Inspection on 02/04/07 for Doncaster Road 54

This inspection was carried out on 2nd April 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Doncaster Road 54 24/01/09

Doncaster Road 54 16/01/06

Doncaster Road 54 15/08/05

Doncaster Road 54 15/03/05

Doncaster Road 54 23/08/04

Doncaster Road 54 18/03/04

Doncaster Road 54 09/10/03

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Doncaster Road 54 Clifton Rotherham South Yorkshire S65 2BU Lead Inspector Ian Hall Key Unannounced Inspection 2nd April 2007 08:15 Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 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 Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 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. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Doncaster Road 54 Address Clifton Rotherham South Yorkshire S65 2BU 01709 836809 NONE NONE 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) The House of Light Trust Andrea Ellis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A condition of registration is that the home can provide care for one named individual residing at the home who is over 65 years of age. 16th January 2006 Date of last inspection Brief Description of the Service: 54 Doncaster Road Canna is a residential care home registered to provide personal care and accommodation for 3 persons with a learning disability. It is owned by the House of Light Trust, a charitable organisation that has other care homes in the area for people with a learning disability. The home is a three bedroom semi-detached house. It is situated in a residential area of Rotherham close to a park and other community facilities such as shops and public houses. The homes facilities are domestic in scale and reflect ordinary living principles. Two of the residents rooms are on the first floor. The third service user has a bedroom on the ground floor and is accommodated within a recently built extension. The alterations to the home have also provided a downstairs bathroom, a larger refurbished kitchen and a refurbished lounge/dining area. The home is tastefully decorated and residents have personalised their rooms to their own individual taste. There are pleasant gardens to the front and rear of the property and a patio area is accessible via the dining room and the downstairs bedroom patio doors. Information gained on the 2nd April 2007 indicates the current fees are £480.73 to £665.25 for residential care and additional charges are made for holidays, hairdressing, toiletries and hobbies. These fee charges only applied at the time of inspection, more up to date information may be obtained from the home. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 08:15am and concluded at 12:40pm. The inspection included a tour of the building, reading records, discussions with service users and staff, observation of service users and mealtimes. The inspector also met with the registered manager and another member of staff. What the service does well: What has improved since the last inspection? What they could do better: Documentation is currently being updated to include more pictorial images to improve service users access and understanding of them. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 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 Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5. People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Pre admission assessments had identified individual needs that had been planned for before the service users moved into the home. Individual written contracts detailing terms and conditions of residence provided clear information for people who use the service. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 9 EVIDENCE: Service users and care staff confirmed that they had discussed the care and service provision before admission to the home. Assessments had been undertaken by skilfully and sensitively by an experienced and qualified member of staff. The assessments were very comprehensive and included an in depth profile for each individual. Their likes and dislikes, choices and wishes and preferences were recorded. The plans focussed on meeting positive outcomes for each individual, they promoted dignity privacy and encouraged independence. Particular attention had been paid to ensuring the service user was able to settle into their new home; they had been allocated a key worker to give them information, answer any questions and feel comfortable in their surroundings. The case files examined contained written contracts they had agreed with that state both terms and conditions of residence. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users were actively involved in planning their care, setting personal goals and facilitated to lead an independent lifestyle. EVIDENCE: Service users confirmed that they had been involved in planning their care with their key workers. These care plans were up to date and had been drawn up having discussed their “hopes and dreams” for the year. The information recorded was comprehensive and enabled staff to ensure that all aspects of social support and healthcare needs were met. Each care plan could easily be used by people who were not familiar with the care needs to ensure individual needs were being met. The care plans had been reviewed on a regular basis. Service users were encouraged to make their own informed decisions and to take responsible risks within their daily lives both inside and outside the home. These were monitored with risk assessments recorded and continuously Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 11 evaluated to promote safety of service users. Examples of risk assessments seen within care plans included awareness of emergency procedures and going out alone. Evidence indicated that health and safety risk assessments were undertaken for each room. People who live at the home were continuously consulted about the service and were able to influence key decisions in the home. Flexible staffing linked to the assessed needs of the service user ensured that the care and support offered, and did not limit their choice and preference. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users were encouraged to maintain and develop social and independent living skills within the home and local community. Service users were encouraged to eat a healthy and varied diet. EVIDENCE: The three service users had identified their “hopes and dreams” for the coming year. These formed the focus of their care programme for the coming year. Individual choice of activities such as supporting football teams, visits to town and meals out, taking part in a drama group and choosing their annual holiday were being facilitated by their key workers and the care team. Service users from the three House of Light care homes regularly socialise at each other’s homes. Christmas and New Year celebrations had been shared Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 13 with their friends who reside in the sister homes. The three houses are in close proximity to each other. Personal development was encouraged with service users attending the theatre, and activities at the Gateway and over 55’s clubs. The home had an open visiting policy service users had been supported and facilitated to maintain close links with their families and friends. Through discussions with service users and staff it was evident that service users were encouraged and supported in making independent decisions, these included their choice of meal and their plans for each day. Routines were kept to a minimum and were flexible in accordance with service user needs and wishes. Service users were offered and encouraged to eat a healthy diet to maintain their wellbeing. They planned and shopped for food for the weekly menu. Service users helped to prepare the meals on the day of inspection, which helps in developing independent living skills. Staff were always available to discreetly provide support, guidance and assistance whenever this was required. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users confirmed that their physical and emotional needs were met. Safe systems for the ordering, storage and administration of prescribed medication were in place to protect service users. EVIDENCE: Records clearly recorded personal and healthcare needs and detailed how they were to be met and documented the services accessed. Staff sensitively supported and facilitated service users with this process. The staff had a good knowledge of each service user’s individual needs, dislikes, preferred routines and care needs. Staff were observed to treat each service user as an individual and respond skilfully to their changing needs. This demonstrated that staff understood each service user’s needs and abilities and how to respond with appropriate actions. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 15 Staff were observed administering medications and helping service users to take their prescribed medicines. Records were correctly maintained and medicines stored safely. The home had a range of policies and procedures to provide guidance for staff and maintain the safety of service users. Staff had received accredited training for safe administration of medicines. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes adult protection policy and complaints procedure were clear and accessible and promoted protection of service users. EVIDENCE: Service users confirmed their satisfaction with the care and services provided at the home and were clear when they described how they would deal with anything or person who made them unhappy. The complaints procedure ensured that service users and their relatives were aware how to make a complaint and who would deal with them. Staff knew the importance of taking the views of service users seriously, and listening to and responding to any issues raised. Staff were conversant with the policies and procedures for adult protection, these included the included safeguarding guidance issued by the local authority. Staff knowledge and understanding were checked regularly and their practice updated regularly. Staff and service users all said that the manager was approachable and were confident that any concerns would be listened to and appropriate action taken. The manager confirmed and records demonstrated that no complaints had been made to the home or any external agency. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well-maintained odour free and homely. Service users bedrooms were comfortable, individually decorated and furnished to meet their needs. EVIDENCE: All areas within the home were well- lit, clean, tidy and well maintained. The garden area of the home provided a pleasant seating area for residents to use when the weather is warm. Service users are encouraged and supported with personalisation of their bedrooms with pictures, photographs and ornaments. Bathrooms and toilet areas were equipped with appropriate aids and adaptations to meet service users needs. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 18 The stylish décor of the home was of a good standard and there were plans in place to re-decorate some areas. This is part of a planned programme of maintenance and renewal, which ensures the home remains in a good overall condition. Management has a good infection control policy and encourage staff to work within the policy to reduce the risk of infection. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including looking at training and supervision records and speaking to available staff. Staff had received training to meet the service user’s general and specific needs. A good range of training was available for staff. Appropriate support and guidance was offered to new staff, enabling them to safely care for service users. The home operated a recruitment policy that promoted the protection of service users. EVIDENCE: The staff spoken to were friendly, approachable and relaxed when talking about the care that they provided. Staff said that they enjoyed working at the home, that there was a family atmosphere and that they worked very well as a team. A training and induction programme for staff was in place enabling them to meet the assessed and changing needs of residents. Discussions with staff and Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 20 records checked demonstrated that staff had received a good range of training that included Moving and Handling, First Aid and Health and Safety. A staff training record plan had been devised which demonstrated the training that staff had attended. Individual training records checked demonstrated that staff had been offered the refresher training that they required, to ensure that they were conversant with changing legislation and safe working practices. The manager said that newly recruited staff had completed the Learning Disability Award Framework, (LDAF) award, which will give them a recognised induction into supporting the service users who use the service. A recruitment policy and procedure was in place. The recruitment of committed and good quality staff is seen as the key to delivery of a high quality service. The company emphasis was to take care in selecting the right person for the job. All new staff completed a probationary period during which they were required to demonstrate competence before being offered a permanent contract. The application and interview selection is based upon specific criteria a person specification. The two staff files checked contained a range of information including two references, declaration of health and qualifications/training. Staff had received a Criminal Records Bureau Check at the enhanced level to promote the protection of service users. Regular staff meetings were held to ensure staff were involved in the development of the service. Staff expressed that they felt valued members of a caring and committed staff team. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including interviewing the registered manager and observing staff as they work. The health, safety and welfare of residents was promoted and protected. EVIDENCE: The registered manager had many years experience within the caring profession which, enabled her to contribute to the care of service users and communicate a clear sense of leadership to staff. She had completed the registered managers award and an NVQ level 4 qualification. She had good people skills and led by example promoting person centred care and effective outcomes for people who use the service. There was a mutual respect between the manager and staff. The manager commented that the staff were supportive and flexible to the needs of the Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 22 service. The staff spoke highly of the manager commenting that she was enthusiastic, supportive, and approachable and a good manager. The staff said that meetings took place on a regular basis enabling them to share information and to contribute to the development of the service. The staff had received training including fire training which promoted safe working practices and the health, safety and welfare of the service users and their colleagues. Risk assessments had been completed and were reviewed regularly. Service records for fire safety and other maintenance records were up to date. Service users finances were properly recorded and personal allowances provided. Management, staff and service user meetings were held regularly the written minutes from these meetings were available for inspection. Audits of the quality of care and services provided were undertaken regularly the results were published and any areas for improvement were actioned promptly. The quality audit tools had been updated and amended appropriately. Policies and procedures had been reviewed annually and promoted best practice and service user choice and independence. Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 4 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 4 29 3 30 4 STAFFING Standard No Score 31 3 32 4 33 4 34 4 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 x LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 4 x 4 x x 3 x Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Doncaster Road 54 DS0000003129.V329036.R01.S.doc Version 5.2 Page 26 - 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. 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