CARE HOME ADULTS 18-65
28 Newland Street 28 Newland Street Crumpsall Manchester M8 5RY Lead Inspector
Steve O`Connor Unannounced Inspection 27th September 2005 01:00 28 Newland Street DS0000021706.V254286.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 28 Newland Street DS0000021706.V254286.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. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 28 Newland Street Address 28 Newland Street Crumpsall Manchester M8 5RY 0161 740 9785 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) Southfields Care Homes Limited Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th February 2005 Brief Description of the Service: The home is a terraced house situated in the Crumpsall area of Manchester with easy access to local facilities e.g. shops, services, places of worship, pubs and local transport. The home provides accommodation for 2 persons with mental health problems. The service users accommodated are funded to receive staffing on a one to one basis due to the complexity of their needs and their challenging behaviour. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 27th September 2005. Time was spent talking with people, the manager, some of the staff on duty and observing how staff worked with people. In addition people’s files and other documents were inspected. A tour of the premises was also made. The previous inspection in February 2005 had identified a few areas that the home needed to improve upon. These areas had been actioned by the home. The CSCI had not received any concerns or complaints about the home since the last inspection. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. During the inspection it was found that the company that owned and run the home had been sold. The staff had only recently been informed of the change but had already met with representatives from the new company (Regard). The areas that need improvement and identified in this report will be reported to Regard as needing urgent attention. What the service does well:
The home supports people who have long-term mental health problems and would find it very difficult to live on their own in the community without a high level of support. The agency has the staff team to provide this level of support. Through talking to people and watching how staff work with them it was seen that a good relationship had been developed. People joked and laughed with each other and the staff spent time with people in and out of the house. Several examples were seen of social, leisure and education activities that people participated in. An area that the home took very seriously was in maintaining people’s general and mental health. The home supported people to access local general health services such as the G.P. dentist, chiropodists, etc. The home had made sure that people received support from specialist mental healthcare services and had worked with those services to monitor and maintain people’s health. To try to make sure that people stay well the staff were very aware of when people’s mental health was deteriorating and the behaviours they showed. The staff was able to describe clearly how they try to reduce people’s stress and provide a calm and relaxed atmosphere.
28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 6 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. 28 Newland Street DS0000021706.V254286.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 28 Newland Street DS0000021706.V254286.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): 2 People’s needs were assessed prior to living at the home. EVIDENCE: The home had received an assessment of people’s needs from the purchasing authority prior to them coming to live at the home. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 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 the following standard(s): 6 and 9 The care plans reflected people’s current goals and needs but the home did not provide staff fully with the guidance and training required to respond to known risk situations. EVIDENCE: People had an individual care plan that detailed all aspects of personal, social and health care needs and how their needs would be met. The plan was completed with the involvement of the person, their representative and their care manager. Care plans were reviewed on a six monthly basis. The recording to show the activities people participated in was at times very brief and did not show how the home was meeting a person’s goals. It is recommended that the home ensure that all social, leisure, domestic and community based activities are fully recorded. The home used a standard format to look at situations, events and behaviour that may cause a risk to people’s wellbeing. Once identified, the home developed support guidance for staff in how to minimize those risks. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 10 There were incidents where staff would have to physically intervene to prevent a person harming themselves or others. These risks associated with people’s behaviour and mental health was not clearly identified in the risk assessments nor was there sufficient guidance provided to staff in how to safely manage the situation. All areas of risk and hazards associated with people’s mental health and behaviour must be identified and clear and detailed guidance provided to staff in how to manage these situations. Staff must participate in training in how to work and respond to challenging behaviour. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 11 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 and 13 EVIDENCE: People were supported to access the local community. Information had been gathered by staff about local facilities and shared with the people living at the home. People had the support of staff on a one to one basis to enable them to undertake activities independently from one another and to pursue their own interest. Staff rotas enabled staff to support people to attend activities of their choice in a flexible manner. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 and 20 The home supported and encouraged people to maintain their person and healthcare needs. However, the medication administration systems had inaccuracies that could place people at risk. EVIDENCE: People living at the home were independent in meeting their personal care needs and received prompting and encouragement from the home to maintain this. People’s goals for maintaining their personal and healthcare were recorded in the person’s care plan. People’s general and mental health was supported through the staff teams knowledge of a person’s behaviour and triggers for ill health and supported people to access general and specialist healthcare providers when required. The medication administration system was seen and found, on the whole, to be accurate. However, some issues need addressing. Prescribed Paracetomol was being used ‘as required’ (PRN), the coding system on the MAR sheets was not used correctly and no record made of the reasons for not administering, a signature was missing for an administered medication on the MAR sheets and changes to people’s medication had not been confirmed in writing by the prescribing GP.
28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 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 the following standard(s): 23 The home’s financial auditing systems did not fully protect people. EVIDENCE: The home had a complaint policy and procedure and a copy of the MultiAgency Protection of Vulnerable Adults. All staff had received training with regards the protection of vulnerable adults and had been issued with a copy of the policy and procedures of the home. The system for managing people’s personal finances was checked and found that the home did not undertake regular auditing of the spending and receipts. The financial records must be audited and checked on a regular and ongoing basis. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 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 the following standard(s): 24 and 30 The home did not fully provide a homely, comfortable or safe environment and the hygiene systems did not fully protect people from harm. EVIDENCE: During a tour of the premises the following areas of concern were noted. 1.The kitchen units looked worn and dated. Some of the work surfaces were cracked and broken and need replacing. 2. The bathroom sealant was in a bad condition and needs replacing. 3.The shower does not work and needs repairing. 4. The bathroom is in need of decoration. 5. The front bedroom is in need of decoration. 6. Bedroom furniture is of poor quality and is damaged and needs replacing. 7. The staff bedroom is in need of decoration. The laundry facilities are located in the kitchen. The door and front panel have areas missing and must be repaired. The kitchen has a hand-wash basin but no appropriate soap or hand drying facilities.
28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: These standards were not assessed during this inspection. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: These standards were not assessed during this inspection. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 17 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 X 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 1 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
28 Newland Street Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000021706.V254286.R01.S.doc Version 5.0 Page 18 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 YA9 Regulation 13 Requirement All areas of risk and hazards associated with people’s aggressive behaviour must be identified and clear and detailed guidance provided to staff in how to manage these situations. Staff must participate in training in how to work and respond to challenging behaviour. The financial records of each person’s spending must be audited and checked on a regular and ongoing basis. The medication administration system was not accurate and the home must address all the issues raised in Standard 20 of this report. All the areas identified in standard 24 must be made good. A plan of action for addressing all the areas identified must be provided to the CSCI within the timescale stated. People and staff must have access to suitable soap and hygienic hand drying in the bathroom and kitchen areas.
DS0000021706.V254286.R01.S.doc Timescale for action 01/12/05 2 YA9 18 01/12/05 3 YA23 13 01/10/05 4 YA20 13 01/10/05 5 YA24 23 31/12/05 6 YA30 13 31/12/05 28 Newland Street Version 5.0 Page 19 7 YA30 13 All the staff team must have undertaken food hygiene training. 31/12/05 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 Refer to Standard YA6 Good Practice Recommendations It is recommended that the home ensure that all social, leisure, domestic and community based activities are fully recorded. 28 Newland Street DS0000021706.V254286.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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