Inspection on 29/09/05 for Trafalgar Street

This inspection was carried out on 29th September 2005.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trafalgar Street 18/05/09

Trafalgar Street 22/05/07

Trafalgar Street 03/03/06

Trafalgar Street 01/02/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Trafalgar Street 2 Trafalgar Street Carcroft Doncaster South Yorkshire Lead Inspector Janet McBride Unannounced Inspection 29th September 2005 12:40 Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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 Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Trafalgar Street Address 2 Trafalgar Street Carcroft Doncaster South Yorkshire 01757 270430 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 Donald Smith Miss Gillian Stacey Prior Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2005 Brief Description of the Service: Trafalgar Street is a care home providing personal care and accommodation for adults with Autistic Spectrum Disorders. The home is registered for 4 places and has been open since July 2004. Accommodation is provided in a four bed roomed house, and all single bedrooms, which are located on the first floor, two of these have ensuite facilities. Service users have access to the garden at the rear of the home. The home is located in the village of Carcroft close to shops, pubs and other community facilities and the village is only 5 miles from Doncaster Town centre. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A statutory unannounced Inspection was completed on the 29th September 2005,starting at 12:40 and finished at 16:50 hours. During the Inspection we looked at a chosen selection of the National Minimum Standards, sampling of records, document reading and tour of the premises. Discussion with management, interviews with staff members and discussion with all residents at the home at the time of the Inspection. A number of comment cards were left at the home for relatives, residents and visitors to complete, some of which were received back and their comments included in the report. What the service does well: What has improved since the last inspection? The manager and her staff continue to work hard at ensuring all the Residents are happy within the home. Arrangements have been made for the manager to hold a budget to purchase equipment and usually renewal required by the home. The Commission for Social Care Inspection has also received of Regulation 26 visit reports completed by the Registered Provider. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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 Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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): None of these standards were assessed at this Inspection. EVIDENCE: Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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): None of these standards were assessed at this Inspection. EVIDENCE: Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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): 12 13 14 15 16 The manager and her staff tries to run the home in the best interest of the residents, staff support residents to become part of and participate in the local community and engage in fulfilling activities. EVIDENCE: Residents have opportunities to develop either by attending college, day care and take part in appropriate activities. Staff spoken to explain that daily routines promote independence, choice and freedom for all residents, and as they progress and re-assessments take place they aim each individual achieve their potential, but working at their own speed. Only three residents within the home and all spoke to the inspector, one resident stated that he’s moved from another home he’s had more chances to take part in more activities. Another informed me that he attends college two days a week and has recently started voluntary work one day a week, which he enjoys and took great delight in speaking about what he does. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 11 Residents spoke about the sort of activities they take part in for example; swimming every week, visit social events to meet other people which help them develop their social skills. They also go shopping, cinema, out for meals and two of the residents talked about their recent holiday in Blackpool when they went for five days. None of these standards were assessed at this Inspection. All residents are risk assessed with regard to the different events and venues they visit. All resident maintain links with families and friends, by phone and some go on regular weekend leave; all parents and families are involved with reviews. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 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 The manager and her staff ensure that resident’s healthcare needs are met, and they are supported in receiving personal care in a way they prefer, and this helps them have some control over their lives. EVIDENCE: Staffs ensure that personal care requirements and routines are recorded; these routines promote dignity and privacy wherever possible along with independence in carrying out personal hygiene or toilet tasks. Staff try to ensure consistency and support for all service users, and choice is given at all times if possible. Any medical issues or concerns are normally raised at the initial assessment. All service users have access to GP.dentist, optician and chiropodist whenever required. The home does have the private services of a psychiatrist whenever needed and documented evidence was available to check. Accident book was checked and shows that staff document the appropriate Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 13 records, and would record if residents have visited accident and emergency. Medication was discussed with the manager and records checked, some MAR sheets were found to be hand written but were not signed by two staff. Secondary dispensing was an issue on the last Inspection, and although the home has developed a policy for this, secondary dispensing must crease and ensure that the pharmacist dispense resident’s medication. No residents self medicate, therefore staff, all of which have completed accredited medicine courses, administers all medication. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 14 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 Resident are protected from abuse or neglect by ensuring that all resident and families are provided with information to enable them to raise concerns or complaints about the home and their care they receive, and adult protection policies, procedures and training for staff are in place at the home. EVIDENCE: Each resident has been given the homes complaints procedure in an appropriate format. No complaints recorded since the last Inspection. The home has an Adult Protection procedure including Whistle Blowing. Adult protection policy and procedures in place at the home, and since the last Inspection three staff has completed Abuse and Prevention course at Doncaster College, hopefully other staff will be able to attend. Abuse training for staff is done within the Autism awareness package and this is completed during induction. Staff that was interviewed confirmed they are aware of these policy and procedures Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 15 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 The home provides a pleasant living environment, and resident are encouraged to help with household tasks, which encourages them be independent. Personalisation of bedrooms reflects the interests and promotes residents independence. EVIDENCE: The home’s premises are suitable for its stated purpose; service users live in a very homely environment that is accessible, safe and well maintained. When staff report any problems or concerns, the homes handy man that ensures that any general maintenance of the home is carried out, and evidence was seen that these repairs are documented when reported and completed. Tour of the outside premises found that CCTV camera’s are for security purpose only and do not impinge on service users daily life. Tour of the premises found them very clean and tidy, the home employ a domestic for communal areas, but service users are encouraged to complete some household tasks, for example keep own bedroom tidy and help with washing of clothes with the support from their key workers. Domestic laundry facilities are on site. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 16 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): 31 32 34 35 Resident’s benefit from a stable staff group, therefore ensuring that residents are supported by staff who are familiar with their needs and are aware of their roles and responsibilities. EVIDENCE: Stable staff group at the homes, and staff confirmed they were given job descriptions, and they had been provided with copies of the Codes of Practice issued by the General Social Care Council. Training at the home was discussed with the homes manager, staff and training files examined. Training files seen show that all staff have individual files that highlight what training as been completed, and what updates are needed, but the home as not got an staff induction programme that meets sector skills, however the home have ordered induction programmes through a national company and are hoping this will be in place soon. At the present time no staff are N.V.Q. trained, but six care staff are working towards either N.V.Q level 2 or level 3, the home is aiming to achieve the minimum of NVQ 2 qualification for 50 of the work force by the end of 2005.The manager his also an NVQ assessor. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 17 Staff is only confirmed in to post after a CRB check has been completed. No new staff since the last Inspection, when staff files were checked on the last Inspection they showed the homes recruitment policy and procedures had been followed. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 18 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): 37 38 39 42 43 Resident’s health, safety and welfare are promoted and protected, and records required by regulation and for their protection are maintained. Resident’s benefit from a well run home that encourage residents to make decisions about all their daily living needs within the home. EVIDENCE: The manager as considerable work experience with adults affected by ASD in both residential and day care settings, and she has completed the Registered manager’s award. Those staff spoken too confirmed that the manager creates an open and positive atmosphere within the home, and his very supportive and encourages development for staff. A number of auditing systems in place, and evidence were seen that homes manager carries out a number of audits e.g. care plans, medication, risk Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 19 assessment and health and safety audits. Evidence was found that the home seeks the views of service users in an appropriate format. Since the last Inspection the manager as developed a questionnaire for parent and families to complete, this as been sent out recently and when its received back the manager will analysis and put into a format so that it can be fed back to parents and also measured against the aims and objectives of the home. The owner also visits the home on a regular basis and completes regulation 26 reports, these were available to examine, but suggested these are sent to the Inspector at the local office. Safe working practice was discussed and records checked, all records seen e.g. fire safety are checked and records kept. The home usually checks water temperatures on a weekly basis and record the findings, but no recorded evidence was found, they were checked immediately and found satisfactory. Most of the staff has completed a first aid training course, which is accredited and requires an update every three years. A number of staff has completed health and safety courses at Doncaster College, and other staff have commenced on health and safety OCN level 2 certificate course. The home has appropriate Insurance cover in place and on display in the home. Discussed budget arrangements with the manager, since the last Inspection she now holds a budget to enable her to purchase equipment and usually renewals. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 20 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 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trafalgar Street Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 2 3 DS0000059567.V250636.R01.S.doc Version 5.0 Page 21 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 YA20 Regulation 13(2) Requirement Timescale for action 2 YA35 18 3 YA42 13 Medication; 1) Secondary dispensing must cease and alterative 01/12/05 arrangement must be made. (Timescale of 31/3/05 not met) 2) Handwritten MAR sheets must have two signatures for verification of medication regime. Staff training and Development; 01/01/06 induction programme must be in place that will meet sector skills. (Timescale of 1/5/05 not met) Water temperatures must be 30/09/05 checked on a regular basis with records kept. 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 YA32 Good Practice Recommendations Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required time-scales. Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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. Extracts may not be used or reproduced without the express permission of CSCI Trafalgar Street DS0000059567.V250636.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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