Inspection on 10/11/05 for 23 Mount Pleasant

This inspection was carried out on 10th November 2005.

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

23 Mount Pleasant 08/06/07

23 Mount Pleasant 06/11/06

23 Mount Pleasant 13/07/05

23 Mount Pleasant 15/10/04

23 Mount Pleasant 04/06/04

23 Mount Pleasant 05/02/04

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 23 Mount Pleasant, Chesterton Newcastle Staffordshire ST5 7LH Lead Inspector Ms Wendy Jones Announced Inspection 10th November 2005 1.45pm 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 23 Mount Pleasant, Address Chesterton Newcastle Staffordshire ST5 7LH 01782 565437 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) Choices Housing Association Limited Ms Susannah Jane Chard Care Home 8 Category(ies) of Learning disability (8), Physical disability (4) registration, with number of places 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: 23, Mount Pleasant is registered to provide care for eight adults with a learning disability, four of whom may have a physical disability. This is one of a group of homes managed by the Choices Housing Association that is based in North Staffs. This accommodation is purpose-built and situated on two levels. Each level provides a self-contained unit, which accommodates four service users. Access between the two floors is via a staircase. The ground floor comprises of four single bedrooms, spacious lounge, spacious kitchen/diner, assisted bathroom, separate toilet and laundry. The first floor comprises of four single bedrooms, spacious lounge, spacious kitchen/diner, assisted bathroom, separate toilet and an office, which also serves as the staff sleep-in room with en-suite facilities. The grounds are compact but well-maintained, with a private and enclosed patio area to the rear accessible to all service users. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out on 10th November 2005. Information for the report was provided from a completed pre-inspection questionnaire; from service users and relatives feedback; from discussion with 4 service users and staff; from observation of interactions; from inspection of care records and other relevant documentation and the physical environment. Service users residing in the ground floor flat have severe to profound learning disabilities and are unable to mobilise independently and they require staff assistance to meet all their personal care needs. Service users living in the first floor flat are relatively independent, requiring prompts and emotional support and guidance to enable them to live as independently as possible. What the service does well: 5 positive feedback forms were received, 1 was mixed and issues raised were discussed and resolved during this visit. The service has a statement of purpose and service user guide, which provide accurate information about the aims of the service, the facilities available and the skills and experience of the staff team. Care plans and life plans were reflective of the assessed needs of service users and were subject to regular review. It was evident that service users were involved in the care planning process. Behavioural management strategies had been developed based upon principles of recognised good practice. Service users’ personal and health care needs were being appropriately met, with evidence in health action plans of attendance at routine health appointments. There was evidence of good relationships between staff, management and service users. Procedures were in place for the protection of vulnerable adults and service users spoken to during this visit knew how to complain. All bedrooms were for single occupancy and exceeded the minimum standard. Communal space was adequate for the needs of service users; each flat had a comfortable and pleasantly decorated lounge and a separate kitchen/dining room. Staffing levels, training and frequency of supervision was good, with evidence provided of good induction procedures and outcomes. By the end of the inspection year the service will have 50 of the workforce trained at NVQ level 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 6 2. The manger and her deputy have both achieved the Registered Care Manager’s award. Recruitment records were of a good standard, with evidence that appropriate checks had been carried out. 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. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. The home’s Statement of Purpose and Service User Guide were good, providing service users and prospective service users with details of the services the home provides, thus enabling an informed decision about admission to be made. EVIDENCE: The service had a Statement of Purpose and Service User guide. A review of both documents was reported to be underway by the organisation. Service users would be involved in this review. The Statement of Purpose identified the service philosophy, aims and objectives. The Service User guide was in a user-friendly format, and contained a summary of the Statement of Purpose, details of the terms and conditions of residency and a summary of the complaints procedure. A sample of care records provided evidence that service users were supported to visit the service on a number of occasions prior to making a decision to move into the home. The trial visits would provide staff and service users alike to assess compatibility and suitability of the placement. Based upon the pre-admission assessments seen, it was evident that the service was able to meet the needs of service users. The manager expressed some concern that pre-admission information provided for one service user may not have presented an accurate representation of his ability. This issue 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 9 was being discussed with relevant social services and health professionals and would be subject to further review. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 the following standard(s): 6,7,9 and 10 Care plans were reflective of the assessed needs of service users; there was evidence of regular reviews. EVIDENCE: A sample of care records showed a good standard, and regular reviews of care. Each service user has support plans and risk assessments. A very detailed 24hour plan of care provided staff with explicit guidance and information about the usual routine and care needs of the individual. Where a care need had been identified, a support action plan had been introduced. Formal 6-monthly reviews of care were undertaken and more frequent 6-weekly key worker/ service user reviews were undertaken. There was evidence of service user involvement with care planning and one service user confirmed that he had signed and agreed his care plans. Behavioural management plans had also been developed and advice sought from independent psychology and behavioural services. Staff have received training in the proactive management of behaviours, and focussed on redirection, de-escalation and diversional techniques. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 11 The recent escalation of challenging behaviour of service users was discussed, and the inspector was satisfied that the manager was managing the situation appropriately, seeking advice from other professionals about behavioural management strategies. Care records and confidential information was stored in the staff room/sleep-in room when not in use. The service has access to information procedures and complies with Data protection legislation. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 the following standard(s): 12,13,15,16,17. Service users are supported to access a range of social, recreational, and occupational activities, to promote links with the local community. Dietary needs of service users were well catered for, with a varied selection of food available that met service users’ tastes and choices. EVIDENCE: Evidence from records seen and from discussion demonstrated that service users were supported to access appropriate activities outside of the home. Service users had weekly timetables which provided a guide for them and staff. A newer service user attended college once a week, and had a number of social activities built into his weekly timetable. The participation options records in the home provided an audit trail for the manager to monitor the number of activities provided for each individual and the quality of the activity provided. It was hoped that he would be able to access more structured activities in future months. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 13 Another service user worked with the organisation maintenance team and also had a voluntary job. Two service users attended specialist day services between Monday and Friday each week. There was evidence provided of regular contact with families and friends, service users were supported to undertake visits, or receive visitors in the home. Key workers also supported service users to correspond with relatives periodically. Mealtimes are flexible, dependent on service user routines and commitments; a choice of meal is available for all meal times, and a record of food provided for each service user is maintained. Specialist dietary needs of service users were known and recorded; there was evidence of dietetic input and advice. Service users are included in choosing menus, planning and going shopping for food, particularly on the first floor. This service user group were more independent and able to access and use the kitchen without minimal support. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 the following standard(s): 18,19,20 The personal and health care needs of service users were well met, providing a positive outcome for service users. The medication at the home was well managed, promoting good health. EVIDENCE: All service users have a learning disabilityand four have additional physical disabilities, requiring assistance with all of their personal care needs, including dressing, toileting, help with meals, bathing and washing. Two service users have hearing impairments and six have some degree of visual impairment. Four service users have difficulties with communicating effectively and have limited verbal communication skills. Three service users have autistic tendencies or have a diagnosis of autistic spectrum disorder. One service user has recently developed links with the National Autistic Society. Health issues were recorded and appropriate action taken to monitor them and to ensure that treatment was received and kept under regular review. Preventative health appointments are arranged and 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 15 service users also receive regular specialist health care input from dietetics, behavioural specialist as required, epilepsy specialists and a physiotherapist. Medication records were appropriately maintained and certificated staff training was provided by Boots chemist. Most of the staff had received the training; others were scheduled to undertake it. Staff receive an assessment of competence before they administer medication. Records of medication received and returned were maintained. One service user was being supported to self-medicate. Protocols for as-required medication were satisfactory. The temperature of the medication storage facility was being monitored. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 the following standard(s): 22, 23 The home has a satisfactory complaints system, with evidence that service users feel that their views are listened to and acted upon. Arrangements for protecting service users were satisfactory, protecting them from the risk of harm or abuse. EVIDENCE: No complaints have been received by the home or have been referred to the Commission for Social Care Inspection. Service users spoken to do not have any concerns about the care or service they received and knew to whom they should go if they had any concerns. The complaints procedure was included in the Service User guide and Statement of Purpose, in a pictorial, user-friendly format. The manager stated that all mandatory training, including Vulnerable Adults training, was up-to-date. Procedures for the protection of service users were in place and a confidential reporting procedure based upon Public Interest Disclosure Act was in place. One service user has been admitted to the accident and emergency department of the local hospital since the last inspection. No Vulnerable Adults investigations have been undertaken at this home in the last 12 months. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 the following standard(s): 24, 26, 27, 30 The standard of the environment within this home is good, providing service users with an attractive and homely place to live. EVIDENCE: This inspection did not include a detailed inspection of the environment. The home appeared clean, tidy and well maintained throughout. Some redecoration of the communal areas in the home has taken place since the last inspection and double-glazing had been replaced throughout. Plans for the future included the refurbishment of the ground floor bathroom and both kitchens. All bedrooms were for single occupancy and exceeded the minimum standards in terms of size. One service user asked to have a key to his bedroom door; other service users on the first floor had their own keys. A problem had occurred with a service user accidentally walking into an occupied bathroom. The door had a privacy lock in place. It was suggested that an additional visual reminder could be provided to alert service users that the bathroom was engaged or vacant. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 18 The ground floor laundry room is awaiting some work outstanding since the last inspection. The work is necessary to replace wall tiles and to reorganise it to provide better storage. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. After a period of instability in staffing, there is now a good match of wellqualified staff offering consistency of care within the home. The standard of vetting and recruitment practices is good, with appropriate checks being carried out to ensure service users are not placed at risk. EVIDENCE: Staffing levels on the day of the inspection included: manager from 8.30am, 3 support workers from 7.30am-3pm, 2 staff from 2.30pm-10pm and 1 member of staff from 4.30pm-11pm sleep-in. The reported weekly hours were 541.5 per week, inclusive of a 5 percentage for sickness and annual leave. Actual hours provided were 478 per week as there was a 30-hour staff vacancy. A sample of recruitment files provided evidence that satisfactory recruitment procedures were in place. One member of staff gave a very satisfactory account of her induction and the support she had received at the home, confirming that she had received regular one-to-one supervision sessions. Two staff have left the service since the last inspection, no-one has been dismissed and the agency/bank staff usage recorded in the eight weeks prior to the inspection was 35 hours. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 20 The manager confirmed in the pre-inspection questionnaire and during conversation that mandatory training was up-to-date for all staff. Fourteen staff were employed at the home: six had achieved NVQ level 2, two were undertaking the training and one was waiting for certification. Three of the six undertaking the training were predicted to complete it by the end of November 2005. Information provided in the pre-inspection questionnaire included evidence that servicing of equipment and necessary health and safety checks were routinely carried out. Policies and procedures required by regulation were in place. Relevant procedures have been produced in user-friendly formats for the benefit of service users. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 The manager has a clear development plan and vision for the home, which she has effectively communicated to the service users, staff and relatives. She is supported by her senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The manager and her deputy are qualified nurses and have completed the Registered Managers Award. Policies and procedures are reflective of those required by regulation. Records showed that very regular fire drills were undertaken, with staff and service user names recorded. Weekly fire alarm tests were carried out and a record maintained. Monthly fire equipment checks were also recorded, and fire training had been carried out on annual basis. The staff also carried out additional daily visual health and safety checks. Service users gave a 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 22 satisfactory account of the fire evacuation procedure. Action to address crumbling tarmac discussed at previous inspection, which presented a possible trip hazard, was awaiting action by the organisation. Monthly visits to the home and reports on its conduct are undertaken by a representative of the organisation and copies of these reports are forwarded to the Commission for Social Care Inspection. Service users required varying degrees of support with the management of their personal allowances. These records were not inspected during this visit. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 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 3 3 3 X X Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X 3 3 X X 4 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 23 Mount Pleasant, Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 4 X 3 3 X 3 x DS0000004983.V259100.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation 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 2 3 Refer to Standard YA27 YA24 YA42 Good Practice Recommendations Consider the provision of a visual reminder to service users that the bathroom is occupied or vacant. The missing tiles in the laundry should be replaced, to improve the appearance of this area and improve the storage facilities. Thre organisation should carry out the work necessary to the crumbling tarmac in the grounds of the home. 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 23 Mount Pleasant, DS0000004983.V259100.R01.S.doc Version 5.0 Page 26 - 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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