Inspection on 20/04/05 for 28 Pasley Street

This inspection was carried out on 20th April 2005.

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

28 Pasley Street 10/07/07

28 Pasley Street 23/08/06

28 Pasley Street 28/09/05

28 Pasley Street 04/11/04

28 Pasley Street 29/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 28 Pasley Street Stoke Plymouth Devon PL2 1DP Lead Inspector Brendan Hannon Announced 20/04/05 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. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 28 Pasley Street Address Stoke, Plymouth, Devon, PL2 1DP 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) 01752 561459 The Durnford Society Limited Vacant Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Age 18yrs Date of last inspection 4/11/05 Brief Description of the Service: The home is located in two combined terraced houses, on the end of a terraced street, in the Stoke area of central Plymouth. A full range of amenities and facilities are within walking distance though, the home has its own vehicle. The home can accomodate up to nine service users over three floors. The home is in an unusual layout being entered on the ground level at the front but then with stairs both descending to accomodation in the lower ground floor level and ascending to accomodation on the first floor level. There are no residents bedrooms on the ground floor. There are three communal bathrooms and showers. There are no shared rooms and due to the age of the building all the ceilings are reasonably high giving an additional feeling of space in the home. There are two communal lounges, a kitchen diner and another dining area off one of the communal lounges. There is a large area of patios and parking space to the rear of the building. This can be accessed either from the lane to the rear of the building or from the rear of the lower ground floor. The service offered by the home is for men and women with a learning disability over the age of 18 and perhaps beyond the age of 65. As all of the service user bedrooms are above and below the ground level the home would have difficulty supporting residents with significant mobility difficulties. The present group of residents has a mixed range of ages and abilities. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. Preparation for the inspection included analysis of the pre inspection questionnaire, the previous inspection report and correspondence with the home over the last 12 months. An inspection plan was developed from this information. The inspector was in the home from 10.00am to 3.30pm. The inspector spent time with or spoke to six of the nine service users, with particular attention being given to two residents whose care was looked at closely. The whole of the building was inspected. Four care staff, the manager and the general manager responsible for the home on behalf of the Durnford Society Ltd. were spoken to during the inspection. The registered manager and deputy manager were spoken to at length. Care planning files, care delivery records, medication records, communication books, and health and safety records were inspected. What the service does well: What has improved since the last inspection? The management system for the home has become aware of the changes that need to be made in the areas of care planning, risk assessment and record keeping both so that the management of care in the home can be improved and residents needs can be better met. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 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 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 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) 1,2,3,4 The home provides adequate information about the service and support to allow a new resident, and their representatives, to initially make an informed decision to use the service and then to move in successfully. The service is clear about the needs that it can meet and those that it cannot meet. EVIDENCE: Both the service users guide and the homes statement of purpose were available. Both these documents needed to be updated to take account of changes of personnel at the home. This information enables potential new residents and their supporters to understand the service provided by the home. Residents and care staff were observed and spoken to throughout the inspection. It was judged from this evidence that residents needs were being met. In more recently admitted residents files there was information received by the home before the resident’s admission. However sometimes this was not from a person qualified to carry out an assessment. The home should always obtain an assessment from a professional source before an admission is agreed to. A recently admitted resident was seen to be happy, excited and motivated to get the best from the service. There was a good record of residents’ daytime and overnight visits to the home before moving in. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 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 The delivery of resident’s care is generally adequate but is undermined by poor care planning and by poorly managed individual residents risk assessments. These failures will lead to residents receiving a poorer service due to the provision of inconsistent, poorer managed care and inconsistent poorer quality management of residents’ risks. EVIDENCE: Resident’s care plans were sampled. There is a good Durnford Society care plan and risk assessment format available to use. Most residents’ files had a care plan but some did not. Also care plans had not been reviewed for some time, leading to some information being inaccurate. All residents must have a comprehensive and detailed care plan so that the staff can be effectively directed to meet the resident’s identified needs. There were individual risk assessments in resident’s care plans. However they were generally of poor quality. They did not identify all the risks and agreed restrictions affecting the resident and they also did not address the identified risks in enough detail. The limitations of the risk assessments were particularly obvious for the residents with the greatest needs. In these cases the information was not only limited, but because of infrequent reviewing, was also at times inaccurate. Individual residents risk assessments must be comprehensive and detailed to identify all the risks and agreed restrictions 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 10 affecting the resident and the measures in place to reduce their risks to an acceptable level. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 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 standard(s) 12,17 Residents have enough appropriate activity to ensure a good quality of life while living at the home. Residents receive enough, varied, good food. EVIDENCE: The manager and staff described at length the activities that were enjoyed by the residents. This information was supported by the observation of equipment and resources used by the residents when taking part in these activities. The residents generally have enough individualised activities taking place with the support of the home. However the quality of this activity could not be identified as there was no accurate listing of the resident’s activities in their care plan and there were no individual daily records being maintained for the residents. Such a plan and record of individual activity would clearly show the daily valued activities being participated in by the residents. Similarly it could be seen from the menu plans, by observing a delivery of fresh meat from the local butcher, the various stocks of food and drink in the very large fridge freezer, and the food preparation taking place during the inspection that residents are supplied with enough, good quality food. The deputy manager described in detail how decisions on the meals to be delivered 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 12 are arrived at. There is a four week menu plan but this has not been updated for at least eighteen months. Changes are made to the menu plan based on consideration of the residents’ food preferences and with some discussion with the residents. However the consultation and choices could be offered more consistently and creatively. The consultation that does take place should be recorded in existing documentation, such as menu planning and care plans, and also in a new food provided record, which is required under standard 41 of this report. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 13 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) 18,20 The residents’ health is well maintained by fully supporting the residents’ personal care needs and, in general, through the satisfactory administration of their medication. EVIDENCE: All the residents present in the home at the time of the inspection were seen. There was no observable evidence of any personal care issue not being met. The management of the home stated that personal care needs were always met first no matter what staffing issues arose in the home. Well maintained chart records were in use for recording all the residents weights on a regular basis and keeping a record of all health appointments attended. There were also individual chart records for fluid intake and food intake to address particular residents needs. These records and the observed care being delivered were adequate to show that generally residents health and personal care is being supported. There is a medication profile (a list of prescribed medications) on each residents care plan. The home uses a monitored dosage blister pack system and good medication administration records for this system were seen. However the homes medication storage cabinet was much too small to accommodate the increased volume of medication caused by an older group of residents. All prescribed medication must be stored securely at all times. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 14 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 Complaints are properly managed by the home protecting the welfare of the residents. EVIDENCE: There is an adequate complaints procedure which is clearly displayed in the home. There have been no complaints made to the home over the last twelve months. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 15 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) 24,26,29,30 The residents benefit from a homely, comfortable, clean and well maintained building that has been appropriately adapted to meet their needs. EVIDENCE: The home was looked at closely and only a few minor repairs were noted. The quality of the living environment and the standard of decoration in the home was very good. The home was clean and odour free. In recent years improvements have been made to address the increased physical disability needs of the residents. Physically adapted bathrooms and toilets have been developed in the home. Also some useful devices have been installed such as motion sensors in some toilets/ bathrooms to turn the light on without the need for light switches. Unfortunately the buildings structure has made it impossible to produce any bedrooms on the ground floor. Therefore there is no facility in the building for a resident who is dependant on a wheelchair. All the bedrooms had been decorated and personalised to meet the taste of the resident using them. Some of the residents choose to use a key to their bedroom. The opportunity to make this choice should be extended to all residents by putting appropriate locks on the remaining bedrooms that do not yet have this facility. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 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) 32,33,34,35,36 Resident’s needs are met by enough competent, qualified, properly vetted and trained staff. EVIDENCE: The homes record of the hours worked was checked and this showed that there is always an adequate number of staff on duty to meet the needs of the residents. However it was noted that the level of need in the home is high. Also the amount of external day care provided as part of the care contract has declined which then requires the home to support more resident activity. These influences may make it necessary to increase the staffing levels in the home in the future to maintain the residents quality of life. Approximately half of the staff team are NVQ2 or above, qualified. A thorough training programme is run by the organisation to ensure that the level of qualification of the staff in the home is maintained. The organisation is also actively training new staff in the Learning Disability Award Framework which is designed to give specific skills to work with learning disability. This training enables staff to meet residents needs soon after beginning work with the organisation. The pre inspection questionnaire was written by the management of the home and stated the dates of return of all the staff Criminal Records Bureau clearances. However no personnel records or training records were available in 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 17 the home as they have been retained at the organisations head office. It was agreed that in future a copy of these records would be kept in the home to verify that the recruitment procedures have been followed. Similarly, though some training information could be obtained and sampled during the inspection, it was agreed that a record of each staff members training would in future be kept at the home. These changes will allow inspection to independently verify that staff are being properly vetted and trained. A programme of individual staff supervision sessions is being followed amounting to six sessions per year. This monitoring will help to ensure that the quality of staff practice delivered to the residents is as good as possible. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 18 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) 37,38,39,41,42 The management of the home is effective and is aware of the changes that need to be made to ensure that the management of care in the home is improved so that residents needs continue to be met. EVIDENCE: A new manager, Michelle Durrant, came into post at the beginning of April 2005. She intends to make various changes within the home including complying with the requirements given, and noting the recommendations made in this report. The new manager and existing staff were seen to be working well together. Good working relationships amongst the staff will promote better quality support for the residents. The organisation has developed a new quality assurance system. However it was agreed that this should be reviewed to enable greater involvement from the residents, who it was felt would have difficulty with the design of the proposed questionnaire. Such difficulties would stop the residents engaging properly in the process used to maintain the quality of their service. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 19 Though some records seen during the inspection were good, such as the Medication Administration Record, there were a number that were either missing or were poorly maintained. There should be a record of the food actually provided to the residents and inventories of resident’s personal possessions. There should be more demonstration on paper of personal care delivery and resident’s participation in the decision making in the running of the home. Finally there should be demonstration of the quality of resident’s day-to-day lives. It was advised that an effective way to manage this would be through an individual daily log of each resident’s activity. The introduction of these records will assist management in monitoring the delivery of care to the residents at the home. Health and safety is generally well managed in the home though, as noted under standard 9, a number of new risk assessments must be written both for the residents individually and for the facilities in the home to demonstrate that the risks affecting residents are assessed and are being maintained at an acceptable level. It was required that each hot water outlet that has not been physically adapted to limit hot water temperature and each radiator that has not been covered must be individually documented in risk assessment. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 3 x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x x 3 3 Standard No 11 12 13 14 15 16 17 x 3 x x x x 2 Standard No 31 32 33 34 35 36 Score x 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 28 Pasley Street Score 2 x 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 1 2 x D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 21 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 6 Regulation 15 Requirement Timescale for action 20/10/05 2. 9 13 3. 4. 20 41 13 17 All the residents must have a careplan in place which is comprehensive and detailed. All the residents needs must be identified and how staff are to meet these needs. 20/08/05 Each resident must have a comprehensive and detailed individual risk assessment. This assessment must include all restrictions of choice or personal freedom agreed to be in the residents best interests. An individual risk assessment must be in place for each hotwater outlet and radiator that has not been physically adapted to limit hot water and surface temperatures. There must be adequate storage 15/07/05 to ensure that all prescribed medication is stored securely. All the required basic records as 15/07/05 listed in Schedule 3 and 4 of the Care Homes Regulations must be kept. Other records to demonstrate the valued lifestyle and the care delivered by the residents must also be kept. 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 22 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. Refer to Standard 1 2 17 26 Good Practice Recommendations Both the service user guide and the statement of purpose should be maintained up to date and accurate. Detailed assessment information should be gathered by professionals trained to do so before an admission is agreed. The required food record should also demonstrate consultation with residents, choice offered and residents participation in food delivery. Residents bedrooms should be lockable to provide privacy for the resident and security for the residents possessions. A key should only be retained by the home when indicated in the care plan or individual risk assessment. The quality of the recruitment process should be demonstated by records available at the home. The quality of training by the staff should be demonstrated by records available at the home. The quality assurance sytem should be reviewed to ensure that it is as accessible as possible to residents participation. 5. 6. 7. 34 35 39 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 28 Pasley Street D52-D04 S3507 28 Pasley Street V213201 200405 Stage 4.doc Version 1.20 Page 24 - 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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