CARE HOME ADULTS 18-65
275a Rutland Road 275 Rutland Road Pitsmoor Sheffield S3 9PZ Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 21st February 2006 09:30 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 275a Rutland Road Address 275 Rutland Road Pitsmoor Sheffield S3 9PZ 01142 734990 01142 770940 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) Sheffield City Council - Disabilities Services Division Mr Steven Danford Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection Brief Description of the Service: Rutland Road is a care home providing short-term care to adults with learning disabilities. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries and pubs). Accommodation is on two floors and consists of two bedrooms, a small lounge and dining kitchen area on the ground floor. On the second floor there are a further three bedrooms. There are sufficient toilet and bathing facilities. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Jayne Barnett - Middleton carried out this unannounced inspection from 09.30 to 12:30 pm. Opportunity was taken to make a tour of the premises, inspect a sample of records and policies and talk to the member of staff on duty and briefly to the assistant manager. The inspector wishes to thank the member of staff on duty for her assistance and time throughout the inspection process. What the service does well: What has improved since the last inspection?
Since registration an assistant manager had been appointed, to support the registered manager in developing the service and supporting the staff team.
275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 6 There were plans in place to re-decorate the home and to replace some furniture. The assistant manager said that the residents would be involved in choosing new colour schemes for the home. 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. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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 and 4. The statement of purpose and service user guide was in need of review. Needs assessments were available on the residents files checked. They contained appropriate information about the residents care needs, which ensured that the service was able to meet individual needs. Prospective residents were given the opportunity to visit the home for trial visits before making a decision to use the service. EVIDENCE: The manager said that there was a statement of purpose and service user guide. He confirmed that these were in need of review to ensure that prospective residents had the information that they needed to make an informed choice about using the service. A full needs assessment was carried out for residents prior to their admission. Staff from the home also visited prospective residents prior to their stay. This confirmed that the service was appropriate for the resident, and provided staff with the information to formulate an individual plan of care. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 9 There was an admission policy to ensure that prospective residents were able to visit the home before making a decision to use the service. Introductory visits were offered which included day visits and overnight stays. The staff said that this gave the resident the opportunity to meet the staff and also ensured that the service was able to meet the resident’s individual needs. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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 and 9. The care plans checked did not reflect the current needs of the resident. Detail all of the residents care needs were not recorded and the plans checked had not been reviewed on a frequent basis. Risk assessments were in place to support residents to take risks as part of an independent lifestyle. However, they had not been reviewed on a regular basis to ensure that the safety of service users was promoted. EVIDENCE: Two care plans were checked, which did not fully describe the action required by staff to ensure that all aspects of residents, social support and healthcare needs were met. A new care plan format had been introduced which did cover all of the required information. However some sections had been completed whilst others including emotional needs, communication and personal hygiene had not been completed. The care plans had not been reviewed on a frequent basis and did not truly reflect the resident’s current needs. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 11 Resident files contained risk assessments relating to all aspects of service users lives both inside and outside the home. They identified the individual risks that were presented to residents on a daily basis and the action required to reduce the risk, which enabled residents to live independently. However, they had not been reviewed on a regular basis to promote the safety of residents. The staff member had a good knowledge of residents’ individual needs. She said that many of the residents stayed at the home on a regular basis and that over a period of time she had gained a good insight of residents likes, dislikes, preferred routines and care needs. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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): 13,15 and 17 Residents were encouraged to maintain and develop social and independent living skills. Opportunities were provided for residents to engage in activities within the home and maintain links within the local community. Residents were encouraged to eat a healthy and varied diet. EVIDENCE: Residents were supported to maintain and develop independent living skills. The staff said that residents were encouraged to continue to carry out daily activities as they would at home. This included light cleaning, ironing and preparing meals. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 13 Residents had regular opportunities to access appropriate activities. During the week residents were supported to attend day centres and groups within the local community. The staff member said that weekend activities including bowling and trips to the local pub and cinema were organised. One resident, who was not from the local area, chose not to attend a day centre. The staff member described how they had supported him to visit the local shops and amenities during his initial stays and that he was now confident to leave the home independently. Discussions with staff and observations demonstrated that the routines within the home were flexible. The residents were encouraged to make choices about their daily living activities. Staff spoke in detail about their daily routines and confirmed that they were flexible to the needs of the residents. Residents were offered and encouraged to eat a healthy diet. Meal times were flexible to suit individual needs. The daily meal was planned in consultation with residents to ensure that all needs were catered for. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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): 20. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. The records checked did not clearly record medicines received into the home and some medication administration records did not accurately record the amount of medication to be administered. EVIDENCE: There was a medication policy and procedure to ensure that staff adhered to safe practices. Medication was checked on a sample basis. The medication administration records checked did not clearly record the amount of medication that had been received or disposed of, and it was difficult to track the specific amount that had been brought into the home by the resident. Clear records need to be maintained to ensure that there is no mishandling. The administration instruction on some medication administration records (MAR) checked did not clearly record the amount of medication that should be given, and this could result in the incorrect dose being administered. Medicines were securely stored and staff responsible for administering medication had received training to promote the safety of tenants. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23. The homes complaints procedure was clear and accessible, ensuring that any complaints made by residents or their relatives would be listened to and action taken to deal with complaints promptly. There was an adult protection procedure, which promoted the protection of residents. EVIDENCE: The complaints procedure ensured that residents or their relatives were aware of how to make a complaint and who would deal with them. A record of complaints was maintained which demonstrated that no complaints had been made to the home since it was registered. The staff member spoken to had a good awareness of the complaints procedure, she commented that the staff would always try to resolve any concerns that the resident may have and said that the manager would always make time to listen. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. Staff had received Adult Protection training enabling them to identify and report any allegations or incidents of abuse to residents. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 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 the following standard(s): 24,25 and 30. The home was clean, comfortable and on the whole well maintained. Residents were provided with an environment that met their individual needs and lifestyles EVIDENCE: The home is a two-storey house. Accommodation is on two floors and consists of two bedrooms, a small lounge and dining kitchen area on the ground floor. On the second floor there are a further three bedrooms. There are sufficient toilet and bathing facilities. All areas within the home were clean and tidy and generally well maintained. A radiator guard in one bedroom was loose, creating a potential safety hazard to residents. The bedrooms were individually decorated, clean and each had a television and video. The staff member said that the bedrooms were allocated dependent on resident’s abilities, for example residents with limited mobility would be allocated a bedroom on the ground.
275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 17 There were plans in place to re-decorate the home and to replace some furniture. The assistant manager said that the residents would be involved in choosing new colour schemes for the home. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 18 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 and 35. Staff had received training to meet the residents general and specific needs. A good range of training was available for staff. Appropriate support and guidance was offered to new staff, enabling them to safely care for service users. The home operated a recruitment policy that promoted the protection of service users. Staff files required some minor amendments to ensure that they included the required information. EVIDENCE: The Staff were friendly, approachable and relaxed to talk about the care that they provided. Positive and appropriate relationships were observed between staff and residents. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Discussions with staff and records checked demonstrated that staff had received a good range of training that included Moving and Handling, First Aid and health and safety. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 19 A staff-training matrix and training plan had been devised which demonstrated the training that staff had attended. Individual training records checked demonstrated that staff had been offered the refresher training that they required, to ensure that they were conversant with changing legislation and safe working practices. A recruitment policy and procedure was in place. Two files checked contained a range of information including two references, declaration of health and qualifications/training. The manager and staff said that all staff had received a Criminal Records Bureau Check at the enhanced level to promote the protection of residents. However, the files checked did not evidence that a CRB check had been carried out prior to their employment at the home. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 20 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 and 42. The staff said that they were well supported by the manager. The health, safety and welfare of residents was promoted and protected. EVIDENCE: The registered manager had many years experience within the caring profession which, enabled him to contribute to the care of service users and communicate a clear sense of leadership to staff. He has recently completed the registered managers award and a NVQ level 4 qualification. Staff spoke positively about the support that they received from the manager stating that they could contact him at anytime should they need advice. The staff had received training including Fire training, moving and handling and First Aid, which promoted safe working practices and the health, safety and welfare of the tenants and their colleagues. 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 21 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 2 2 3 3 X 4 3 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 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X X X X 3 X 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 1 2 3 4 5 6 7 Standard YA1 YA6 YA6 YA9 YA20 YA20 YA24 YA34 Regulation 4,5 15 15 15 13 13 23 19, Schedule 2 Requirement The statement of purpose and service users guide must be reviewed. The service user plans must contain all of the required information. Service user plans must be reviewed at least every six months. Risk assessments for service users must be updated and reviewed on a regular basis. Records of medication received into the home must be maintained. The administration of medicines must be accurately recorded. The Radiator guard in the identified bedroom must be secured to the wall. Staff files must evidence that a satisfactory CRB, POVA check has been carried out prior to employment. Timescale for action 01/07/06 30/05/06 30/05/06 30/05/06 01/05/06 01/05/06 01/05/06 01/05/06 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 23 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 None. Good Practice Recommendations 275a Rutland Road DS0000062380.V274470.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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