Inspection on 05/01/06 for Mount Road (104)

This inspection was carried out on 5th January 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mount Road (104) 20/04/07

Mount Road (104) 09/09/05

Mount Road (104) 22/03/05

Mount Road (104) 25/08/04

Mount Road (104) 29/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Mount Road (104) High Barnes Sunderland SR4 7NN Lead Inspector Miss Andrea Goodall Unannounced Inspection 5th January 2006 1:00 Mount Road (104) DS0000015778.V262562.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 Mount Road (104) DS0000015778.V262562.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. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mount Road (104) Address High Barnes Sunderland SR4 7NN 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) 0191 5228121 0191 5228121 www.c-i-c.co.uk. Community Integrated Care Sarah Louise Loftus Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 09/09/05 Brief Description of the Service: The home at 104 Mount Road provides personal care and accommodation for up to 3 people with a learning disability. It began operating in 1989 and was later registered under the Registered Homes (Amendment) Act 1991. The care service is provided by CIC (Community Integrated Care). The house is the property of Three Rivers Housing Association, which remains responsible for general maintenance and repairs. The premises consist of a good-sized terraced house in a quiet residential area. It is close to a local shopping area, pubs and a bus service to the City centre. There is a small run of steps up to the front door so the home would not be suitable for people with significant mobility needs. On the ground floor there is a comfortable lounge and a dining room. At the back of the house is a large family sized kitchen/diner, a utility room with laundry equipment and access to the back yard. There is also a small toilet on the ground floor. On the first floor are 3 single rooms, and a small staff sleepin room that doubles as an office. On a mezzanine landing there is a bathroom and a separate small toilet. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on afternoon and early evening in January 2006. Most of the time was spent talking with the 2 ladies who live here, looking at their bedrooms with them, and joining them for a teatime meal. Time was also spent talking about the home with 2 staff, and looking at care records. Since the last inspection one lady, who has lived here for over 10 years, has moved into her own flat. This is a great success because that person and the staff have worked very hard together over the past year to make sure she is ready for semi-independent living. Recently a new resident moved into the home. There is one vacant place at the home at this time. What the service does well: What has improved since the last inspection? There are now 2 staff on duty all day and evening. This is necessary to meet the personal care needs of the 2 residents, and also allows residents to be helped to go to their own individual activities. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 6 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. Mount Road (104) DS0000015778.V262562.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 Mount Road (104) DS0000015778.V262562.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. Prospective residents needs and abilities are assessed prior to moving in to ensure that the home can meet their needs. EVIDENCE: Since the last inspection one resident has left the home to go to semiindependent living. One new resident has moved into the home. Before she moved here, a Care Manager of the Social Services Department carried out an assessment to see what she needed. The Manager of the home then carried out assessments to see if this home could meet her individual needs. The assessments include the potential resident, their relatives, their Social Worker, and any other people involved in their care at this time. In this way, the home only admits people whose needs could be met here. There is currently one vacant place at the home, and the needs of any potential new resident would be assessed in this way. The new resident has now lived at the home for a few weeks and it was evident that her needs are being met at this small home. Mount Road (104) DS0000015778.V262562.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 & 7. Residents assessed needs and their personal goals are reflected in an individual plan of care. Residents make their own decisions about their lives, with support if needed. EVIDENCE: The assessment records for the new resident are in place in her care file. This helped to develop an individual plan of care, which sets out the areas of daily living that she requires support with. The care plan will also include goals towards future independent living skills in areas such as social, domestic and finances, to whatever degree this will be possible. At this time staff are still assessing the new resident to find out what level of capability she has in these areas already. The people who live here are encouraged to make their own choices and decisions about their daily lifestyles. Residents and staff spend time together talking about future plans and what residents would like to do. It was clear from discussions and observations that residents make their own decisions about how to spend their day, what to wear, what to eat and where to go. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 10 One resident had chosen to go to Disneyland Paris a few months ago, and described how much they had enjoyed it with the photographs of their holiday. Residents are also included in making decisions about potential new residents to ensure their compatibility. Mount Road (104) DS0000015778.V262562.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, 16 & 17. Residents choose their own daytime occupations. Residents rights are respected and their responsibilities are promoted. Residents are offered a healthy diet and enjoy their meals and mealtimes EVIDENCE: At this time the 2 ladies who live here each spend a couple of days a week at their different day centres. These are long standing day care arrangements that residents choose to continue at this time. On all other day the 2 ladies are supported to engage in community-based activities such as shopping, and daily living activities such as housework. The residents also enjoy a number of individual hobbies such as music, jigsaws and art & crafts. These daytime occupations currently suit the physical capabilities and increasing age of the residents. The residents are fully involved in the daily running of the home in terms of domestic tasks, with support where necessary. They are encouraged to take responsibility for their own rooms and possessions. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 12 It was clear that residents rights are respected and valued by the staff. Residents can spend time in the privacy of their own rooms whenever they wish, and staff do not enter their rooms without seeking permission. Both residents are involved in choosing meals, and menus are based on their known preferences. Meals are traditional, healthy and appetising. Residents are involved in setting the table and clearing up. At this time the residents tend not to be so involved in preparing meals due to their capabilities. Residents can choose to dine in the pleasant dining room or the dining area in the large family kitchen. Mealtimes are a sociable occasion where residents and staff can talk about their day and plan for their evening social events. Mount Road (104) DS0000015778.V262562.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 & 20. Residents receive support in the way that they require. Staff manage medication on behalf of the residents in an appropriate way. EVIDENCE: The 2 ladies who live here require some physical support with their personal care need. One person requires the support of 2 staff to get in and out of the bath, then the supervision of one staff whilst bathing due to their health care needs. The other person needs staff support to get into the bath and with washing hair. In discussions, staff confirmed that only the female staff support the ladies here. There is one male staff, but he is does not physically support the residents with their personal care needs. In this way the residents receive gender-appropriate support. The 2 residents have been assessed as not able to manage their medication at this time, so this is managed by staff. Medication is stored, managed, administered and recorded in the right way. The home keeps a list of the staff who are designated as responsible for administering medication. Currently 3 of the 6 staff have had accredited Safe Handling of Medication training. The others have not had this training yet, Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 14 although they have had a brief training from the pharmacists about the Monitored Dosage cassette system. Mount Road (104) DS0000015778.V262562.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): 23. Residents are protected from abuse by the homes procedures. EVIDENCE: As with all adult care services in Sunderland, the home has adopted the citywide MAPPVA (Multi-Agency Panel for the Protection of Vulnerable Adults) procedures. These are robust methods for dealing with suspected abuse. The Manager and staff have had training in the MAPPVA procedures. In discussions staff were able to describe their responsibilities to report suspected abuse. Mount Road (104) DS0000015778.V262562.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, 26 & 30. Residents live in a pleasant, safe and comfortable home. Residents bedrooms promote their independence, but the level of lighting needs to be sufficient for their needs. The house is clean and hygienic. EVIDENCE: There have been a number of planned improvements to this house over the past couple of years. These improvements have made a significant difference to the quality of accommodation for the people who live here. The home now provides a well decorated, comfortable home. The home is also well maintained. At this time both WCs require attention to the flush, although both were still usable. Staff confirmed that this had been reported for action in the near future. The home is a terraced house and so is indistinguishable from the neighbouring properties. There is a back yard where residents can sit out in shelter and privacy in better weather. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 17 There is one vacant place at the home at this time. There is a small run of steps up to the front door so the home would not be suitable for people with significant mobility needs. The 3 bedrooms are a good size and the people who live here make good use of their own rooms for privacy when they want some quiet time. All the bedroom doors have locks and keys. The 2 ladies who live here tend to choose not to use their keys, but the keys are in the bedrooms doors for their easy access. All the bedrooms also have a lockable drawer so that residents can keep their personal possession secure. The lighting in the hallway and landings are suitably bright, but both bedrooms have quite low lighting and the contrast between the two areas takes time to adjust to. The bedroom used by a resident with poor sight has only a 60watt bulb and this might make it difficult for her to see any tripping hazards in her room as she enters (depending on the type of visual impairment). The other bedroom has an energy-saving bulb that will brighten after time but provides very low light when first switched on. The home is very clean. The 2 ladies are fully involved in all the daily household tasks, with the support of staff where necessary. The house has a utility room with a domestic washing machine that is suitable for this small home, and the people who live here. At this time 2 staff have received training in Infection Control. The remaining staff have still not yet received this statutory health & safety training. Staff currently use latex protective gloves to promote good hygiene when carrying out some tasks. However latex can cause allergic reactions, where alternative materials do not. At the time of this visit both residents toothbrushes were lying together on a bathroom shelf. This does not support infection control. Mount Road (104) DS0000015778.V262562.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. Residents are supported by competent, qualified staff. Residents are protected by the homes recruitment practices. Residents needs are met by appropriately trained staff. EVIDENCE: The staff team consists of the Registered Manager, and 5 support staff. Three of the support staff have attained NVQ (care qualifications) level 3, and the remaining 2 staff are starting training towards these qualifications. All the staff are mature and experienced. There are 2 staff on duty between 8am to 10pm to provide support to the 2 residents. This means that their personal care needs can be met and they can be supported to attend their individual occupations and social activities. There is one sleep-in staff on duty each night. This level of staffing currently meets the needs of the 2 ladies who live here. There have been no changes to staff personnel since the last inspection, and this supports the continuity of care of the people who live here. One former bank staff is now employed permanently at the home and one part-time staff is now employed on a full-time basis. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 19 There is clearly a good relationship between residents and the staff. Residents described all staff as nice. Staff demonstrated a very good understanding of peoples capabilities, preferences and needs. CIC operates through recruitment and selection procedures, including all necessary clearances and checks on applicant staff before they start work at this home. In this way residents are protected by the employment of suitable staff. Staff confirmed that there are good training opportunities and this is promoted by CIC. All staff have, or are working towards, suitable care qualifications. Staff receive training in health & safety matters, and other appropriate topics. At this time individual staff training records were not available, as these are correctly and confidentially stored by the Manager. There is also a group staff training matrix which indicates the different courses (and dates) that staff have already attended. This matrix is not up to date as it does not include all members of staff. Mount Road (104) DS0000015778.V262562.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): 39 & 42. Residents views of the service are sought, but not always in a way which suits their needs. The health, safety and welfare of residents is promoted and protected. EVIDENCE: Residents are included in discussions and decisions about their home. They have monthly care plan meetings with their keyworker where they talk about their goals and aspirations, and they have daily chats with support staff about their home. They are also asked for their views of the service at annual reviews of their placement. CIC also use a satisfaction questionnaire from time to time to gain the views of the people who use their services. However the last questionnaires used by CIC were in quite small print and in quite complex language for the people who live here. In this way, residents cannot complete the questionnaires without support, and this could have affected their responses. Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 21 Staff confirmed that the people who live here would be more able to complete a pictorial questionnaire, although they may still need support from independent advocates or relatives. The home is well maintained and there were no health & safety issues noted within the house at this time. Staff practices during everyday tasks ensure that residents health & safety is promoted and protected. Mount Road (104) DS0000015778.V262562.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 X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 4 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 4 X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mount Road (104) Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 x DS0000015778.V262562.R01.S.doc Version 5.0 Page 23 Mount Road (104) DS0000015778.V262562.R01.S.doc Version 5.0 Page 24 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. 2. Standard YA24 YA30 Regulation 23(2)p 13(3)& 18(1)c(i) Requirement Bedrooms must be sufficiently well lit to meet the needs of the residents. The remaining staff must receive training in Infection Control.(Previous timescale of 01/12/05 not met.) Timescale for action 01/03/06 01/04/06 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. 3. 4. 5. Refer to Standard YA20 YA30 YA30 YA35 YA39 Good Practice Recommendations The remaining staff who are responsible for the administration of medication should receive training in Safe Handling of Medication. Consideration should be given to replacing latex gloves with vinyl gloves. Residents need support to keep their personal grooming equipment separate, e.g. individual toothbrush holders. The staff training matrix should include all members of the staff team. CIC should consider revising the format of Residents Questionnaires in order to meet the communication needs of the people who use this service. DS0000015778.V262562.R01.S.doc Version 5.0 Page 25 Mount Road (104) Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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