Inspection on 28/09/05 for 28 Pasley Street

This inspection was carried out on 28th September 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

28 Pasley Street 10/07/07

28 Pasley Street 23/08/06

28 Pasley Street 20/04/05

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 Unannounced Inspection 28th September 2005 09:45 28 Pasley Street DS0000003507.V251432.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 Pasley Street DS0000003507.V251432.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 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 28 Pasley Street Address Stoke Plymouth Devon PL2 1DP 01752 561459 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) The Durnford Society Limited Ms Michelle Durrant 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 DS0000003507.V251432.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 18yrs Date of last inspection 20th April 2005 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 accommodate 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 accommodation in the lower ground floor level and ascending to accommodation 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 DS0000003507.V251432.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Preparation for the inspection included analysis of the previous inspection report and correspondence with the home over the last six months. An inspection plan was developed from this information. The inspector was in the home from 9.45am to 1.00pm. The inspector spent time with or spoke to four of the nine service users, with particular attention being given to two residents whose care was looked at closely. Two residents were on holiday and one resident was in hospital at the time of the inspection. The whole of the building was inspected. Two care staff, and the Registered Manager were spoken to during the inspection. The Registered Manager was spoken to at length. Care planning files, residents’ daily diaries, care delivery records, medication records, and health and safety records were inspected. What the service does well: The home has a stable staff team who seek to provide a homely and comfortable place for the residents to live. The home provides good information about the service to potential new residents, and their representatives, so that they can make an informed choice about whether to use the service. The home is good at managing new residents moving in so that this process is carried out successfully. One new resident said how much he liked his new home. The delivery of resident’s care is generally good and residents have enough appropriate activity to ensure that they have a good quality of life both through leisure and valued life activity. Residents receive enough, varied, good food. Residents’ personal care needs are met and medication is well managed. Complaint procedures and adult protection are properly managed by the home protecting the welfare of the residents. The residents benefit from a homely, comfortable, clean and well maintained building that has been appropriately adapted to meet their needs. The home was commended in this report for the cleanliness and hygiene of the home, which has been achieved while retaining a homely domestic atmosphere. The residents’ rooms are individual and personalised to the tastes of each resident. Resident’s needs are met by enough competent, qualified, vetted and trained staff. The homes management is effective. 28 Pasley Street DS0000003507.V251432.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 Pasley Street DS0000003507.V251432.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 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 The home provides adequate information about the service 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 from care management before the resident’s admission. A recently admitted resident said he was happy to be living at the home and talked happily about his life at Pasley Street. There was a record in his daily diary of his initial visits to Pasley Street before he decided to move into the home. His successful settling in at Pasley was also evidenced by entries in his daily diary. Pasley Street has successfully used different, but appropriate approaches, to manage the admission of different new residents. 28 Pasley Street DS0000003507.V251432.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): 6,7,8,9 The delivery of resident’s care is good but is undermined by poor care planning and the lack of individual residents risk assessments. Despite problems in care planning the home is actively empowering the residents to develop as independent a lifestyle as possible. EVIDENCE: Resident’s care plans were sampled. There is a good Durnford Society care plan and risk assessment formats available. All the residents’ files had a care plan. 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. Progress has been made in this area since the last inspection but there continues to be considerable work to be completed in order to meet the standard required. There were some residents without their necessary individual risk assessments and where risk assessments were in place they were generally of poor quality. All the risks and agreed restrictions affecting the individual resident were not identified and they also did not address the identified risks in enough detail. Individual residents risk assessments must be comprehensive and detailed to 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 Page 10 identify all the risks and agreed restrictions affecting the resident and the measures in place to reduce these risks to an acceptable level. Where residents have agreed to restrictions of facilities or of choice, in order to maximise the resident’s quality of life, these issues must be documented either in care planning or in risk assessments. Examples of this would be the non-use of a bedroom door key through personal resident choice or the need to be escorted whenever the resident leaves the home in order that their safety is maintained. Adequate care planning and risk assessment will help residents’ care to be delivered in a planned and consistent manner and will further improve the residents’ quality of life. However despite the continued problems in care planning and risk assessment there was considerable evidence of the home actively seeking to empower the residents to a more involved and independent lifestyle. Examples of this included the use of bedroom door keys, symbols used in the kitchen to indicate the location of cutlery, glasses etc, the use of a symbol based daily planner in one residents room and the use of laminated pictures of different meals to enable a resident to make food choices. Further evidence of the residents’ active lifestyles was available in the new individual resident daily diaries. Entries showed residents being empowered to help to make their own beds and to participate in a range of kitchen activity. Residents, who are enabled to participate in their home and are empowered, have more control over their daily lives. 28 Pasley Street DS0000003507.V251432.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): 12,13,14,15,16,17 Residents have enough appropriate activity to ensure a good quality of life while living at the home. Residents receive enough, varied, good food. EVIDENCE: Information from the new resident daily diaries, supported by information directly from the staff on duty, described some of the activity enjoyed by the residents. Activity in the community included work placements, art classes, social club, the theatre, shopping, lunches in town, ten-pin bowling and visiting friends. Activity is also supported within the home including sewing, DVD films, music, singing and dancing, hand massage and nail painting. All the sampled residents’ information showed individualised and varied activity being enjoyed by the residents both in the community and in the home. The introduction of daily diaries has produced an accurate record of residents’ activity and experience of the service. This new information will help with the review of care planning and risk assessment. The quality of residents’ activity was not accurately detailed in care plans. It could be seen from the menu plans, and the various stocks of food and drink in the large fridge freezer, that residents are supplied with enough, good quality food. There is a four-week menu plan. Changes are made to the menu 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 Page 12 plan with consideration of the residents’ food preferences and following some discussion with the residents. The consultation that does take place should be recorded in existing documentation, such as menu planning and care plans, and also in the new food provided record. This food record has been designed and will show in detail the variety and choice of food received by the residents. This will soon be brought into use. This record will help to establish the food preferences, and the nutritional quality of the food, received by the residents. 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 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 the following standard(s): 18,19,20 Residents’ health is well maintained by meeting residents’ personal care needs, by supporting their access to health resources and through the effective administration of residents’ medication. EVIDENCE: All the residents present in the home were seen and there was no observable evidence of any personal care issue not being met. Chart recording of residents’ weights was seen. There were also individual chart records for fluid intake and food intake to address particular residents needs. A sample of residents’ records showed appointments with psychiatric health, learning disability nursing, physiotherapy and GP health services. During the inspection the specialist in patient link nurse visited to gather the necessary information for the care of one resident who is presently an inpatient in general hospital. These records and the observed care being delivered showed that residents’ health and personal care is being supported. The home uses a monitored dosage blister pack system and good medication administration records for this system were seen. There is a medication profile in each resident’s file. A new medication storage cabinet has been obtained for the home which is large enough to hold all the residents medication securely. Residents’ health and stability is maintained by well-managed and correctly administered medication. 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 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 the following standard(s): 23 The welfare of the residents is protected by thorough adult protection procedures. EVIDENCE: The home has all the appropriate anti abuse policies and procedures in place. Some of the staff have already received anti abuse training from Plymouth City Councils Adult Protection Unit and all the rest of the staff are booked to attend this training before the end of 2005. 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 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 the following standard(s): 24,26,27,28,29,30 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 toured during the inspection and no necessary repairs were noted. The quality of the living environment and the standard of decoration in the home were very good. The home was very clean, hygienic and odour free. This unannounced inspection found the bathrooms, toilets, kitchen and laundry exceptionally clean and well maintained. Appropriate laundry facilities are in place to control the spread of infection. Standard 30 has been exceeded and the service is commended for cleanliness and hygiene within the home. 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. All the bathrooms and toilets are fitted with override type locks that can be locked from the inside to give privacy but can also be opened from the outside in the event of an emergency. The bathrooms had been decorated to make them feel more domestic in character. 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. All the bedrooms had been decorated and personalised to meet the 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 Page 16 taste of the resident using them. All the bedrooms are fitted with appropriate locks. Some of the residents choose to use these locks and others do not. The organisation has provided the resources to maintain the décor in the home to a high standard. Furnishings and fittings were of good quality. A good quality living environment will meet both the residents’ physical and emotional needs. 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 Page 17 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): 33,34,35 Resident’s needs are met by enough competent, qualified, properly vetted and trained staff. EVIDENCE: The Registered Manager stated that the number of care hours provided has significantly increased since April 2005 in order to meet the increased needs of the residents. There are usually three staff on duty in the morning, two in the afternoon and evening and one waking staff and one sleeping staff at night. The Registered Manager stated that the staffing level in the home is adequate to meet the needs of the residents. 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. At the Announced Inspection there were no personnel records or training records available in the home. There is now a personnel file for each member of staff containing both vetting information and the staff member’s record of training. These changes enable inspection to independently verify that staff are being properly vetted and trained. 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 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 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): The management of the home is effective and is aware of the changes that need to be made to the management of care so that residents needs continue to be met. EVIDENCE: A new Registered Manager, Michelle Durrant, came into post at the beginning of April 2005. She has achieved both the Registered Managers Award and the NVQ4 in care. She intends to make various changes within the home including complying with the requirements given, and noting the recommendations made in this report. The Registered Manager and 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 and is implementing a new quality assurance system. However 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 DS0000003507.V251432.R01.S.doc Version 5.0 Page 19 The records seen during the inspection were good, such as the Medication Administration Record, accident record, and residents’ daily diaries. Inventories of resident’s personal possessions were up to date. These records 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. The Registered Manager stated that valves to control hot water temperature have been fitted to all the hot water taps in the home except those in the kitchen. It was required that each radiator that has not been covered must be individually documented in risk assessment. Good management of health and safety protects the welfare of the residents. 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 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. 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 3 3 3 X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 X 3 4 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 28 Pasley Street Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X 3 3 X DS0000003507.V251432.R01.S.doc Version 5.0 Page 21 Yes 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 YA6 Regulation 15 Requirement All the residents must have a careplan which is comprehensive and detailed. All the residents needs must be identified and how staff are to meet these needs. (The original timescale for completion of this requirement was 20/10/05) 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 resident’s best interests. An individual risk assessment must be in place for each radiator that has not been physically adapted to limit surface temperatures. (The original timescale for completion of this requirement was 20/08/05) Timescale for action 31/03/05 2 YA9 13 31/12/05 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 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 Refer to Standard YA1 YA17 YA39 Good Practice Recommendations Both the service user guide and the statement of purpose should be maintained up to date and accurate. A record of the food provided to residents should be kept. The quality assurance system should be reviewed to ensure that it is as accessible as possible to residents to enable their participation. 28 Pasley Street DS0000003507.V251432.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Ashburton Office 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 DS0000003507.V251432.R01.S.doc Version 5.0 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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