Inspection on 11/12/06 for 23 Cecil Road

This inspection was carried out on 11th December 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

23 Cecil Road 27/08/08

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 23 Cecil Road 23 Cecil Road Dronfield South Yorkshire S18 2GW Lead Inspector Ivan Barker Key Unannounced Inspection 11th December 2006 09:30 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23 Cecil Road Address 23 Cecil Road Dronfield South Yorkshire S18 2GW 01246 291673 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) Milbury Care Services Mr Nicholas James Butcher Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Milbury Care Services is a subsidiary company of Paragon Healthcare Limited to be registered to operate a service namely 23 Cecil Road, Dronfield as a care home providing personal care for up to 6 service users of both sexes under the category Learning Disability under 65 (LD under 65) To admit one named service user aged 17 years to reside at 23 Cecil Road under the category LD 16-17 years The maxim number of service users to be accommodated at 23 Cecil Road, is 6 N/A 2. 3. Date of last inspection Brief Description of the Service: The home is a converted building situated in the village of Dronfield, which is on the boundary of Derbyshire and South Yorkshire. It consists of a lounge, dining room, kitchen, activity rooms and office on the ground floor, with bedrooms and bathrooms on the 1st and 2nd floors. The home does not have a lift facility. The fees for the home are not set at a minimum or maximum, but each individual service user has a contract with specific costs to met their assessed needs. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’). The person present at the inspection was: Mr N Butcher, manager. Pre inspection work was undertaken prior to the inspection. Then within this inspection, which occurred over a four and a half hour period, the inspector toured the building, examined documentation and spoke with service users, staff, and manager. As part of the inspection process, the method of case tracking was used. This means that specific service users were selected as part of the process and their care and service provision examined, and their views sort. What the service does well: What has improved since the last inspection? What they could do better: The home had been registered for 5 months and had made considerable effects ‘too get things right’, and the service users were satisfied with their care, and the staff proud of their achievements. However to achieve so much in the first 5 months the medication training had been an ‘oversight’, which the inspector has confidence that it will be addressed as a matter of urgency. Regarding the repairs to the home the inspector understands that the system for repairs to occur is to inform head office who ‘source out’ the repair to certain companies as required. The company should review this practice, as often repairs need to be undertaken within short time scales. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 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 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ needs were being assessed prior to the admission. Comprehensive documentation and the recording of information will ensure that each member of staff will be aware of the service users needs prior to admission. EVIDENCE: At the time of the visit, three service users were residing within the home. Two service users were at the home, one was at college. The two at the home were case tracked. The manager advised the inspector that, the Company employ Senior Case Planners to ‘source’ potential clients, who undertake an initial assessment. The person is then referred to the appropriate service within the Milbury organisation. At this point the manager of the home would undertake his assessment to establish if the home could meet the clients needs. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 9 The inspector examined the documentation provided by the manager and found it to be quite extensive. Each assessment, which identified the service users needs, was converted into a specific contract for that individual. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Accurate, up to date care plans will assist the staff to deliver a good standard of care to service users. EVIDENCE: On examination of the care plans the inspector found that the care plans were extensive and details all aspects of the care needs of the individual. These included the required social, mental and physical interventions. The plans were up to date and reviewed at regular intervals. The daily entries within the plans recorded a considerable amount of information that would assist with the re-evaluation. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 11 For example: This included their social interaction for that day, but also included medical conditions, (seizures) which an individual had suffered. The service users who spoke with the inspector had limited ability to express themselves, however the inspector established that they were satisfied with their care. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The availability of activities and outing and the participation within the selection and preparation of meals will enhance the service users’ quality of life. EVIDENCE: The inspector was shown evidence of activity programmes for each of the service users. The latest plan was for the previous week and not for the current week. The manager apologised that plans had not been produced for the current week, but identified that it was ‘only Monday morning’. The inspector identified that there was a considerable number of ‘blanks’ within the programmes and the manager agreed that activities was an area, which required ‘more work’. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 13 The home had a 7-seater vehicle, which was available for service users. The manager identified that service users contributed to the vehicle costs through their individual contract payments. Regarding the meals, the manager informed the inspector that staff and service users eat together at the dining table. He went onto inform the inspectors that, at the Sunday Lunch the meals for the following week were discussed and a shopping list drawn up. Staff and service users then shopped for the meals on a Monday. The inspector examined the menu which was displayed in the kitchen, which was accessible to service users. The meals were varied from Pizza to a Sunday roast. Service users were also involved within the kitchen and helped to cook and to prepare the meals. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff who administered medications, without the necessary training could place the service users at risk, as they would not be aware of how to recognise and deal with problems. EVIDENCE: The service users had the opportunity to access the primary care facilities, which included GP and dental services etc. The medications were stored within metal cupboards within the office. The office could be locked when the room was left unattended. The administration of medication was through the ‘Boots’ system. The medication administration records were pre printed and all the administration boxes were signed. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 15 On discussing the care staff training on medication, the manager and staff informed the inspector that only some staff had received medication training, yet all staff were administering medications. The inspector informed the manager that only staff, who had received the necessary training should administer medications. It was agreed that staff who had receive training would administer the medications and training for the other staff would be undertaken as a matter of urgency. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A Complaints procedure and Safeguarding Adults procedure was in place. Staff had received Safeguarding Adults training. These will allow service users to be supported and protected. EVIDENCE: The complaints procedure was printed within the service user guide. A copy of the guide was attached to the notice board. The inspector, when monitoring the environment observed that there was a service user guide within each of the bedrooms. The manager discussed the complaints procedure with the inspector and identified that the complaints were all held at head office, although he was aware that within the 5 months of registration there had been no complaints regarding the home, lodged at head office, as this would be raised on the monthly audits by the region manager. The benefits of analysing complaints, as part of the quality assurance monitoring, were discussed. The manager informed the inspector that following these discussions a ‘ local complaints record would be useful’. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 17 Regarding Adult protection, the inspector examined the training records of staff and observed that some staff had attended Adult Protection training, and the new staff were booked onto a course in January 2007. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment, monitored at this inspection, had been maintained to the required standard to provide a generally well-maintained environment for services users. EVIDENCE: The home was clean and well decorated and odour free. This would reflect that the home had only been registered for 5 months. On touring the building the inspector observed that the 3 rooms, which were occupied by service users, had been personalised by pictures, posters and included items, which would be in a younger persons room i.e. stereo etc. On discussing the bedrooms with the service users, they informed the inspector that they were satisfied with the current décor, and furnishing and 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 19 identified that they were able to exercise a choice regarding the décor and furnishings. The inspector observed that one of the banister rails was missing near the top of the stairs. This had created a gap approximately 15cm, which would be large enough for a small child to fall through. However it should be recognised that at the time of the visit, no small child was at the home, or service user to crawl through. The manager advised the inspector that the repair had been identified and reported to head office, the previous Thursday 7th December. This repair needs to occur as a matter of urgency. Regarding the repairs to the home the inspector understands that the system for repairs to occur is to inform head office who ‘source out’ the repair to certain companies as required. The company should review this practice, as often repairs need to be undertaken within short time scales. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The robust staff recruitment process regarding the checking of staff will contribute toward the protection of service users. EVIDENCE: On duty at the time of the visit was: The manager and 2 care staff. The deputy manager came on duty mid morning to participate in a review of a service user’s care. On examination of the rota it was established that the staffing was as follows: A.M. P.M. N. 23 Cecil Road 2 care staff 2 care staff 1 care staff and 1 waking care staff. DS0000067816.V323497.R01.S.doc Version 5.2 Page 21 The manager was supernumerary for 3 shifts a week. On examination of the staff training records, the staff had received training in fire, moving and handling and other training, but not medication training as raised within a previous section of this report. On examination of 2 staff files, the inspector established that the files contained all the information required within Schedule 2, except that one member of staff had a POVA check, but no Criminal Records Bureau check. It was established by speaking with the manager and the member of staff that the member of staff had worked at the home for 2 weeks and had completed the Criminal Records Bureau application form and was currently being supervised within the home, as required by the legalisation, until a satisfactory check is obtained. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and extensive quality assurance systems were in place that should assist the manager and owners to measure the home against expected outcomes and ensure that service users benefit from a well managed home. EVIDENCE: The Manager had undergone the fit person process as part of the registration. He was a registered Learning Disability Nurse. The inspector asked the manager when he would be commencing the NVQ 4 qualification training. The manager advised that his managers had discussed it, but he was unable to offer any dates. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 23 The inspector was able to speak with the regional training officer, who was contacted by the manager. He advised the inspector that he was currently in negotiations with some training companies, but the intention was for the manager to commence onto the NVQ 4 / Registered Managers Award in February 2007. The inspector accepted this date. Regulation 26 notices were completed, and sent to the CSCI. Monthly quality assurance audits had occurred, unfortunately the records showed a brief summary of the findings rather that what had been monitored. The manager informed the inspector that he would ensure that a copy of the monitoring tool would be available for the next inspection. The manager and staff held Service User meetings on a regular basis, and minutes were recorded. The last meeting was on The 8th December 2006. Copies of these minutes were displayed on the notice board. 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 25 N/A 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 YA20 Regulation 18 Requirement The registered person must ensure that staff administering medications have required the required training. The registered person must ensure that repairs are untaken to maintain a safe environment. Timescale for action 11/01/07 2 YA24 23 11/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 23 Cecil Road DS0000067816.V323497.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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