Inspection on 23/02/06 for Paks Trust Clarence Street

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Paks Trust Clarence Street 22/01/07

Paks Trust Clarence Street 21/09/05

Paks Trust Clarence Street 01/03/05

Paks Trust Clarence Street 10/08/04

Paks Trust Clarence Street 21/03/04

Paks Trust Clarence Street 23/10/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Paks Trust - Clarence Street (17/18 & 42) 17 Clarence Street Nuneaton Warwickshire CV11 5PT Lead Inspector Justine Poulton Unannounced Inspection 23rd February 2006 09:30 Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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 Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Paks Trust - Clarence Street (17/18 & 42) Address 17 Clarence Street Nuneaton Warwickshire CV11 5PT 02476 742201 02476 742201 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) PAKS Trust Mr Robert S Forsyth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Mr Forsyth achieves the NVQ Level 4 in Managing Care, including the Registered Managers’ Award by 1 February 2006. PAKS Trust must provide adequate support to the registered manager, which takes into account his level of management experience and experience of working in residential care. For the first 12 months from the date of this (the registration) certificate this support will include regular (at least quarterly) meetings with a care home manager who has current experience of providing an operational presence in a care home, who will act as the registered manager’s mentor. This mentoring process will be in addition to supervision and support from the registered manager’s line manager. 21st September 2005 Date of last inspection Brief Description of the Service: The registration of Clarence Street covers three separate houses in one street. Two of the houses are for two residents and the other is for one resident. These are terraced houses, each providing a domestic environment as a care home setting. Two of the houses have a communal living room, kitchen and bathroom on the ground floor. The third has the bathroom on the first floor. Service users’ bedroom(s) are also the first floor. All of the houses are staffed 24 hours a day and personal care is offered to some degree in all three houses. The registration is for residents with learning disabilities. PAKS Trust operates this service. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday and was carried out between 9:00am and 13:00pm. The manager, resident that was at home and staff on duty co-operated fully with the inspection. A total of 12 standards were inspected on this occasion, of which 4 had shortfalls. One resident was at home during the inspection, and was spoken with informally. One member of staff was on duty and was also spoken with informally. Records, files, policies and procedures were also inspected. The inspector would like to thank the manager, resident and staff for their cooperation and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Work is required to bring all of the residents care plan documentation up to a consistent standard across all three houses within the registration. Urgent work must be undertaken to repair the roof of property number 42, to ensure the health, safety and well-being of the residents that live in the house. Similarly, advice must be sought from the local fire officer with regards to loft partitions between adjoining properties, in order to ensure that fire safety is maintained within these spaces. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 6 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. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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 Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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): x EVIDENCE: No new residents have been admitted to the home since the last inspection, therefore key standard 2 is deemed to be not applicable on this occasion. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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, 7 and 9 A clear, consistent care planning system is not in place across all three houses, to adequately provide staff with the information needed to satisfactorily meet residents’ needs. Residents are supported to enjoy active lifestyles of their choosing in a safe manner. EVIDENCE: Key standard 6 was inspected at the previous inspection of this home on 21/09/05, at which time a requirement was made for residents care plans across all three of the houses included within the registration to be of a consistent standard. This requirement has been partly met, and will therefore be carried forward. In conversation it was clear that one resident spoken with decided on a daily basis what he was going to do that day. Examples such as going for a walk into town if the weather is good or watching the television if the weather is bad were given. Similarly, he said that the choice of which college courses he chooses to attend via the PAKS day service are his decision, and gave the example of having completed a course in painting and drawing recently. Currently he stated that he is doing a course in photography which he is enjoying. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 10 Examination of residents care plans available provided evidence of risk assessments having been completed on an individual basis, which were dated and signed and reviewed. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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): 13 and 17 People living in this home have opportunity to live ordinary and meaningful lives appropriate to their needs. They are supported and enabled to be part of the local community in which they live. A varied and wholesome selection of food is available that meets residents’ dietary needs. EVIDENCE: Key standards 12 and 15 were inspected at the previous inspection of this home on 21/09/05, and were met. Staff spoken with during the inspection gave examples of community based activities that the residents enjoy on a regular basis, including going to local pubs, out for meals, to theatres and on shopping trips. This information was confirmed within individual daily records looked at. Each house is domestic in size and style. As such the kitchens and the equipment within them is in keeping with this. Each kitchen is decorated differently, reflecting the personalities of the residents within each house. Shopping is undertaken on a weekly basis within each house, and is geared around the menus that are planned with or by the residents. One resident Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 12 spoken with said that he chooses what he wants to eat on a daily basis, based on what he feels like at the time. Records were available to confirm that all of the necessary kitchen and food health and safety checks are carried out in accordance with guidelines. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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): 19 Residents’ health-care needs are identified on their care plan and are being met with appropriate specialist support. EVIDENCE: Key standards 18 and 20 were inspected at the previous inspection of this home on 21/09/05, and were met. Records examined confirmed that routine health care appointments such as visits to the dentist and opticians are offered to residents at the recommended intervals. In one care plan examined a North Warwickshire Primary Care Trust Clinical Health Action Plan had been completed in July 2005. Written records of appointments attended including and treatment prescribed and the subsequent outcome were in place. Records of any specialist treatments and interventions were also available, along with specialised information to enable the staff team to support the residents with specific healthcare needs as necessary. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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 and 23 The home has a satisfactory complaints system in place and can evidence that residents’ views would be listened to and acted upon. There are policies and procedures in place for the protection of service users from harm. EVIDENCE: All three homes within the registration have a copy of the organisations complaints leaflet in place. A form is available within this for recording any complaints received. Although the manager said that there have been no complaints made to the home, it was not possible to verify this as the complaints record is held at the organisations head office. One resident spoken with during the inspection said that he would have to say something to a member of staff if he had a complaint, in order for it to be dealt with. Copies of the Warwickshire County Council Social Services “Making a Complaint” leaflet were available for residents to use should they need to. Organisational policies on guidance to care staff on the abuse of vulnerable adults, bullying in the work place and the application of the POVA register were in place in the home. Staff spoken with said that they have undertaken training in the protection of vulnerable adults, provided by the organisation and through the Learning Disability Awards Framework. The manager said that there have been no allegations of or suspicions of abuse made since the last inspection. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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 The appearance of this home creates a comfortable and homely environment for the people living there. Urgent improvement to the roof of one of the properties will ensure that residents health and safety is maintained at all times. EVIDENCE: Key standards 24 and 30 were inspected at the previous inspection of this home on 21/09/05, and were deemed to be met. The manager advised during the inspection that considerable damage had been done to the roof of property number 42 during the winter. A number of roof tiles had become damaged and tiles were balanced precariously in the guttering. This has had a negative impact on the bedroom space of the two residents that live in the home. Rainwater comes through the roof and the bedroom ceilings, making the rooms damp. Electrical equipment has had to be removed as it was considered too dangerous to leave it in the bedrooms. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 16 The manager stated that attempts have been made to get the landlord of the property out to have a look at the damage, with a view to getting the roof replaced or repaired, however at the time of the inspection this had not been achieved. An immediate requirement was issued during the inspection regarding the state of the roof. Since the inspection further contact has been made with the Registered Person concerning this issue, who advised that the organisation has engaged a building company to commence work on the repairs within the next week. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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): 36 Residents benefit from a supervised and enthusiastic staff team who work towards common goals. EVIDENCE: Key standards 32, 34 and 35 were inspected at the previous inspection of this home on 21/09/05, and were deemed to be met. Standard 33 was also inspected at this time and was met. Standard 36 was also inspected at the last inspection of this home at which time a requirement was made for staff to be provided with formal, recorded supervision a minimum of six times per year. Written records, which were verified by staff, confirm that this now takes place, therefore this standard is now met. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.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 and 42 Evidence of completion of the necessary managers qualifications will ensure confidence that the home is managed by an appropriately qualified person. The health and safety of the residents is compromised by the lack of fire safety precautions within the roof space of the properties. EVIDENCE: Key standard 42 was inspected at the previous inspection of this home on 21/09/05, and was deemed to be met. The manager said that he had now completed the NVQ IV in Care and the Registered Managers Award, but was awaiting the certificates. It was noted during the inspection that there was no dividing partition in the roof space between property number 42 and the next door house, which potentially leaves the property vulnerable in the case of a fire. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 19 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 2 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x 2 x x x x 2 x Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 20 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 YA6 Regulation 15 Requirement The registered manager must ensure that the standard of residents care plans across the houses be addressed to guarantee that a consistent approach for all of the residents is achieved. (31/12/05, part achieved) The Responsible Individual must ensure that the roof of property number 42 must be repaired or replaced urgently. The Registered Manager must submit copies of his certificates for the NVQ IV in Care and the Registered Managers Award once received to the Commission for Social Care Inspection. The Registered Manager must contact the local fire officer for advice concerning partitions between the roof spaces of adjoining properties. Timescale for action 13/04/06 2. YA24 23(2)(b) 24/03/06 3. YA37 9(2)(b)(i) 14/04/06 4. YA42 23(4) 14/04/06 Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 21 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 YA24 Good Practice Recommendations It is recommended that all plastic sliding doors be replaced. Paks Trust - Clarence Street (17/18 & 42) DS0000004458.V284126.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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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