Inspection on 05/04/05 for Plas Newydd

This inspection was carried out on 5th April 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Plas Newydd 27/11/07

Plas Newydd 11/05/06

Plas Newydd 15/11/05

Plas Newydd 22/12/04

Plas Newydd 18/05/04

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 Plas Newydd 34 Hereford Road Shrewsbury Shropshire SY3 7RD Lead Inspector Michael Moloney Unannounced 5th April 2005 09:15 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 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 Stationary 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. Plas Newydd Version 1.10 Page 3 SERVICE INFORMATION Name of service Plas Newydd Address 34 Hereford Road, Shrewsbury, Shropshire, SY3 7RD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01743 271064 01743 289127 Bethphage Mission Wendy Sandra Evans Care Home 5 Category(ies) of Learning Disability (5) registration, with number of places Plas Newydd Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: No conditions. Date of last inspection 22/12/04 Brief Description of the Service: Plas Newydd is a large adapted town house situated in the Meole Brace area of Shrewsbury and has good road access and parking. The landlords of the property are Bourneville Village Trust, however, the home is operated by Bethphage Great Britain and registered to provide personal care and accommodation for up to five adults with a learning disability. The companys web-site (www.bethphage.co.uk) outlines their core values as being: Safety People we support live and work in physical situations that are safe, whilst being able to take acceptable risks. Those people are supported in an environment that is free from abuse and neglect. Respect People are treated with the respect they deserve as citizens regardless of their differences, and that peoples diversity is celebrated. Personal Growth Opportunities are provided for people to maintain existing skills and learn new ones. Efficiency The services are provided efficiently, and in a reliable and consistent way. To ensure that all our resources are used efficiently to meet the needs of the people we support. Plas Newydd Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.15 and lasted for two and a half hours. Two of the five service users had medical appointments during the morning and therefore they and the staff assisting them were not there for a proportion of the inspection. The inspection was carried out by observing activity within the home, looking at records and case tracking. The nature of the needs and disabilities of the service users concerned made ascertaining their views by direct means very difficult. Therefore the views of the staff had to be relied on to a great extent. However, observation confirmed that the service users were calm and relaxed in their company approaching them freely when the need arose. What the service does well: What has improved since the last inspection? What they could do better: There is evidence to show that staff work extremely hard to maintain the quality of life of the service users. However, there are concerns about the number of staff available to provide this service and the form that home’s management will take after the registered manager leaves in the near future. The home must also ensure that all pre-employment checks are available before new employees are allowed to commence work with the service users Plas Newydd Version 1.10 Page 6 and staff must receive supervision at least six times a year. They must also ensure that a copy of the complaints procedure is available at all times. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Plas Newydd Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Plas Newydd Version 1.10 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 standard(s) 2 and 5 Appropriate procedures are in place that would enable the successful admission of new service users to the home. EVIDENCE: Although no new service users have been admitted to the home for some time the home has an appropriate admissions policy in place should the need arise. The home now has service user contracts in place that outline the elements required within the National Minimum Standards for Younger Adults. These include such things as the rooms to be occupied, the period of notice required, the rights and responsibilities of both parties etc. This document has been produced in plain text as it is considered that it is unlikely that any of the current service users could understand the concepts within it whatever the format due to the nature of their disabilities. Plas Newydd Version 1.10 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 standard(s) 6, 7, and 9 The current service users are unlikely to be able to contribute to the assessment process due to the nature of their disabilities. Despite that, appropriate service user plans, decision making processes and risk assessments were seen to have been developed to identify the service users wishes and needs and safe ways to meet them although there are some concerns about the availability of staff to ensure that the needs identified within the service user planning process can be delivered. EVIDENCE: The Individual Plans of the service users were seen to contain the information that would enable staff to work towards goals identified for the service users. Given the range of needs and the dependency levels of the service users these had, of necessity, involved very little direct input from the individuals concerned. The manager also confirmed that the input from the service users’ families varied according to the individuals circumstances. The various elements identified within the Individual Plans had also been risk assessed and it was seen that these assessments were regularly reviewed. Plas Newydd Version 1.10 Page 10 Staff did express concern that staffing levels continue to be difficult to maintain with the current rota showing that a number of the future shifts will only have two members of staff on duty as opposed to the three required by the Commission for Social Care Inspection which may put the fulfilment of the care plans at risk. Plas Newydd Version 1.10 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 standard(s) 12, 13, 15, and 16 Links with the community are good and enrich service users’ social and educational opportunities. The manner in which the staff team have interpreted their needs is also good enabling their views to be taken into account. EVIDENCE: Given the dependency and disability levels of the service users it is not possible for their education and occupation to be considered in other than the broadest sense as it is unlikely that they would be able to access the world of work or any of the mainstream education establishments. However, talking to the staff and the manager and reading the individuals records showed that maintaining the self help skills of the service users has a high priority. They also showed that the service users are also assisted to access such resources as the local library. Service users also have a number of vehicles available to them so that they can get to the various venues. The manager also confirmed that further finances had been made available to improve the levels of staffing to assist one particular service user. Plas Newydd Version 1.10 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 standard(s) 18 and 19 The personal and healthcare needs of the service users are met. EVIDENCE: The inspector saw service users being treated in a respectful and dignified manner. Any personal care needs were dealt with in a discreet manner. Preferences about how they preferred to be dealt with were seen to be outlined within their personal plans and any necessary specialist equipment was seen to be available. All of the service users looked well cared for. The health care provision was seen to have been demonstrated on the morning of the inspection with one service user being taken to an emergency appointment at the dentist and a second being taken to a fitting for his specialist footwear. The daily records were seen to contain other entries for similar appointments on other occasions. Although the medication was not fully inspected on this occasion it was noted that all of the staff have received appropriate training in this area. Plas Newydd Version 1.10 Page 13 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 standard(s) 22 and 23 The service users are protected from abuse and the staff enable their views to be taken into account despite the nature of their disabilities. EVIDENCE: The home reported that they had received no complaints or any allegations of abuse since the last inspection. The home had a copy of the local policies and procedures for the protection of vulnerable adults, however, a copy of the home’s complaints procedures that had been available at previous inspection could not be found on this occasion. Although the level of the disabilities of the service users means that they are unlikely to be able to access these formal policies observation of the staff interacting with them and communicating between themselves indicated that they would be aware of any dissatisfaction expressed and it was seen that a whistle blowing policy is available to be used. Plas Newydd Version 1.10 Page 14 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 standard(s) 24 and 30 The standard of the environment is good providing service users with an attractive and homely place to live. EVIDENCE: The home is situated in the south of Shrewsbury and is an older property that has been converted to its present use in a sensitive and practical manner that is consistent with others in the neighbourhood. The home has its main laundry area situated in the basement with access through areas that are not used for food preparation or consumption thereby reducing the risk of cross contamination. The manager confirmed that these facilities remain unchanged. A further domestic washing machine is situated in the kitchen and is only used for training purposes. Plas Newydd Version 1.10 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 36 Although currently the home is staffed to an acceptable level there are some concerns that it will remain so in the near future and the needs of the service users will not be fully met. Insufficient care has been taken in collating preemployment checks on staff. Service users may be put at risk if unsuitable staff are employed. EVIDENCE: Although the home is required to have three members of staff on duty during the main part of the day the projected rota shows that only two will be available on a number of occasions. Staff on duty at the time of the inspection also expressed concern at this potential situation. The home must ensure that the staffing levels (a minimum of three day staff) previously stipulated by the Commission for Social Care Inspection are maintained. Only one employment reference was available for inspection relating to the latest recruit to the home’s staff team. Staff must not be allowed to commence working with the service users until the information required under Schedule 2 of the Care Homes Regulations 2001 has been obtained. The records showed and the manager confirmed that staff supervision was taking place but not with the required frequency. This situation must be rectified. Plas Newydd Version 1.10 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42 The premises are maintained in a safe manner although there is currently a lack of clarity about who will manage the facility after the current registered manager leaves in the near future. EVIDENCE: Accident and fire prevention records were seen to be appropriately maintained and the Portable Appliance Testing was confirmed by the manager to be scheduled in the near future. Both the current manager and her deputy were unclear about the management arrangements for the home when she, the registered manager, leaves in the near future. The manager said that their quality questionnaires had been sent to the relatives of the service users but, as yet, no replies had been received. Given the nature of this group of service users it would not be possible to involve them in this more formal type of quality assurance procedure. Plas Newydd Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 x 3 3 Standard No 31 32 33 34 35 Score x x 2 3 x Page 18 Plas Newydd Version 1.10 14 15 16 17 x 3 3 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x Plas Newydd Version 1.10 Page 19 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 22 33 Regulation 22 18.1 Requirement The home must have a copy of its complaints procedue available at all times Levels of staff agreed with the Commission for Social Care Inspection shall be available at all times at the home. Staff must not be allowed to commence work with the until all of the information required under the Care Homes Regulations 2001 have been obtained. ( Previous timescale of 7/3/05) All staff must receive recorded supervision at least six times a year. Timescale for action 16/05/05 16/05/05 3. 31 19.1 & 17.2 Immediate 4. 36 18.2 18/07/05 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 Good Practice Recommendations Plas Newydd Version 1.10 Page 20 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn Shrewsbury Shropshire, SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Plas Newydd Version 1.10 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!