Inspection on 07/12/05 for Amersall Court

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Amersall Court 04/05/07

Amersall Court 10/05/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

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

CARE HOME ADULTS 18-65 Amersall Court Amersall Road Scawthorpe Doncaster South Yorkshire DN5 9PQ Lead Inspector Janet McBride Unannounced Inspection 10:20 7 December 2005 th Amersall Court DS0000065521.V264839.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 Amersall Court DS0000065521.V264839.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. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Amersall Court Address Amersall Road Scawthorpe Doncaster South Yorkshire DN5 9PQ 01302 781857 01302 788624 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) Doncaster MBC Ms Lynda Stocks Care Home 18 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4), Physical disability (14) of places Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Amersall Court is a care home for adults offering care to two different service users groups aged 18 to 65 with physical disabilities/ learning disabilities, accommodating 18 service users. The home was purpose built and has been opened for two years, and accommodation is in three bungalows, there is also a two-bedded unit for semi-independent living. Each of the three bungalows provides single bedrooms with en-suite toilets and showers, a communal lounge and kitchen/dining room. The semi-independent unit provides communal lounge/dining, kitchen and shared bathroom; corridors internally connect all of the accommodation. To the rear of the home is a large, enclosed patio area, and a car park is provided at the front of the home. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Amersall Court, on the 7th and 8th of December 2005, commencing at 10:20 and finished at 17:10,the visit on the 8th December was to discuss any issues that were raised on the 7th with the manager and feed back about the Inspection. This was the home second Inspection since April 2005,any standards not covered in this inspection was covered in the unannounced inspection that was conducted early in the year. It may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. During the Inspection we looked at chosen number of documents, sampling of records, tour of the premises and direct and indirect observation of staff interaction with residents, this Inspection also included individual and group discussions with residents, and feedback from relatives and visitors on the day. Any issues or concerns that were raised were discussed with the Manager and Team manager during or at the end of the Inspection. What the service does well: What has improved since the last inspection? Since the last Inspection there as been change of the Registered provider, from South Yorkshire Housing Association to Doncaster Metropolitan Borough Council. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 6 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. Amersall Court DS0000065521.V264839.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 Amersall Court DS0000065521.V264839.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): 23 Prospective service users are individually assessed prior to admission to the home, to ensure that their needs will be met. EVIDENCE: Three service users care plans were checked and evidence was seen that service users are individually assessed prior to admission to the home, to ensure that their needs will be met. Lots of information was available in individual care plans, evidence that other professionals are involved and that care plans are developed based on individual needs, including health action plan for one service users. Staff evidenced a commitment to service users, but insufficient staff impacted on staff availability to meet individual needs. All of the service users and staff spoken to felt that staffing levels had not increased in line with service users dependency. Staffing vacancies and sickness levels impacted on the amount of individual staff time and range of activities that could be offered. Amersall Court DS0000065521.V264839.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): 679 Most service users health care needs are identified and met, however some shortfalls have a potential to place services and staff at risk. EVIDENCE: Each service user had an individual plan of care; three individual care plans were examined, they contained a range of information, including evidence of other professional involved, health action plan for one service user and the plans evidenced if they had been drawn up with the service user or their representative involved, but no evidence that the home use advocacy groups for those service users that do not have family members. Service users were enabled to take responsible risks; any limitations were recorded and agreed in the individual plan. A number of issues were raised and discussed with the manager, some documentation had not been completed in a new service users care plan, care notes not in date order and difficult to follow, nutritional assessments not completed, weights not recorded and risk assessments not in place. Care plans were last audited in November 2004 and advised the manager that care plans should be audited on a regular basis. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 10 From discussions with staff and reading of documents suggest that some needs were not being addressed, e.g. aggressive behaviour. Management must address this issue and risk assessment must identify any risk to either the service users or staff and what action to take to prevent any harm to either the service users or others. Risk assessments were only found in one of the three service user plans checked. Amersall Court DS0000065521.V264839.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): 11 12 13 14 15 16 17 Service users rights are respected and daily routines promote independence, individual choice and freedom of movement. Staff ensures that service users have access to and choose a range of appropriate activities. EVIDENCE: Staff interviewed was aware of the need to give opportunities to service users to maintain and develop social, emotional, communication and independent living skills. However the staffing did not always enable this to happen due to staffing levels, e.g. long-term sickness and vacant posts. All of the service users who chose to do so were involved in some form of education or day centre resource. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 12 The home don’t employ an activities organiser, but staff within the home try to organise activities whenever possible. Staff was aware that service users wished to access leisure activities and tried to accommodate this where possible. If this required staff to assist the service users outside the home this was not always possible, as there were not the numbers of staff on duty. Despite staffing levels many staff continued to take service users out in their own time so that they were able to enjoy some leisure activities. The home had its own mini bus to facilitate outings. Service users were supported to maintain links with their families, and the home had an open visiting policy, the majority of service users had contact with relatives. Three service users commented that they were happy at the home both with care they received and the staff who the feel work hard at making them feel wanted and cared for. From observation on the day and speaking to service users, the daily routines appear flexible with service users staying in bed if they wished. Observations between staff and service users was good with service users being called by their preferred name, all being attended to promptly and staff respecting privacy by knocking on doors before entering. Service users chose the menu, and alternatives were offered. Plentiful stocks of food were seen in the three bungalows. All of the service users asked said that they enjoyed the food, although no evidence was found that service users had been nutritional assessed. Take-away meals were provided and meals out on occasions, at the service users preference. Amersall Court DS0000065521.V264839.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 Service users health is monitored and staff can access all NHS health care facilities, but some medication practices require attention. EVIDENCE: Records clearly show detailed information of service users personal care needs. Staff interviewed was aware of any restrictions on privacy, e.g. danger when bathing alone, and stated that risk assessments would be in place to identify these risks and how they can be managed. Service users had access to a range of health care professionals, including District Nurses, Chiropodists, Dentists and Optician. Staff supported service users to access these, and any contact with health care professionals was recorded. Service users spoken with confirmed that they feel health care needs were assessed and met, and service users on learning disability unit have a health action plan. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 14 Each bungalow kept individual service users medication, appropriate storage facilities were provided. Medication stocks and records were examined on each unit and a number of issues were raised, staff did not sign hand written medication sheet, no reason was documented when medication was omitted and stock of medication was out of date. Service users that self medicate must be risk assessed and have care plan in place, and service users must have medication reviewed. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 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 23 Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and the care provided, and staff and management have a good understanding of Adult Protection and robust polices are in place to protect residents. EVIDENCE: The organisation has a comprehensive Concerns Complaints procedure (DMBC View Point). There is also a monitoring form that is used to record complaints, this meets the requirements and includes timescales for complaints to be acknowledged and investigated. Discussed with staff that stated that if service users have any concerns they usually raised at residents meetings, and evidence was seen in minutes taken. The home has DMBC policy on Adult Protection and Whistle blowing, and therefore have the appropriate policies and procedures in place for dealing with adult protection. Discussion with staff confirmed they were aware of these polices and procedures, although some staff requires training and updates on adult abuse, and this needs to be addressed by the manager, and DMBC. On examination of the homes incident reports, it was found that the Commission for Social Care Inspection had not received any notifications of some aggressive incidents that have happened within the home, advised staff that any incident involving service users must be reported to the Commission for Social Care Inspection. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 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 30 Service users live in a safe, comfortable and accessible environment with any specialist equipment they require to maximise their independence. EVIDENCE: The home was purpose built and designed to suit the client group, and offer care to two different service users groups aged 18 to 65. Unit 1 accommodates four elderly service users with learning disabilities, and unit 2 and 3 both accommodate six service users with physical disabilities and unit 4 as two beds but at the present is being used for one-service users with physical disabilities. Corridors internally connect all of the accommodation, and is fully accessible for service users in units 2 3 and 4,but unit 1 has a keypad for service users safety. Each of the three bungalows provides single bedrooms with en-suite toilets and showers, a communal lounge and kitchen/dining room, unit 4 semiindependent unit provides communal lounge/dining, kitchen and shared bathroom. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 17 Tour of all units was found to be well maintained, clean and tidy, looked very homely with fresh flowers, pictures and ornaments around the home. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 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): 31 32 33 34 35 36 The registered manager and staff have the skills and experienced, and try to manage the home, in the best interest of service users. But DMBC must ensure that staff are trained and updated, to ensure that service users individual and appropriately trained staff meets joint needs. This ensures that service users are safeguarded and protected. EVIDENCE: The registered manager has worked at the home a long time and understands her responsibilities and other staff roles. Staffing was discussed with the manager and duty rotas examined, which shows high levels of sickness including staff on long term sick, and vacant posts that have not been filled for some time. The staff displayed a high level of commitment, and covered duties over and above their contracted hours to ensure minimum numbers were maintained. No evidence was found that staffing is assessed according to the dependency levels of service users, therefore a review of staffing levels, which takes into account service users increasing needs, must be undertaken and sufficient staff provided to meet these needs. The home had a thorough recruitment procedure, and staff recruitment records are held at the Councils head offices, however no new staff have been Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 19 recruited since the last Inspection. The manager was able to confirm that appropriate checks had taken place and all staff had Criminal Records Bureau checks, and provided two written references. Training was discussed with the manager new staff induction and foundation training remains the same and met requirements. Each member of staff had an individual training profile, and although staff have the competencies and qualities required to meet service users’ needs, training files show that most staff require training or updates in moving and handling, food hygiene, first aid and abuse training. Staff can access NVQ training and out of the 31 care staff at the home, 7 staff has completed NVQ and 4 other staff are on NVQ courses at the present, therefore the home will not meet the standard of having 50 of staff NVQ trained by December 2005. Supervision of staff was discussed with the manager and deputy and records checked, some staff has received formal supervision, but many are outstanding and no staff has received their yearly appraisal, adversely staffing and the managers sickness has had an impact on this standard. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 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 41 42 Staff at the home are enthusiastic and work positively with service users to improve their quality of life. The Registered person must ensure that staff is appropriately trained to protect service users and meet their care needs. EVIDENCE: The registered manager has worked at the home a long time and understands her responsibilities and ensures that staff is aware of there roles. Quality assurance was discussed and audits checked; the manager is used to carrying out audits within the home as these were conducted on a monthly basis when SYHA were the Registered Providers. Since DMBC has become the Registered Provider no audits have been completed apart from the Regulation 26 visits. No evidence was available that the home seeks the views of family and visitors, but feedback is sought at residents meetings and the minutes of these were available for the Inspector top read. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 21 Records required by Regulation was discussed with the manager regulation 37 notifications, has the CSCI as only received them from home when there been a death, advised the manager the scope of notifications that must be sent to the CSCI. Health and safety was discussed with both the manager, staff, indirect observation of staff and records checked. All staff spoken to was aware of policy and procedures and confirmed they completed fire training and drills. Records seen were found satisfactory, with the exception of; staff require updates in moving and handling, food hygiene and training in first aid as there must be a first aider identified on the duty rota at each shift. Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 2 X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Amersall Court Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X 2 2 X DS0000065521.V264839.R01.S.doc Version 5.0 Page 23 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(1)(2) Requirement Timescale for action 01/01/06 2 YA9 13(4)(C) 3 YA20 13(2) Care plans; 1) Staff must complete all documentation when service users are admitted to the home. 2) Documentation in care notes must be clear and easy to follow. 3) Service users weights must be recorded. Risk assessment and risk 01/01/06 management strategies must be completed when any risks are identified. Medication; 01/01/06 1) Two staff must sign Mar sheets that are hand written. 2) Staff must document why medication is omitted. 3) Service users that self medicate or change times of medicine must be risk assessed and have a care plan to monitor the situation. 4) Service users must have medication reviewed on a regular basis. Stocks must be rotated. DS0000065521.V264839.R01.S.doc Version 5.0 Amersall Court Page 24 4 YA23 18(1)(C) 5 YA33 18(1)(a) Protection, The Registered 31/01/06 person must ensure that staff is trained to deal with aggression in accordance to D.O.H guidance. Staffing, The Registered person 31/01/06 must ensure that the home have a staff team with sufficient numbers and skills to support service users assessed needs at all times in accordance with the guidance recommended by the department of health. Recruitment, DMBC recruitment policy must be addressed, as the home has had a number of vacant posts for a long time. The Commission for Social Care Inspection require evidence of how DMBC are addressing this issue. Training and development, The Registered provider must ensure that staff can access and receive training and updates, so they are trained and competent to do their job.e.g. moving and handling and first aid. Supervision and appraisals, all staff must receive supervision on a regular basis and yearly appraisals. Regulation 37 notifications, The registered manager must inform the CSCI of any occurrence that happens within the home. 31/01/06 6 YA34 18 7 YA35 18 28/03/06 8 YA36 18 31/01/06 9 YA41 17(1) 01/01/06 Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA3 YA7 YA12 YA32 Good Practice Recommendations Insufficient staffing numbers have an impact on the amount of time that staff can spend with the service users. Advocacy groups should be available for service users. Service users would benefit from an activities person being in post. The Registered person should ensure 50 of the staff team should achieve NVQ level 2 in care . Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Amersall Court DS0000065521.V264839.R01.S.doc Version 5.0 Page 27 - 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!