CARE HOME ADULTS 18-65
East Bank Road 458a East Bank Road Sheffield South Yorkshire S2 2AD Lead Inspector
Jayne Barnett-Middleton. Unannounced Inspection 22nd November 2005 09:30 East Bank Road DS0000002957.V261574.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 East Bank Road DS0000002957.V261574.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. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service East Bank Road Address 458a East Bank Road Sheffield South Yorkshire S2 2AD 0114 265 7717 0114 253 1029 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 Ms Sharon Prior Care Home 20 Category(ies) of Learning disability (20) registration, with number of places East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The 20 beds include 3 places for a service user with an additional physical disability (PD). 29th June 2005 Date of last inspection Brief Description of the Service: East Bank road is a care home accommodating 20 younger adults with learning disabilities. The service has three houses on East bank Road. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries and pubs) There is a private garden area, which is well maintained and safely accessible to all the service users. Each house is built over two floors; no lifts are on site therefore upstairs rooms have to be accessed by the stairways. All bedrooms are single and each house has suitable lounge and dining space. The home provides twenty-four hour support to the service users who have varying degrees of disability. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30am to 3 pm. Seven staff and the manager were spoken to. A sample of records was examined and a partial inspection of the houses was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection?
Residents with high support needs had been reassessed. It was anticipated that extra staffing hours would be available, to improve the level of activities and support provided. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 6 The dining and lounge area in House 1 had been redecorated and a new kitchen installed, which presented a clean and comfortable environment. Two bedrooms in House 1 identified at the last inspected as in need of refurbishment had been redecorated. The manager confirmed that she had made enquiries to provide the Learning Disability Award Framework, (LDAF) award, for staff, which would give them a recognised induction into supporting the residents who live at the home. It was anticipated that the staff would commence this training within the near future. 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. East Bank Road DS0000002957.V261574.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 East Bank Road DS0000002957.V261574.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): 2 and 4. Resident’s individual aspirations and needs were assessed prior to their admission, to ensure that the service was able to meet the service users full range of needs. Prospective residents were given the opportunity to visit the home for trial visits before making a decision to live there. EVIDENCE: A full needs assessment was carried out for all residents prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. There was an admission policy to ensure that prospective residents were able to visit the home before making a decision to move there. Introductory visits were offered which included an initial visit to the home for a drink and to meet the staff and service users progressing to day visits and overnight stays. The manager described in detail the support that had been offered to one service user, which included short visits progressing to longer stays until the resident was comfortable about moving into the home. East Bank Road DS0000002957.V261574.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): 6,8 and 9. Residents had individual care plans, which contained detailed information about their care and support needs. Regular meetings were held with residents to seek their views on how they wished the service to be developed. Risk assessments, which supported residents to lead full lifestyles, minimised risks for the individual had been devised and reviewed regularly. EVIDENCE: Care plans checked set out in detail the action that was required by staff to ensure that all aspects of resident’s personal, social support and healthcare needs were met. Records checked and discussions with staff confirmed that care plans were reviewed on a frequent basis to reflect the resident’s current needs. Resident meetings were held regularly, which enabled residents to contribute to the running and organisation of the home.
East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 10 There was an excellent monthly newsletter, which informed residents about past activities, forthcoming events and information about facilities within the home. Resident’s files contained detailed risk assessments relating to all aspects of residents lives both inside and outside the home. They clearly identified the individual risks that were presented to residents on a daily basis and the action required to reduce the risk, which enabled residents to live an independent lifestyle. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Service users were encouraged to maintain and develop social and independent living skills. Opportunities were provided for service users to engage in activities within the home and maintain links within the local community. Service users were encouraged to eat a healthy and varied diet. EVIDENCE: Residents had regular opportunities to access appropriate activities. Regular activities were available within the home, which included bingo, barbecues and parties. On the day some residents had gone out for a pub lunch whilst others were attending local day centres. One resident was visiting the local shops with the support of the staff. Since the last inspection residents with high support needs had been reassessed. It was anticipated that extra staffing hours would be available, to improve the level of activities and support provided. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 12 Residents were encouraged and supported to maintain positive relationships with their families and friends. Relatives were invited to activities planned at the home. The staff spoke in detail about how they supported one resident to maintain weekly visits with their relative. Residents were offered and encouraged to eat a healthy diet. Menus varied in each house dependent on the resident’s likes and dislikes. The staff had a good knowledge of individual needs and were able to describe resident’s individual preferences. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Residents received personal support, which promoted their privacy, dignity and independence. Resident’s physical and emotional needs were met. Daily records required more detail to ensure that the residents healthcare needs could be monitored. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. EVIDENCE: The staff had a good awareness of service users individual physical and emotional needs and spoke positively about the progress that some residents had achieved. Residents received good support from healthcare professionals who visited them. There were records to evidence that service users were receiving regular visits from their general practitioner, dentist and other healthcare professionals. On the day two residents were being supported to attend healthcare appointments. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 14 Daily records were maintained of the resident’s physical and emotional health and the care that had been provided. One record checked recorded that the resident had suffered ill health, however there was no record to detail the action that had been taken, or the observation that had been provided, to ensure that the residents health had been monitored. There was a medication policy and procedure to ensure that staff adhered to safe practices. Staff had received medication training; all promoting that medication was appropriately administered to residents. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure, which promoted the protection of service users. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Staff spoken to was confident that any complaints/concerns would be dealt with appropriately. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff confirmed that they had received Adult Protection training. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26 and 30. The home was clean, comfortable and on the whole well maintained. Residents were provided with an environment that met their individual needs and lifestyles EVIDENCE: The houses were generally well maintained, clean and furnished in a homely manner. Since the last inspection the dining and lounge area in House 1 had been redecorated and a new kitchen installed, which presented a clean and comfortable environment. The patios and garden areas were very well maintained. The staff spoke positively of how the residents had been involved in the improvements made in the garden area. The manager commented that the garden was popular during the summer months and there were pictures in the monthly newsletter of parties and barbecues that had taken place. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 17 Resident’s bedrooms were comfortable, individually furnished and personalised to meet their needs. The manager commented that service users were encouraged to choose their own colour schemes and it was evident that residents had been encouraged to personalise their bedrooms with photographs and ornaments, which encouraged residents to retain their own identity. Two bedrooms in House 1 identified at the last inspected as in need of refurbishment had been redecorated. The ground floor toilet in House 1 was in need of redecoration as the paintwork was dull and the boarder was torn. The floor covering in the bathroom in house 1 was in need of replacement as it was worn and stained and did not present a clean and comfortable environment. Housekeepers were employed in all houses and a good level of cleanliness was maintained. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. A caring and committed staff team supported residents. Staff received training and support appropriate to their role. The home operated a recruitment policy that promoted the protection of service users. Staff files required some amendments to ensure that they included the required information. EVIDENCE: Most of the staff at the home had worked there for sometime. It was evident that the staff had formed positive and appropriate relationships with residents. All the staff spoken to were professional, relaxed, friendly and were able to demonstrate a very good knowledge of residents individual needs. The manager confirmed that the minimum staffing levels at the home had been reviewed and that she was in the process of trying to secure extra staffing hours, to ensure that residents with high support needs could be offered a better level of support to access the community. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 19 Staff spoken to confirmed that they had received training appropriate to their role to ensure that they were conversant with changing legislation and safe working practices. The manager confirmed that she had made enquiries to provide the Learning Disability Award Framework, (LDAF) award, for staff, which would give them a recognised induction into supporting the residents who live in the home. It was anticipated that the staff would commence this training within the near future. One staff member who had recently been employed at the home confirmed that they had received the appropriate induction and support to carry out her role in a safe manner. A recruitment policy and procedure was in place. Two files checked contained a range of information including two references, declaration of health and qualifications/training. The files did not contain a full employment history of the employee. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of service users. The staff confirmed that they were receiving regular supervision to enable them to discuss their development and to identify any training requirements. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The staff said that they were well supported by the management team. Forums were in place, which enabled residents and staff to contribute to the day-to-day running of the home. The health, safety and welfare of service users 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. The manager had almost completed a NVQ Level four qualification. All staff spoke positively about the support that they received from the management team describing them as “approachable” and “very supportive”. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 21 Residents and staff meetings were held on a regular basis, which provided them with the opportunity to contribute to the day to day running of the service. Staff spoken to said that the meetings were “useful” and that they felt comfortable to suggest ideas and express their opinions. South Yorkshire Housing Associations quality assurance officers visited the home on a regular basis to carry out monitoring of the service to ensure that the home was working within the law and their policies and procedures. The staff had received regular training to promote the health, safety and welfare of service users and their colleagues. East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
East Bank Road Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000002957.V261574.R01.S.doc Version 5.0 Page 23 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 Standard YA19 Regulation 15,17 Requirement Daily Care records must be more detailed to ensure that service users healthcare needs can be monitored. The toilet on the ground floor in house 1 must be redecorated. The floor covering in the bathroom in House 1 must be replaced. Staffs’ personal files must contain a record of the employee’s full employment history. Any gaps in employment must be accounted for and recorded. All staff must receive all of the training required by the sector skills council training targets. Timescale for action 30/12/05 2 3 4 YA24 YA24 YA34 23 23 19 30/01/06 30/01/06 30/12/05 5 YA35 18 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations East Bank Road DS0000002957.V261574.R01.S.doc Version 5.0 Page 24 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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