CARE HOME ADULTS 18-65
Station Road 3 & 5 Station Road Woodhouse Sheffield South Yorkshire S13 7QH Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 10th January 2006 09:30 Station Road DS0000003016.V275642.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 Station Road DS0000003016.V275642.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. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Station Road Address 3 & 5 Station Road Woodhouse Sheffield South Yorkshire S13 7QH 0114 269 4905 0114 269 3588 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) None New Era Housing Association Limited Mr Harold Bernard Ellis Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registration includes 4 places for residents with additional physical disabilities (PD). 25th May 2005 Date of last inspection Brief Description of the Service: Station Road consists of two purpose built bungalows on one site and is registered to provide a service for twelve people with a learning disability. Four of those service users may also have a physical disability. The home is situated in the village of Woodhouse, near to the shops and public transport. Each of the two bungalows provides accommodation for six service users, including a communal lounge, dining room and sufficient bathing facilities. All of the bedrooms are single. Separate laundry facilities are provided in each bungalow. The home has a large enclosed garden and parking spaces. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Jayne Barnett - Middleton carried out this unannounced inspection from 09.30 to 14:30 pm. Opportunity was taken to make a tour of the premises, inspect a sample of records and policies and talk to staff and tenants. The inspector had the opportunity to speak to most of the staff on duty. It was not possible to formally interview any of the residents, due to their high support needs but the inspector spoke to several residents informally. What the service does well: What has improved since the last inspection?
Person Centred Plans were being developed. These were very detailed and showed how the tenants wished to be supported and what their future aspirations were.
Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 6 The bathing facilities in one of the houses were not adequate, however work to provide a new bath and hoist was scheduled to commence within the very near future. The manager had addressed the issue of the staff team not working effectively as a team. Some staff said that staff moral within the home was improved, whilst others believed that more improvements could be made in this area. 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. Station Road DS0000003016.V275642.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 Station Road DS0000003016.V275642.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): 2. Needs assessments were available on the tenants files checked. They contained appropriate information about the tenants care needs, which ensured that the home were able to meet their needs. A previous requirement to provide extra staff support for service users with high support needs had not been met. EVIDENCE: A full needs assessment was carried out for tenants prior to their admission. This confirmed that the service was appropriate for the tenant, and provided staff with the information to formulate an individual plan of care. A previous requirement to provide extra staff support for service users with high support needs had not been met. The staff confirmed that extra staff support would enable them to support service users with high support needs to access the community on a more frequent basis. Station Road DS0000003016.V275642.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 and 9. Person Centred Plans were being developed. These were very detailed and showed how the tenants wished to be supported and what their future aspirations were. The care plans that were checked had not been reviewed on a regular basis. A previous requirement to reassess tenants with high support needs had not been met. Person Centred Plans were being developed and it was anticipated that this would provide the information required to determine the individual level of support that the tenants required. All tenants had risk assessments, which enabled them to take risks as part of an independent lifestyle. Those that were checked had not been reviewed on a regular basis. EVIDENCE: Person centred plans were being developed by the staff and tenants. One person centred plan was checked, which was detailed and clearly stated how the tenant wished to be supported in all aspects of their lives.
Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 10 One care plan was checked, which did not contain all of the information required by the regulations. The plans checked had not been reviewed regularly and therefore did not reflect the current needs of the tenant. A previous requirement to provide extra staff support for tenants with high support needs had not been met. The staff confirmed that extra staff support would enable them to support tenants with high support needs to access the community on a more frequent basis. An example of this was that one tenant required support on a weekly basis to attend a day centre. The staff reported that they could not always support him to attend this activity, as extra staff support was not always available due to the current staffing levels. Tenants files contained risk assessments relating to all aspects of tenants lives both inside and outside the home. They identified the individual risks that were presented to residents on a daily basis and the action required to reduce the risk, which enabled tenants to live an independent lifestyle. However, they had not been reviewed on a regular basis to promote the safety of tenants. Station Road DS0000003016.V275642.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): 12,13,14 and 17. Some of the tenant’s have regular opportunities to access age, peer and culturally appropriate activities; others with higher support needs had limited opportunities. Opportunities were provided for tenants to engage in activities within the home. The daily routines within the home were flexible and promoted independence, individual choice and freedom of movement. A choice of menu was offered and individual dietary needs were catered for. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 12 EVIDENCE: The majority of service users had opportunities to access appropriate activities. Care plans checked demonstrated that service users had access to activities including day centres, visits to the cinema and bowling. The staff confirmed that service users with high support needs had limited opportunities to access activities as they required 1:1 or in some cases 1:2 staff support and that the present staffing levels were not appropriate to enable equal opportunities for all service users. Staff reported that when sufficient staff and transport was available shopping trips and pub lunches were organised. Some activities were provided within the home, which included board games and karaoke. The staff commented that tenants had enjoyed a recent holiday to Butlins and that a holiday to Spain was planned for later in the year. Discussions with staff and observations demonstrated that the routines within the home were flexible. The tenants were encouraged to make simple choices about their daily living activities. Staff spoke in detail about their daily routines and confirmed that they were flexible to the needs of the tenants. Tenants were offered and encouraged to eat a healthy diet. Menus varied dependent on the tenants likes, dislikes and dietary requirements. The staff had a good knowledge of individual needs and was able to describe tenants individual preferences. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Tenants received personal support, which promoted their privacy, dignity and independence. Tenants physical and emotional needs were met. The person centred plans, that were being developed, contained detailed information about how the tenants personal support should be met by staff in order to meet their individual needs. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. The records checked did not clearly record medicines received into the home or disposed of. EVIDENCE: Person centred plans were being developed, which identified in detail how personal support should be offered to each individual. This included the times that they rose and retired and what level of support they required to wash and dress. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 14 Tenants received good support from healthcare professionals who visited them. There were no records in one care plan checked to evidence the healthcare visits that the tenant had received, the treatment administered and any follow up action that was required to promote the their health. All tenants seen appeared very well cared for, they were clean, hair and nails had been attended to and male residents were shaved. There was a medication policy and procedure to ensure that staff adhered to safe practices. Medication was checked on a sample basis. The medication administration records checked did not clearly record the amount of medication that had been received or disposed of, and it was difficult to track the specific amount that had been received or returned to the pharmacy. Clear records need to be maintained to ensure that there is no mishandling. The administration instruction on one medication administration record (MAR) checked did not clearly record the amount of medication that should be given, and this could result in the incorrect dose being administered. Medicines were securely stored and staff responsible for administering medication had received training to promote the safety of tenants. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The homes complaints procedure was clear and accessible, ensuring that any complaints made by tenants and their relatives would be listened to and action taken to deal with complaints promptly. There was an adult protection procedure, which promoted the protection of service users. Tenants financial interests were safeguarded by the procedures at the home. EVIDENCE: The complaints procedure ensured that tenants and their relatives were aware of how to make a complaint and who would deal with them. A record of complaints was maintained which demonstrated that no complaints had been made at the home since the last inspection. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. Staff had received Adult Protection training enabling them to identify and report any allegations or incidents of abuse to tenants. Arrangements were in place for tenants who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that tenants were able to access their monies for personal items as they wished. Systems were in place to protect service users from financial abuse and the senior staff and the manager carried out regular audits and checks. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The houses were generally well maintained, odour free, well decorated and homely. The patio and the gardens were well maintained. The tenant’s bedrooms were comfortable, individually personalised and furnished to meet their needs. The bathing facilities in one of the houses were not adequate, however work to provide a new bath and hoist was scheduled to commence within the very near future. EVIDENCE: An inspection of both of the houses was made. The houses were generally well maintained safe and comfortable. Some minor maintenance issues were noted; House 3: The seal that joined the floor covering in the bathroom was worn, causing the floor covering to lift, which presented a potential tripping hazard to staff and tenants. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 17 The corridor carpet was beginning to show signs of wear and tear and did spoil the overall appearance of the environment. This will need to be replaced within the near future. The wall in the main lounge, near the radiator, was in need of redecorating. It did appear that a smaller radiator had been fitted to replace the old one and some maintenance was required to match the old colour scheme with the current décor of the lounge. House 5: The seal that joined the floor covering in the dining room was worn, causing the floor covering to lift, which presented a potential tripping hazard to staff and tenants. The staff reported that quotes had been obtained for the bathroom and dining room floor coverings and it was anticipated that work would be undertaken to either repair or replace these within the near future. The tenant’s bedrooms were comfortable, individually personalised and furnished to meet their needs. All the bedrooms were very clean, spacious and were individually decorated to reflect their different tastes. The bathing facilities in one of the houses did not meet the tenants needs, however work to provide a new bath and hoist was scheduled to commence the following day. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 18 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): 32,34 and 35. Many of the staff employed have worked at the home for many years and therefore know the tenants well and can offer them a consistent service. Staff had received training to meet the tenant’s general and specific needs. A good range of training was available for staff. Appropriate support and guidance was offered to new staff, enabling them to safely care for service users. The home operated a recruitment policy that promoted the protection of service users. Staff files required some minor amendments to ensure that they included the required information. EVIDENCE: The Staff were friendly, approachable and relaxed to talk about the care that they provided. Positive and appropriate relationships were observed between staff and tenants. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Discussions with staff and records checked demonstrated that staff had received a good range of training that included Moving and Handling, First Aid and health and safety.
Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 19 A staff-training matrix and training plan had been devised which demonstrated the training that staff had attended. Individual training records checked did not demonstrate that staff had been offered the refresher training that they required, to ensure that they were conversant with changing legislation and safe working practices. Two staff members who had recently been employed at the home confirmed that they had received the appropriate induction and support to carry out their role in a safe manner. Both commented that the staff team and manager had been “supportive” during their initial days of employment. A recruitment policy and procedure was in place. Two files checked contained a range of information including two references, declaration of health and qualifications/training. Both files did not contain a recent photograph of the employee. One file did not contain a full employment history of the employee. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of tenants. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 20 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): 38 and 42. At the previous inspection the staff team appeared divided and the staff moral was low. The manager had addressed the issue of the staff team not working effectively as a team. Some staff said that staff moral within the home was improved, whilst others believed that more improvements could be made in this area. The health, safety and welfare of service users were on the whole promoted. Maintenance issues in relation to health and safety have been highlighted in other sections of this report. EVIDENCE: The manager has worked at the home for several years and has recently been appointed as manager. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 21 The staff reported that a full staff meeting had taken place to address the issues of staff moral and the opinion that there was a division between the two teams of staff. Two staff said that this had proved positive and that the opportunity to discuss individual concerns had resulted in some improvements in working relationships between the two teams. Two staff commented that there could be further improvements by being given the opportunity to work in both houses. They felt that this opportunity would give all staff the opportunity to understand the needs of the tenants and their daily routines. Overall the home was well maintained. Some minor maintenance issues were noted and these have been highlighted within the report. A fire extinguisher, located in the laundry at House 3, was placed behind the washing machine. This needs to be placed either on a wall bracket or located where is can be easily accessed in the event of a fire. The staff received training including Fire training, moving and handling and First Aid, which promoted safe working practices and the health, safety and welfare of the tenants and their colleagues. Please see staffing in relation to refresher training. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X X 3 X X X 2 X Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The service user plans must contain all of the required information. (Requirement first made 11/1/05) As appropriate service users must have their needs reassessed. (Requirement first made 25.5.05) Service user plans must be reviewed at least every six months. Risk assessments for service users must be reviewed on a regular basis. A review of the staffing levels must be made in order to ensure that service users needs are met, including their social living skills and access to the community. (Requirement first made 11/1/05) Records of healthcare visits, the treatment offered and any follow up action must be maintained. Records of medication received into the home and disposed of must be maintained. The administration of medicines must be accurately recorded. All areas of the home must be
DS0000003016.V275642.R01.S.doc Timescale for action 01/04/06 2. YA6 15 01/05/06 3. 4. 5. YA6 YA9 YA12YA13 15 15 12,16 01/05/06 01/04/06 01/05/06 6. 7. 8. 9. YA19 YA20 YA20 YA24 12 13 13 23 01/04/06 01/03/06 10/01/06 01/03/06
Page 24 Station Road Version 5.1 10. YA34 19 11. 12. YA35 YA42 18 23 kept in good repair. Maintenance issues identified in this report must be carried out. The staff recruitment files must contain all of the information required by the regulations.(Requirement first made 25.5.05.) All staff must be offered statutory training at the required frequencies. Fire equipment must be located where is can be easily accessed in the event of a fire. 01/04/06 01/05/06 10/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA24 YA37 Good Practice Recommendations The corridor carpet in House 5 should be replaced within the next six months. The manager must achieve NVQ level 4 in care and management. Station Road DS0000003016.V275642.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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