Inspection on 12/01/06 for Stonesby House

This inspection was carried out on 12th January 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stonesby House 30/10/08

Stonesby House 26/11/07

Stonesby House 06/03/07

Stonesby House 04/05/06

Stonesby House 30/11/05

Stonesby House 08/07/05

Stonesby House 04/11/04

Stonesby House 23/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Stonesby House 147 Stonesby Avenue Leicester Leicestershire LE2 6TY Lead Inspector Ruth Wood Unannounced Inspection 12th January 2006 09:30 Stonesby House DS0000028065.V276905.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 Stonesby House DS0000028065.V276905.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. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stonesby House Address 147 Stonesby Avenue Leicester Leicestershire LE2 6TY 0116 2831638 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) Mr Osman Amar Saghir Mrs Sylvia Ann Martin Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration. Date of last inspection 30th November 2005 Brief Description of the Service: Stonesby House provides a service for eleven adults with mental health needs under the age of 65. The home, an extended semi- detached house, is situated on the main Stonesby Road close to shops and other amenities. There is a bus stop near to the home and regular bus service to Leicester and Wigston. There are two double and two single bedrooms upstairs with a further five single bedrooms downstairs. All except one bedroom have full ensuite facilities. The home has a large, open plan lounge/dining room and an additional room, recently added to the building in which service users can smoke. This room is conservatory style with minimal furniture. There are small garden areas to the front side and rear of the property that are predominantly paved. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place on a weekday morning between 9:45am and 1:15pm. Some standards not previously inspected were assessed, together with progress in meeting outstanding Requirements (the deadline for some Requirements had not been reached). The Inspection focussed on discussion with the Registered and Deputy Managers, examination of records and a brief tour of certain areas of the building. Service users’ activity was observed in communal areas but the Inspector did not enter into lengthy discussion with any service users on this occasion. Of the twenty-seven Requirements made at the previous Inspection, nine have been met and sixteen are still outstanding. Two Requirements relating to restrictions on what service users can eat and where have been removed as discussions with social services commissioners confirmed that information about these conditions had been present in the Statement of Purpose when service users were placed in the home. Four new Requirements were made at this Inspection. What the service does well: What has improved since the last inspection? What they could do better: Some improvement is still needed in care planning and service users’ risk assessments including those relating to self-administration of medication. Documentation is still required stating under what circumstances some service users should be given ‘as required’ medication. The Registered Provider is still to produce an adequate staffing assessment to ensure that staffing levels meet the needs of service users. Likewise clarification of service users’ terms and conditions is still needed. Further work is also needed to ensure that service Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 6 users have opportunities to access education, leisure and occupational activities. Five of the ten staff still require Criminal Records Bureau checks and some staff also require written references. Staff training and supervision also need improving. The Provider and Manager must improve their awareness of Adult Protection Procedures and ensure that the relevant policies for the home are written and implemented. 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. Stonesby House DS0000028065.V276905.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 Stonesby House DS0000028065.V276905.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): 5 Significant improvements are still needed in the quality of information about the home available to service users. EVIDENCE: A document outlining, in an accessible format, what actions by a service user may put their placement at risk has still not been produced. The document must also clarify the use of verbal and written warnings, which from examination of care records, appear to have been issued to service users in the past. Stonesby House DS0000028065.V276905.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): 6,7,9 Improvements are being made in care management and risk assessment but more improvement is needed to ensure service users’ needs are met. EVIDENCE: The Registered and Deputy Manager stated that they had been working to improve care plans so that they were an accurate reflection of the care people needed and received. One plan was examined in detail and showed some improvement in key areas. Some areas of risk were identified and the ways of managing the risk detailed; this process needs completing. A system of review is in the process of being implemented for all care plans and review forms had been produced. Restrictions on the service user’s choices were clearly documented and they were signed and dated by the service user. It was agreed that such restrictions should also be included in the system of review. The care plan examined was not signed or dated by the service user or assessor. The process of updating all care plans was still in progress and a more comprehensive assessment will be undertaken at the next Inspection. CSCI have still not received copies of protocols stating which staff members can access money from service users’ accounts. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 10 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): 17 There has been some improvement in the diet offered to service users but more nutritional balance is needed. EVIDENCE: Discussion was held with the Registered and Deputy Manager about the progress made in meeting the Requirements made at the previous Inspection. Those relating to education, leisure and social opportunities for service users will be fully assessed at the next inspection. Menu records and diet monitoring sheets were examined. These suggested that there had been some improvement in the nutritional quality of the meals served but there was still an apparent lack of fruit and vegetables in the majority of service users’ diets. There had been improvement in the way certain service users’ diets were monitored, particularly those with specific dietary needs. Statements still appear on service users’ plans placing restrictions on certain foods. These restrictions were discussed with commissioners of the service at the Vulnerable Adults Strategy Meeting held on 24/01/06. It was agreed that as the information about these restrictions had appeared in the home’s Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 11 Statement of Purpose at the time when service users were placed in the home, further Requirements relating to the restrictions would not be made. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 12 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): 18,19,20 Health and personal care needs are generally well met; improvement is still needed in the documentation relating to service users’ medication. EVIDENCE: Risk assessments relating to medication administered by service users have been improved following guidance given at the previous Inspection but they still contain inappropriate information. There was still no documented information as to under what circumstances certain service users should be given ‘as required’ medication. The importance of this was discussed at length with the Registered Manager, to ensure consistency of approach by all staff members. Continence advice for the two service users identified at the previous Inspection has been sought and general healthcare needs were discussed. There was documentary evidence in place to suggest that service users have access to regular GP, chiropody, optical and dental services and the majority of service users receive input from a consultant psychiatrist. Service users’ needs for personal support are documented in their care plans and service users’ appearance suggested they were being appropriately supported. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 13 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): 22,23 Although there is a good Complaints Procedure in place policies and practices within the home do not protect service users. EVIDENCE: The home’s Complaints Procedure is clearly displayed and is easy to understand detailing the steps service users should follow if they are unhappy with any aspect of the service they receive. It also contains full details of the CSCI and how to contact an independent advocacy service if further support is required. This is good practice. A policy detailing the appropriate staff response to challenging behaviour by service users has still not been written or implemented (it is noted however that the new deadline given at the previous Inspection was 31/01/06). The Inspector discussed the importance of this policy given that an incident of challenging behaviour had led to the initial complaint made in June of last year. The policy on whistle blowing requires some minor modifications; staff also need to be made aware of this policy. The Registered Provider and Manager must also obtain copies of the Multi-Agency policy relating to the Protection of Vulnerable Adults from Abuse together with the Guidance issued by the Department of Health and ensure that they are aware of and follow the guidance contained in both documents. The home’s recruitment practices are still placing service users at risk. (See Standard 34) Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 14 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 Environmental standards in the home continue to improve. EVIDENCE: Several outstanding environmental Requirements/Recommendations have been completed or are in the process of completion. The service user’s door has been repaired and another service user’s bedroom has been redecorated although not in her own choice of colour. New flooring is being laid in one service user’s bathroom and in the upstairs communal bathroom. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 15 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): 33,34,35,36 Inadequate staffing levels and recruitment practices together with poor supervision compromise the safety of service users and the quality of support they receive. EVIDENCE: The current week’s staffing rota was examined. This still shows periods between 8pm and 10pm when only one staff member is on duty. Mr Saghir (the Registered Provider) is still to provide an appropriate staffing assessment based on the service users’ level of need. The Residential staffing tool for Younger Adults was discussed with the Registered Manager. There are currently 10 staff members working in the home; of these 5 do not have Criminal Records Bureau checks, although these have now been applied for. Not all staff have two written references on record; one staff member had no written references. The home’s Reference Pro-Forma has no space for the address and telephone number of the referee so it is difficult to trace the source of the reference. The Registered Manager described how the Reference Pro-forma had been given to one candidate to pass to her own referee. The Manager acknowledged that it was entirely possible that the candidate themselves could have completed this form. All staff now have a formal training record. It was noted that one staff member who had started employment in August last year has not yet received any training. There is no evidence of a system of staff supervision within the home. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 16 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): 40, 41,42 Significant improvement has been made in health and safety policy and practice. EVIDENCE: Some of the home’s policies still refer to the National Minimum Standards for Older People rather than those for Younger Adults. A basic information sheet is now in place for all service users. Assistance has been obtained from the health and safety inspector and a full Control of Substances Hazardous to Health (COSH) assessment is in place together with risk assessments relating to safe working practices. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 17 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 X 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X X 2 3 3 X Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 18 Yes 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 YA5 Regulation 5 Requirement Timescale for action 31/01/06 2. YA6 15 The reasons why service users would be issued with verbal and/or written warnings must be clearly documented within the service users terms and conditions. Service users and/or their representatives must be made aware of these conditions. Who has the authority to issue such warnings should also be clearly documented. (Previous timescales of 12/08/05, 07/10/05 and 31/12/05 not met) The Registered Manager must 31/01/06 ensure that each service user has an up to date care plan, which accurately reflects their current needs and how these needs are to be met. This care plan must be signed by the assessor, the service user and be dated. (Previous timescales of 19/08/05 and 14/10/05 not met) Clear protocols must be in place stating which staff members can access money from service users’ accounts, that service DS0000028065.V276905.R01.S.doc 3 YA7 17 31/01/06 Stonesby House Version 5.1 Page 19 4. YA9 13 5 YA12 16 6 YA14 16 7. YA17 16 8. YA20 13 9 YA20 13 users have given permission for this and the placing authority has given their agreement to this practice. Copies of these protocols must be forwarded to CSCI. (Previous timescales of 05/09/05, 04/10/05, 12/10/05 & 13/12/05 not met.) Risk assessments must be put in place to ensure that service users are supported to take responsible risks without placing themselves in unnecessary danger. (Previous timescales of 19/08/05 & 31/12/05 not fully met.) The Registered Manager must identify opportunities for service users to participate in appropriate activities or education. The Registered Manager must identify opportunities for service users to engage in appropriate leisure activities based on their own interests and abilities. The Registered Provider must ensure that a varied and nutritious diet is available for all service users, which reflects their health, cultural and religious requirements. (Previous timescale of 31/12/05 not fully met) Individual risk assessments must be completed for those service users administering some of their own medication. These must be regularly monitored and reviewed. (Previous timescales of 12/08/05 and 30/09/05 and 31/12/05 not fully met) The reasons why a service user may be given ‘as required’ medication must be clearly detailed in their care plan. DS0000028065.V276905.R01.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 Stonesby House Version 5.1 Page 20 10. YA23 13 11. YA23 13 12. YA23 13 13 YA23 13 14 YA24 23 15. YA33 18 16. YA34 19 (Previous timescale of 31/12/05 not met) A policy detailing the appropriate response to challenging behaviour by care staff must be written. This must include details as to how more vulnerable residents are to be protected. (Previous timescales of 26/08/05 14/10/05 not met.) A policy on whistle blowing must be written and implemented within the home. (Previous timescales of 26/08/05 and 14/10/05 not met.) The Registered Person must ensure that staff are aware of the Multi- Agency policy relating to the Protection of Vulnerable Adults from Abuse. (Previous timescales of 26/08/05 and 14/10/05 not met.) The Registered Provider and Manager must obtain a copy of the Department of Health’s Guidance concerning the Protection of Vulnerable Adults and ensure that it is followed. Broken floor tiles in the upstairs bathroom must be repaired or replaced. (Previous timescales of 26/08/05 and 07/10/05 not met) The Registered Person must ensure that there is sufficient staff on duty at all times to meet the needs of residents. (Previous timescales of 08/07/05 and 20/09/05 and 30/11/05 not met) The Registered Person must obtain Criminal Record Bureau checks for all staff working at the home. (Previous timescales of 05/09/05, 14/10/05 and 31/12/05 not met) 31/01/06 31/01/06 31/01/06 03/02/06 31/01/06 12/01/06 31/01/06 Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 21 17 YA34 19 18 19 20. YA35 YA36 YA40 18 18 17 Two written references must be obtained for all staff members before they commence employment. All staff must receive appropriate training to enable them to meet the needs of service users. A formal system of staff supervision must be implemented within the home. The Registered Person must ensure that the homes policies and procedures are appropriate to the category of service users living there. (Previous timescale of 31/12/05 not met) 12/01/06 12/01/06 28/02/06 31/01/06 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. 3 Refer to Standard YA6 YA9 YA34 Good Practice Recommendations It is strongly recommended that key staff receive appropriate training in care planning. It is strongly recommended that key staff receive training in risk assessment. It is strongly recommended that the Reference Pro-forma used be modified to include contact details of the referee. Stonesby House DS0000028065.V276905.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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