Inspection on 07/03/06 for Salisbury Court

This inspection was carried out on 7th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salisbury Court 05/11/08

Salisbury Court 28/11/07

Salisbury Court 13/02/07

Salisbury Court 28/09/05

Salisbury Court 08/02/05

Salisbury Court 02/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Salisbury Court Off Barnoldby Road Waltham Grimsby North East Lincs DN37 0BS Lead Inspector Tina Bettison Unannounced Inspection 7th March 2006 09:30 Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Salisbury Court Address Off Barnoldby Road Waltham Grimsby North East Lincs DN37 0BS 01472 821634 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) www.mencap.org.uk Royal Mencap Society Ms Ruth Adamson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28 September 2005 Brief Description of the Service: Salisbury Court is care home providing personal care and accommodation for 6 adults with learning disabilities some of who also have associated physical disabilities. New Era Housing Association owns the building. Mencap provides staffing and support. The home is located in the village of Old Waltham. It is close to local shops and amenities and there is a regular bus service from the village to nearby Grimsby and Cleethorpes. The home is a detached dormer bungalow in a quiet residential area. All accommodation for service users is provided on the ground floor with the staff sleep-in room/office and shower/toilet on the first floor. The six bedrooms are for single occupation and each has a wash hand basin. The home has a bathroom with an Aqua Nova assisted bath and toilet, a shower room with wheelchair access and toilet and a separate toilet. There is a combined lounge/dining room and adjacent kitchen and a separate laundry room. The gardens are easily accessible to the service users and there is a car parking area. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and was an unannounced inspection. Mencap have been going through a period of change particularly in relation to staffing. The Registered Manager Ruth Adamson is working at another care home on a temporary basis and whilst this is happening there is a temporary manager at Salisbury Court - Maggie Kirkby. This manager was on a day off at the time of the inspection therefore two staff members assisted the inspector. Some of the records, particularly relating to staff were not available on the day of inspection due to the managers absence however care records were examined. There was only one service uses at home on the day of inspection and she was in bed therefore the inspector was unable to observe care practices. The inspector had a follow up conversation with the service manager after the inspection. What the service does well: Mencap provides accommodation and personal care support and is a good service for adults with a learning disability and other needs. The primary aim is to enable people to develop as much independence as possible, whilst helping them to be more confident and access community facilities. The bungalow is located in the local community and is on a bus route making all leisure facilities and shops easy to get to, service users are helped to join in with a range of leisure and educational activities in the community. All service users are provided with a single room that is nicely personalised to their own taste, in a house for no more than 6 people thereby providing them with a home and private areas to their liking where they can spend private time or receive visitors. Families are encouraged to be involved as much as they wish to and are made to feel welcome when visiting their relative. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: NMS 2 and 5 were met at the previous inspection therefore they were not assessed at this inspection. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 Service users have individual plans however the lack of updating, monitoring and review compromises this leading to service users needs maybe not being met. EVIDENCE: NMS 9 was met at the previous inspection therefore it was not assessed at this inspection. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 10 At the previous inspection it was identified that the home had introduced new service user plans that were more comprehensive however the ones examined had not been updated for some time and for one service user whose needs had significantly changed, this was not reflected in the plan. This had not improved much at this inspection. Two care files of service users were examined as part of the inspection. Although one of the service user plans examined identified some updates the other did not. Staff were able to tell the inspector how one of the service users had been into hospital for surgery and then subsequently discharged to the home for convalescence which appeared to have been very well managed by the home. They provided additional support to the service user at a time of significant need whilst in the hospital and all care and support had been amended to meet her needs on discharge. Although a risk assessment had been completed on discharge there was no evidence on file of a review taking place and the care plan had not been updated to reflect the significant change in needs. An updated plan was faxed to the inspector following the inspection however staff must ensure they are pro active in updating plans as needs change and not just when requested to. Risk assessments had been completed for service users. Service user plans referred to risk assessments but did not specify which one. There was evidence in the other care file that the service users care had been reviewed by the home. However the manager and staff at Salisbury Court must ensure that individual care plans are reviewed with the service user, significant professionals and family, friends and advocates as agreed with the service user at least every six months and that individual care needs are updated and documented in the files to support and provide evidence that service users needs are being identified and met. This remains an outstanding requirement. The service users individual plans gave details of all family contacts and agencies involved in the service user’s care. Specialist care plans had been obtained, for example the learning disability community nurse had developed a care plan for a service user with epilepsy. Service users’ likes and dislikes were identified and each had a moving and handling assessment. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Service users are supported to continue their personal development and have access to the community for a wide range of leisure pursuits. Family contact is maintained and all service users enjoy a healthy diet. EVIDENCE: Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 12 Staff informed the inspector that none of the service users had any work placements either work experience or paid employment. However service users were given the opportunity for continued personal development through attendance at day services, where they could participate in art, craft sessions, cookery, road safety, communication skills, music and basic life skills dependant on their individual needs, likes and dislikes. Specialist services were also provided e.g. trampolining, hydrotherapy and horse riding. Service users were involved in or could observe domestic tasks e.g. taking own cup into the kitchen, watching staff clean rooms. The home had a range of indoor activities such as jigsaws and craft materials and staff supported service users to access community facilities and maintain contact with families. The religion of the service user was recorded in the care file. The home had a TV, DVD, video and music centre in the lounge/dining room with a range of videos for service users to watch. Service users could also have their own TV, hi-fi, radio etc in their bedroom. Service users were supported to access a range of leisure activities in the community these included bowling, swimming, out for walks, pub meals, theatre, shopping, hairdressers and to see bands perform. Relationships with the neighbours was said to be good. The inspector was informed that all service users had been or were due to be supported to have a holiday and the cost of their holiday was part of the basic contract price. Staff confirmed that they have a very active parents group who are very involved in the home. The home had an open door visiting policy. Staff spoken to during the inspection confirmed that service users’ family and friends could visit the home at any time without making prior arrangements. And that some of the service users regularly went back to their parents for visits, for tea or weekend stays. The inspector was informed that family members were invited to social events in the home and parents meetings were regularly held. Service users individual files contained contact details for their family and friends as well as dates of birthdays, anniversaries etc. Service users could see family and friends in their own bedroom or in the communal lounge/dining area. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 13 All bedrooms were fitted with a lock and a key could be provided although this was felt not to be appropriate for the current service users. The menu was developed on a 3 weekly cycle and was kept flexible due to service users being out and about. Breakfast consisted of cereals, toast, tea, coffee, fruit juice or milk. The majority of the service users had a cooked lunch at the day centre so a snack tea was provided. On Saturday and Sunday a full cooked breakfast was provided and a cooked meal later on in the day. One of the service users had nutritional risk assessment and one service user was on a healthy eating plan to maintain weight, health and general well being. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 14 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, 21 Service users receive personal care and support, which promotes their dignity and respect. All specialist equipment is provided to enable this to happen. EVIDENCE: NMS 19 and 20 were met at the previous inspection therefore they were not assessed at this inspection. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 15 The home did not provide nursing care the services of the district nurse or community learning disability nurse would be accessed if necessary, however they were providing care to a service user following surgery and training had been provided by the nurses to enable this. All service users had a moving and handling assessment completed. The inspector observed that personal care was provided in private in the service users bedroom or in the bathroom. The home had a mix of male and female staff and endeavoured to provide same gender care although there were no service users at the home who had requested this. Wheelchairs had been provided for service users who required them following assessment from the physiotherapist. The home had a hoist, a specialist toilet seat, a specialist chair and an Aqua Nova bath. The home had the equipment they needed to provide care for the service users. A key worker system, records of service users likes and dislikes and partnerships with families and other agencies ensured consistency and continuity of support. The service user group at the home were of a relatively young age and the home had not had to deal with aging, terminal illness or death of a service user. Individual care files examined did not evidence that the service users or their relatives had been consulted about their wishes concerning terminal illness and death. As identified at previous inspections the registered person must ensure that consultation regarding this takes place and is recorded, this remains an outstanding requirement. There was a corporate policy and procedure regarding terminal illness and death. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 16 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): Complaints made to the manager of the home are not handled appropriately and relatives are not confident that their concerns will be listened to, taken seriously or acted upon. Strategies are in place to ensure that service users are protected from abuse, neglect and harm. EVIDENCE: At the previous inspection, discussion with relatives had highlighted that some of the relatives concerns did not appear to have been addressed and resolved. Therefore the inspector had advised that the manager keep a record of all complaints however minor they may seem and a record of all action taken to resolve the issues. The complaints record and discussion with management identified that concerns/complaints were being recorded however there was no record of whether the complainant was satisfied with the action taken or not. The manager must ensure that relatives are given an opportunity to comment as to whether they are satisfied with the action taken and response to their concerns. This remains an outstanding requirement. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 17 The home had a copy of the Multi agency Protection of Vulnerable Adults (POVA) policy and guidelines. The home also had a copy of the Mencap corporate POVA policy, which has been updated since the previous inspection. Staff had received “protect me” training. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The bungalow is accessible and suitable to meet service users needs, however wear and tear of communal furniture and decorations compromises this. EVIDENCE: Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 19 The home is situated in the centre of Old Waltham close to local amenities and bus routes. The home continued to provide the same average living space as at 31st March 2002 and details of room sizes were given in the home’s statement of purpose. All accommodation for service users was provided on the ground floor and accessible to wheelchair users. The inspector found the environment to be cheerful and odour free. The rooms were well decorated with service users bedrooms reflecting individual needs and choice, however the furniture and decorating in the communal areas was showing signs of wear and tear and would benefit from replacing/redecoration. The kitchen was well equipped and the cooker had a safety guard. The inspector was informed that there is a maintenance and renewal programme for the fabric and decoration of the premises, which included timescales for the replacement of carpets and redecoration of bedrooms and the hall and lounge all to be implemented in April 2006. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 20 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): 32,33,36 Service users benefit from a staff team that works positively with service users to improve their quality of life, however the lack of NVQ qualifications is of concern. EVIDENCE: NMS 35 was met at the previous inspection therefore it was not assessed at this inspection. The inspector was unable to assess NMS 34 as the staff did not have access to staff files. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 21 The service manager informed the inspector that Mencap had now implemented the recommendations from the internal staff review. The total hours now provided was given as 387.5 hours and included 37 hours of the manager. The total hours provided also included the hours for domestic and non-care tasks that were also the support workers responsibility. The residential forum guidance suggests a minimum of 326.03 care hours, so the hours now provided exceeds this. The inspector was informed that the manager is supernumerary to the rota and does not generally undertake care tasks. Staff are responsible for domestic and cooking duties as well as service user care. Turnover of staff was average; the home currently has two vacancies. The posts have been advertised. Staff spoken to appear motivated and said that they enjoyed their work. They reported good relationships with GPs, Community Learning Disability team and other agencies. The home had only 1 staff out of 14 with NVQ level 3 in care and 1 staff with a HND in social care. The registered manager should ensure that 50 of all care staff in the home are registered and working towards NVQ level 2. There was a policy regarding staff supervision. Staff reported that the temporary manager had started a supervision programme but the frequency was not as high as the six-times a year as required by this standard, therefore this remains an outstanding requirement. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 22 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): EVIDENCE: NMS 37,39 and 42 were met at the previous inspection; therefore they were not assessed at this inspection. Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 2 33 3 34 x 35 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x x 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 x x 2 x x x x x x x Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2) Requirement The registered person must ensure that individual plans are reviewed with the service user, significant professionals and family, friends and advocates every six months and service users plans updated to reflect changing needs. (Timescale of 28/09/05 not met) Timescale for action 01/06/06 2. YA7 12 (3) The registered person must 01/06/06 demonstrate that any limitations on service users rights or choices are made in their best interest, through the assessment process and are documented in the individual service user plan. (Timescale of 31/8/05 and 31/01/06 not met) The registered person must consult service users or their relatives regarding their wishes in the event of terminal illness and death. (Timescale of 31/8/05 and 31/01/06 not met) The registered person must keep a record of all DS0000002910.V286045.R01.S.doc 3. YA21 12 (2,3,4) 01/06/06 4. YA22 22 01/06/06 Salisbury Court Version 5.1 Page 25 5. YA24 13 6 7. YA24 YA32 13 18 8. YA36 18 (2) concerns/complaints and a record of all action taken to resolve the issues. The manager must also ensure that relatives are given an opportunity to comment as to whether they are satisfied with the action taken and response to their concerns. (Timescale of 28/09/05 not met) The registered person must replace the furniture in the communal areas that is showing signs of wear and tear. (Timescale of 31/03/06 not met) The registered person must ensure that the home is redecorated. The registered person should ensure that at least 50 of care staff are registered and working towards the NVQ level 2 in care. The registered person must ensure that the frequency of staff supervision is a minimum of six times a year (pro rata for part time staff). (Timescale of 28/09/05 not met) 01/06/06 01/06/06 01/06/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Salisbury Court DS0000002910.V286045.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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