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Inspection on 13/10/05 for Chapel Street Care Home

Also see our care home review for Chapel Street Care Home for more information

This inspection was carried out on 13th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Current service users are well supported by staff to develop and maintain daily living skills. Some have paid jobs and others attend Day Centre and college. They are involved in community activities and also have a choice of activities available within the home. Staff are supported to train and develop in order to meet the needs of service users and the overall management of the service is effective.

What has improved since the last inspection?

Some decorating has been completed in bathrooms. Staffing records, including training profiles, are better organised.

What the care home could do better:

The premises are fairly well maintained, but a few areas need some attention. Bathrooms have been decorated but the floors still need replacing as they are stained. The stairs are steep and some carpeting on stairs is threadbare in places and needs replacing before it becomes a risk to safety. Also, the conservatory is very spacious, but soon becomes very hot and uncomfortable. Action needs to be taken to improve this facility. There was evidence of staff responding to complaints from a relative and such complaints and concerns should be referred to the manager so that they can be dealt with via the complaints procedure.

CARE HOME ADULTS 18-65 Chapel Street Care Home 3-5 Chapel Street Kirkby In Ashfield Nottinghamshire NG17 8SY Lead Inspector Meryl Bailey Unannounced Inspection 13th October 2005 12:00 Chapel Street Care Home DS0000008646.V255970.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 Chapel Street Care Home DS0000008646.V255970.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. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chapel Street Care Home Address 3-5 Chapel Street Kirkby In Ashfield Nottinghamshire NG17 8SY 01623 757902 01623 720988 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 (Housing & Support Services) Sarah Louise Hall Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: 3 – 5 Chapel Street provides accommodation for nine service users with a learning disabilities. The accommodation is not accessible to wheelchair users. It comprises two adapted joined houses with three floors, including a self contained flat. The home is situated in a residential area, with good access to local shops, pubs and transport. There is a garden to the rear of the property. The service users are encouraged to be as independent as possible with staff support, and all appear to be well integrated into the local community. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and conducted by one inspector during two mornings (13th and 20th October 2005). Service users were not at home on either day. The main focus of the inspection was on staffing and management of the service. The area service manager for Mencap and two staff were present on the first day and the registered manager was present on the second day. The need for a second visit was to enable the inspection of staffing records accessible only by the registered manager. Staff gave their views about the care provided. The communal areas and bathrooms of the home were inspected, but just one bedroom was seen. Service users files and staffing files were sampled. What the service does well: 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. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 6 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 Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 7 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 The needs of prospective service users are assessed prior to admission. EVIDENCE: There was a full assessment of needs for the most recently admitted service user. The needs identified were set out in an individual plan of support. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 8 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 Needs and risks are addressed in an individual plan for each service user. EVIDENCE: One individual plan was examined in detail and found to be comprehensive and contain some relevant risk assessments. Up to date information was recorded by staff in daily notes attached to the plan. Standardised forms were used for the paln and the service user had signed her agreement in appropriate places. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 9 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): Key standards were met at the last inspection (12, 13 and 17 were exceeded). EVIDENCE: Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 10 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): Key standards were met at the last inspection. EVIDENCE: Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 11 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 The formal complaints procedure has not been used for all concerns raised and the outcomes of discussions are not clear. Service users are appropriately protected from abuse. EVIDENCE: There were no formal complaints recorded, but there was reference to complaints raised by a relative in the individual daily notes for one service user. The notes showed that a support worker had listened to the complainant, but the outcome was not recorded. It is recommended that any verbal complaints made by service users or their relatives be referred to the manager and that they are dealt with via the complaints procedure. Following the last inspection, the manager clarified the amended area adult protection procedures for all staff. There has, though, been no need to use these procedures. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 12 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 A clean, homely environment is provided, which is mostly comfortable though not totally well maintained. EVIDENCE: The home is on three floors and upper floors are accessed by narrow staircases only. The environment was, generally, homely and the furniture appeared comfortable and of a high quality. The lounge was cramped for the number of service users at the home, but the conservatory provided additional space for dining and activities. However, no change has been made to the conservatory, which often became uncomfortably hot so that full use was not made of the area. Temperatures were being monitored and it was 22°C on the first morning of this inspection. It was recommended at the last inspection that the ceiling blinds be replaced. This has not been done though quotes for the work had been obtained and alternatives were being explored. One service user’s bedroom was seen and was personalised and decorated to a high standard. The walls of the bathroom and toilet on the first floor have been redecorated since the last inspection, but the floor coverings were not replaced and were stained. The floor of the bathroom on the second floor was in a similar state. The stair carpet was threadbare in places and could pose a trip hazard if left to deteriorate further. Although maintenance was needed the staff had supported service users in maintaining a high standard of cleanliness throughout the home. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 13 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, 33, 34 and 35 Staff are supported to train and develop in order to effectively meet the needs of service users. The recruitment practices protect service users. EVIDENCE: Training records showed that all staff have received Foundation Training with Mencap. This is comprehensive and accredited within the Learning Disability Award Framework. Staff are given paid time to undertake their training whilst service users are at day services. Two staff were working on National Vocational Qualification level 3 and two more are due to start this level. The duty rota showed that, during the day, at least two staff are on duty when service users are at home. Additional 1:1 support is given for one service user. At night there is only one staff member, who sleeps in an ensuite bedroom on the second floor. During the past six months there have been three occasions when staff have needed to respond to service users during the night. There was a mixed staff group of males and females to reflect the service user group. All staff were over 18 and those sleeping in were over 21. Staffing records were complete for most staff (see standard 41) and there were copies of contracts and job descriptions. There were records of Criminal Record Bureau checks having been carried out on all staff, but some basic details were not available for one member of staff. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 14 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): 39, 41 and 42 The overall management of the service safeguards the best interests of service users, though one staffing record remains incomplete. Service users’ views and comments are valued and health and safety is promoted within the environment. EVIDENCE: The views of service users have been sought via questionnaires and an action plan was available to show that their comments have been used in improving the service. Regular meetings were held with service users and each Tursday evening they discussed menus and had a rota for deciding on meals and assisting with cooking for each day. Records seen were generally well maintained and staffing records were better organised than previously, though a proof of identity and basic information on an application form were missing for one staff member. Service users records were well organised and all records were held securely. Health and safety records were maintained and the fire log was up to date. Staff were trained and retrained in safe working practices and some appropriate risk assessments were in place. Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 15 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 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chapel Street Care Home Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 3 X 2 3 X DS0000008646.V255970.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? Yes 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 2 2 Standard YA24 YA24 YA41 Regulation 23(2)(b) 23(2)(b) 17(2) Requirement Replace floor coverings in bathrooms Replace stair carpeting Timescale for action 31/01/06 31/01/06 Maintain full records in respect of 31/12/05 each member of staff and ensure these are held within the care home. (This refers to one incomplete record only) 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 YA22 Good Practice Recommendations It is recommended that any verbal complaints made by service users or their relatives be referred to the manager and that they are dealt with via the complaints procedure. Replace ceiling blinds in the conservatory. 2 YA24 Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Chapel Street Care Home DS0000008646.V255970.R01.S.doc Version 5.0 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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