Inspection on 25/04/05 for Chapel Street Care Home

This inspection was carried out on 25th April 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 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

Chapel Street Care Home 08/12/08

Chapel Street Care Home 16/10/06

Chapel Street Care Home 13/10/05

Chapel Street Care Home 17/12/04

Chapel Street Care Home 04/05/04

Similar services:

Hillside

Applegarth

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Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Chapel Street Care Home 3-5 Chapel Street Kirkby in Ashfield Nottinghamshire NG17 8SY Lead Inspector Meryl Bailey Unannounced 25 April 2005, 10:00am th 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 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 Stationary 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 C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Janine Tregelles, Royal Mencap Society Ms Sarah Louise Hall Care home 9 Category(ies) of Learning disability, x 9 registration, with number of places Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17/12/04 Brief Description of the Service: 3 – 5 Chapel Street provides accommodation for nine service users with a learning disabilities. It comprises two adapted joined houses, 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 C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 one morning. Many of the service users were at home as the local daycentre was closed for the week due to staff training. The manager and two staff were present. Some service users and staff gave their views about the care provided, but no visitors were present on the day of this inspection. The communal areas of the home were inspected and a sample of bedrooms were also seen. 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 C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 standard(s) 1,2,3 The needs of current service users are met within this setting. EVIDENCE: The individual records show that needs are regularly reviewed and additional 1:1 support is provided for one service user as required to enable his needs to be met alongside others in this home. A self contained flat forms part of the home and is occupied by a couple with support. Due to the layout of the home on different levels and with narrow stairs and odd steps, it would not be appropriate for anyone with mobility needs and this must be made clear to any prospective service users. However there are no current vacancies. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 standard(s) 6, 7 and 9 Individual plans address needs and risks, but strategies in place are not all agreed. EVIDENCE: Individual Plans are comprehensive and contain some relevant risk assessments. A behaviour issue identified during inspection was not assessed and recorded. The strategy put in place by one staff member, to restrict the use of a toilet, had not been agreed by the manager or service user and this needs to be reassessed along with staffing arrangements during the night. (See also standard 33.) There was evidence of other aspects of the plans being agreed and signed by service users or family members. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15, 16 and 17 Lifestyle choices and opportunities for leisure activities are varied and appropriate. Service users feel respected and encouraged to be part of the local community. A healthy diet is offered. EVIDENCE: Service users attend daycentres, chat club, work placements and colleges. Three service users are in employment. One service user returned from work at a hotel during the inspection, but others were at home “on holiday” for one week from the day centre. The service users reported that they have a wide and varied social life and enjoy appropriate leisure activities including football, Gateway club, Snooker club and going out for evening meals. Other activities within the home include pool table, television and gardening. Individual preferences are recorded on files including preferred names. The menu is chosen and agreed at resident meetings and a service user was observed being supported in preparing fresh vegetables. Information and encouragement is given on healthy eating and diets for medical needs such as diabetes. Staff report that support is given to maintain relationships with family and friends, who visit for tea occasionally. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 standard(s) 18, 19 and 20 Personal support and health needs are met. EVIDENCE: Personal support needs are detailed in the individual plans. Some service users have had well person health checks and other medical appointments are noted. Medication is well organised and held securely. Records show appropriate procedures for recording medication are followed. One service user has responsibility to administer her own medication and this is appropriately risk assessed and monitored. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 standard(s) 22, 23 Service users are aware of how to make their views known. Staff protect service users, but the procedures are not clear enough to ensure service users are always protected. EVIDENCE: The complaints procedure has been amended since the last inspection so that service users are given contact information regarding the Commission as part of the procedure. No complaints have been recorded since the last inspection. Two service users confirmed they know how to make a complaint. Advocates from “Advocacy Alliance” have been involved with some individual service users. The manager has attended a training session with the area adult protection unit, though certain parts of the amended area procedure were not made clear. A discussion was held during inspection regarding this to clarify that a manager of the local Social Services Department must always determine the course of investigations into any allegation of abuse. The registered manager must now ensure the procedures within the home are up to date and clear for other staff. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 standard(s) 24, 25, 27, 28, 30 A homely environment is provided, which is mostly comfortable and safe. Bedrooms suit the needs of individual service users and sufficient shared toilets and bathrooms are available, though not all well maintained. EVIDENCE: The environment is homely and the furniture appears comfortable and of a high quality. The service users bedrooms are clean, personalised and decorated to a high standard. Three service users said that they are satisfied with their individual rooms. The conservatory is used for dining and activities. This area soon became uncomfortably hot during the day and it is recommended that ceiling blinds be replaced. The home is on three floors and upper floors are accessed by staircases. There are grab rails to the stairs, but no lift. Service users are used to using the stairs to their bedrooms. The majority of the home was found clean and fresh with the exception of the top floor toilet that had been locked. Redecorating commenced in February 2005, but work has been halted and the walls of the bathroom and toilet on the first floor are in a poor state. Some of the shared washing facilities had no paper towels. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36 Staff are clear about their roles and staffing ratios meet the needs of service users during the day. The lack of staff awake at night could potentially put service users and staff at risk. EVIDENCE: 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 and the manager’s hours are additional. At night there is only one staff member, who sleeps in an ensuite bedroom on the second floor. Two service users have bedrooms on the same floor. Due to information given during this inspection about a service user who is frequently out of bed during the night, this sleep in arrangement needs to be re assessed. Staffing records are not all present (see standard 41), though there are copies of contracts and job descriptions. There are records of Criminal Record Bureau checks having been carried out on all staff, but not all references are on file. Staff report a range of training undertaken, but recorded information was not available regarding the training and development programme for staff. The manager reported that all staff have recently undertaken training in challenging behaviour, with a course called “Effective Communication and De-escalation.” Staff reported that they receive 1:1 supervision with the manager. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41 and 42 The overall management of the service safeguards the best interests of service users, though there are some omissions within staffing records held at the home. Service users’ views and comments are valued and health and safety is promoted within the environment. EVIDENCE: The manager has been registered with the Commission since the last inspection. Senior managers at Mencap maintain regular contact. Staff commented that the manager is well organised and staff and service user meetings are held regularly. A survey of service users views has been carried out, but the report of the outcome is not yet available. Records are generally well maintained, but on checking staffing records some references were not found. The manager stated that some may be held at Mencap’s regional office. Health and safety records are maintained and the fire log was up to date. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 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 2 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 4 x 2 2 x 2 Standard No 11 12 13 14 15 16 17 x 4 4 4 3 3 4 Standard No 31 32 33 34 35 36 Score 3 x 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chapel Street Care Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 2 3 x C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 Page 16 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. 1. Standard YA 6 Regulation 12, 13 and 15 Requirement Ensure any strategy to restrict access to any facility is agreed and is in place as a result of a risk assessment. This must be recorded in the service users support plan and kept under review. Ensure the Adult Protection procedures within the home are up to date and clear for all staff. Complete redecoration of the bathroom and toilet on the first floor. Having regard to the needs of service users during the night, review the need for wakeful staff to ensure sufficient and appropriate staff are available. Maintain full records in respect of each member of staff and ensure these are held within the care home. Timescale for action 31st May 2005 2. 3. 4. YA 23 YA 24 YA 33 13(6) 23(d) 18(1)(a) 31st May 2005 31st May 2005 31st May 2005 5. YA 41 17(2), (3) Schedule 4.6 31st May 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 Page 17 Chapel Street Care Home 1. 2. 3. 4. 5. Standard YA 1 YA 27 YA 28 YA 30 YA 35 Include information about the physical limitations of premises (stairs) in the Service User Guide for any prospective Service Users. Ensure the toilet on the second floor is clean and available at all times unless agreed as a result of a risk assessment. Replace ceiling blinds in the conservatory. Make paper towels available in all shared washing facilities. Formulate a clear training and development profile for each member of staff. Chapel Street Care Home C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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 C53 C03 S8646 Chapel Street V223415 250405 Stage 4.doc Version 1.30 Page 19 - 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. 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