Inspection on 18/05/06 for 58 Park Road (Royal Mencap Society)

This inspection was carried out on 18th May 2006.

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

58 Park Road (Royal Mencap... 12/12/05

58 Park Road (Royal Mencap... 23/08/05

58 Park Road (Royal Mencap... 04/08/04

58 Park Road (Royal Mencap... 17/05/04

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

CARE HOME ADULTS 18-65 58 Park Road (Royal Mencap Society) 58 Park Road Kettering Northamptonshire NN16 9LL Lead Inspector Mrs Moira Mosley Unannounced Inspection 18th May 2006 08:00 58 Park Road (Royal Mencap Society) DS0000012884.V292392.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 58 Park Road (Royal Mencap Society) DS0000012884.V292392.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. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 58 Park Road (Royal Mencap Society) Address 58 Park Road Kettering Northamptonshire NN16 9LL 01536 416550 01536 416550 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) Royal Mencap Society Mr Keith Millhouse Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: Park Road is registered to provide care for up to four adults who have a learning disability. The home is a four bed-roomed residential house located opposites a large park, close to Kettering town centre. Service users access a range of community facilities by bus or other transport. The house has a good-sized open plan dining kitchen and comfortable lounge. There is also a fully enclosed rear garden and patio, which provides a private and pleasant sitting area for the service users. They access healthcare, occupational training and work in the community. The staff team supports the service users to pursue an active social and recreational life style according to their individual needs and preferences. The service users weekly contribution to the fees is currently £62.35 per week. There is currently an acting manager in post who is applying to the Commission for Social care Inspection for registration. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a statutory unannounced inspection by two inspectors. The inspection process included the collation of information and pre-inspection planning to gather information and then three hours were spent in the home. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for service users and their views of the service provided. This is achieved primarily through the process of ‘case tracking’ which involves reviewing the care of specific service users including looking at their records, talking to them and their families or representatives where possible and talking with the care staff who provide the personal care to those selected. The care of two service users was reviewed on this inspection to include care plans, risk assessments, medication and other records. In addition all four service users were met and although some have communication difficulties and were unable to voice their views they all demonstrated their feelings about being in the home. Discussions were also held with two staff members and a period of observation undertaken. The acting manager was on leave on the day of the inspection and a follow up telephone conversation was made to give some feedback and clarify issues. What the service does well: There is a very positive approach to promoting independence and accommodating individual needs that include disability issues and the different cultural backgrounds of the service users with the environment set out and clear documents and policies written to meet the various needs. The staff and service users in the home were very welcoming and wiling to talk to the inspectors about all aspects of the home. Two of the service users spoken to were very positive about life in this home and all four appeared very happy and settled with positive interactions observed between staff and them with choices being offered and explained. In addition the acting manager submitted the pre inspection questionnaire and questionnaires were received from two relatives and the four service users. The questionnaires from both service users and relatives were positive with no issues of concern raised. There is a consistent and stable staff team who demonstrated a good understanding of the individual needs of the service users and it was evident they use a variety of methods to aid communication. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 6 Care plans are completed to a high standard with good levels of information to ensure a consistent approach and they work well with the professionals including psychiatry, GP and community learning disability nurses to ensure needs are identified and addressed. 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. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 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 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are being fully assessed to ensure their needs can be fully met. EVIDENCE: Within the service users files there are comprehensive assessment documents that are completed and highlight all aspects of physical and mental health needs with a focus on service users’ abilities rather than disabilities. There have been no new admissions over the past year to this home. However the staff were aware of the Mencap assessment procedure that would be used for any new referral and demonstrated a thorough process including assessment visit by the manager and visits to the home by any prospective service user over a period of time depending on their needs to ensure they were happy with the home and were compatible with the other service users. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 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 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ needs are fully met through an effective care planning system. EVIDENCE: The care plans seen for the two service users whose care was tracked were very comprehensive. There is a great deal of relevant information which staff confirmed they use to ensure a consistent approach to meeting needs identified. There was detailed direction for staff on how to meet needs with the service users involved in and signing the care plans. The care plans included personal care needs, social, physical, communication and independence goals and included information about the cultural and religious needs of the service users. There is a new care plan process being implemented and the staff are involved as keyworkers working with the service users to develop these. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 10 One of the service users spoken to is working towards independence and spoke about how she is being supported to achieve this with n emphasis on making choices and decisions about her life. She was very proud of the progress made and had clear goals for her future. Risk assessments are in place for all areas and identify the reasons for any restrictions made to ensure a safe environment along with a promotion of selfchoice and independence being encouraged. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.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): 11,12,13,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to be as independent as possible with a good range of leisure activities available that enable them to lead full and active lives. EVIDENCE: The service users attend a variety of day placements including college, day centres and individual activities to suit their needs. Staff confirmed that they work with the service users to encourage activities both on an individual and small group basis. They have good links with are active within the local community and access local facilities and services. The staff confirmed and documentation evidences good family and friends support within the home with frequent visits, home visits and telephone contact to keep in touch. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 12 Relationships between service users and staff were positive; staff encouraged and enabled service users rather than taking over and controlling what they were doing. One service user spoke about her independence and was increasing her skills in cooking, cleaning and going out independently. This has included occupational health input and support from other professionals to help her move forwards and she was really happy with what was happening. The staff prepare the meals with the assistance of the service users depending on their skills and abilities. They all discuss the menus and are involved in the shopping for and preparation of food to suit their likes and dislikes. The kitchen was well organised with good records to show how they maintain the necessary health and hygiene requirements. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.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): 18, 19, 20 and 21. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are being fully addressed to meet individual needs. EVIDENCE: The information in service users’ personal care assessments is very good with detail about the level of support needed and gives clear directions for staff to meet individual needs according to their preferred choices. There is evidence of input from a range of health professionals including the GP, community nurse, podiatry, dental and physiotherapy input where needed. They have intimate care plans clearly giving direction to staff about individual needs for personal care and promoting independence, with consideration to the privacy and dignity of the service users. There is information about specific syndromes within the care plans with staff signing to say they have read the documents this supports staff in having a better understanding of the needs of the service users. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 14 Service users are weighed regularly and there was evidence for one service user who had been losing weight of a maintenance plan and monitoring of all health needs. There are medication procedures in place for the safe ordering, storage, administration and disposal of medication. The medication administration records were cross-referenced to the medication stored for the four service users. One service user is self-medicating and the necessary plans are in place to encourage this independence along with monitoring procedures to ensure it is a safe practice. There was one service user who had been prescribed a medication for use prior to a podiatry appointment; although there were plans in place the directions on the medication were not clear and the staff on duty agreed to remove them as they were no longer required. Each service user has information about what they would like to happen if they were to become ill and plans for their funeral have been discussed and agreed, along with details about their religious needs and church attendance is arranged to suit individual preferences. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 15 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 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is an effective system for the home to respond appropriately to complaints made and service users are protected from abuse with their views listened to. EVIDENCE: The home uses a range of methods to assist service users to make their views known and has a system in place for recording and acting on any complaints or issues raised by the service users. The service users indicated in their questionnaires that they would speak to their keyworker if they had any concerns. Staff training records showed that staff had received training on abuse issues and staff spoke to were clear on what they would do if they had any concerns raised about the care of the service users and were able to clearly identify what they would consider to be abuse when working with service users. Staff spoke about the high expectations within the home in regard to how they work with the service user with a strong emphasis on respect and their role in providing positive role modelling. There have been no allegations made since the last inspection. There is an effective system in place for the management of service users money with individuals having their own bank accounts and risk assessments in place to assist individuals manage their finances as independently as possible with safeguards in place. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing service users with a homely place to live although the propping open of fire doors could be a risk in the event of a fire. EVIDENCE: The home is well furnished and is fully maintained to provide a very comfortable and homely environment. In one of the bathrooms upstairs it was noted that the lock appeared to be fitted backwards which could result in a service user being locked in and prevented them in maintaining their privacy when using the bathroom, this was raised with the staff and during the subsequent telephone conversation with the acting manager it was confirmed this had been changed. The use of door wedges in the communal doors on the ground floor was discussed and they were removed at the time of the inspection to prevent the risk in the event of a fire. The acting manager has since confirmed that they are planning to fit automatic door closures and quotes are being made. There is a maintenance system in place and satisfactory fire and environmental health reports were available to ensure it was a safe environment. The grounds 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 17 are well maintained and give accessible space for the service users to use at any time. The home was clean in all areas and the laundry systems are effective. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitably qualified and trained staff are provided in adequate numbers to ensure resident needs can be met. EVIDENCE: The staff files were not available as the acting manager was not present, however discussions with staff demonstrated that staff have received the training needed in order to perform effectively within their roles and they stated that all staff are currently up to date with statutory training and this is confirmed in the homes pre inspection questionnaire. The staff spoke about the induction process for new employees and this is detailed over a 3 month period with to ensure new staff receive sufficient information before fully undertaking their role unsupervised. The staff spoke to have achieved their National Vocational Qualifications (NVQ) at level 2 or above and they said that the company were very keen on training to ensure staff are kept up to date and given the opportunity for new training. Staff spoken to confirmed that they felt there were sufficient numbers of staff on duty to meet the service users needs. There is a very stable staff team with a low turnover, which ensures a consistent team to provide the care needed. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 19 The staff confirmed that there is a detailed recruitment procedure including Criminal Records bureau (CRB) checks, to ensure that staff don’t have any past criminal records or other reasons why they should not work in care with vulnerable people, prior to commencement of employment. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a proactive management approach to address issues identified and service users’ views are being sought with working practices in place to ensure that the health and safety of service users is promoted and protected. EVIDENCE: The acting manager is in the process of applying to the CSCI for registration. The staff spoke highly of the management of the home and it was evident through observations of the positive relationship between the service users and the staff team. There are regular house meetings with the service users and they are supported and encouraged to be involved in the running of the home as far as possible. There is a Quality Assurance system including a monthly audit of all areas of the home by the service manager with action plan identified for any shortcomings noted. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 21 There was evidence of questionnaires that had been sent out with service users being supported by staff from the day centres to complete. A development plan was formulated from the results for any issues identified. There are effective systems in place for health and safety issues to be addressed and there were no concerns identified at the time of this inspection, apart form the wedging open of fire doors which was addressed at the time of the inspection. The fire records were seen and showed there were regular tests and there is a system in place to ensure maintenance is kept up to date. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 22 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 3 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 4 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 3 3 X 3 X X 3 X 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 23 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. Standard Regulation Requirement Timescale for action 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 The fitting of automatic door closures should be considered to assist with service user movement within communal areas without compromising safety by the use of door wedges. 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 58 Park Road (Royal Mencap Society) DS0000012884.V292392.R01.S.doc Version 5.1 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!