Inspection on 03/11/05 for Stakesby Road (89)

This inspection was carried out on 3rd November 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stakesby Road (89) 17/05/07

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 David Blackburn Unannounced Inspection 3rd November 2005 08:45 Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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) The Wilf Ward Family Trust Kathryn Mansfield Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: 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, bathroom and toilet facilities. Stakesby Road provides accommodation for residents who have severe learning and physical disabilities. Appropriate aids and equipment are provided to assist service users. The staff seek to provide a holistic care regime, offering personal care, help, advice and guidance with daily living skills and activities, a catering service, a laundry service and domestic services. Social activities are arranged by the staff in-house and at external locations. Some residents attend day care placements. All residents are registered with a local general medical practice in the town. Their doctors arrange access to the more specialised health services. The staff team has developed very good relationships with the Community Learning Disability Team (CLDT) and Consultant Psychiatrists who provide a valuable resource and input into the home. Stakesby Road is owned by the local health authority. The care input is provided by the Wilf Ward Family Trust, a registered charity. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection upon which this report is based was the second to be undertaken in the inspection year April 2005 to March 2006. It was carried out over four hours including preparation time. The focus was on those key standards not assessed at the first inspection in May 2005 together with those parts of other standards that were subject to a requirement or recommendation. Care plans were examined together with some policies and procedures. Some parts of the premises including two bedrooms were seen. Discussions were entered into with the staff on duty. Three residents were spoken with though their ability to communicate was very limited. Their feedback was mainly oneword answers, gestures or facial expressions. Observation throughout the inspection showed a very good rapport between residents and staff. What the service does well: Residents remained at the centre of all activity in this home. Their needs were given priority and all tasks, routines and duties carried out focused without exception on the residents. Residents were able to undertake a number of activities in the home and at external locations that greatly enhanced their life experiences. Appropriately carried out risk assessments meant they could undertake a variety of activities in safety. Residents’ right to independence, choice and freedom of movement were all key components to the way life in the home was organised. Routines were designed to enable residents to benefit from a number of different experiences. Residents enjoyed a varied menu that met their individual preferences and dietary requirements. Residents were offered personal care and health care in a manner that met their requirements and promoted their overall wellbeing. Residents were assured of protection from harm through good policies and procedures designed to safeguard them from harm. Staff had a good understanding of adult protection issues that further promoted residents’ safety. Residents continued to live in a homely environment. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 Page 6 Residents could feel confident their needs would be met by a competent, able, motivated and well-trained staff group. The registered provider’s recruitment and selection procedure was designed to further protect residents from harm. The home was well managed and provided an environment in which residents could feel safe and secure. 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. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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): 0 None of these standards was assessed. EVIDENCE: Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 and 9 There was a clear and consistent care planning system in place that adequately provided staff with the information needed to appropriately meet residents’ needs. EVIDENCE: The case file of each resident was examined. They continued to be well organised and easy to use. There was a wealth of information on each file giving a clear picture of the individual resident, their strengths and their needs. A personal support plan (PSP) was on file. This detailed a number of activities of daily living together with the objective to be achieved and the support needed to meet that goal. A written PSP review was being undertaken every three months. Copies were seen on the files. A series of risk assessments were found on each file. These showed risks associated with numerous activities both in the home and at outside locations, for example the hydrotherapy pool. The assessments indicated the anticipated risk and how it was to be managed. The assessment of each activity clearly showed the benefits to be achieved by the resident from participation. None of the residents was denied an activity because a risk could be identified. Rather Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 Page 10 staff were pro-active in arranging many activities but with clear evidence they had researched the risks involved and taken the appropriate action to minimise or eliminate them. All risk assessments were subject to review. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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, 16 and 17. Residents were able to undertake a number of activities in the home and at external locations that greatly enhanced their life experiences. Residents’ dietary needs were met through the provision of varied and nutritious meals. EVIDENCE: All residents suffered from learning difficulties together with physical disabilities. None could therefore undertake any form of employment. Similarly none had been assessed as benefiting from mainstream further education classes. All residents attended day care placements on certain days each week. These were generally seen as a vehicle for diversionary activities rather than educational learning. Residents undertook a variety of activities in the home and at outside locations. At home these included music therapy, aromatherapy and themed party nights, for example Halloween. Outside the home residents could access a local hydrotherapy pool, go shopping, enjoy the theatre and eat out. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 Page 12 Staff continued to look for other activities in-house and outside. They said that disability was no bar in their eyes and they made positive and strenuous efforts to ensure their residents led a full and active social life in the home, in the town and wider afield. The extra staffing recently agreed meant that more one-to-one or two-to-one time could be offered and more activities undertaken on an individual basis. Staff said they had noticed the benefits for the residents in terms of the increased time they were able to give to the various aspects of their care. The replacement of the mini bus with two specialist vehicles could only increase this freedom and flexibility. The residents’ personal support plans (PSP) showed how care was to be provided and by whom. Despite the residents’ multi and very differing needs staff were able to promote and maintain individual choice and maximise independence. Staff said routines in the home were designed around the residents and the meeting of their needs. Staff were observed to interact with residents throughout the inspection. They were well able to recognise, understand and respond appropriately to every word, gesture or facial expression. The menus were devised by staff based on the known likes, dislikes, preferences and choice of residents. Observation by staff of residents’ reaction to additions to the menu gave a clear indication as to whether or not a particular item was liked. A variety of food was offered and the small resident number meant that individual choice and preference could be met. Staff were observed to assist with breakfast and with drinks during the morning. This assistance was given in a quiet, dignified and unobtrusive manner. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 and 19. Residents’ privacy and dignity were maintained through proper attention to how care was given. Residents’ health needs were well met with evidence of good multi-disciplinary working taking place. EVIDENCE: The case files detailed each resident’s personal and health care needs and how they were to be met. There was a firm accent on the maintenance of each individual’s privacy, dignity and independence. All personal care was given behind closed doors. Residents were assisted in shopping for clothes and personal items. Hairdressing and beauty therapy were provided in local salons in the town. The necessary specialist lifting and moving equipment had been provided with clear instructions on the residents’ file about how and when it was to be used. Staff confirmed they had received training in the use of this equipment. A whole discrete section was on each file relating to health care needs. Included was information on the health action plan, medical log and medication requirements. Any special needs or requirements were clearly detailed, for example epilepsy management. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 and 23. Residents were assured their concerns would be acted upon through a relevant complaints procedure. They were protected from harm by staff’s clear understanding of adult protection policies and procedures. EVIDENCE: A complaints procedure was available in written and pictorial form. It detailed how to complain, to whom and gave timescales for response. It showed the name and address of the current regulatory authority. An “abuse” policy and procedure was seen. It was written with specific reference to dealing with disclosures concerning people with disabilities. Staff confirmed training in adult protection was given at induction and when undergoing LDAF training (Learning Disability Award Framework). The registered manager said staff undertaking National Vocational Qualifications in care had to complete a compulsory unit on adult protection issues. The registered manager had a copy of the original multi-agency agreement on adult protection. She was advised to obtain a copy of the revised protocol, discuss this with staff and then implement its’ recommendations. Staff took responsibility for residents’ personal money. Proper policies and procedures were in place and observation showed these were being followed. Records of all transactions were kept. A reconciliation of the actual money with the records revealed no discrepancies. Bank books were held in residents’ names. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 and 30. Residents were able to live in a homely and comfortable environment. EVIDENCE: The premises remained in good condition internally and externally. Proper attention was given to general upkeep with re-decoration, refurbishment and re-carpeting carried out as necessary. Those parts of the premises seen were clean, tidy and odour free. Appropriate systems were in place for the laundering of bedding, linen, towels and personal clothing. Proper attention was given to matters of hygiene and infection control. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 and 34. Residents were supported by a properly recruited, competent, motivated and trained staff team. EVIDENCE: The registered manager was supported by an assistant manager and 11 care staff. Extra staff hours had recently been agreed and appointments were being made to those posts. Male and female staff were employed from different backgrounds bringing with them a range of skills, knowledge, expertise and life experiences. The staff on duty were seen to interact extremely well with residents and there was an evident rapport between the two groups. Staff displayed a high level of commitment to and concern for the residents in their care. Staff confirmed they had undertaken in-house induction and external LDAF training. Two had achieved a National Vocational Qualification in care to level 2 while five others were working towards this award. All recruitment to the home was done following the selection procedures of the registered provider. They detailed the arrangements for the recruitment, selection, interview and appointment of staff. The necessary clearances, for Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 Page 17 example references and enhanced disclosures from the Criminal Records Bureau, had been obtained. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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): 41 and 42. Residents’ health and safety was promoted and protected. EVIDENCE: Those records seen were being maintained in an appropriate manner. Staff files had been seen earlier in the year at the registered provider’s headquarters. They were found to be satisfactory. Proper attention was being given to matters of health and safety. Staff confirmed attendance on a number of courses including manual handling, first aid and food hygiene. A number of safety reports and certificates were examined. All were satisfactory apart from the safety certificate for the gas installation and supply that had expired the previous week. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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 X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stakesby Road (89) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X X X 3 1 X DS0000007841.V261179.R01.S.doc Version 5.0 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 YA42 Regulation 13(4) Requirement A current safety certificate for the gas installation and supply is required. Timescale for action 30/11/05 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. Refer to Standard YA23 Good Practice Recommendations The registered manager should obtain a copy of the revised multi-agency protocol on adult protection, discuss this with staff and implement its recommendations. Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Stakesby Road (89) DS0000007841.V261179.R01.S.doc Version 5.0 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. 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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