This inspection was carried out on 7th March 2006.
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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
30 Newland Street 30 Newland Street Crumpsall Manchester M8 5RY Lead Inspector
Steve O`Connor Unannounced Inspection 7th March 2006 13:00 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 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.V285744.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th September 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.V285744.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 7th March 2006. Time was spent talking with people and 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 September 2005 had identified a few areas that the home needed to improve upon. The majority of these areas had been actioned by the home. Those outstanding were reiterated in this report. At the previous inspection an immediate requirement was issued due to health and safety concerns regarding a back yard gate and back door security. These issues had been dealt with by the home within the agreed timescales. 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. What the service does well: What has improved since the last inspection?
At the previous inspection it was found that people’s care plans did not reflect the goals and aims of what people wanted to achieve. The home had worked with people and had clearly identified social, leisure and development opportunities that people wanted to take part in.
30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 6 The care plan now gave a much more rounded view of each person, of what they can do and what they wanted to achieve. Having to rely on support from others can mean that people lose some of the control over their own lives as decisions and choices are made for them. The home has worked to support and encourage people to make their own choices and decisions about the lives they want to lead and the activities they want to participate in. Several examples were found where a person has been encouraged and supported to take up educational opportunities to meet their personal ambitions. What they could do better:
Providing people with a place to live that is attractive, well maintained and furnished has beneficial affects on their health and motivation as well as a positive impact for staff working at the home. The house requires investment in refurbishment and decoration to raise its standard. The home are in the process of planning for refurbishment and progress will be monitored through the inspection process. Training provides staff with the knowledge and skills they need to support people safely and in accordance to legislation, regulation and good practice guidance. Areas such as Medication Administration and Food Hygiene need to be addressed. To make sure that the staff the home employs are safe to work with vulnerable people the registered provider must provide the CSCI with its policy, procedure and conditions for undertaking POVA First checks. The role of the registered manager is to ensure that the home delivers a quality service to the people it supports and meets the organisations targets for quality and the National Minimum Standards. The home must submit a named person to be the registered manager of the home. Copies of all accidents and incident records must be maintained in the home and be available for inspection at all times. The registered provider must provide the CSCI with an updated action plan on the progress in meeting the identified targets from the January 2006 ‘Mock Inspection’. It is recommended that the home fully consult and take into account people’s choices and decisions in the refurbishment of the home. Evidence of this consultation should be documented. It is recommended that the home’s training programme include the provision of at least five paid training and development days (pro-rata) per year. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 7 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.V285744.R01.S.doc Version 5.1 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.V285744.R01.S.doc Version 5.1 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): No judgement was made. EVIDENCE: The core standard was assessed during the previous inspection. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 People are encouraged and supported to make their own decisions and choices. EVIDENCE: The previous inspection report highlighted the need to improve people’s care plans so that they better reflected the holistic needs and all the support staff provided. The care plans had been improved and contained a clear set of goals that people wanted to achieve and the support required to achieve them. Records were being maintained of the situations and support that helped people to meet their goals. The home encourages people to make decisions and choices about their own life. Relevant information and support is provided to help people make these judgements and choices. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 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): 15, 16 and 17 The home supports people to maintain family links, develop their own routines and a diet that people enjoy. EVIDENCE: At the previous inspection the staff raised the issue of having the time to be able to support people in finding out about opportunities for social, leisure and development. The staff spoken to stated that they were encouraged to work with people to find the information needed so that they could take up new opportunities. People are encouraged and supported to maintain and develop links with their families and friends based on people’s own wishes. Peoples’ routines are set by themselves in terms of the activities that they participate in. There are no rigid routines for meals or other domestic tasks and there is some flexibility in the support provided to support them. People living at the home can be independent in the community and are able to decide for themselves what they want to do.
30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 12 Meals are determined by people themselves and their own personal choices and preferences. The home does provide support and guidance regarding healthy diet choices. Mealtimes are flexible and are taken when it suit people and not the home. There was a reasonable stock of food in the home. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 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): No judgement was made. EVIDENCE: Whilst discussing medication issues with the staff it was found that staff received their medication administration training in-house. Both the ‘Mock Inspection’ report of the 24.01.06 and the Regulation 26 report of the 28.02.06 identified that staff require training in the medication administration. The regulation 26 report identified this as a priority. However, staff on duty informed the inspector that they were going to start this course but were then told that there was no more funding for distance learning courses. All staff responsible for the administering of medication must undertake the required medication training. The core standards were assessed at the previous inspection. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 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): 22 People do feel that they can raise their concerns and will be listened to. EVIDENCE: The previous inspection report required the home to improve the monitoring and auditing in managing people’s money. The financial records were being kept accurately. Both the people who live at the home can express themselves fully and will raise their concerns and worries with the staff or management team. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 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): No judgement was made. EVIDENCE: The previous inspection highlighted a number of areas in the house that needed repair, replacement and decoration. The back yard gate had been replaced and the back door bolt was repaired. The bathroom toilet seat had been replaced but no other repairs and decoration had taken place in the bathroom. The bedroom of one person had not been decorated nor the poor furniture and furnishings replaced. The issue of poor furniture in the bedrooms was raised in the ‘Mock Inspection’ report of the 24/01/06 and a timeframe of the ‘end of February’ was stated in the Action Plan. This had not been achieved and so the requirement was reiterated. The organisation has undertaken an audit of the refurbishment needs of the property and progress will be assessed through the inspection process. It is recommended that the home fully consult and take into account people’s choices and decisions in the refurbishment of the home. Evidence of this consultation should be documented. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 16 An audit of the furniture in people’s bedrooms had been completed in May and June 2005. Suitable hand washing facilities had been provided in the bathrooms and kitchen. At the previous inspection it was found that some staff had not undertaken upto-date food hygiene training. Speaking to the staff on duty it was found that they had not all received this training. This requirement was reiterated. The core standards were assessed at the previous inspection. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 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): 32, 34 and 35 The home provided a programme of vocational training that provided staff with the required qualifications. The home does not have all the systems and practices in place to show that it fully undertakes safe recruitment practices and has provided staff with the training required to undertake their role. EVIDENCE: Five of the eight support workers had achieved the NVQ level 2 qualification. The recruitment process and procedures are operated by the main organisation Southfields Care Homes Ltd. The documentation and checks required are maintained at the main office and samples of these files were assessed on the 28th February 2005. Files were seen with completed application forms, references received and a contract of terms and conditions. The procedure for obtaining the required Criminal Records Bureau (CRB) and POVA (POVA) check was explained and files were seen with the CRB reference number and date of issue. The use of the POVA First check was discussed and it was found that there was a misunderstanding in that it was believed that staff could start working as long as the required supervision was in place.
30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 18 It was also found that it was standard practice for the organisation to seek a POVA First for all staff. The CRB and Department of Health guidelines highlight that this check should only be made in exceptional circumstances. The registered provider must provide the CSCI with its policy, procedure and conditions for undertaking POVA First checks. The main organisation had given a deputy manager from another of its care homes the role of training coordinator. She was in the process of undertaking a training audit of the staff team to establish exactly what training had been undertaken and when this was achieved. The home also maintained a training log for each of the staff team. The results of the training audit and any action plan developed to address any identified training needs must be provided to the CSCI. Through discussions with the management and some of the staff team it was stated that if staff are not on the rota on the day of a planned training/development event then they are not paid for attending that event. The National Minimum Standards identify that staff should receive at least five paid training and development days (pro-rata) per year. It is recommended that the home’s training programme include the provision of at least five paid training and development days (pro-rata) per year. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 No judgement could be made regarding the management of the home. The home has developed a process of quality assurance but this has not yet been fully implemented and not all the systems are place to evidence that the health and safety of people is being maintained. EVIDENCE: At the time of the inspection the home did not have a named manager who could be nominated as registered manager. A care worker was working in an ‘acting’ senior role. Management support was provided through the organisations management structure who would visit the home on a regular basis. The registered provider must submit an application for a registered manager to take responsibility for the home. The home has introduced a new quality assurance system that includes the production of a regulation 26 monthly report and a ‘mock’ inspection using the National Minimum Standards and scoring. The home are also introducing an 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 20 annual ‘Satisfaction Survey’ to gain the views of the people living at the home, relatives, carers and other relevant professionals. The ‘Mock Inspection’ undertaken on the 24th January 2005 identified that improvements were required around the following issues. The Statement of Purpose and Service User’s Guide, the service user contracts, staff training, involving people in the recruitment of staff, service user meetings, information provided to people regarding their community, condition of the furniture and staff meetings. An action plan was developed from this report. The registered provider must provide the CSCI with an updated action plan on the progress in meeting the identified targets from the January 2006 ‘Mock Inspection’. It was also found that introduction of the quality assurance system was not known or understood by the staff on duty at the time of the inspection. It is recommended that the home keep staff updated and informed of the quality assurance system. Evidence was seen of updated COSHH and Fire Risk Assessments. Copies of accident and incident records were returned to the organisation main office. Copies of all accidents and incident records must be maintained in the home and be available for inspection at all times. A fire log is maintained for visual checks and fire drills. Fire, gas and electrical equipment was being serviced on an annual basis. 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 2 X X 2 X 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 22 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 YA20 Regulation 18 Requirement Timescale for action 01/06/06 2. YA24 23 All staff responsible for the administering of medication must undertake the required medication training. All the areas identified in 01/06/06 standard 24 must be made good. (Timescale of 31/12/05 not met) 3. YA30 13 All the staff team must have undertaken food hygiene training. (Timescale of 31/12/05 not met) 01/06/06 4 YA34 13 The registered provider must provide the CSCI with its policy, procedure and conditions for undertaking POVA First checks. The results of the training audit and any action plan developed to address any identified training needs must be provided to the CSCI. The registered provider must submit an application for a registered manager to take responsibility for the home. 01/05/06 5 YA35 18 01/05/06 6 YA37 8 01/05/06 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 23 7 YA39 24 8 YA42 12 The registered provider must provide the CSCI with an updated action plan on the progress in meeting the identified targets from the January 2006 ‘Mock Inspection’. Copies of all accidents and incident records must be maintained in the home and be available for inspection at all times. 01/05/06 01/04/06 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 YA24 Good Practice Recommendations It is recommended that the home fully consult and take into account people’s choices and decisions in the refurbishment of the home. Evidence of this consultation should be documented. It is recommended that the home’s training programme include the provision of at least five paid training and development days (pro-rata) per year. It is recommended that the home keep staff updated and informed of the quality assurance system. 2 YA35 3 YA39 30 Newland Street DS0000021707.V285744.R01.S.doc Version 5.1 Page 24 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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