CARE HOME ADULTS 18-65
Station Road 3 & 5 Station Road Woodhouse Sheffield S13 7QH Lead Inspector
Shelagh Murphy Unannounced 25 May 2005 10:25 am 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. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Station Road Address 3 & 5 Station Road Woodhouse Sheffield S13 7QH 0114 2694905 0114 2693588 Not known New Era Housing Association Limited 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) Mr Harold Bernard Ellis PC Care Home Only 12 Category(ies) of LD Learning disability - 12 registration, with number of places Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: The registration includes 4 places for residents with additional physical disabilities (PD). Date of last inspection 11 January 2005 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 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 J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Shelagh Murphy carried out this unannounced inspection from 10:25 to 14:40 pm. Julia Sewpaul, deputy manager, from New Era was present during the inspection. The registered manager was on annual leave. Opportunity was taken to make a tour of the premises, inspect a sample of records and policies and talk to staff and residents. The inspectors had the opportunity to speak to 4 staff on duty. It was not possible to formally interview any of the tenants at the time due to their high support needs but the inspector spoke to several tenants informally. What the service does well: What has improved since the last inspection?
Three service users had had Person Centred Plans devised since the last inspection. These were very detailed and reflected the tenants needs and aspirations. The plans had been devised in conjunction with the tenants, their relatives, friends and staff. Some of the tenants had had their bedrooms re-decorated; they had been involved in choosing the colours and furnishings etc. A representative from a local advocacy service had visited the home to explain their role and to make contact with the tenants and their key-workers.
Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 6 The central heating system has been replaced. Training in adult protection and the administration of medication, had been organised for the staff to complete over the next few months. What they could do better:
Staff morale was low. Staff who spoke to the inspector appeared de-motivated and lacked enthusiasm. This had not been the inspector’s experience of these staff during previous inspections. The staff that worked in the two houses were not working as a team. There was resentment within both staff groups about working within the other team. The staff felt that this was caused by the way the two houses were managed differently. There was also an issue about the staffing levels in the two houses. The inspector was concerned that the low staff morale will have a negative effect on the tenants who will pick up the resentment from staff towards each other. The staff reported that the registered manager and the deputy manager had had to re-apply for a manager’s job; they said this had also unsettled the team and caused resentment. All of the staff team who spoke to the inspector complained that they did not have adequate numbers of staff to support some of the tenants appropriately as their needs had gradually changed as they had become older and more dependent. The inspector checked records spoke to staff and observed that three tenants did not have any planned meaningful activities during the day. The staff and the deputy manager advised that these tenants all had high support needs and required either 1-1 or 1-2 staff support and or a specialist day service provision. The medication administration sheets from the pharmacist needed to have clearer instructions about administration. The staff needed to complete the sheets using the key printed on the sheets. Staff recruitment procedures may need to be reviewed as the staff reported that because the procedure is so long and laborious two newly recruited staff had failed to take up their posts and this had meant they had been without replacement staff for an unacceptable amount off time. Some of the risk assessments checked identified risks but did not contain details of actions to be taken to minimise risks. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 7 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 J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 8 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 Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 9 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 tenants who had recently moved in to the home had, had their needs assessed, this ensured the home were able to meet their care needs. The staff said some of the tenants needs had increased as they had aged. They had developed mobility problems and they were increasingly more dependent on the staff to enable them to take part in activities and outings. As a result some of the tenants support needs were not always met. EVIDENCE: Copies of needs assessments, for the tenants who had just moved in to the home were contained in tenants care plans. The information from the full needs assessment had been incorporated into the resident care plans. Several tenants did not have needs assessments on their care files as they had lived at the home for over ten years. These tenants had high support needs, which had increased since they moved in to the home and this meant the staff were not able to meet all of their present needs. The tenants need to have their needs reassessed to ensure they are receiving appropriate levels of support to meet their needs. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 10 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, 7 and 9. Three tenants had had Person Centred Plans, which had been developed by tenants, relatives, friends and staff. They were excellent, very detailed and showed how the tenants wished to be supported and what their future aspirations were. The tenants who had recently moved in to the home had care plans, these reflected there assessed needs and actions to be taken by staff to ensure these needs were met. Some of the tenants with high support needs, who had lived at the home for numerous years, had care plans, which did not reflect the fact that their needs had changed. These tenants need to have their needs reassessed to ensure they receive adequate staff support. It was clear that some service users were encouraged to make decisions about their lifestyles with assistance from staff, as some service users had very detailed plans. Some of the other tenants did not have the same opportunities, as they needed greater levels of staff support to assist them, which were not available. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 11 All of the tenants had had risk assessments devised, which enabled them to take risks as part of an independent lifestyle. Not all of the risk assessments had details of how to reduce the risks involved and this could place service users and staff at risk. EVIDENCE: One Person Centred Plan was checked and was detailed and clearly stated how the tenant wished to be supported in all aspects of their lives. Two care plans were checked in detail one was far more detailed than the other but neither contained all of the information required by the regulations. One of the tenants with high support needs had a care plan, which had not been reviewed since 20.5.04, another tenants plan did not contain details of any meaningful planned activities and therefore the tenant’s needs in this area were not being met. The staff reported that this was because they needed extra staff support and this was not always available due to the current staffing levels. There was evidence in the care plans that some tenants had been supported to make decisions about their lifestyles and were supported to manage these. It was reported by staff, that other tenants who had high support needs did not have these same opportunities. An example of this was that one tenant needed 2:1 staff support to access the community and this level of staff support could not be guaranteed, therefore they could not plan regular activities with the tenant. Three risk assessments were checked and two did not contain details of how the staff were to minimise the risks to tenants and staff. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 12 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, 13, and 17. Some of the tenants were supported to take part in appropriate activities and attended day services and training courses. These tenants also took part in community and leisure activities. There were three tenants in the home who did not have any planned activities during the day and their opportunities to access community and leisure activities were very limited because they had high support needs and the staff reported that they did not have adequate numbers of staff to support them to access these. These tenants’ needs were not being met in this area. The tenants said they enjoyed the food at the home and that choices were available. EVIDENCE: In the care plans it was recorded that some tenants had weekly day services, attended training courses and had planned leisure activities. Other care plans had very little if any details of how the tenant’s needs in these areas were met and it was clear that their needs in this area were not being met.
Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 13 Three tenants were observed to wander about the home with very little staff input and when asked what was planned for them, the staff said they had no specific activities arranged for these tenants as their support needs meant they needed 1-1/1-2 staff support to access the services. These tenants had not had their needs reassessed for many years. The deputy manager reported that some of the tenants had recently had their needs reviewed by social services social workers but the outcomes to these had not yet been received. There was sufficient supply of fresh food at the home and staff reported that there was always an adequate supply of food available. The tenants told the inspector that they enjoyed the meals at the home. The staff reported that meals were served to the tenants and they were offered a choice. The tenants likes and dislikes, regarding food were recorded on the care plans checked. The staff prepared meals and the individual tenants choices were recorded on menus each day. Staff reported that they shopped for the food at local shops/supermarkets and that some tenants were involved in this. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20. The medication procedure and administration within the home was generally adequate but more details needed to be recorded on the drug sheets to ensure the staff had clear instructions about how and when to administer medication as the lack of clear details for staff could place tenants at risk. A training course on the administration of medication had been planned for the staff team to complete over the next six months. EVIDENCE: The medication procedure was checked with the medication sheets, the following issues were found: - Several sheets did not record that a medication was for occasional (PRN) use only, and therefore was being used daily and the staff were not always using the codes which explained the reason for missed medication doses and this looked as though the tenants had not been given medication. Training records showed and three staff confirmed they had been booked on to a medication-training course within the next four weeks. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 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 standard(s) 22 and 23. There is a complaints procedure, which meets the regulations in place at the home. The staff reported that they believed tenants complaints would be listened to and acted upon by the registered manager. There were systems in place to protect tenants from abuse and procedures to follow if allegations of abuse were made. EVIDENCE: There is a complaints procedure at the home and it is available in different formats to enable easier access for the tenants to make complaints. It contained all of the details required by the regulations. The deputy manager reported that the tenants had made no complaints over the last six months. One complaint had been made by a neighbour and was now resolved. An appropriate adult protection policy and procedure was available in the home, the staff knowledge of the actions to take should allegations of abuse be made was very good. Not all of the staff had completed adult protection training but plans to complete this were in place. Some risk assessments had been devised to protect tenants from abuse and staff felt these were adequate to minimise the risks to the tenants. Systems were in place to protect service users from financial abuse and included independent audits and regular checks by senior staff and managers. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 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 standard(s) 24, 25, 29 and 30 The houses were well maintained, safe, clean, free from odours, well decorated and comfortable. The bedrooms were all individually decorated and furnished these surroundings met the tenant’s needs. The bathing facilities in one of the houses were not adequate to meet the tenant’s needs and needed to be replaced. EVIDENCE: An inspection of both of the houses was made with staff that worked at the home. The houses were well-decorated, clean, safe and well maintained. The staff reported that the tenants found their homes comfortable. All of the tenant’s bedrooms were checked and contained furnishing and fixtures appropriate to meet their individual needs. The bedrooms were all decorated individually and this reflected their different tastes, some tenants had specialist beds and chairs to meet their individual needs.
Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 17 The bathing facilities in one house did not meet the tenant’s needs and was not being used by staff. A quote had been made to replace the bath and another specialist bath will need to be purchased to ensure the tenants are bathed in a safe manner. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. The future management of the home is unclear, as the registered manager has been asked to reapply for his post at the home. This has caused uncertainty for the tenants, managers and staff. The home has a stable staff team, most of who have completed recognised care awards and receive regular training. Many of the staff have worked at the home for years and therefore know the tenants really well and can offer them a consistent service. The staff team were divided and there was low morale, which will have an adverse effect on the tenants if the two teams of staff do not work cooperatively together. There were staff recruitment policy and procedure in place to protect the tenants. Staff are supervised by their line managers to ensure they are accountable for their roles. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 19 EVIDENCE: The managers of the home were in the process of re-applying for the post as manager of the home and this had also created uncertainty about the future management within the home. Training record were checked and showed that over 5O of the staff team had completed the NVQ2 care awards. Most staff had completed the mandatory training required and they reported they felt equipped to work safely with the tenants. Training in adult protection and the administration of medication had been planned for later in the year. The staff were not working as a team. The staff that worked in the two houses were being managed differently and as a result staff reported low morale. The staff also reported they were short staffed at times and all of this was creating resentment and division between the two teams of staff. This atmosphere will have an adverse effect on the tenants if it is not addressed as a priority. The staff recruitment procedures were generally robust, two recruitment files were checked and contained most of the information required, one file needed to include a photograph of the staff member and one needed evidence that the staff had two form of I.D recorded on them. Both had up to date CRB details. The staff reported they received regular supervision from their line managers. Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 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 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) None of these standards were checked. Not applicable as the standards were not checked during this inspection. EVIDENCE: Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 2 x 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 x x x 2 3 Standard No 11 12 13 14 15 16 17 x 2 2 x x x 3 Standard No 31 32 33 34 35 36 Score 3 3 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Station Road Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 22 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. 2. 3. Standard YA6 YA6 YA7 YA9 Regulation 15 15 15 Requirement Service user plans must be completed in full. (Requirement first made11/1/05). As appropriate service users must have their needs reassessed. Risk assessments must be completed for all service users and placed on their plans of care.(Requirement first made 11/1/05). Sufficient staff must be employed to ensure that service users needs are met, including their social and independent living skills.(Requirement first made 11/1/05). A review of the staffing levels must be made in order to ensure service users can access the community to meet their needs. Then appropriate action must be taken to ensure service users needs are met.(Requirement first made 11/1/05). All administration of medicines must be correctly recorded. (Requirement first made11/1/05).. Laundry floor covering must be
J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Timescale for action 30.9.05 31.12.05 30.9.05 4. YA12 12,18 30.9.05 5. YA12 YA13 12, 16 30.9.05 6. YA20 13 7. YA30 23 Immediate on the day of the inspection 25.5.05. 30.9.05
Page 23 Station Road Version 1.30 8. YA29 23 9. YA33 12 10. YA34 12 repaired/replaced. (Requirement first made11/1/05).. The use of the bath in House 3 must be reviewed to ensure it meets the service users needs. Then appropriate action must be taken to ensure service users needs are met. (Requirement first made11/1/05). Action must be taken to address the concerns raised by staff about the division between the two teams of staff. Staff recruitment files must contain all of the information required by theb regulations 30.9.05 31.10.05 31.10.05 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 YA37 Good Practice Recommendations The manager must achieve NVQ level 4 in care and management by 2005 Station Road J55 S3016 Station Road V218820 25.05.05 UI Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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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