Inspection on 25/08/05 for St Marys Gate (25)

This inspection was carried out on 25th August 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Marys Gate (25) 23/05/07

St Marys Gate (25) 10/01/06

St Marys Gate (25) 23/09/04

St Marys Gate (25) 27/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 25 St Marys Gate 25 St Marys Gate Euxton Chorley PR7 6AH Lead Inspector Val Turley Unannounced 25 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 25 St Marys Gate Address 25 St Marys Gate Exuton Chorley PR7 6AH 01257 241899 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Link-Ability Charity Ltd Mrs Karen Whittle Care home with nursing 4 Category(ies) of LD Learning Disability (4) registration, with number of places 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the overall total of 4 a maximum of 3 service users requiring personal care who fall into the category of LD. 2. Within the overall total of 4 a maximum of 1 service user requiring nursing care who falls into the category of LD. 3. The registered provider must, at all times, employ a suitably qualified and experienced manger who is registered with the Commission for Social Care Inspection. 4. Staffing must be provided to meet the dependency need of the service users at all times and will comply with any guidelines which may be user through the Commission for Social Care Inspection regarding staffing levels in care homes Date of last inspection 23 September 2004 Brief Description of the Service: St Mary’s Gate is registered to accommodate four service users with a learning disability. The home is one of a number of properties operated by Link-Ability, which is a non-profit making Voluntary Organisation. Link-Ability provides a service for both adults and children who in addition to having a learning disability also have additional complex health and/or behavioural difficulties. It is the aim of the Organisation to provide a tailor made package of care for each service user. In pursuing this aim there is close collaboration between LinkAbility and the service users parents/relatives. St Mary’s Gate is a purpose built bungalow situated in the village of Euxton. There is a range of local amenities, and those which are accessed further away in the Chorley district. The home is well suited to the needs of the service users, with facilities and equipment having been installed to meet their individual care needs. These are regularly reviewed to ensure they remain appropriate. All clients have their own bedrooms and these have been decorated and furnished to reflect the individuals taste, preferences and interests. There is a communal lounge and dining room, kitchen, laundry and guest bedroom, which serves as the staff sleeping facility and office. There are gardens on either side of the home, one of which provides an enclosed and private area. The front of the home faces onto a courtyard, which is shared with neighbours. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in August 2005 by one regulation inspector. As the service users living at the home had communication difficulties, the inspection involved interaction with and observation of two of the service users who were present during the inspection and also discussion with and observation of the staff working there, an examination of records, policies and procedures and a tour of the premises. As part of the inspection, the inspector used “case tracking” as a means of assessing some of the National Minimum Standards. This process allowed the inspector to focus on one of the service users living at the home. All records relating to this individual were inspected along with their room occupied at the home. What the service does well: What has improved since the last inspection? 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 6 A great deal of work had been undertaken to improve the service users care plans. These were thoughtful in their approach and encouraged staff to consider in detail the support needs of the service users. Since the last inspection the homes policies and procedures had been reviewed and updated. 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. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The pre-admission process is in sufficient detail to ensure that potential service users needs can be met. EVIDENCE: This standard could not be fully assessed at this inspection, as there had been no new admissions to St Mary’s Gate since 2003. Previous inspections have shown that the pre-admission process is in sufficient detail to ensure that service users are compatible and that individual needs can be met. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 Care plans are detailed and personalised to help ensure that staff are able to provide appropriate support to service users and work with them to achieve carefully selected goals. EVIDENCE: The care plan of one of the service users was examined during the course of the inspection. The plan was based on a variety of information drawn from a number of relevant sources. The plan included the service users preferred day and night routines and this was observed to be followed during the course of the inspection. Discussion with staff indicated that they were aware of the preferences of the service user and planned ahead to ensure that she was involved in appropriate activities and that periods of rest were also built into the day. Support staff spoke of the need to be able to communicate with the service user, using a limited number of signs as well as being able to understand other methods she used to communicate e.g. facial expressions. This detail was included within the care plan and the staff were observed to respond appropriately to the service user when communicating with her. The plan also included information regarding the possibility of the service user self-harming when distressed or when support staff are unable to understand her communication. Strategies for working with these situations were included. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 10 Risk assessments were also included within the plan covering all activities both inside and outside of the home. These assessments included guidance as to how risks could be minimised. In addition to the day-to-day support needs of the service user individual goals had also been built into the plan. These included the support required by the service user to achieve these goals. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 16 Staff supported service users to participate in a range of appropriate community-based activities that service users had indicated a preference for. EVIDENCE: The care plan examined included details of the activities the service user enjoyed and were scheduled for her. These included swimming and trampolining, visits to shops etc. It was confirmed from records on the daily record sheet that the service user had been involved in these activities. Staff spoke of supporting the service user on a recent introduction to a college course. Although the service user accessed these activities with the assistance of the support staff, staff were clear that the service user herself would make her wishes known if she did not wish to access them. Again this information was included within the care plan. Routines within the home were flexible depending on the individual needs and wishes of the service users. On the day of the inspection staff were observed to support a service user to decide upon and follow her own activities for the day. The service users resident at the home were unable to become involved in the daily housekeeping tasks, but staff stated that they involved service users as 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 12 far as possible. Staff were observed to talk to the service users as they went about their duties. On the day of the inspection one of the service users was included in the discussion that took place as part of the inspection process. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 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 standard(s) 18 The support staff had a good knowledge of service users preferences and personal care needs and provided personal support sensitively and in accordance with their wishes. EVIDENCE: The file of the service user, which was examined during the course of the inspection, included details of the personal care provided within the care plan. The plan also included possible strategies to use on the occasions the service user did not wish to receive some aspects of personal care. The staff discussed their approaches to providing personal care to the service user and it was clear that they had an understanding of her needs and personal preferences. Personal support was provided within the privacy of her bedroom. The service user was clearly comfortable with the staff providing the support. A record was kept with the care plan of all health related appointments attended and planned. These were recorded in such a way so as to allow staff to keep track the service users health needs. The home was well equipped with technical aids to allow staff to provide personal care safely. Records indicated that the service user had had regular contact with her family and the members of staff on duty confirmed this. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 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 standard(s) 23 The home had good policies and procedures in place in order to protect service users. EVIDENCE: The home had robust policies and procedures in place for responding to allegations of abuse. Discussion with the registered manager confirmed that she had a full understanding of the policies and procedures and the action she would need to take if she was made aware of any allegations. The care plan examined during the inspection included details of strategies the support staff should adopt if the service user presented any challenging behaviour. Details of the service users financial expenditure was kept on the service users file. Policies and procedures dealing with the service users finance were comprehensive. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 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 standard(s) 30 The home was clean and hygienic, providing a safe environment for both service users and staff. EVIDENCE: The home was observed to be clean and hygienic. Laundry facilities were sited so that soiled linen did not have to be taken through any areas were food was stored, prepared, cooked or eaten. Hand washing facilities were available within the laundry area. The policies and procedures in place were comprehensive. Equipment within the laundry allowed soiled linen to be washed at appropriate temperatures. In addition to the organisations policies the home had additional infection control guidelines in place, which were specific to its own situation and service users needs. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The support staff had received training enabling them to meet the changing needs of the service users. The professional development of staff was encouraged, but this could be further improved to the advantage of the both the service user and staff team. EVIDENCE: Link-Ability is a member of a local training consortium, which provides training opportunities for support staff working with people who have a learning disability. This has provided the work force with a variety of training opportunities. There was evidence on staff files that the organisation had an induction programme in place and a member of staff confirmed this. Discussion with the manager and a member of staff confirmed that the staff an individual training and development assessment and profile which is reviewed every twelve months. It was recommended that the staff team be provided with the full range of training courses available to allow them to determine as far as possible their own professional development. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The manager ensured that the home was well maintained and that staff had received appropriate training to maintain the health, safety and welfare of the service users. Some additional work should be undertaken that this approach is underpinned by clear policies and procedures and so avoid any potential confusion in an emergency situation. EVIDENCE: The manager had ensured that the home was well maintained and that all equipment and systems had been serviced appropriately, ensuring as far as possible that the environment of the home was safe. There was evidence that staff had received mandatory training in relevant topics including first aid and food hygiene. Members of staff confirmed this. The manager had also developed day-to-day procedures in respect of infection control issues. All of these measures ensured as far as possible the health, safety and welfare of the service users and staff. The home provided annual fire training for the staff and staff also used team meetings to discuss action that would be taken if a fire broke out. It was 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 18 recommended that the homes written fire procedure be reviewed to ensure that the guidance provided was appropriate to its specific situation. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x x 3 x Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 25 St Marys Gate Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 20 NO 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA 35 YA42 Good Practice Recommendations Staff should be provided with the details of the full range of training courses available via Link Ability. The homes writen fire procedure should be reviewed. 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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 25 St Marys Gate F57 F08 S5938 25 St Marys Gate V246429 250805 Stage 4.doc Version 1.40 Page 22 - 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. 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