Inspection on 11/09/06 for Progress House (Kilnhurst)

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Progress House (Kilnhurst) 16/02/06

Progress House (Kilnhurst) 28/09/05

Progress House (Kilnhurst) 14/03/05

Progress House (Kilnhurst) 16/09/04

Progress House (Kilnhurst) 06/02/04

Similar services:

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

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

CARE HOME ADULTS 18-65 Progress House (Kilnhurst) 17 Rix Road Kilnhurst Rotherham South Yorkshire S64 5TZ Lead Inspector Sarah Powell Key Unannounced Inspection 11th & 22nd September 2006 2:30 DS0000003137.V310006.R01.S.doc Version 5.2 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 DS0000003137.V310006.R01.S.doc Version 5.2 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. DS0000003137.V310006.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Progress House (Kilnhurst) Address 17 Rix Road Kilnhurst Rotherham South Yorkshire S64 5TZ 01709 589385 01709 582111 NONE 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) Sapphire Care Services Limited Post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000003137.V310006.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Progress House is a detached property in a residential area of Kilnhurst near Rotherham. It provides care for 4 service users with learning disabilities ages 18 to 65. There is parking to the front of the property and an enclosed garden at the rear with a patio. DS0000003137.V310006.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection in the year 2006/07 unannounced and took place over two days starting on 11th September 14:30 and finished at 18.15 then 22nd September 2006 at 09:30 and at 13.00. As part of the inspection process the inspector spoke to 2 residents, and the Manager. it was 2006 at finished 2 staff, A tour of the building took place, observing the standard of the environment, staff and service users. A number of records were examined these included medication, two service users care plans, staff rotas, recruitment, training, quality assurance systems and health and safety records. Feedback was given to the Manager when the visit was completed. What the service does well: What has improved since the last inspection? There is a new service user at Progress House he has settled very well and all service users get on well together this is helped busy a good staff team who understand the service users needs. The home has had new carpet throughout and new furniture is ordered for all rooms a new television is also being provided for the small lounge, which will give service users the opportunity to sit alone, if they wish. The service users spoken ton had enjoyed choosing the carpet and colour for their bedrooms and were looking forward to the new furniture arriving. DS0000003137.V310006.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000003137.V310006.R01.S.doc Version 5.2 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 DS0000003137.V310006.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Good assessments are in place to determine service users needs can be met. EVIDENCE: Three of the service users at Progress house have lived there a number of years the fourth service user moved in last month from another home in the group and their needs were fully assessed prior to moving into Progress House. The new manager is also aware of the need to fully assess prospective service users to ensure the needs of the service users are identified and can be met also taking into consideration the existing service users. DS0000003137.V310006.R01.S.doc Version 5.2 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 & 9. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Individual needs and choices of service users are met. EVIDENCE: The care plans were very detailed and comprehensive and clearly identified service users needs and how to meet these needs. The new service user still had the care plan which came from the other home this was not as detailed as the other service users plans in progress hours, the manager was aware of this and was due to start reviewing and updating the plan to ensure all his needs are identified and met. The service users also need to complete a person cantered plan and health action plan the manager is currently sending for this paperwork and will then commence the work. The health action plan cannot be started until the staff have received a training session from the learning disabilities team in Rotherham and this is being arranged. DS0000003137.V310006.R01.S.doc Version 5.2 Page 10 It was evident from talking to staff and service users that service users are able to make decisions are given choices and are able to take reasonable risk as part of an independent lifestyle. DS0000003137.V310006.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Independent lifestyles are promoted and service users needs regarding education, leisure, community links and meals are met. EVIDENCE: Staff support service users to continue their education or learn new skills. Two service users attend day centres Monday to Friday and the other attends a college in Worksop Monday to Friday ensuring they are able to take part in age, peer and appropriate activities. The new service user is currently being assessed as to the appropriate day care facilities to meet his needs. DS0000003137.V310006.R01.S.doc Version 5.2 Page 12 Speaking to the service users their needs regarding education are fully met. When not attending college or day centres the service users have a full programme of activities these are in the plans of care which enable service users to be part of the local community. The activities programme is drawn up with the involvement of the service users and are flexible to ensure the needs of the service users are met. The service users said they enjoy the activities and are able to choose what they would like to do sometimes this is as a group or individually. Service users are able to see family and friends when they wish and a number of the service users regularly visit families. Staff are aware of service users rights regarding intimate relationships and are currently seeking help for one of the service users from a specialist to ensure his needs are met. Meals and mealtimes are very flexible all service users are able to choose what they wish to eat although a healthy diet is promoted. Service users cook their own meals with support from staff and service users spoken to also said they went shopping for the food with a member of staff. DS0000003137.V310006.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs regarding health care and personal support is met. EVIDENCE: Service users spoken to say they are able to maintain their own personal care with some support from the staff this was also seen documented in the plans of care. Service users told the inspector they choose their own clothes and hairstyles, which reflected their personality. Health care needs of service users are maintained, all service users are registered with a GP. All access local dentists, chiropodists and opticians. They also receive an annual health check from their GP’s. This was will documented in the care plans, the service users also told the inspector they go to these appointments assisted by staff. The home has a good medication policy and procedure medication is stored correctly and good records kept. Currently no service user has been assessed as able to self medicate but this is regularly reviewed. DS0000003137.V310006.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a good complaints procedure. Procedures to protect service users from abuse could be more robust. EVIDENCE: There is a clear and effective complaints procedure, which includes set timescales. The complaints procedure also states that the CSCI can be contacted at any time. The home had received no complaints since the last inspection. The home has a good adult protection policy which clearly defines different types of abuse and staff were well aware of different types they were also aware of the importance of whistle blowing, however they were not clear what procedure to follow with regard to whistle blowing. The homes whistle blowing policy only stated to contact people within the company with two names listed. This needs to be more comprehensive and following an inspection at another home that manager has put forward a revised list and the company is currently reviewing this and the full comprehensive list which includes the local procedure to follow is in the process of being sent to all homes to ensure service users are safeguarded. DS0000003137.V310006.R01.S.doc Version 5.2 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 & 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is well maintained and clean. EVIDENCE: The home had new carpets fitted between the two inspection dates and all new furniture is on order for the bedrooms, lounge and small lounge including a new television for the small lounge. The service users were able to choose the colour carpets they wanted in their bedrooms and one service user showed the inspector his bedroom and was very pleased and were looking forward to the new furniture. Maintaining a clean environment for the service users to live in. DS0000003137.V310006.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Recruitment procedures protect service users staff support service users and understand their needs. More staff are needed to maintain staffing levels to meet service users needs. EVIDENCE: The staff personal files were looked at during last years inspection these contained all the required information, completed application form, two written references, CRB checks and all other relevant information to protect service users. Staff training for all mandatory training was up to date staff told the inspector training was very good and all new staff had received induction. The home at present is short staffed and staff are working short and long hours. Weekends appear to be the worse with only one member of staff on duty for three service users. One service user visits his family every weekend. DS0000003137.V310006.R01.S.doc Version 5.2 Page 17 These staffing numbers are not adequate they do not meet the needs of the service users. There are two support workers on evenings but if a one service user has their 1 to 1 this again leaves only one support worker with three service users, which again is not adequate staffing numbers. The manager has been putting additional staff on duty when she is able but with only four permanent members of staff this is very difficult. This needs to be addressed urgently to ensure the safety of service users and their needs met. Due to the staff shortages the manager has been working shifts and has no supernumerary days, which is required for managerial administration within the home. Service users told the inspector the staff are lovely and always help you. Staff are working hard to meet the needs of the service users but additional staff members need to be recruited to fully meet the needs of the service users. DS0000003137.V310006.R01.S.doc Version 5.2 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, 39 & 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service Good quality monitoring systems and health and safety procedures. The manager needs to register with CSCI. EVIDENCE: The home has got good quality monitoring systems based on seeking views of service users and Regulation 26 visits are carried out to ensure service users views underpin development in the home. Service users told the inspector staff listen to them and ask their views and choices. DS0000003137.V310006.R01.S.doc Version 5.2 Page 19 The home has a comprehensive health and safety policy and the manager told the inspector that all staff receive health and safety training. The manager also told the inspector that all safety certificates are kept at the home and all checks are up to date to safeguard service users. However on checking the certificates it was noted that PAT testing was out of date by four months the manager tried to chase this up at the time of the inspection and was hoping to get a date within the next two weeks for this to be carried out. The manager has since contacted the inspector to confirm the PAT testing has been carried out. The manager has been in post at Progress house since February 2006 but has not yet registered with CSCI. The manager is currently finishing her NVQ level 3 and then will register on the Registered managers Award. DS0000003137.V310006.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 X 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X DS0000003137.V310006.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 Timescale for action 01/02/07 2. YA33 18 3. YA37 8 Ensure all the Person Centred plans and health action plans are completed for all service users and the new service users plan is also reviewed and updated. Ensure additional staff are 01/12/06 recruited to ensure the staffing levels can meet the needs of the service users. The manager needs to apply to 01/01/07 become the registered manage with CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000003137.V310006.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000003137.V310006.R01.S.doc Version 5.2 Page 23 - 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. 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