Inspection on 01/03/05 for Priory Road

Care Homes For Adults (18 ­ 65)Priory Road9 Priory Road Nether Edge Sheffield South Yorkshire S7 1LWUnannounced Inspection1st March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Priory Road Address 9 Priory Road, Nether Edge, Sheffield, South Yorkshire, S7 1LW Email address None Name of registered company Sheffield Alcohol Advisory Service Name of registered manager Mr Stuart Hawkshaw Type of registration Care Home No. of places registered 6 Tel No: 0114 281 3183 Fax No: 0114 281 3183Category of registration, with (number of places) Past or present alcohol dependence (6) Registration number C060000173 Date first registered 14th September 1987 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 23rd March 2004 YES NO 05/10/04 If Yes refer to Part CPriory RoadPage 1 Date of inspection visit Time of inspection visit Name of inspector 11st March 2005 09:50 am - 15:50 pm Paula Loxley N/AID Code073014Name of inspector 2 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionN/A Stuart Hawkshaw- Registered ManagerPriory RoadPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementPriory RoadPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Priory Road. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Priory RoadPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Sheffield Alcohol Advisory Service at Priory Road project is a residential home with facilities to care for up to six men and women with alcohol related problems. Priory Road is a large detached house situated in an attractive residential area of the city. The home has 1 double and 4 single bedrooms. One to one support and group counselling is provided by the staff of the home, with the aim of reshaping lifestyles and routines to enable service users to learn to enjoy life without drink.Priory RoadPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors SummaryThe inspection, which was unannounced, was conducted over one day. As part of the inspection process the inspector met with the manager and staff currently working at the home. The inspector spoke with two of the service users that currently live at the home. The inspector also observed the interaction between staff and service users and made visual observations of some areas of the home. A selection of the homes records, policies and procedures were examined in detail. The inspector also checked the progress made on the requirements outstanding from the previous inspections at the home. The action taken to address these issues has been detailed in this report under the relevant standard. Any requirements not addressed have now been carried forward with a short timescale for the required action to be taken. The inspector would like to thank the staff and service users for their help with the inspection process. Choice of Home (Standards 1-5) The home had produced a detailed statement of purpose and service user guide. Service users confirmed that they had received all of the relevant information relating to the service prior to their admission to the home. Detailed full needs assessments had been completed by the appropriately trained person and service users had been able to visit the home prior to their admission. Service users had received detailed and informative contracts/ statement of terms and conditions, from the registered provider of the service and from the housing association with regard to their tenancy. Individual needs and Choices (Standards 6-10) Service users had detailed care plans that clearly identified their individual needs in relation to all aspects of their care. Service users had been actively involved in the development of their care plan. Care plans had been signed by service users to confirm their agreement and to confirm that they had been provided with copies of the relevant documentation including policies and procedures. Service users had been involved in the development and review of the house rules and a group contract had been agreed. Service users confirmed that staff encouraged them to be independent and to take control over their own lives without alcohol. Staff had supported with social and leisure activities, as and when required, and the appropriateness of each activity had been discussed and agreed. Staff provided out of hours on call support for each service user living at the home. Staff support had been provided by the floating support worker once they had left the home to live independently in the community.Priory RoadPage 6 Lifestyle (Standards 11-17) Service users confirmed that all staff supported them effectively in maintaining and developing their social and independent living skills. Staff had encouraged service users to develop and maintain social activities outside of the home as this was an important aspect of their recovery to appreciate social activities without alcohol. Staff had supported service users with administrative tasks, grants and financial advice and had developed links with other agencies that could offer the appropriate advice and access resources for each individual. The house rules and daily routines clearly promoted freedom of movement, individual choice and independence. Any restrictions imposed had been discussed and agreed and were documented in the service users plan. Service users were able to choose what they wished to eat at each mealtime and they were responsible for cooking their own meals. The stocks of food confirmed that service users had a good choice of food that was nutritious and varied. Personal and Healthcare Support (Standards 18-21) The manager confirmed that service users health care needs were met. Care plans checked confirmed that service users had access to a variety of health care specialists as and when required. Positive relationships had been developed with the local GP surgeries and service users health care needs had been reviewed and reassessed on a regular basis. Service users self-administered their medication and had responsibility for ordering repeat prescriptions when required. The home had the appropriate policies and procedures in place in relation to medication and ageing and death. Concerns, Complaints and Protection (Standards 22-23) The home had the appropriate adult protection policies and procedures in place and staff had completed detailed training. They were aware of the different forms of abuse, reporting procedures and timescales. Staff had also completed training on coping with aggression, assertiveness and violence. Environment (Standards 24-30) The home was domestic in style and was homely and welcoming. Service users confirmed that this was how they saw the home. In the main the home was well maintained and attractively decorated. As a consequence of the hard work of one service user the rear garden areas had been attractively developed and landscaped since the last inspection. Service users had individually personalised their bedrooms and they confirmed that they were comfortable at the home. One bathroom was in need of redecoration now that repairs on the cracks to the internal walls had been completed. Staffing (Standards 31-36) The previously agreed staffing levels had been maintained by the home and service users confirmed that they had access to staff when required. Staff were aware of their own roles and responsibilities and of those of the manager. Staff had developed positive relationships with each individual living at the home and observations of staff interaction with service users confirmed that staff were supportive, approachable and responsive to their needs. Staff employed by the home had a wealth of experience, skills and knowledge of working with service users with alcohol related problems. Staff had undertaken training relevant to their role at the home and were committed to further training and personal development. The home operated thorough recruitment procedures and staff received regular supervision. One staff file checked did not contain copies of all of the relevant documentation. Conduct and Management of the Home (Standards 37-43) Priory Road Page 7 The manager was in the process of completing his training at NVQ level 4 in care and management. He was committed to further training for himself and all members of the staff team. The manager was keen to ensure that the service was developed in line with the standards and regulations for the service. Service users were encouraged to feedback their views on the quality of the service provided by the home and they confirmed that the manager was always approachable and supportive. Service users and staff stated that their opinions and ideas were valued and respected. Records checked were in the main well ordered and up to date and information could be easily accessed. Minutes of staff meetings had been maintained and the homes policies and procedures had been reviewed and updated. Records of fire drills and instruction did not contain all of the required details and one fire door was in need of repair. COSHH risk assessments were in the process of being updated. Not all staff had completed statutory training.Priory RoadPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 13 17 YA41YA4 2COSHH risk assessments for all cleaning substances used by the home must be completed.30/04/05Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 3 YA25 YA27 YA37 Double bedrooms must be phased out unless two service users currently living there choose to continue sharing. In existing homes en-suite toilets and washbasins should be provided where possible. The registered manager must hold qualifications at NVQ level 4 in management and care by the end of 2005.Priory RoadPage 9 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). N/AMET (YES/NO)Priory RoadPage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The bathroom must be re-decorated. 1 23 YA24 The grouting to the tiles around the bath must be replaced. Staff files must contain a copy of the individuals birth/marriage certificate. The records of fire training must indicate if it was a fire instruction or a drill. They must include the time of the instruction/drill, the names of those present and the outcome/action taken. YA41YA42 All staff must complete fire instruction training at least twice per year and records of this must be maintained. Fire drills must be conducted twice a year and records of this must be maintained. 4 18 13 23 12 YA42 All staff must complete statutory training, including refresher training, as required. The fire door leading to the laundry must be repaired. 31/07/05 30/04/05 30/06/05217 19YA34YA4130/04/0517 3 18 135YA42YA2430/04/05Priory RoadPage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 YA27YA29 A walk in shower should be installed at the home.Priory RoadPage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NA YES YES NO NO NO YES NO YES YES YES YES NO NO NO YES YES YES 2 0 0 YES YES YES YES 2 X 01/03/05 09:50 6.0Priory RoadPage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Priory RoadPage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 380.00 380.00 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 15 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Discussions with the manager, staff and a service user confirmed that full needs assessments had been completed prior to each individuals admission to the home. These were seen on the three files checked by the inspector. They were detailed and informative and clearly identified each individuals needs. They had been completed by the referring social worker attached to the homeless assessment unit or substance misuse team. Information from this initial assessment had been used to develop the service users individual plan. Any restrictions on choice or freedom had been agreed with each service user prior to their admission. Family members, friends or partners of service users had been involved in the admission process as appropriate to each individual. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Staff employed by the home, were skilled and experienced in working with service users with alcohol related problems. They were committed to meeting each individuals needs by offering the appropriate support and counselling on an individual basis and via group counselling sessions. Service users had regular daily access to staff and this was flexible to ensure that extra support was provided when individuals most required it. Service users, at the time of their admission, had been provided with clear information relating to the support provided by staff, house rules and duration of their stay at the home. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Discussions with staff and service users confirmed that service users were able to visit the home on an introductory basis prior to their admission to the home. Staff confirmed that the admissions process was extremely thorough as it was a priority to ensure that service users were appropriately placed at the home. They confirmed that they first met with prospective service users outside of the home to discuss the service provided. It was important that they determined that the individual was ready to change their lifestyle to learn to live and enjoy life without alcohol. Following this meeting, prospective service users then visited the home to meet the other service users and to discuss further the support provided by staff, house rules and the terms and conditions relating to their stay there.Priory RoadPage 16 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 4 Key findings/Evidence Standard met? Staff and service users confirmed that each service user had been provided with an individual written contract at the time of their admission to the home. Signed copies were seen on the individual care plans checked. The contracts seen included all of the required information and were very detailed.3 Each service user had been provided with two contracts. One was between the service user and the registered provider in relation to the support provided by staff and other issues relating to the registered service. The second contract was between the service user and Northern Counties Housing Association and related to the terms of the tenancy agreement regarding the accommodation.Priory RoadPage 17 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? The inspector checked three service users care plans. These were well ordered and set out and information could be easily accessed. Care plans were detailed and related to the specific needs of each individual. Staff confirmed that service users were involved in the development and ongoing review of the care plan. The service users key worker had made regular entries regarding the progress made and any current issues or concerns. Details of the advice and support provided by staff to facilitate each individuals needs had been recorded. Service users preferences in relation to support offered by staff of a specific gender had been recorded as had their permission for the inspector to see their file. Individual risk assessments had been completed and had been signed by the service user. Copies of policies relating to admissions (including a check list), finances, medication, house rules, smoking and missing persons were seen on the three files checked. Service users had signed to confirm that they had been made aware of the content of these documents. All sections of the care plans checked were up to date. Any specialist input had been provided as and when required and records of this had been maintained. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 18 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home had the appropriate policies and procedures in place in relation to confidentiality. Staff spoken to were aware of these. All records were securely stored as required. Information on the Data Protection Act 1998 was seen on file within the home. It was positive to note that on the individual files checked there was evidence that service users had been informed by staff of confidentiality issues.Priory RoadPage 19 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 20 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 21 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Staff and a service user interviewed, confirmed that the daily routines and house rules encouraged and promoted individual choice, independence and freedom of movement. Any restrictions imposed had been discussed and agreed and information relating to this had been recorded in the care plan. Staff had informed service users of their responsibilities in relation to house keeping tasks and daily routines at the time of their admission to the home. The routines were regularly discussed and reviewed to ensure that all service users accepted responsibility for their specific tasks. This was seen as an important aspect of each individuals care as it provided them with the opportunity to take responsibility for their own lives whilst working towards recovery and change. Service users had a dedicated dining room for their sole use. They confirmed that they were happy that they now had a private area where they could eat and relax. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The home did not have written menus as each service user was able to choose what they wished to eat at each mealtime. All service users had their own stocks of food in the freezer, fridge and pantry. Service users confirmed that they ate well and that the times of meals were flexible. All service users contributed towards a weekly house keeping fund and this money was used to purchase coffee, tea and milk for the home. Food was donated to the home from `Crisis Fare share on a regular weekly basis. The inspector checked the stocks of food and this confirmed that service users were provided with varied, healthy and nutritious meals.Priory RoadPage 22 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Service users confirmed that staff employed by the home were extremely supportive and attentive to their individual needs. Service users were encouraged to be independent and staff had supported them as appropriate according to their needs at the time. Service users had been able to choose which staff they wished to support them with any aspects of their care. Service users family and friends had been included in discussions as appropriate to each persons situation. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? Service users spoken to and care plans checked, confirmed that each individuals health care needs had been assessed and access to the appropriate support had been provided as required. Staff confirmed that the local health care centres were extremely supportive and service users had access to a variety of health care professionals as required. Details relating to each individuals healthcare, including appointments, had been recorded in the care plans checked.Priory RoadPage 23 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Staff informed the inspector that all service users currently living at the home selfadministered their medication. Medication profiles were seen on the care plans checked and reviews had been completed as and when required. Service users were responsible for ordering their medication via their GP and lockable facilities had been provided in bedrooms for securely storing any items of medication. Service users had been provided with a copy of the homes medication policy and these were seen signed and retained on the individual files checked. Service users were aware that they had to inform staff of any changes to their medication. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? The home had the appropriate policy in place for staff dealing with the ageing, illness and death of a service user. Staff spoken to, were aware of this policy and the manager confirmed that staff would deal with this issue sensitively. The policy stated that the provider would endeavour for the service user to remain at the home, and that the home would meet their needs as identified at the time. The manager confirmed that external professionals would be accessed for palliative care, assistance and advice and that counselling would be provided if required.Priory RoadPage 24 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X X X 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 25 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The home had the appropriate policies and procedures in place in relation to adult protection. The policy included the DOH Guidance `No secrets and the procedures included `Whistle Blowing. Staff had completed the appropriate training and were aware of the different forms of abuse and procedures and timescales to be followed. There had been no allegations of abuse.Priory RoadPage 26 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? On the day of the inspection the home was clean, fresh smelling and in the main well maintained and decorated. Rooms were individually personalised and service users stated that they were comfortable at the home that was homely and had a relaxing and welcoming environment. The exterior gardens were attractive and well maintained. Since the last inspection, the inspector is aware from the manager, that one service user had spent a considerable amount of time developing the rear garden areas. This had vastly improved the appearance of the garden and all service users had benefited from his hard work and commitment towards this project. Seating was provided and a pond with water features and ornaments had been installed. There were planters, potted plants, lawned and paved areas and wind chimes hanging on the trees. The manager confirmed that there was a planned renewal and redecoration programme for the home. Any recommendations made by the local fire and environmental health departments had been actioned. One bathroom was in need of redecorating now that structural work to the walls had been completed. The tiles around the bath were in need of re-grouting as these areas were stained and unpleasant.Priory RoadPage 27 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO NO YES 4 0 1 0 4 00 0 1 00 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 28 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home had a sufficient number of toilets and baths and these were close to the lounge, dining room and bedrooms. Showers were provided over the baths in two bathrooms. The inspector was aware from discussions with staff that the showers, over baths, could not always be safely accessed by service users that had mobility problems.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 29 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 9 Key findings/Evidence Standard met? This standard was not applicable as the home did not have any service users that required any adaptations to be made to the building or who required any specialist equipment to be provided.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This standard was not checked on this occasion as it was assessed at the last inspection and the home scored a 3. This means that at that time it met the required minimum standard.Priory RoadPage 30 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? The three staff employed by the home were aware of their roles and responsibilities and of those of any external line management. Staff had clearly defined job descriptions and contracts of employment and copies of these had been retained on individual staff files. Service users had been informed of the support provided by staff at the time of their admission to the home. Staff were extremely skilled and knowledgeable and were fully aware of the needs of each service user living at the home. They worked consistently as a team with each individuals care plan to ensure that each service user received the right level of input and support when they most needed it. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? Service users confirmed that staff were approachable and supportive and that they had access to staff when needed. Staff provided out of hours on call support and this had ensured that any issues or concerns were quickly dealt with. Service users were able to meet with staff individually and for group counselling sessions on a regular basis. Staff were committed to further training and the development of the service. Positive relationships had been developed with specialist agencies and other professionals to ensure that the necessary support could be accessed when required. The deputy was in the process of completing training in care and management at NVQ level 4 and the support worker had almost completed level 3.Priory RoadPage 31 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X 111 X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 111 Nursing X X XXX3 Key findings/Evidence Standard met? Staff had a range of skills, knowledge and training and this had ensured that service users needs could be met by the home. Staff were keen to ensure that each individual developed and maintained their independence and they had supported with this as identified within each persons care plan. Staff had worked closely with each service user and had provided them with the opportunity to work on their problems whilst living in a safe environment. Staff stressed the importance of each individual being supported to find their own solutions to their problems. On-going support and advice had been provided to service users once they had left the home and lived independently in the community. Regular staff meetings had been held and minutes of these meetings had been maintained.Priory RoadPage 32 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The inspector checked three staff recruitment files. Staff recruited to work at the home had had to provide references, proof of identity and evidence of qualifications and training. All staff had completed a CRB check at the enhanced level. Staff had been provided with a copy of the GSCC (General Social Care Council) code of conduct as required. Staff files checked contained copies of the relevant documents including passport, qualifications and training certificates. One file did not contain a copy of the individuals birth certificate. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The manager confirmed that all staff had completed induction and foundation training to the required specification. All staff had a training and development plan and were committed to further training and personal development. Staff confirmed that they identified their training needs for the year at their annual appraisal. In addition to NVQ level 3 and 4 training staff had also completed training on parenting skills and child protection issues during the last year. Staff training and development had appropriately been linked into the aims and objectives of the service and the changing needs of the service user group. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff confirmed that they received regular formal supervision with their line manager and that this was a supportive process. Notes of these sessions had been retained. Supervision sessions had covered personal training and development, the aims and objectives of the service, service development and its links with other specialist services and their work with individual service users. The manager confirmed that the registered provider had developed a new policy on staff supervision.Priory RoadPage 33 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The manager confirmed that he was continuing to study towards his qualification at NVQ level 4 in management and care and that he hoped to successfully complete this in the near future. The manager and staff were aware of their individual roles and responsibilities and of those of any external line managers. The manager confirmed that he was keen to ensure that the written aims and objectives of the home were achieved and that service users were provided with the necessary support as identified within their individual contracts and care plan. The homes certificate of registration was on display as required. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Staff and service users confirmed that the registered manager was supportive and very approachable. The manager was committed to the future development of the service to ensure that service users needs were met and that they continued to receive a high standard of care at the home. Staff and service users were able to discuss any ideas, issues or concerns that they may have with the manager. They confirmed that the appropriate action had been taken and changes implemented when it had been assessed that this was required to meet an individuals needs at that time. Staff and service users had regular access to the manager on an individual or group basis.Priory RoadPage 34 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The manager and the records checked confirmed that feedback, regarding service users views of the quality of the service provided by the home, had been sought on a regular basis via individual and group discussions. Service users had access to inspection reports and had been made aware of forthcoming inspections by the CSCI. Service users confirmed that they were actively encouraged to feedback their views and that staff were always willing to listen to what they had to say. They stated that the staff, manager and external line manager of the home, valued any contribution that they made in any discussions and that their views were respected. Detailed regulation 26 reports, had been completed by the responsible individual for the service on a monthly basis as required and these were available for inspection at the home. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The manager confirmed that the policies, procedures and practices used by the home had been recently reviewed to ensure that they complied with current legislation and covered all of the required topics. Staff and service users had access to these and were aware of the policies and procedures in place at the home. Service users had been provided with copies of some of the homes policies and they had signed to confirm that staff had explained these to them and that they were aware of any relevant procedures in relation to their stay at the home.Priory RoadPage 35 Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The inspector checked a range of the records that the home were required to keep. All records were securely stored and were well ordered. In the main records were up to date and the required information could be easily accessed. Staff had a signing in book where they recorded their daily hours worked at the home. Staff meetings had been recorded and minutes of these meetings had been maintained. There was a visitors book in the hallway for all visitors to sign in and out of the home. Risk assessments had been completed for the building and the manager confirmed that the COSHH risk assessments were in the process of being completed for all products currently used by the home. Care plans clearly detailed the needs of each individual and service users confirmed that they could access their own records if they wished. Several sections of the care plans checked had been signed by the service user to indicate that they agreed with the content and action plan. The records of fire training did not indicate if there had been a fire instruction or drill, the outcome/action taken, persons present or the time it had taken place. There was no evidence to confirm that fire training had taken place regularly since February 2004 although a drill had been held in February of this year. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The home had the appropriate health and safety policies and procedures in place and staff and service users were aware of these. Service users had been made aware of health and safety issues relating to the home and these were discussed and updated on a regular basis. Risk assessments, relating to the environment, had been completed, and the manager confirmed that he was in the process of updating the risk assessments relating to COSHH. Staff had completed some statutory training although one member of staff had not completed food hygiene training and was in need of refresher training in first aid. The fire door leading to the laundry was in need of repair as it did not close fully without being pulled forcibly. Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met? The home had the appropriate insurance cover in place. The manager confirmed that the registered provider would update the homes business and financial plan each year as the funds for the whole service were allocated and distributed. Service users and staff were aware of the management structures within the home and of those of the external line manager.Priory RoadPage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition N/A CommentsComplianceLead Inspector Second Inspector Regulation Manager DatePaula Loxley N/A Anne Hayselden 1st March 2005Signature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Priory RoadPage 37 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on the 1st of March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Priory Road Page 38 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan within 4 weeks, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOPriory RoadPage 39 D.3PROVIDERS AGREEMENTUnannounced 1st March 2005Registered Persons statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I, Nicola Smith of Priory Road confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Nicola Smith of Priory Road am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Priory RoadPage 40 Priory Road / 1st March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000003003.V177646.R01© This report may only be used in its entirety. 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