CARE HOME ADULTS 18-65
Mansfield Road Short Stay Unit 27a/29a Mansfield Road Blackpool Lancashire FY3 7HZ Lead Inspector
Mrs Ruth Edgington Unannounced Inspection 25th February 2006 9.45 Mansfield Road Short Stay Unit DS0000064782.V275745.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 Mansfield Road Short Stay Unit DS0000064782.V275745.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. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Mansfield Road Short Stay Unit Address 27a/29a Mansfield Road Blackpool Lancashire FY3 7HZ 01253 477666 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) Blackpool Borough Council Mrs Barbara Mary Crouch Care Home 5 Category(ies) of Learning disability (5), Physical disability (5), registration, with number Sensory impairment (5) of places Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to accommodate a maximum of 5 service users who fall within the following categories: LD (learning disability) PD (physical disability) SI (sensory disability) 11th June 2005 Date of last inspection Brief Description of the Service: Mansfield Road can provide accommodation for a maximum of 5 adults who have a learning disability and require respites care (short stay). The period of stay depends on the needs of the individual resident and their relatives. The accommodation consists of two single bedrooms on the first floor and two single bedrooms and a self-contained flat on the ground floor, all of which have en-suite bathing and toilet facilities. There is also a large lounge, kitchendining room and an additional bathroom The home does not have a passenger lift , therefore this is a consideration when assessing the suitability of possible service users. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 9.45am on a Saturday morning and took place over 2.15 hours. On the days inspection four service users were being accommodated and another service user who had been in the home for an overnight stay, was just going home. The service user’s abilities to communicate varied greatly, however the Inspector was able to have speak with two service users who were able to contributed to the inspection. The Inspector also spoke to the relative of one service user, the manager and three members of staff. Prior to the inspection questionnaires had been sent out to a selection of relatives/ carers and seven were returned, which were all very positive. The Inspector also received a letter from one relative that was full of praise and admiration for the staff and the home. A selection of records were examined and a tour of the home was undertaken. What the service does well:
This home is extremely well managed and the staff group are very committed and work together to ensure that the service users enjoy their stay and have all their needs met. A comment received from one relative was that the staff care for the carers as well as the service users. The total inclusion of all those involved with the individual service users was very evident from comments made in the questionnaires received and from those service users spoken to. The manager said that the individual ”Link workers” (member of staff responsible for an individual service user) work with the families to ensure that every-ones needs are met. One relative said that they felt that the home was excellent and that the staff were wonderful. They also remarked that their family member was the most precious person to them and they would certainly not leave them if they were not happy with everything, which they said they were.
Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 6 The Inspector was able to undertake the inspection in a very warm, friendly atmosphere, in which the service users in the home, who were able, were confident enough to involve themselves in the inspection. Their comments were very positive and they displayed a genuine affection towards the manager and staff. What has improved since the last inspection? What they could do better:
The manager and staff have worked very hard to ensure that the needs of the service users are met, however they recognised that there is always room for improvement and welcome any suggestions made during inspections into ways in which future improvements can be made. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 7 The manager said that they feel that now that they have settled in, the next step forward is to start to make links with the community for the benefit of the service users and the home. The manager is to continue undertaking the required qualification which she has almost completed. 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. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 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 Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 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): The above standards were not assessed. EVIDENCE: Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 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): The above standards were not assessed. EVIDENCE: Mansfield Road Short Stay Unit DS0000064782.V275745.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): The above standards were not assessed. EVIDENCE: Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 12 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 The service user’s physical, emotional, health and personal support needs are met by the procedures in place, which enable staff to care for each service users as an individual. The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure that service user’s medication needs are met. EVIDENCE: The Inspector was able to observe during the visit the support that was given to the service users to maximize their privacy, dignity and independence. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 13 Two of the service users present during the inspection gave their permission for the Inspector to look at their files. They contained very comprehensive information including an “Essential Life Style Plan”. This had been compiled by every one involved in that person’s life and was in a format that the service user could understand. The information was so detailed that anyone involved in their care could read the document and be able to provide the support required. During the previous inspection it was noted that the documentation on which all accidents were recorded was sent to the main office and that a copy was not retained in the home. This situation as been resolved and evidence was available that confirmed that a record of all accidents is available for inspection. At the previous inspection it was noted that the medication records were not always being completed fully and accurately. The policies and procedures for the receiving, administrating and returning of medication to the main carer when the service user goes home, have been reviewed and improved. The Inspector was able to observe the practices being carried out during the inspection and was able to confirm that they now met the standards fully, ensuring that the individual needs are being met. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 14 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 & 23 The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to and taken seriously. Procedures for dealing with and reporting abuse procedure were satisfactory ensuring that people are adequately protected. EVIDENCE: Evidence was seen confirming that the complaints policy and procedure is clear, accessible and meets the requirements of the standards. The manager and staff are aware that residents and their relatives should feel confident that their complaints are listened to, taken seriously and acted upon. The manager confirmed that this also included any minor concerns that relatives brought to their attention. A separate record is kept of any complaints made, the action taken and the outcome. To date there have been no complaints made about this home. Through discussions during the inspection, evidence was gained that confirmed that the manager and staff had knowledge of the Adult Abuse Procedure and POVA (Protection of Vulnerable Adults) and that training had been provided. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 This is a new building, which has been purpose built and provides the service users with an attractive, homely and safe environment. EVIDENCE: As stated this home is newly built and meets all the requirements of the minimum standards and other relevant agencies. A great deal of time and effort has been put into ensuring that the needs of those using the service can be met by the facilities in the home. During the inspection the Inspector was able to speak to a relative of one service user and they said that they were very impressed with the building and the facilities provided. The service users and staff spoken to also had nothing but praise for the home. All bedrooms are for single occupation and have their own bathing and toilet facilities. During the inspection evidence was gained to confirm that staff ensure that service users privacy is maintained at all times. The home was found to be warm, clean and free from any obvious hazards. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 16 In the main the service users offered respite care in this home are more physically able, however a sister home is in the process of being built, which will be able to care for those service users requiring specialist equipment. Mansfield Road Short Stay Unit DS0000064782.V275745.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): 34 The recruitment procedures are robust ensuring protection for the people using this service. EVIDENCE: At the time of the previous inspection there was little information on the staff files to confirm that the correct recruitment procedures had taken place. Examination of the information now retained in the home confirmed that the manager had taken on board the comments made in the previous report and this standard was now being fully complied with. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 18 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 This home is well managed and is run on the best interests of the people using the service. EVIDENCE: The leadership from the manager is very good and the staff spoken to confirmed that they felt supported and valued. The manager also stated that she had a very good committed team who worked well together. The genuine respect that every one in the home has for each other was very apparent through the comments and observations made. The manager has only been in post since May 2005 and during that time she has had to build up a new staff team and transfer the service from the home, which had operated for many years, to these new premises. Since the last inspection the manager has become registered with the Commission for Social Care Inspection (CSCI) and will hopefully have completed NVQ (National Vocational qualification) level 4 in management by March 31st 2006. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 19 Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 20 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 x 3 x 4 x 5 x 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 4 25 4 26 4 27 4 28 4 29 x 30 4 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x 3 x x x x x x Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 21 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. 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. 1 Refer to Standard YA37 Good Practice Recommendations The registered manager should complete NVQ level 4 in management. Mansfield Road Short Stay Unit DS0000064782.V275745.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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