Inspection on 04/05/06 for Stonesby House

This inspection was carried out on 4th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 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 12/01/06

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 Keith Williamson Unannounced Inspection 4th May 2006 09:00 Stonesby House DS0000028065.V292306.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.V292306.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.V292306.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.V292306.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration. Date of last inspection 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 en-suite facilities. The home is “non-smoking” and has a large, open plan lounge/dining room. There are small garden areas to the front side and rear of the property that is predominantly paved. There is a park situated nearby. Currently the fees charged are £279 to £362. Stonesby House DS0000028065.V292306.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection took place over one day, commenced at 9.30 am and was completed in seven hours by one Inspector. An opportunity was taken to view the care plans and other records in detail. Three residents and three staff were spoken with on this visit. The manager, deputy and senior carers assisted with the Inspection, spending time with the discussing the management of the home. No resident, relative or staff questionnaires were returned prior to the Inspection; therefore only comments made on the day by residents have been entered in this report. What the service does well: What has improved since the last inspection? Of the twenty requirements made at the last inspection, three now remain to be actioned. The management team have worked hard too resolve the outstanding requirements and the effort is recognised by the Inspector. Improvement is noted in the areas of care planning and service users’ risk assessments for those relating to self-administration of medication, some guidance has been added stating under what circumstances some residents should be given ‘as required’ medication. The registered provider has produced an updated and amended staffing rota that meets the needs of service users. All the current staff group now have Criminal Records Bureau checks and written references. Staff training and supervision has improved with a training plan now in place, though staff appraisal has yet to be fully implemented within staff supervision framework. Staff now show an awareness of Complaints and Adult Protection Procedures. Stonesby House DS0000028065.V292306.R01.S.doc Version 5.1 Page 6 Protocols are in place to ensure that residents’ finances are dealt with appropriately, the staff on duty at the time demonstrating an excellent working knowledge of the process. 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. Stonesby House DS0000028065.V292306.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.V292306.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): 1, 2, 4 & 5. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The admission process is detailed and effective resulting in accurate information for prospective residents and staff. EVIDENCE: The Statement of Purpose accurately reflects the home’s registration status and states that a service is provided for 11 adults with needs arising from mental disorder. The qualifications and experience of staff are also accurately reflected in the document. Residents’ needs are assessed prior to moving into the home. The registered manager compiles information using the health and social service assessments, providing an information base from which care plans are produced. Introductory visits are arranged prior to residents taking up residence this was confirmed by residents and documented in individual daily records. All case tracked residents have a contract on file; these are yet to be completed detailing the specific bedroom allocated whilst in the home. Stonesby House DS0000028065.V292306.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. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. Residents are not looked after well in respect of their health, medication and personal care needs, areas of risk are not assessed appropriately, resulting in residents being placed at risk in the home. EVIDENCE: Three residents’ care plans were examined in detail. Staff reported these had been recently amended though the latest versions were not available to the inspector. Inspection of the current plans of care indicated these still required detail to be added to complete them. None of the care plans were dated or signed either by the service user or member of staff. Restrictions placed on residents were mentioned directly in the plans viewed. On being spoken with, residents showed an awareness of the restrictions placed on them. Decision making is recognised in the home, and dealt with on an individual basis with each resident, this is also recognised in the care plan. Stonesby House DS0000028065.V292306.R01.S.doc Version 5.1 Page 10 Protocols for staff assisting with residents’ monies are now in place. Care plans are reviewed on a regular basis. Risk assessments are included in some plans, however these are not fully encompassing of individual residents needs, and therefore place residents at some degree of danger. Stonesby House DS0000028065.V292306.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): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. Service users are supported in maintaining their relationships. EVIDENCE: Residents’ personal development is recognised in the individual care plans seen on the day with residents participating in self-care and practical life skills to varying degrees. The possibilities for residents to continue education are limited by what is offered within the community, though this is again recognised in the plans of care, as are community links and social inclusion. Residents did indicate visitors could visit the home, unrestricted by staff. Meals are varied and flexible, current and future residents have been made aware of the dietary restrictions with an explanation in the Statement of Purpose. Residents daily routines are flexible and varied, evidence of individual treatment is recognised in the daily records. Stonesby House DS0000028065.V292306.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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents’ health and personal care needs are met on an individual basis. EVIDENCE: Personal support is offered on a flexible basis, care plans reflect what abilities residents have, these are reviewed and updated. The monitoring of residents weights is not regularly undertaken, though visits from medical staff and General Practitioners is undertaken flexibly. A resident commented “ I can see the doctor when I want, either here or at the surgery”. Medication is administered appropriately, the staff when spoken with, showed a good awareness of administration techniques. Medication is stored securely, the medication administration records (mar charts) being up to date and signed appropriately. Residents spoken with on the day were not aware of the content of their care plan, though were aware of the restrictions mentioned in them. Stonesby House DS0000028065.V292306.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. Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to the service. Continued improvement is required in current practice to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: No complaints policy information was available for staff to view or refer to, though residents spoken with on the day were aware of a number of contacts other than staff in the home they could make any concerns to. Staff showed an awareness of the complaints procedure, and were aware of the whistleblowing and the Protection of Vulnerable Adults policy. The policy and procedure required at the last inspection have not yet been put in place, some information is available to staff in the form of a wall chart, but this does not have all the relevant information for staff to enable them to appropriately deal with Vulnerable Adult issues. The Department of Health guidance for Protection of Vulnerable Adults policy (pova) issues was not available for staffs’ guidance, this should be kept in the home for staffs’ reference. Stonesby House DS0000028065.V292306.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 & 30. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents live in a homely, comfortable and clean environment. EVIDENCE: The environment of the home continues to improve with all outstanding requirements being completed. Security cameras are in place, this is clearly to increase the security of the exterior of the home, and car parking area. The home has a dedicated domestic assistant in place, and when spoken with demonstrated a good awareness of Health and Safety issues. During the inspection the appropriate use of safety equipment was observed. Stonesby House DS0000028065.V292306.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): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Improved staffing levels, supervision and recruitment practices are positively affecting the safety of service users and the quality of support they receive. EVIDENCE: There have been a number of amendments to the staff rota system in the home, and greater coverage of staff is now provided until 10.00 pm. A number of new staff have commenced in the home recently. and training plan is in place, for these staff. An induction There has been an improvement in the employment practices within the home, with all new staff having the appropriate checks in place, prior to commencing employment in the home. Changes have also been made to the staff application form, enabling the management to appropriately follow up staff references. Staff supervision has commenced with staff being given an opportunity to influence the agenda, this is seen as a positive step in enabling staff communication with the management of the home. Stonesby House DS0000028065.V292306.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): Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. Further improvements to Quality Assurance and the availability of Policies and procedures, are required to safeguard service users’ interests. EVIDENCE: The manager is currently working toward the National Vocational Qualification level 4 award. Quality assurance is currently measured from verbal feedback from professionals visiting the home, and the questionnaires circulated by the Commission for Social Care Inspection. The registered provider must look at quality assurance in a more regulated way, issuing unidentifiable questionnaires in an effort to enable the comments to be made honestly. Stonesby House DS0000028065.V292306.R01.S.doc Version 5.1 Page 17 Safe working practices have improved in a number of areas reflected in this report. The availability of regularly reviewed Policies and Procedures would assist the staff in this process, and so further protect residents in the home. Stonesby House DS0000028065.V292306.R01.S.doc Version 5.1 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 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 3 X 3 X X 3 X Stonesby House DS0000028065.V292306.R01.S.doc Version 5.1 Page 19 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 registered person must ensure all residents care plans and risk assessments are kept under review. The original date of the 14th October 2005 was not met. Timescale for action 04/07/06 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 YA6 YA23 Good Practice Recommendations The registered provider should ensure that a written plan (care plan) is completed in respect of all residents needs including those of social care and diversity. The registered provider must ensure a policy detailing the appropriate response to challenging behaviour by care staff must be put in place and shared with staff. This must include details as to how more vulnerable residents are to be protected. (Previous timescales of 14/10/05 and 12/01/06 have not been met.) The registered provider must obtain a copy of the Department of Health’s Guidance concerning the Protection of Vulnerable Adults and ensure that it is available for staffs reference at all times. DS0000028065.V292306.R01.S.doc Version 5.1 Page 20 3. YA23 Stonesby House 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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