s staff recruitment policy and procedure was not examined at this inspection. However, the Acting Manager was not aware of changes to Schedule 2 of the Regulations and therefore could not ensure that a thorough recruitment procedure was in place. At a previous inspection it had been noted that United Response operated an extensive selection and recruitment system that was detailed in a personnel manual retained at the Home. The Acting Manager was not aware of changes to Schedule 4 of the Regulations - regarding the maintenance of a record of all staff training undertaken. The staff training file was, later, not available as the Acting Manager had to leave before the end of the inspection. It was therefore not possible to confirm whether these records were being kept. One member of care staff reported that all staff had received Learning Disability Award Framework (LDAF) accredited training, including induction and foundation training. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 18 One member of care staff confirmed that staff supervision was being provided every two months until the registered manager left in October 2004. She had last had a supervision session in January 2005. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 37 & 42 Service users were not being afforded full protection of their health, safety and welfare. EVIDENCE: The Home was still without a registered manager. A senior care assistant had been given ‘special responsibilities’ to manage the Home pending the current Acting Manager starting in post at the end of April 2005. This manager’s qualifications, competence and experience were not assessed at this inspection. She had not yet been through the manager registration process although this was planned. Recorded refrigerator and freezer temperatures indicated problems with maintaining food safely. Recommendations made by the Environmental Health Officer had still not been complied with. No timescales had been given by the EHO. Other Health and Safety matters were not assessed at this inspection. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 20 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 2 3 3 x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 3 x 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 16 Mansfield Road Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 21 YES 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 1 Regulation 4(1)(c) Sch 2 Requirement The registered person must amend the statement of purpose to reflect the proposed changes in management arrangements at the home and include reference to the contact details of CSCI. (Previous timescale was 31/1/05) The Statement of Purpose must reflect the actual services of this Home and must include reference to the CSCI in the complaints procedure section. Care plans must be reviewed on a regular basis with a twice annual frequency being the target. Care plans must be holistic in nature - taking account of all of a residents individual needs. Each service user’s plan of care must be recorded in a language and format suitable to each individual and the relevant service user must hold a copy. However, if this is inappropriate a copy should be given to the family/professional representative to sign. The Manager must record the reason for this within the care plan (in a Timescale for action 1 October 2005 2. 1 4(1) 1 October 2005 3. 6 15(2)(b) 1 August 2005 1 November 2005 1 November 2005 4. 5. 6 6 15(1) 15(1) & (2)(a) 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 22 6. 6 17(1)(a) Sch 3.2 & 3.3(d) 7. 8. 9. 20 22 24 13(2) 17(2) Sch 4.11 23(2)(b) 10. 11. 24 30 23(2)(b) 13(4)(c) 12. 34 19(1)(b) Sch 2 (revised) 13. 35 17(2) Sch 4.6(g) (revised) 14. 36 18(2) 15. 37 8&9 revised front sheet). (Previous timescale was 31/1/05) The date of admission to the home and a recent photograph of the service users must be included in all of the individual care records. (Previous timescale was 31/1/05) Staff must be provided with periodic accredited training on the use of medicines The action taken by the registered person, in respect of a complaint, must be recorded. Internal paintwork on bedroom windows must be repaired. (Previous timescale was 31/1/05) Both bathrooms must be redecorated (Previous timescale was 30/6/05) The Responsible Persons must ensure that the Home complies with the Water Supply (Water Fittings) Regulations of 1999. (Previous timescale was Ongoing) The registered person must audit all staff files against the recently changed Regulations and Schedules and ensure that the contents are as required. (Previous timescale was 28/2/05) The registered person must audit all staff files against the recently changed Regulations and Schedules and ensure that the contents are as required. (Previous timescale was 28/2/05) The registered person must ensure that all staff are appropriately supervised at least six times a year. The registered person must appoint to the vacancy of manager and that person must 1 September 2005 1 October 2005 1 August 2005 1 October 2005 1 November 2005 1 October 2005 1 November 2005 1 November 2005 1 September 2005 1 October 2005 Page 23 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 16. 42 23(5) 17. 42 13(4)(c) 23(5) apply to be registered with the CSCI. (Previous timescale was 31/3/05) Compliance with the requirements of the report from the Environmental Health Officer must be achieved. (Previous timescale was 31/1/05) The working temperature of the Homes refrigerator and freezer must be within safe limits as directed by the Environmental Health Officer. 1 November 2005 1 September 2005 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 5 Good Practice Recommendations Details of contracting arrangements relating to the service users’ accommodation, including individual terms and conditions of residence should be placed in the service users own room within a copy of the service users guide. (This previous recommendation was not assessed) The registered person should redevelop the front information sheet included in care planning documentation. This should include statements about elements of the NMS that have not been carried out due to unsuitability or service user incapacity. (This was a previous recommendation) The name of the keyworker should be recorded within the plan of care. (This was a previous recommendation) The registered person should indicate in care records why individual bedrooms had not been fitted out and furnished to the standard (revised front sheet). (This previous recommendation was not assessed) 2. 6 3. 4. 6 26 5. 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 16 Mansfield Road C52 C02 S20050 16MansfieldRoad V231238 030605 Stage 4.doc Version 1.30 Page 25 - 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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