CARE HOME ADULTS 18-65
Cottam Road Scheme 1 Cottam Road High Green Sheffield South Yorkshire S35 4PJ Lead Inspector
Mrs Janis Robinson Unannounced Inspection 12:30 29 November 2005
th Cottam Road Scheme DS0000002949.V268573.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 Cottam Road Scheme DS0000002949.V268573.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. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Cottam Road Scheme Address 1 Cottam Road High Green Sheffield South Yorkshire S35 4PJ 0114 284 7429 0114 286 9789 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) South Yorkshire Housing Association Mr John McClure Care Home 18 Category(ies) of Learning disability (18), Physical disability (3) registration, with number of places Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Of the 18 service users in the category LD, 3 can also have an additional physical disability (PD). 28th June 2005 Date of last inspection Brief Description of the Service: Cottam Road provides care for up to 18 people with a learning disability, three of whom may have an additional physical disability. The home is divided into three houses, each accomodating six residents. The houses have thier own kitchen, lounge/dining rooms, laundry and bathing facilities. The garden and large activities room is shared by the three houses. A small car park is provided. The home provides twenty-four hour care, and some residents attend day-centres and community groups. The home is situated within a housing estate close to local ammenities such as bus routes, shops and public houses. There is a bus stop outside the home. Cottam Road Scheme DS0000002949.V268573.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 took place over 3 hours from 12.30pm to 3:30 pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, rotas, staff training and supervision. Interactions between staff and residents were observed. Two residents and all of the staff were spoken with. One member of staff was formally interviewed. Discussions with the homes manager took place. The majority of key standards were assessed and met at the last inspection. What the service does well:
The interactions observed between residents and staff appeared respectful and caring. A service user guide had been provided to each resident to give him or her information about the home. Each resident was provided with a contract, which informed them of their rights and obligations. Trial visits took place, to enable prospective residents and their representatives to make informed choices. Care plans were in place for all residents. These set out in detail the personal, social and health care needs of the individual, and the staff action required to ensure these needs were met. Residents were supported to take risks and make decisions about their lives. A policy on confidentiality was in place, to ensure residents rights were respected. Access to day care facilities and community groups was available to meet residents’ needs. An activities worker visited the home twice weekly, to provide a range of activities to those residents that did not attend any day care resource. Support staff provided some further activities and trips out of the home. There was home an open visiting policy, to encourage contact with relatives and friends. Medication systems were safely managed. There was a complaints procedure in place, to promote residents safety. On the day of the inspection the environment was clean and fresh smelling. It was well decorated. Communal areas contained homely touches to create a comfortable environment. Bedrooms contained personal belongings, which enabled residents to have some control over their personal space. Sufficient bathing facilities were provided to ensure residents personal care needs were met. The laundries and kitchens were well equipped to meet residents’ needs.
Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 6 Agreed levels of staff were being maintained. The home had a thorough recruitment procedure. A staff training record was in place, and individual training records were maintained. Staff received supervision at the required frequency. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. Staff undertook mandatory training to ensure their skills were maintained. 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. Cottam Road Scheme DS0000002949.V268573.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 Cottam Road Scheme DS0000002949.V268573.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): 1,4 and 5. A service user guide was available, which provided information about the home to residents and their representatives. Trial visits were encouraged, to enable prospective residents and their relatives to make informed choices. Contracts had been undertaken with each resident, to inform them of their rights and obligations. The information available and actions taken ensured that standards were met. EVIDENCE: Each resident had been given a copy of the homes service user guide, to give them information about all aspects of the homes procedures, environment and staff. They were in a format suitable for residents and contained pictures and diagrams. These were kept in residents’ care plans. Prospective residents, and their families and carers were encouraged to visit the home to meet staff, residents and have a look around the home before admission to inform their choices. Staff confirmed that this was normal practice. Statements of terms and conditions were undertaken with residents to ensure that they were provided with information about their rights. Cottam Road Scheme DS0000002949.V268573.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): 6,9 and 10 Each resident had a care plan, to ensure his or her opinions had been sought and needs assessed. Residents were supported to take risks to ensure they led full lives as safely as possible. There was a policy on confidentiality, to protect residents’ rights. EVIDENCE: Care plans were well set out and easy to read. Where able, residents had signed the plans to evidence that they had been involved in its drawing up. Plans contained a statement confirming that individuals had access to their plan as they wished, and that staff would support them to read their plan, if needed. The plans contained a comprehensive range of information covering all aspects of personal, health and social care. The plans identified the staff action required to ensure identified needs were met. Risk assessments were in place, to ensure that all identified risks were well managed whilst providing some independence to residents. The policy on confidentiality in place ensured information about residents was kept safe. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 10 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): 12,13 and 15. Residents had opportunities to participate in some activities. Some residents accessed facilities in the local community independently. Staff supported other residents to access these facilities. Contact with families and friends were maintained. EVIDENCE: A range of activities was offered to residents, which included trips out of the home to local shops, clubs and pubs. The frequency of activities had improved since the last inspection, as further staff were available to facilitate activities. All of the staff said that sufficient staff were now available to enable unplanned activities to take place. An activities worker visited the home for two hours on a twice-weekly basis. Staff confirmed that contact with residents’ families and friends were maintained. The home had an open visiting policy to encourage contact for residents. Some residents visited home on a weekly basis in order to maintain independence. Residents often visited their friends who lived in the other houses within the home.
Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 11 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): 20 There were systems in place to ensure medication was handled safely. EVIDENCE: A policy on medication was in place. Care plans contained medication profiles and consent to medication. All medication was stored securely. Medication administration records were fully completed and up to date. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 12 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 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. EVIDENCE: The complaints policy was on display in the entrance area of the home. It contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. The policy had been provided in a format suitable for residents, and contained pictures and diagrams. A copy of the policy was included in the information in each residents care plan. Staff were confident in the homes manager to take any complaints seriously. No complaints had been received by the home since the last inspection. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 13 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): 24,25,26,27,28,29 and 30 The home was clean and in the main well maintained. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and bedrooms were well decorated and personalised. Sufficient bathing facilities were provided. Aids to meet the moving and handling needs of residents were in place. The central laundry and kitchens in each house were well equipped, to meet residents needs. Some wooden skirting boards were in need of repair. One toilet floor was badly marked. EVIDENCE: Communal lounge/dining rooms were provided with homely touches to create a comfortable environment. All of the bedrooms were highly individual and reflected the personalities and interests of the residents, allowing them some control over their personal space. Sufficient bathing facilities were provided and aids and adaptations were in place to meet residents moving and handling needs. Two bedrooms had en-suite shower facilities provided to ensure individual needs could be met. The three houses shared the garden, this was pleasant and well maintained. Procedures were in place for the control of infection to promote residents safety. One house had steps and an inclining
Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 14 path to the entrance. Further handrails had been provided since the last inspection, to improve safety. An external light had been provided. Wooden skirting boards in two houses were badly marked and unsightly. These required repairing. One toilet floor in house two was badly marked and required replacing. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 15 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): 31,32,34 and 36 Staff understood their roles and were provided with job descriptions. Agreed levels of staff were being maintained. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff had not been achieved. The homes recruitment practices required some additions, to ensure a thorough procedure was in operation. Staff supervision took place at the required frequency. EVIDENCE: The staff had a positive attitude to their jobs and displayed high level of commitment to the residents. Friendly and supportive relationships were observed between staff and residents. The homes rota indicated that agreed levels of staff were being maintained. All of the staff reported a good team spirit at the home. The home had a commitment to NVQ training. Of the fourteen care staff; eight staff had achieved NVQ in care at levels 2 or 3. A further five staff were enrolled to commence the training in January 2006. Two staff recruitment records were inspected. These contained the majority of information required, and included two references and proof of identification. One record held a gap in employment history. This had not been explored.
Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 16 CRB records were held at the homes head offices. The manager was e.mailed with confirmation that a CRB had been completed. Records need to be improved to evidence that the CRB was undertaken at enhanced level, the date of the check and the disclosure number. The supervision matrix indicated that staff were receiving supervision at the required frequency of six times each year, to ensure they receive sufficient support and guidance. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 17 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): 42 Health and safety systems were in place to promote residents safety. EVIDENCE: Health and safety systems were checked and serviced. Staff were up to date with aspects of mandatory training, to equip them with the skills needed to maintain residents safety. However, only six care staff had a first aid qualification, which meant that a qualified person was not on duty at all times. Some staff required refresher training in food hygiene, COSHH and moving and handling. At the last inspection all staff were up to date with mandatory training, systems must be put into place to ensure that this is achieved and maintained. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 18 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 3 X x 3 3 Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Cottam Road Scheme Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000002949.V268573.R01.S.doc Version 5.0 Page 19 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 2 3 Standard YA24 YA24 YA34 Regulation 23 23 19 Timescale for action The wooden skirting boards must 31/01/06 be repaired and redecorated, or replaced. The marked toilet flooring must 31/01/06 be cleaned to eradicate marks, or replaced. Information held on CRBs must 31/01/06 be sufficient to determine that the check was suitable.(Previous timescales of 30.04.05 and31/08/05 not met) Gaps in employment history must be explored and evidenced in recruitment records. 4 YA42 13 Sufficient staff must be trained in first aid to ensure a trained person is on duty at all times. (Previous timescale of 30/09/05 not met) The organisation must ensure that sufficient access to internal first aid training is available in order to provide all training needed. Refresher training in moving and handling, food hygiene and COSHH must be provided to staff.
DS0000002949.V268573.R01.S.doc Requirement 31/01/06 5 YA42 13 31/01/06 6 YA42 18 31/01/06 Cottam Road Scheme Version 5.0 Page 20 7 YA42 18 All staff must participate in practice drills at the required frequency. 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations The following information should be recorded on CRB checks; Name of staff. Date CRB was carried out. Whether CRB was enhanced. The disclosure number. Cottam Road Scheme DS0000002949.V268573.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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