CARE HOME ADULTS 18-65
30 Newland Street 30 Newland Street Crumpsall Manchester M8 5RY Lead Inspector
Steve O`Connor Unannounced Inspection 27th September 2005 11:00 30 Newland Street DS0000021707.V254304.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 30 Newland Street DS0000021707.V254304.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. 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 30 Newland Street Address 30 Newland Street Crumpsall Manchester M8 5RY 0161 740 9397 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 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 30 Newland Street DS0000021707.V254304.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 up to 3 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. 30 Newland Street DS0000021707.V254304.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. During the inspection it was found a lack of repairs to the back gate and a bolt to the back door could cause a risk to people’s health and safety. An Immediate Requirement was made to repair/replace the hazards. 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 with one person attending college to take GCSE in English. One of the people who live at the home showed the inspector around the house and pointed out areas that needed attention and repair. He explained what he liked and did not like about the house and his good relationship with the staff team. He said that he had the confidence to be able to express his thoughts and worries and that staff would listen to what he had to say.
30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 6 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 were able to describe clearly how they try to reduce people’s stress and provide a calm and relaxed atmosphere. What has improved since the last inspection? What they could do better:
Both the people living at the home and staff team recognised that the house needed a lot of updating, repairs and redecoration. In fact it was a person living at the home who pointed out many of the faults, broken items and damage to the inside of the house. These included a poor quality and damaged bathroom fixtures and flooring, water damaged ceiling, poor quality bedroom furniture and fittings and the whole house was in need of redecoration. The agency did recognise the importance to people’s wellbeing of living in a pleasant and homely environment but a lack of long-term investment in the house had resulted in living conditions that were not acceptable to the staff team and so should not be acceptable for the people living there. The new company will be informed of the work required and made a priority for their attention. A person living at the home described how they liked to watch football and was interested in gardening or other jobs. He had discussed many of these things with the staff team but none of these had been identified as goals in the persons care plan. The inspector was told that it was not the staff’s role to find out and arrange these types of new activities but to pass on the information to a senior manager to organise. The home had a restricted call telephone and so to find out about these opportunities would mean them having to use their own phones. Supporting people to take up new and meaningful activities is a key role of the home and the staff team. The home must look at ways that allow staff to work
30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 7 with people and have the time and resources needed to take part in activities that are important to them. People and staff must have access to suitable soap and hygienic hand drying in the bathroom and kitchen areas. All the staff team must have undertaken food hygiene training. 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. 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 8 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 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 9 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. 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 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. People were supported to minimise risks that may cause them harm. The care planning process and systems did not fully reflect people’s goals and needs. 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. Through discussions with people it was found that their own expressed goals had not been clearly identified in the care plan. Care plans must identify people’s holistic goals fully. 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. 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 11 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. 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 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): 12 and 13 The home does not fully provide people with the opportunities and activities that they wish to participate in. EVIDENCE: Staff rotas enabled staff to support the people to attend activities in a flexible manner. One person liked to access the community independently and appropriate risk assessments had been undertaken with regards this. Through discussions with the staff team it was found that the responsibility of finding information and opportunities to meet some of a person’s goals was past onto a senior manager outside of the home. People and the staff team must be provided with the time and resources to enable them to identify, facilitate and participate in the opportunities and activities of their choice. 30 Newland Street DS0000021707.V254304.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 and 20 People were supported to maintain their personal care and general and mental healthcare needs. The medication administration systems were appropriate for managing people’s medication needs. 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 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 clear and accurate. 30 Newland Street DS0000021707.V254304.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 home’s policies, procedures and 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. 30 Newland Street DS0000021707.V254304.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 and 30 The home does not provide a comfortable or safe environment nor the systems to ensure the home is hygienic. EVIDENCE: During a tour of the building the following areas of concern were found. 1. The gate in the back yard was rotting and damaged and needed to be lifted up to allow it to be unlocked and opened. This is a risk to people’s health and safety and an Immediate Requirement was issued to make good the damage. 2. A bolt on the back door was broken and made it difficult to open and lock the door. This is a risk to people’s health and safety and an Immediate Requirement was issued to fix the lock. 3. The bathroom is poorly decorated, tiles are damaged and needs replacing, the bath is stained and needs replacing, plaster/grout is falling off the wall into the bath and needs repair, the flooring is in a poor state and needs replacing and the toilet seat needs fitting properly. All these items must be made good. 4. The bedrooms are poorly decorated and must be redecorated in a style chosen by the people living there.
30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 16 5. The quality of the bedroom furniture, fixtures and fittings was poor. All broken, damaged and ill fitting furniture, fixtures and fittings must be replaced in consultation with the people living at the home. 6. The ceiling in the lounge has visible signs of previous water damage and must be made good. The home must undertake an audit of the bedrooms to ensure that they contain the furniture, fixtures and fitting required under the National Minimum Standards. The laundry facilities are located in the kitchen area and are suitable for people’s needs. There is a hand-wash basin in the kitchen but staff have no access to suitable soap and hygienic hand drying. Not all the staff team have undertaken food hygiene training. 30 Newland Street DS0000021707.V254304.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): EVIDENCE: These standards were not assessed during this inspection. 30 Newland Street DS0000021707.V254304.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): EVIDENCE: These standards were not assessed during this inspection. 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 19 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 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 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 2 13 2 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
30 Newland Street Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000021707.V254304.R01.S.doc Version 5.0 Page 20 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 Care plans must fully identify all people’s identified holistic goals fully. People and the staff team must be provided with the time and resources to enable them to identify, facilitate and participate in the opportunities and activities of their choice. 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. All the staff team must have undertaken food hygiene training. Timescale for action 01/12/05 2 YA13YA12 16 01/12/05 3 YA24 23 31/12/05 4 YA30 13 31/12/05 5 YA30 13 31/12/05 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 21 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. 30 Newland Street DS0000021707.V254304.R01.S.doc Version 5.0 Page 22 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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