CARE HOME ADULTS 18-65
Lister Project 2a Basegreen Road Sheffield South Yorkshire S12 3FH Lead Inspector
Mrs Janis Robinson Unannounced Inspection 7th March 2006 09:00 Lister Project DS0000002981.V268782.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 Lister Project DS0000002981.V268782.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. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Lister Project Address 2a Basegreen Road Sheffield South Yorkshire S12 3FH 0114 249 0553 0114 249 0950 j.carr@syha.co.uk 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 Joanne Helen Carr Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (25) of places Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 25 MD mental disorder of which 9 can be used for people with an additional PD (physical disability) This registration includes 5 places at 95 Lister Avenue, Sheffield S12 3FQ; 7 places at 2A Basegreen Road, Sheffield, S12 3FH; 4 places at 2B Basegreen Road, Sheffield S12 3FH; 4 places at 2C Basegreen Road, Sheffield S12 3FH; & 5 places at 2D Basegreen Road, Sheffield S12 3FH 12th July 2005 Date of last inspection Brief Description of the Service: The Lister Project provides personal care and accomodation for up to twenty five service users who have mental health problems. The project consists of five adjacent houses, each accomodating up to five service users. The houses are linked by an external pathway. To the rear of the houses is an enclosed communal garden, which is provided with seating. Each of the houses are provided with a communal lounge, dining room , kitchen, showers and bathrooms. All of the bedrooms are single. A central kitchen provides the main meals for each house. The home is based in a residential area of Sheffield close to shops and public transport. The home is owned by South Yorkshire Housing Association. Lister Project DS0000002981.V268782.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 4 hours from 9.00am to 1:00 pm. An inspection of a proportion of the environment was undertaken. A proportion of records were checked, including care plans, menu, rotas, and staff training. Interactions between staff and service users were observed. Seven service users and the majority of staff on duty were spoken with. Discussions took place with the manager. All of the requirements made at the last inspection, that were within the managers power to deal with, had been actioned. What the service does well:
The interactions observed between service users and staff appeared respectful and caring. Service users said `The staff are nice’, ‘The staff give you what help you need’, and `I like living here’. Care plans were in place for all service users. 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. Service users 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 was available to those service users who wished to access these. Residential Mental Health Workers supported activities and trips out of the home. There was an open visiting policy, to encourage contact with relatives and friends. The routines at the home were flexible, to enable service users to have some control over their lives. The menu was varied, and individual preferences were respected. Service users health care was monitored and access to relevant professionals was available to ensure health was maintained. Medication was stored securely. Staff that administered medication had been trained to do so safely. On the day of the inspection the environment was clean and fresh smelling. Communal areas contained homely touches to create a comfortable environment. A rolling programme of redecoration was in place. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. There was a quality assurance system, which sought the views of service users and their representatives. Insurance cover was provided. Records within the home were stored securely, to respect confidentiality. 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.
Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
Priority must be given to ensuring the risks of fire are minimised, in line with the fire officer’s recommendations. Funding must be provided to update the fire alarm to a more efficient system and enable flame retardant refurbishment to take place. Extractor fans must be provided in smoking areas to improve the environment for non-smokers. Whilst it is acknowledged that a proportion of staff had undertaken external medication training, all staff must be provided with this to equip them with the skills needed to ensure safe practices took place. Staff skills would be further improved with the provision of formal sanctions and restraint training. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 7 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. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 8 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 Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 9 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): Standards one to five were assessed and met at the last inspection. EVIDENCE: Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. Each service user had a care plan, to ensure his or her opinions had been sought and needs assessed. Service users were supported to make decisions to ensure they had some control of their life. Service users were supported to take risks to ensure they led full lives as safely as possible. There was a policy on confidentiality, to protect service users rights. EVIDENCE: Care plans had been updated to improve systems for service user involvement and ensure full and accurate information was recorded. Care plans were well set out and easy to read. Where they had chosen to do so, service users 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. 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 service users. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 11 Service users were able to make decisions about their lives. Service users were observed making choices about where and how to spend their time, and staff respected these decisions. The policy on confidentiality in place ensured information about residents was kept safe. Service users said they liked living at the home, the staff were `good’ and `gave all the help they could’. They said that they had everything they needed. Service users confirmed that they could make decisions, and the routines at the home were flexible. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 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 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 had opportunities to participate in some activities. Some service users independently accessed facilities in the local community. Staff supported other service users to access these facilities if required. Trips out of the home were organised. Contact with families and friends were maintained. Service users rights were promoted and responsibilities were identified. A varied diet was provided and preferences respected. EVIDENCE: A range of activities was offered to residents, which included trips out of the home to local shops, clubs and pubs. Attempts to improve the range of activities provided had been successful. The homes rota had been adjusted to create additional staff on identified days to facilitate activities. Funding for a dedicated activities worker had been agreed. At the time of this inspection the manager was recruiting to this post. Staff continued to motivate service users. A winter ball had been organised for service users and staff, that service users were involved in and looking forward to. Service users also identified trips out, such as short breaks to the coast, which had been facilitated.
Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 13 Staff confirmed that contact with service users families and friends were maintained. The home had an open visiting policy to encourage contact. One service user told the inspector that their daughter and granddaughter visited them regularly. A central kitchen provided the main meals to service users in their houses. Breakfast and snacks were available within each house. Service users said that they enjoyed the food. One service user said that they could have what they wanted. The record of food provided was varied and appeared healthy. Alternatives to the menu were always available. The service users in one house were piloting a scheme to undertake their own menu planning, food shopping and cooking. This was being monitored with a view to introducing this to the other houses, to develop and support service users independence. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. Service users personal support needs were assessed and met. Staff monitored service users physical and emotional health, to ensure this was maintained. Medication was stored securely. Care plan records in relation to medication had been developed to meet standards. Service users needs regarding longterm care and death were identified to ensure these would be carried out. EVIDENCE: Care plans contained information on service users personal care needs in detail. The plans set out the staff action required to ensure all identified needs were carried out. The care plan recordings were specific and comprehensive. Staff had a clear understanding of the individual needs of service users, and the knowledge to ensure personal care needs were met respectfully. The majority of service users were able to independently meet their personal care needs, care plans contained information on encouragement and advice. Care plans contained information on all aspects of health care. Appointments and treatments with health care professionals were recorded to ensure these were monitored and health was maintained. The plans evidenced that service users emotional health was monitored and any concerns identified were referred to relevant specialists. Access to health care professionals was available. Staff responded to any health concerns promptly.
Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 15 Medication was stored securely. Care plans had been expanded to include assessments to self-administer, and consent to medication to evidence that safe and informed practices were carried out. Since the last inspection the medication administration procedures had been improved to better meet service users needs and avoid institutional practices. Medication was kept in secured drawers in service users bedrooms, which meant that service users no longer had to `queue’ for their medication. The homes pharmacist had confirmed this procedure as acceptable and safe. Since the last inspection additional monitoring procedures had been introduced to ensure medication administration was recorded contemporaneously. Care plans contained information relating to long-term illness and dying. The wishes of service users had been sought from them or their representatives, to ensure any specific wishes were carried out. Staff displayed a strong sense of commitment to the service users living at the home. Positive and caring interactions were observed between service users and staff. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. An Adult Protection procedure was in place, to ensure service users safety was promoted. EVIDENCE: There was an Adult Protection policy in place, which included the Department of Health guidance `No Secrets’ to ensure staff had access to all of the information needed to promote residents safety and well being. The organisation had a procedure to provide staff training in Adult Protection on an annual basis to equip them with the skills and knowledge needed to ensure service users were safe and respond to any allegations appropriately. Whilst policies and procedures were in place regarding physical and verbal aggression, staff were not provided with formal training on sanctions or restraints, to equip them with essential skills required. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24. The home was clean and well maintained. Homely touches had been provided to create a comfortable environment. Further provision and refurbishment was required to ensure the environment was as free of risk as possible, in relation to smoking. A rolling programme of redecoration and refurbishment was in place. EVIDENCE: A proportion of the building had been refurbished and redecorated. New flooring had been provided in lounges in two houses. Communal lounges and dining rooms were provided with homely touches to create a comfortable environment. All of the service users said the home was comfortable and they were happy with their rooms. However, some furniture was worn or showed signs of age. Some carpets and furniture were marked and damaged from discarded cigarettes. This did not contribute to the overall comfort of the environment. Due to the complex needs of some service users, damage to the environment constantly took place. This must be reflected within the homes maintenance budget, and sufficient funds made available to ensure a comfortable and wellmaintained environment is provided. In addition, further refurbishment must
Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 18 take place to reduce the risk from heavy smoking, in line with the fire officer’s recommendations. Flame retardant furnishing and flooring must be provided to those rooms identified as high risk within the homes risk assessment. The fire alarm must be updated to ensure a more efficient system is in operation. Extractor fans must be provided for the safety and comfort of service users and staff. It is acknowledged that some flame retardant soft furnishings have been provided to a proportion of rooms identified as high risk. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 and 36. Agreed levels of staff were being maintained. Good relationships between staff and service users were observed. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff were being achieved. Staff undertook periodic training to keep them up to date and equip them with the skills needed to carry out their duties. A staff training plan and individual training records were maintained. 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 service users. Friendly and supportive relationships were observed between staff and service users. The homes rota indicated that agreed levels of staff were being maintained. All of the staff reported a good team spirit at the home. Staff undertook periodic training relevant to their job. Ten of the staff team had undertaken the specialist training in mental health, in response to a requirement made at the last inspection, this training was being provided to all Residential Mental Health Workers, to ensure they are equipped with an understanding of the complex needs of service users, and to provide them with essential skills that reflect the specialist nature of the home. A training plan and individual training records were maintained to ensure effective monitoring took place. Of
Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 20 the 16 care staff, 7 staff had achieved NVQ level 2 or 3 in care. A further 10 staff were undertaking the training at levels 2 or 3 in care. Two deputies were undertaking NVQ level 4. All staff reported that they had regular supervision, to ensure they received sufficient support and guidance. Records inspected evidenced that staff supervision took place at the required frequency. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 and 42. The home was well run. Management were approachable and supportive to staff and service users. Health and safety systems were in place. EVIDENCE: The registered manager was undertaking NVQ level 4 in management and care. Service users and staff benefited from the managements leadership style. Staff said that the manager was approachable and supportive. Service users said the manager was `good’ and `nice’. Health and safety systems were checked and serviced. An audit of mandatory training had taken place and systems were in place to ensure staff were provided with refresher training when needed. Consideration should be given to provide staff fire training over and above the required frequency, in recognition of the fact that the majority of service users smoke, and some discard their cigarettes in a way that is potentially unsafe. Lister Project DS0000002981.V268782.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 X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Lister Project Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000002981.V268782.R01.S.doc Version 5.0 Page 23 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 Standard YA20 Regulation 13 Requirement All staff that administer medication must be provided with formal training in safe medication administration. All staff must be provided with sanctions and restraint training. All areas of the home must be well maintained and decorated. All furniture and carpets showing signs of age and wear must be identified for replacement within the homes maintenence programme. Sufficient budget must be provided to ensure a clean, comfortable and safe environment is constantly maintained. (Previous timescale of 30/09/05 not met) All necessary precautions to reduce the risk of fire must be undertaken. Flame retardant furnishings and flooring must be provided in all rooms identified as high risk. All necessary precautions to reduce the risk of fire must be undertaken. The fire alarm system must be
Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 24 Timescale for action 01/06/06 2 3 YA23 YA24 13 23 01/06/06 01/07/06 4 YA24 23 01/08/06 5 YA24 23 01/06/06 6 YA24 23 updated to provide a more efficient means of detecting fire. Extractor fans must be provided in communal smoking areas. 01/07/06 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 2 Refer to Standard YA37 YA42 Good Practice Recommendations The registered manager must achieve NVQ level 4 in management by 2005. Fire training and fire drills should take place on a regular basis (over and above the minimum required) due to the high number of service users that smoke. Lister Project DS0000002981.V268782.R01.S.doc Version 5.0 Page 25 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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