CARE HOME ADULTS 18-65
Stonesby House 147 Stonesby Avenue Leicester Leicestershire LE2 6TY Lead Inspector
Martin Hefferman Unannounced Inspection 26th November 2007 10:00 Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Stonesby House Address 147 Stonesby Avenue Leicester Leicestershire LE2 6TY 0116 2831638 0116 2831638 bevbudred@yahoo.co.uk 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 Vacant Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration. Date of last inspection 6th March 2007 Brief Description of the Service: Stonesby House is registered to provide care for up to eleven adults with mental health needs. 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 a regular bus service to Leicester & Wigston. There are two double and two single bedrooms upstairs with a further five single bedrooms downstairs. All bedrooms except one have full en-suite facilities. The home is non-smoking inside (individuals living in the home are able to smoke outside) and it has a large, open plan lounge / dining room. There are small garden areas to the front, side and rear of the property that are mostly paved. There is a park situated nearby. At the time of the inspection, fees ranged from £297 to £350 per week. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A visit to the home took place on 26th November 2007, lasting approximately five hours. The main method of inspection used on that day was ‘case tracking’ which involved selecting two people who live in the home and tracking the care they receive through review of their records, discussion with them & staff and observation of care practices. Four people who live in the home and a relative were spoken to during the course of the visit. The inspection also took account of all information received since the date of the last visit, including the findings from a random inspection in July 2007 (which looked at the home’s medication arrangements) and the owner’s self-assessment. What the service does well: What has improved since the last inspection?
Action has been taken to ensure that people who live in the home continue to receive up-to-date information about the services provided. Copies of the home’s statement of terms & conditions have been updated since the date of the last inspection to reflect the actual fees charged. The person in charge has started to undertake weekly audits of the medication arrangements within the home in response to the findings of a random inspection in July 2007.
Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. People benefit from having their needs assessed before coming to live in the home. Action has been taken to ensure that they continue to receive up-to-date information about the services provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No one has moved to the home since the date of the last inspection. Copies of Care Programme Approach assessments and care plans were available for both of the people who were chosen for the purposes of case tracking. Staff from the home had also completed their own assessments of each person’s needs. Records indicate that prospective residents have visited the home before they decided to move in. Copies of the home’s statement of terms & conditions have been updated since the date of the last inspection to reflect the actual fees charged. Both of the statements that were inspected had been signed by the person living in the home. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. A person’s assessed and changing needs are reflected in their individual plan. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual plans were available for the people who were chosen for the purposes of case tracking. The plans that were inspected had been kept under review. The person in charge at the time of the visit stated that an interpreter had been employed to assist one of the people whose records were inspected with the preparation of a person centred plan. The plan set out the person’s likes & dislikes, details of his friends & family and his goals for the future. The person in charge reported that she hopes to complete person centred plans with other people living in the home. The people who were spoken to stated that they could decide how to spend their day. It was evident that they are able to make full use of communal areas and their bedrooms. It was noted that a number of people used the home’s kitchen facilities to make themselves a hot drink. Risk assessments were available for the people whose records were inspected. These set out the actions to be taken to minimise any risks that have been identified.
Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. People who live in the home benefit from being able to live the lifestyle they choose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who were chosen for the purposes of case tracking did not attend formal daytime activities. Records indicate that staff members have encouraged one person to go into town shopping and to participate in sport but that she has declined. The second person regularly arranges a taxi to take him into the city centre. The person in charge stated that staff members were in the process of identifying an appropriate community centre for him to attend if he wished. The people who live in the home are in contact with their families and friends, wherever possible. A relative stated that she visits every week and that she is made to feel welcome. Residents stated that they enjoyed the meal that was provided on the day of the visit. They were given a choice of beef casserole or omelette & salad. It
Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 11 was noted that the casserole was served with potatoes but no vegetables. The person in charge stated that meals were normally served with vegetables. The people who were spoken to confirmed this. They stated that they could choose what they liked for tea. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. People who live in the home benefit from good personal and healthcare support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who were spoken to stated that they are happy with the support they receive from staff members. The individual plans that were inspected detailed any personal care each person requires. The plans also set out details of any healthcare needs that have been identified and of any action that is felt to be necessary as a result. Records of appointments attended by people who live in the home indicate that they have access to appropriate healthcare professionals. A person who was chosen for the purposes of case tracking manages one of his medications. An assessment of his ability to do this safely had been completed but was dated July 2006. The person in charge stated that she would ensure this was reviewed. Records of the medicines received into the home, administered to the people living there and returned for disposal met relevant requirements. The person in charge stated that she had started weekly audits of medication arrangements in response to the findings of a random inspection in July 2007. Staff members have received medication training.
Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. People who live in the home are generally well protected by the home’s arrangements for dealing with complaints and safeguarding adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who were spoken to stated that they would talk to the person in charge if they had any concerns. They have been given an accessible version of the home’s complaints procedure. The person in charge stated that she would amend the procedure to reflect revised guidance from the Commission. Information received following the visit indicated that the home had received one complaint since the date of the last inspection, which was unsubstantiated. The home has policies and procedures on the protection of vulnerable adults and whistle blowing. Staff members have received training on the action to be taken in the event of an allegation or suspicion of abuse. Records are kept of any money held on half of people living in the home. The person in charge was reminded that two members of staff should sign all entries. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. People who live in the home benefit from a generally suitable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who were spoken to indicated that they were happy with the environment in which they live. The areas of the home that were inspected were generally decorated and furnished to a satisfactory standard. They were clean and tidy. It was noted that the carpet on the stairs and landing – which was identified at the time of the last inspection as looking worn - has yet to be replaced. In addition, the drawers inside an upright freezer had been damaged. A health and safety committee undertakes a weekly walk through the home to identify any issues that require attention. The person in charge at the time of the visit stated that residents had been invited to join the committee but had declined. A housekeeper has been recruited since the date of the last inspection. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. People who live in the home benefit from safe recruitment practices and good training of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The person in charge stated that night time staffing levels have been increased since the date of the last inspection to one waking staff member and one senior member of staff sleeping in. It was noted that the rota for the week in which the visit took place did not reflect this level of staffing. The records relating to two members of staff who have been employed since the date of the last inspection indicated that appropriate pre-employment checks had been carried out. New members of care staff complete induction training to the standards set by Skills for Care. The person in charge stated that two of the ten members of staff have completed National Vocational Qualification level 4, three NVQ level 3 and three level 2. Records indicate that staff members have received training on issues such as challenging behaviour, mental health and person centred planning. They were in the process of completing equalities & diversity training at the time of the visit. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. People who live in the home benefit from good management although they remain vulnerable as the owner has yet to apply for the registration of a permanent manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last registered manager left the home in December 2006. The acting manager was not present at the time of this visit. The rota for the week in which the visit took place and subsequent weeks indicated that she was working limited hours at the time. The Commission has yet to receive an application for the registration of a manager. The owner has completed Regulation 26 reports (visits by the registered provider) since the date of the last inspection. People who live in the home complete a survey of their views every six months. The person in charge stated that whilst individuals have received feedback the results have not been Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 17 made available to all interested parties. The person in charge has also introduced regular audits on a range of issues. Staff members have received training on issues such as first aid, fire safety, food hygiene, health & safety, infection control and moving & handling. Records indicate that fire tests & drills have taken place at the required frequency. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 18 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 3 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 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA37 Regulation 8 Requirement The registered provider must submit an application for the registration of a manager. Timescale for action 31/01/08 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 YA24 YA33 YA39 Good Practice Recommendations Environmental issues identified at the time of the visit should be addressed. The staff rota should reflect the actual shifts worked by each person. The results of any surveys should be made available to the people who live in the home and other interested parties. Stonesby House DS0000028065.V355011.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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