Inspection on 13/07/05 for 23 Mount Pleasant

This inspection was carried out on 13th 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.

Other inspections for this house

23 Mount Pleasant 08/06/07

23 Mount Pleasant 06/11/06

23 Mount Pleasant 10/11/05

23 Mount Pleasant 15/10/04

23 Mount Pleasant 04/06/04

23 Mount Pleasant 05/02/04

Similar services:

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 Wendy Jones Unannounced 13 July 2005 11:30am 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. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 23 Mount Pleasant Address Chesterton Newcastle Staffordshire ST5 7LH 01782 565437 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) Choices Housing Association Limited Ms Susannah Jane Chard Care Home 8 Category(ies) of 8 LD registration, with number 4 PD of places 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 15 October 2004 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 v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 13 July 2005; information for this report was provided from discussion with staff; from conversation with service users; from observations of service user and staff interactions; from inspection of the physical environment on the ground floor and inspection of care records and other documentation. Service users residing in the ground floor flat have severe to profound learning disabilities and are unable to mobilise independently, 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. At the time of this visit, two service users were at day services, one service users was in hospital, one service user was working (a voluntary position), another had attended a college placement. There were three service users in the home. What the service does well: The service operates a Person centred approach to care. Care plans were in place to address any assessed area of need. Staffing levels were adequate to meet the needs of service users, the standard of staff training was good, with evidence provided that staff had received mandatory training and planned were in place to access supplementary training appropriate to the service. Staff confirmed that they had received a good induction and felt supported by the more experienced staff team. Menu’s showed a healthy choice of food; fridge and freezer temperatures were recorded daily; food stocks were good. Service users health and personal care needs were appropriately met. Records showed that service users were supported to attend appointments with G.P’s and other health professionals. Medication records were appropriately maintained. All bedrooms were for single occupancy and exceeded the minimum standard of 10sq metres. 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. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 6 Records relating to fire safety were appropriately maintained risk assessments were in place and had been subject to regular reviews. Health and safety audits of the service were carried out regularly and monitored monthly. 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 v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The homes Statement of Purpose and Service User Guide were good providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: The service is registered to provide care and accommodation to up to 8 service users who have learning disabilities. The service is divided into two flats, the ground floor flat provided accommodation for service users who have physical disabilities and is adapted to meet their needs. The first floor flat provides accommodation for four service users who are physically able and require less support. A Service User Guide was included in the care records of service users and was in a format that was user friendly. It provided service users with good information about the service and its staff and staff skill mix. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 9 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. Care plans were reflective of the assessed needs of service users; there was evidence of regular reviews EVIDENCE: The service operated a Person Centred approach (PCP) to care, which sought to establish the wishes and aspirations of each service user, from which staff developed care and action plans to ensure that the needs of service users were met. The model of care followed principles that promoted independence and involvement of service users. There were monthly reviews of care plans, key workers met with the manager or senior staff to assess the effectives ness of plans and a formal 6 monthly review of the PCP was undertaken. The evidence of the records showed that regular monitoring and reviews were undertaken. Each service user was allocated a key worker who supported them to make decisions about their lives, and supported them to maintain contact with family and friends. Risk assessments formed part of the action plans developed from the PCP and as with the care plans were reviewed regularly. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 10 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) 17 Dietary needs of service users were well catered for with a varied selection of food available that met service users tastes and choices. EVIDENCE: Service users residing in the ground floor flat required staff to prepare and cook their meals and require assistance at meal times. Food choices are provided by staff providing a choice of meals, picture referencing or trial and error, based upon the staff’s knowledge of service users dietary likes and dislikes and special requirements. Service users on the first floor were more able to make more informed choices and participated in selection and food preparation. They were observed to freely access the kitchen to make drinks and snacks. Records of meals provided indicated that service users were provided with a varied diet and had access to healthy choices. The records also showed that on occasion’s meal choices were unnecessarily repeated, it was suggested that 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 11 staff check the previous day’s meals to ensure that this did not happen on a regular basis. Staff had been trained in basic food hygiene, records of daily fridge, freezer and hot food temperatures were maintained. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 12 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) 19,20. The health care needs of service users were well met; access to health services was facilitated by staff to ensure appropriate health monitoring and treatment. The medication at the home was well managed promoting good health. EVIDENCE: The health care needs of service users were appropriately met; the records showed that service users were supported to attend health related appointments. There was evidence in the records seen that service users health care needs were monitored and action taken by referral to the relevant health professionals. Tracking of care practice evidenced that appropriate action had been taken to ensure that a service users health care needs had been properly investigated. The records for the administration of medication were appropriately maintained; with evidence of staff signatures on each occasion medication was administered. The medication file contained a list of staff signatures, and initials and contained a record of the purpose and effect of each prescribed medication. Protocols for the administration of as required medication were in place. Staff responsible for the administration of medication had received training; new staff would be referred for this training following a period of induction. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 13 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. The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: The service has a complaints procedure, which was displayed in the home and included in the service user guide, and had been produced in a format that was more user friendly. Since the last inspection the CSCI has not received a complaint relating to this service. Procedures for the protection of vulnerable adults were in place. Staff received training during the rolling programme of induction. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 14 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) 24,27,29,30. The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: The service provides two flats, each able to accommodate up to four service users adaptations have been made to ensure that the physical needs of service users can be adequately met. All bedrooms were for single occupancy, with appropriate furnishing and fittings. Bathing and toilet facilities were in adequate numbers to meet the needs of service users. The ground floor bathroom had a specialist bath and adaptations to meet the needs of the service users. The integral thermometer in the bath had broken, although it was reported that the thermostat was operating correctly. The hot water temperature was routinely checked with a separate thermometer until the bath thermometer could be repaired. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 15 The hot water temperature during the visit was 52c, in excess of the recommended safe temperatures. It was recommended that the bathing procedures was reviewed and that a caution sign was fitted to the bath, to ensure that staff were reminded that the water temperature may be high and to safeguard service users. It was accepted that all service user required support to bathe and the risk to then was reduced. The service has a number of storage areas on the ground floor one of which housed the mains electrical supply to the home, during the inspection a number of items were stored in close proximity to the electric box, increasing the fire safety risk. It was suggested that further thought is given to more appropriate storage. The facility for storing the main hot water cylinder was also used to store continence wear, the temperature in this area was naturally high, following this inspection the manager stated that she had discussed this matter in the past with fire safety officers, and no significant risk had been identified. The main laundry for the home was located on the ground floor, the service had recently been fitted with a new washing machine, remedial work will be necessary to repair or replace the wall tiles in this area. It was suggested that with further thought this area could be reorganised to provide an additional storage area. The home was clean throughout and the standards of house keeping good. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 16 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) 32,33,35. Staff morale was high resulting in an enthusiastic workforce that worked positively with service users to improve their whole quality of life. EVIDENCE: Since the last inspection the service had recruited a full staff team. Staffing on the day of the inspection included 1 senior staff 7.30-3pm, 1x 7.30-12.30pm, 1x 7.30-1.30pm, 9.30-4.30pm(9.30-12.30 manual handling training). 2x 2.30pm-10pm, 1 x 2.30-10pm(1.30-4.30 manual handling training). The total weekly budgeting hours were recorded as 481 per week. Evidence from discussion with staff and from the records seen indicated that mandatory staff training had been provided or was scheduled for the permanent staff team. As at previous inspections bank staff were not routinely included in the mandatory training sessions, following discussion with the manager following this visit it was confirmed that the bank staff used by the home had been referred for mandatory training up dates. Discussion with one of the newer staff, confirmed that the service and organisation induction was of a good standard. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 17 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) 42 The health and safety of service users was assured appropriate fire safety checks, procedures, training and drills. EVIDENCE: Fire safety records were appropriately maintained, with evidence of weekly fire alarm and emergency lighting checks; fire training was recorded for April 2005, very regular fire drills had been carried out. A review of the fire evacuation procedures had taken place since the last inspection to reflect a reduction in night staffing numbers. This change had been subject to agreement and discussion with fire safety offices and the CSCI, and had been reviewed periodically. Staff, service users and relatives had been consulted about the changes, staff spoken to on the day of this visit confirmed that they felt that the measures in place, which included a new alarm system, exterior lighting and a call care system were satisfactory. Health and safety is monitored on a weekly basis, from the records seen. Action to address crumbling tarmac, which presented a possible trip hazard was waiting action by the organisation. 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 18 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 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x 3 4 Standard No 11 12 13 14 15 16 17 x x x x x x 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 23 Mount Pleasant Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 19 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 ya42 Regulation 13 Requirement Ensure that appropriate action is taken to reduce the risk to service users from high hot water temperatures. Timescale for action 13/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA20 YA24 YA24 YA17 YA42 YA24 Good Practice Recommendations The storage temperature of medication must be monitored to ensure that it is not excessive. The missing tiles in the laundry should be replaced, to improve the appearance of this area. A review of the laundry facilities should be considered to increase the storage facilities available in the home. The service should closely monitor the menus to ensure that service users receive a varied diet. Thre organisation should carry out the work necessary to the crumbling tarmac in the grounds of the home. Flammable materials should not be stored in close proximity to the mains electrical supply 23 Mount Pleasant v239104 e51-e09 s4983 23 mount pleasant v239104 130705 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Stafford - 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. 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