Inspection on 28/03/06 for Edgar Street Residential Care Home

This inspection was carried out on 28th March 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Edgar Street Residential Care... 07/02/07

Edgar Street Residential Care... 05/10/05

Edgar Street Residential Care... 09/03/05

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Edgar Street Residential Care Home 3 Edgar Street Huncoat Accrington Lancashire BB5 6ND Lead Inspector Mrs Julie Playfer Unannounced Inspection 28th March 2006 12:45 Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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 Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Edgar Street Residential Care Home Address 3 Edgar Street Huncoat Accrington Lancashire BB5 6ND 01254 872119 01254 872119 adelepilk@aol.com 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) Dr Morgiana Muni Nazerali-Sunderji Miss Adele Pilkington Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission 5th October 2005 Date of last inspection Brief Description of the Service: 3 Edgar Street is registered with the Commission for Social Care Inspection to provide personal care and accommodation for 6 adults with a learning disability aged 18 to 65 years. The home is semi-detached in a residential cul-de-sac. It is close to local amenities and within walking distance of public transport to the nearest large towns. The accommodation is provided on 2 floors. There is a lounge, conservatory, kitchen with dining area, and laundry facilities. All bedrooms provide single accommodation. The residents have access to and use all areas of the home, with supervision from staff if required. Outdoor space, with seating, is available. The philosophy of the home is one of promoting independence and enabling residents to make informed choices about how they live their lives. This is reflected in the individualistic manner in which daily support is planned and carried out and the number and variety of activities which the residents are supported to participate in. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over five hours on 28th March 2006. The previous inspection took place on 5th October 2005. No additional visits have been made to the home since the last inspection. The purpose of the inspection was to assess important areas of life and to check progress to meet a previous legal requirement and good practice recommendations. On the day of inspection there were 6 residents accommodated at the home. Information was obtained from staff records, care records and policies and procedures. The inspector also spoke to the residents, the staff on duty and the registered manager. A partial tour of the premises was also undertaken, with the consent of the residents. What the service does well: What has improved since the last inspection? The service users guide had been updated to include details about the qualifications of the registered provider, registered manager and staff. The registered manager had developed a comprehensive system of measuring the quality of the service. Feedback had been sought from the residents and their relatives and an annual development plan had been produced for the Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 6 home. The registered manager had also developed a means of monitoring the implementation of the plan based on monthly targets. 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. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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 Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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, 2, and 5 Residents were provided with useful and informative information about the services and facilities provided in the home. Resident’s needs were properly assessed and reviewed. EVIDENCE: Written information was available for residents in the form of a service users guide and statement of purpose. Both documents were presented in a suitable format and the service users guide had been distributed to all residents. Since the last inspection the service users guide had been updated to include details about the qualifications of registered provider, registered manager and staff. Care records indicated that the residents’ needs had been assessed before admission by a social worker and the previous registered person. The assessments were kept under review by the current registered manager and the staff at the home. All assessments were completed in consultation with the residents and their next of kin, as appropriate. All residents had been issued with a contract/terms and conditions, which covered all the elements listed in the National Minimum Standards. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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 The care planning system fully addressed the needs of the residents and provided clear guidance to staff on how these needs were to be met. The established consultation arrangements ensured residents were able to participate in all aspects of life in the home. EVIDENCE: From the case files seen, it was evident each resident had a plan of care, based on the assessment of needs. The plans set out in detail the action needed to be taken by staff to ensure all needs were met. The care plans were supported by daily records of care and support. Any changes, issues or concerns were recorded along with all appointments, events and activities the residents had been involved with. All the residents spoken to were aware of their records and could access them at any time. The information in the daily records was collated into a monthly evaluation report, which included a review of the care plans and goal plans. An overall review was held once a year. The residents were fully involved in the review process and the development of their care plans. It was the practice of the home to support responsible risk taking and policies and procedures supported this approach. Detailed risk assessments and Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 10 management strategies covered activities indoors and in the wider community and were included within the residents’ plans. During conversations with residents it was evident they were consulted both informally and formally and they were able to fully participate in life in the home. The format of resident’s meetings was decided by the residents who referred to such meetings as “Service User Chats”. The residents set the agenda for the meetings and agreed on any action to be taken. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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): 11, 12, 13 and 14 Residents were provided with good opportunities to engage in a wide range of appropriate activities and were supported to use community facilities. EVIDENCE: The individual plans and care records demonstrated that residents had opportunities to maintain and develop practical life skills, such as cooking and using public transport. Residents had good access to an extensive range of recreational activities both inside and outside the home. Activities outside the home included; bowling, trips to the cinema, shopping, going out to restaurants and the use of leisure centres. The residents also attended the Hyndburn Neighbourhood Project, which was designed for all members of the local community. One resident had recently attended a calligraphy course and showed the inspector a file of her work. The residents pursued a number of occupational and educational activities. As such, one resident had three part time jobs, three people attended college and three people worked in a local charity shop. One person also attended a day Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 12 centre. Staffing levels were reviewed at regular intervals, which enabled residents to pursue individual leisure interests. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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 The residents’ healthcare needs were identified and met. Personal support was provided in a manner, which respected the residents’ rights to privacy and dignity. Whilst appropriate arrangements were in place for the management of medication, in order to minimise potential errors, attention must be given to one aspect of the record keeping and staff should complete accredited training. EVIDENCE: The residents’ individual care plans set out the personal support each resident required and provided details of how this support was to be delivered. Residents spoken to confirmed personal support was provided in private and their rights to privacy and dignity were respected. The registered manager and staff ensured consistency and continuity for residents by the use of a key worker system. Healthcare needs were appropriately assessed and were included in the care plan. In addition to the care plan the residents had a health action plan, which detailed their medical history and current health. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. All residents were registered with a local General Practitioner. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 14 There was a set of policies and procedures in respect of medication and appropriate records were maintained of receipt, administration and disposal of medicines. However, it was noted that one discontinued medication had not been clearly marked on the medication administration record. At the time of the inspection two people were self-administering their own medication within a risk management framework. The staff were undertaking accredited training, but had not fully completed the course. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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 Systems were in place to ensure any concerns of residents would be acted upon. Policies and procedures and staff training were in place to respond to any allegations or suspicions of abuse. EVIDENCE: Both informal and formal arrangements were in place for the registered manager and staff listened to and acted on the views and concerns of residents, by means of the “service user chats” (resident’s meetings) and everyday conversation. The complaints procedure was included in the service users guide and was verbally explained to residents as necessary. The procedure had been updated since the last inspection to inform residents they may raise a complaint with the Commission at any point in the process. The home had received one complaint, since the last inspection, which was being investigated by the registered provider. The investigation had not concluded at the time of the visit. A copy of “No Secrets in Lancashire” (The Joint Strategy for the Protection of Vulnerable Adults) was available, along with a specific procedure setting out the required response in the event of any allegations or suspicion of abuse. There was also a whistle-blowing policy available for staff. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 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 and 30 The residents were provided with a clean, safe and well-maintained home. EVIDENCE: The home is situated in a residential area in Huncoat. Accommodation is provided in 6 single rooms. Communal space is provided in a lounge, conservatory and kitchen with a dining area. There is a garden at the rear of the property, which the residents said they enjoyed using in fine weather. The furnishings and fittings were domestic in character and of a good quality throughout. At the time of the inspection, the premises were well maintained, comfortable, clean and free from offensive odours. There were established systems in place for the maintenance of the property and the renewal of fabric and decoration. The bedrooms had been decorated and furnished according to personal taste. Residents were able to bring in and purchase their own personal belongings, many of which were displayed in their rooms. Residents were able to use their rooms at any time, should they wish to spend time pursuing their own activities. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 17 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, 33, 34 and 36 The residents benefited from well supported and supervised staff, who were in sufficient numbers to meet the needs of the residents. The staff recruitment process must be improved in order to minimise any potential risks to the residents. EVIDENCE: Staff were issued with job descriptions, which set out their roles and responsibilities. Staffing levels were in line with previous guidance issued by the local authority and were regularly reviewed in line with any planned activities. Since the last inspection, two new staff had been recruited. It was evident from the files seen that both people had completed an application and attended the home for a face to face interview. The residents had been involved in the recruitment process and commented that they enjoyed this role during the “service user chats”. However, it was noted that the applicants had not provided a full working history, a reference had not been sought from current employers and one person had not provided the dates of past employment. Both staff had completed a POVA and criminal records bureau check before commencing employment. From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 18 referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. Staff meetings were held on a regular basis. The meetings gave the opportunity to staff to share experiences and develop teamwork. The registered manager ensured staff received supervision at least six times a year and had an annual appraisal of their work performance. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 19 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): 37, 39 and 42 Effective systems were in place to measure the success of the service in achieving its outcomes for residents. The health, safety and welfare of residents was promoted and protected. EVIDENCE: The registered manager had the overall responsibility for the management of the home and had a job description, which reflected the aims and objectives of the home. The manager had previously completed NVQ level 4 in Management. Since the last inspection the registered manager had achieved the Registered Manager’s Award and was working towards NVQ level 4 in Care. The registered manager had also undertaken periodic training to update her knowledge and skills. Since the previous visit to the home, the registered manager had devised comprehensive systems to measure the quality of the service. Feedback had been obtained from residents and their relatives by means of a satisfaction survey. The results had been collated, published and produced in a pictorial format. An annual development and improvement plan had been developed Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 20 and systems had been put into place to monitor the implementation of the plan, which included monthly targets. The home had a full set of policies and procedures relating to health and safety. Staff received health and safety training, which included food hygiene, first aid and fire safety. Appropriate arrangements were in place for the storage of hazardous substances and a central valve was fitted to the boiler to regulate the water temperature. The electrical and heating systems were serviced at regular intervals and the home had an electrical safety certificate dated May 2004, which was valid for five years. The fire log demonstrated that staff had received training on fire safety and there was evidence to indicate the fire equipment was serviced and tested at regular intervals. The registered manager had carried out and recorded risk assessments on all safe working practice topics and completed weekly maintenance and safety checks on the environment. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 21 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 3 2 3 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 x 33 3 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 22 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. 2 Standard YA20 YA34 Regulation 13 (2) Requirement Timescale for action 28/03/06 28/03/06 All discontinued medication must be clearly marked on the administration record. 17, 18, 19 All records and documentation relating to the recruitment of new staff must be collated and maintained in line with the requirements of the Regulations. 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. 2. Refer to Standard YA20 YA37 Good Practice Recommendations Staff should complete the accredited medication training. The registered manager should complete NVQ Level 4 in Care. Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Edgar Street Residential Care Home DS0000062212.V276294.R01.S.doc Version 5.1 Page 24 - 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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