Inspection on 17/05/07 for Stakesby Road (89)

This inspection was carried out on 17th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Stakesby Road (89) 03/11/05

Stakesby Road (89) 24/05/05

Stakesby Road (89) 21/09/04

Stakesby Road (89) 08/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Stakesby Road (89) 89 Stakesby Road Whitby North Yorkshire YO21 1JF Lead Inspector Pauline O`Rourke Key Unannounced Inspection 17th May 2007 10:30 DS0000007841.V333221.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 DS0000007841.V333221.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. DS0000007841.V333221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stakesby Road (89) Address 89 Stakesby Road Whitby North Yorkshire YO21 1JF 01947 602452 01947 602452 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.wilfward.org.uk The Wilf Ward Family Trust Kathryn Mansfield Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000007841.V333221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: Stakesby Road is registered to provide long-term accommodation to 3 younger adults who have a learning disability and/or a physical disability. Kay Mansfield is the Registered Manager and the local health authority owns it with care provided by the Wilf Ward Family Trust a registered charity. 89 Stakesby Road is a dormer style bungalow situated in a private residential area of Whitby. A former private dwelling, it now provides suitable accommodation for the three residents. There are gardens to the front and rear of the building accessible to the residents. There are three bedrooms offering residents single room accommodation. A communal lounge is provided with a television, video and music stereo systems. There is a dining room, a domestic style kitchen, an adapted bathroom and toilet facilities. Information about the service is available on request and it can be provided in a variety of formats. On the17th May 2007 the cost to the residents was between £108.95 and £143.60 per week, this is determined through a financial assessment. This covers the accommodation costs, the local health authority and social services departments meet the cost of the personal care. They and their carer are informed of this cost prior to their admission. DS0000007841.V333221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered from the provider, service users and relatives. A site visit to the home was carried out on 17th May 2007. It focused on the key standards. An inspection of some of the premises was undertaken. A number of records were also examined. Discussions were held with the two members of staff on duty. The manager in the form of a pre-inspection questionnaire supplied information and surveys were sent out to professionals and residents. Feedback was received from 2 residents and their families and 1 care manager and 2 health professionals as well as 3 GP’s. Time was also spent observing the interactions between the staff and residents. What the service does well: All the people who use, or want to use the service at Stakesby Road would have to tell someone of the help they need. This information is used to make a care plan. The care plans used are detailed and tell the carers everything from how people like to get up, go to bed, what they like to do during the day and how it is best to communicate with them. These care plans are reviewed every two months, and people who are important to the resident are involved if they want to be. Those people who live at Stakesby Road have a full programme of activities and they enjoy going out shopping, to the hydrotherapy pool, holidays, museums, and trips to the seaside, and local pubs. There are enough staff on duty to help the people who use the service to get out and about either individually or as a group. Everyone who lives at Stakesby Road has a key worker. This member of staff keeps in touch with the family and makes sure that birthdays and Christmas cards are sent to the family. They also make sure that the person they help has enough clothes and personal items. They also make sure that everything goes along according to the resident’s diary. The staff are well trained and have been thoroughly checked before they started working for the Wilf Ward Family Trust at Stakesby Road. The staff have regular training to make sure they have the skills needed to ensure the needs of the residents are met. The service is well managed and the staff like having a manager who listens to them and asks for their opinion. The manager makes sure that any work needed on the building is carried out and she makes sure it is a safe place to live and work. DS0000007841.V333221.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000007841.V333221.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 DS0000007841.V333221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who decide to use this service have the information needed to ensure their needs can be met. EVIDENCE: There have been no admissions to the home since it opened, but a discussion was held with the Registered Manager about how a new admission would take place. The Wilf Ward Family Trust has a proven admissions policy and this ensures that a multi disciplinary assessment is undertaken prior to any admission. The home usually receives an assessment and makes as initial decision about suitability before the person who requires support and their family are contacted. The process then becomes a series of visits and short stays to determine whether the placement is suitable. A trial period is then planned and the length of this trial is dependent on the needs of the individual. As part of the assessment process the wishes of the established residents are taken in to account. The case files seen of current residents contained comprehensive assessments and evidence of regular reviews of the care plans. DS0000007841.V333221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service are able to make decisions on a day-to-day basis about their lives and this allows them to remain as independent as possible. EVIDENCE: All the people in the home have a comprehensive care plan and there is evidence to show these are reviewed when necessary. The staff spoken with were knowledgeable about the care plans and they involve the residents relatives, where appropriate, in all reviews. The residents were seen during the visit making their own choices about what they wanted staff to do for them. All of the service users have non-verbal communication methods, and the staff have developed an understanding of these methods and they are clearly identified in the care plans. Occasions where how the residents may refuse to do something were highlighted. A DS0000007841.V333221.R01.S.doc Version 5.2 Page 10 daily diary is maintained for each resident that informs the staff and the review process. One relative said: They always act on the way my relative behaves especially on indication of things they dislike. All of the residents had up to date risk assessments in place in relation to their individual needs and their differing daily living abilities. These documents are reviewed regularly incorporating specialist assistance when necessary. The residents have complex needs and the staff were seen to treat each one as an individual at all times during the visit. Special equipment such a large swing and a hammock have been provided for the garden so that all the residents can enjoy this area of their home safely. DS0000007841.V333221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are encouraged to make decisions about their daily life and staff provide appropriate support and encouragement for them to remain independent. EVIDENCE: On the day of the visit the 3 residents were at home, however two were getting ready to go out. One was going to a hydrotherapy pool with two carers and the other went to do some personal shopping. The remaining resident choose to listen and watch a DVD. This resident went out later in the afternoon to have some pampering of his or her own. Their daily diaries outlined what they should be doing and the staff always checked with them that they still wanted to take part in their chosen activity. There was sufficient staff available to ensure the residents could go out regularly. The residents enjoy a variety of activities, such as rebound therapy, aromatherapy, and DS0000007841.V333221.R01.S.doc Version 5.2 Page 12 music, keep fit and baking and are going on holiday in the near future. The staff follow the philosophy ‘if I can do it so can they’ and this means that nothing is out of bounds. All activities have been risked assessed and equipment provided if they require it. One resident had been provided with a radio that required them to turn it on by touching a special button. This enabled them to decide when they listened to music and when they wanted it to be quiet. The staff were seen to be respectful of the residents and always kept them informed of what tasks they were carrying out. The key workers keep the residents relative informed of what is going on and include them as much as they want to be. The mealtime observed was relaxed and whilst only a snack meal the resident appeared to enjoy it and was appropriately supported by the manager during it. The residents and staff eat together and staff interact with the residents and not just with each other. There is a set menu but this is flexible enough to allow for them to eat out, or get a takeaway or just to change it depending on the abilities of the staff. One resident needs a pureed diet so when they go out staff take a hand blender so that they can enjoy the same food as everyone else. DS0000007841.V333221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents’ health and personal care needs are met on an individual basis. The staff employ the principles of respect, dignity and privacy in all interactions with the residents. EVIDENCE: The case files for the three residents were seen and they contained detailed information for the individual concerned about how they like or need to be approached and assisted with all their personal care tasks. The staff spoken with during the visit had a clear understanding of these instructions and the reasons why they were so detailed. Evidence was available in the case files that advice has been sought from the local Learning Disability Support team in relation to equipment and changes in the care plans. Each resident has a key worker and they work closely with any family members and the residents to ensure their routine and care plan remain up to date and appropriate. Staff were observed treating the residents with respect and in accordance with their care plan. DS0000007841.V333221.R01.S.doc Version 5.2 Page 14 The three residents are all registered with the local surgery and one of the GP’s who responded to the questionnaires said ‘I am very impressed by the level of care shown at the home’. The manager confirmed that they had a good relationship with the local surgery and tried to take the residents when possible to see the doctor rather than rely on house visits. The residents also have input from an occupational therapist and a physiotherapist who has been supportive in ensuring the right equipment is provided. There was gender specific health information in the resident’s files. The residents are unable to self medicate so the manager and staff administer their medication. The storage and administration was appropriate and all staff have completed a learning distance course in the Safe Handling of Medicines as well as practical observations during their working time. DS0000007841.V333221.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their representatives are able to express their concerns through the complaints procedure and are protected from abuse, so their rights are protected. EVIDENCE: There is a robust complaints procedure in place, a copy of which is available in the residents file. They are in large print and picture format. The Wilf Ward Family Trust also has a resident Group, which meets to discuss how residents might like to improve the services available. A representative is named and contact details are displayed in the hallway of the home. The Wilf Ward Family Trust or the Commission has received no complaints. An Adult Protection protocol is in place and staff were aware of their responsibilities under this procedure. Staff have received training through National Vocational Qualification and their induction and foundation training. The manager also reinforces the training in the monthly staff meetings. DS0000007841.V333221.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents live in a well-maintained, clean property that allows them to access all areas, promoting their independence. EVIDENCE: The home is a 3 bed-roomed bungalow and is clean, comfortable and well maintained. The residents each have their own rooms and the rooms seen during the visit were personalised and reflected the interests and personality of the occupant. All of the residents are able to access all areas of the home and there is appropriate equipment available to ensure their needs can be met. The garden area is also accessible to the residents and appropriate equipment was available in the garden to ensure they were safe whilst outside. The staff were aware of the infection control policy and were seen to be implementing this during the visit. DS0000007841.V333221.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are supported by well-trained staff in sufficient numbers that they are seen as individuals and the care provided is pertinent to their needs. EVIDENCE: The Wilf Ward Family Trust has a well established and robust recruitment process and all necessary checks would be carried out prior to anyone being deployed in the home. Two of the staff files have been previously checked during a visit to the head office of the organisation. The rota’s received prior to the inspection indicated that the home is staffed appropriately. During the site visit the residents plans provided the staff with clear instruction including where two members of staff were required for one resident. The staff spoken with said that they felt the staffing was adequate and that they had time to spend with the residents on a one-to-one basis. The whole routine during the visit was relaxed and staff were seen interacting positively with the residents. The pre-inspection questionnaire showed that the staff have received training in fire safety, first aid, food hygiene, prevention of ulcers and pressure sores, DS0000007841.V333221.R01.S.doc Version 5.2 Page 18 LDAF and the administration of rectal diazepam. Future planned training includes safe handling of medicines, first aid and fire training. Staff spoken with said that they had access to training on a regular basis. Staff have monthly supervision where they are expected to set their own learning goals and identify training needs. Team meetings are an opportunity to ensure everyone is aware of any changes to the residents’ plans and to put forward ideas for future activity plans. One of the relatives was very positive about the interaction between the staff the residents and felt that their quality of life was much improved because of that. DS0000007841.V333221.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents live in a well managed home where the administration of the home is based on openness and respect. This allows the residents to retain their individuality and independence. EVIDENCE: The Registered Manager has completed the registered managers award and is an experienced manager. The staff said that she operates and open door policy and she works with the staff. The staff said that she asks for their ideas and opinions on issues and listens to what they say, but they also said that if she needs to make a decision she does. During the visit it was evident that the manager was very much part of a team and when the staff took out 2 of DS0000007841.V333221.R01.S.doc Version 5.2 Page 20 the residents it was the manager who stayed to provide one-to-one care for the remaining resident. The Wilf Ward Family Trust has a thorough quality assurance programme within the trust and where possible involves residents as much as possible. The individual homes carry out small quality checks and these are carried out by a visiting manager. The records seen during the site visit were maintained to high standard and contained detailed and pertinent information. They were stored securely and the staff could access them when necessary. The records for the residents’ monies were found to be accurate and up-to-date. Someone from outside the home but from the Wilf Ward Family Trust checks the accounts on a regular basis. All the working practices within the home are safe and staff keep accurate accident records, this information is used to inform the care plan and in requesting specialist input. Staff have received training in the health and safety procedures and all the policies are read by the staff. The records relating to health and safety issues that were seen during the visit were up to date DS0000007841.V333221.R01.S.doc Version 5.2 Page 21 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 4 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 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 4 X X 4 X DS0000007841.V333221.R01.S.doc Version 5.2 Page 22 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. 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. Refer to Standard Good Practice Recommendations DS0000007841.V333221.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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