Inspection on 03/03/06 for Trafalgar Street

This inspection was carried out on 3rd March 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 2 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 29/09/05

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 DN6 8AF Lead Inspector Janet McBride Unannounced Inspection 3 March 2006 13:00 rd Trafalgar Street DS0000059567.V284008.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 Trafalgar Street DS0000059567.V284008.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. Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Trafalgar Street Address 2 Trafalgar Street Carcroft Doncaster South Yorkshire DN6 8AF 01757 270430 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.V284008.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 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 has been registered for 4 places since it opened in July 2004. 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 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. Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at 1 pm. on the February 2006. This was the home second Inspection since April 2005,any standards not covered in this inspection was covered in the unannounced inspection that was conducted early in the year. It may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. During the Inspection we looked at chosen number of documents, sampling of records, partially tour of the premises and indirect observation of staff interaction with residents, it was a very relaxed atmosphere in the home and three of the four service users were seen and spoken to during the Inspection. Any issues or concerns that were raised were discussed with the manager during and at the end of the Inspection. What the service does well: What has improved since the last inspection? The manager ensures she addresses all of the issues raised, and she and her staff continue to work hard at ensuring all the service users are happy within the home. Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 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.V284008.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 Trafalgar Street DS0000059567.V284008.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): Prospective service users individual needs are assessed prior to admission to the home this ensures that their needs will be met. EVIDENCE: All referrals for admission have the required documentation giving the history of the potential service user; they are then assessed by the homes manager. One new admission since the last Inspection, was discussed with the manager and documentation checked, this service user’ is subjected to care programme approach supervision. Care plan had a full assessment which involved other professionals, and copy of recent review, all of which demonstrated that the home ensured they could meet service users needs before admission. The manager and staff through appropriate training, and appropriate psychiatric input ensure that service users receive continued support within the home. Trafalgar Street DS0000059567.V284008.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): 679 Care plans reflect what care is needed for each individual, which are reviewed and updated; this ensures that staff has the information to meet service users care needs. EVIDENCE: Care plans were discussed with the manager and one new service users care plan was examined. Care plans are devised from the initial assessment, the care plan seen reflected the needs of that individual, with appropriate risk assessments in place including risk assessments for any daily activities or social activities that they participate in, records show they are reviewed and updated on a regular basis to reflect service users changing needs. Evident that service users are involved in some parts of care planning, some of this is discussed with them, and ensures they are aware of social workers and other professionals being involved in their care. Appropriate psychiatric input and continued support, is evident as the home as the services of a psychiatrist specialising in Autistic Spectrum Disorders who Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 10 reviews service users on a regular basis, this also provides support if needed for the staff. Each service user is assessed on their ability to make decisions about all their daily living needs, and are involved with their key worker and have plans in place to do daily tasks on what ever level they are able to participate in. Staff try to support and help service users be as independent as possible and make decisions about every day issues. Three out of the four service users were spoken to, say they have choices and that staff support them to make decisions. Appropriate formats are used to give information to the service users, and advocacy groups are available to support service users as the home used them in the past when needed. Trafalgar Street DS0000059567.V284008.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): 17 Dietary needs of service users are well catered for, with a balanced and varied selection of food available to meet individual tastes and choices. EVIDENCE: Menus and mealtimes were discussed with staff, the home promotes a healthy and nutritious diet, and service users do choose what they want to eat and go shopping for food with staff. Staff gave examples, most have cereal and toast for breakfast but at weekend they have a cooked breakfast. All service users help as much as possible, some help prepare food and make their own packed lunches with supervision, all can help with setting table and washing pots after meals. Most main meals are eaten all together and at times go out for meals or have takeaways. Service users did not a have nutritional assessment within their care plan, although they are weighed on a regular basis and staff will make a referral to their GP or dietician if any concerns or issues are identified, suggest that all service users should be nutritional assessed. Trafalgar Street DS0000059567.V284008.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): 20 Service users health is monitored and staff can access all NHS health care facilities. Medication practice of secondary dispensing puts service users at risk of receiving incorrect medication. EVIDENCE: This standard was assessed at the last Inspection and issues were raised all have been addressed with the exception of secondary dispensing, but the homes manager as taken a proactive approach to this and is working with the local pharmacist to try and resolve any issues. Trafalgar Street DS0000059567.V284008.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): The key standards were assessed at the last Inspection and met, and the home has had no complaints since this time. EVIDENCE: Trafalgar Street DS0000059567.V284008.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): 28 The quality of furnishings and fittings is good and shared space is very comfortable and homely. EVIDENCE: Communal areas are very comfortable, homely and provides a safe environment for service users, tour of the home found it well-maintained, clean and very tidy. Trafalgar Street DS0000059567.V284008.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 35 The home has a very enthusiastic and stable staff group who work positively with the service users; this ensures that staff is familiar with their needs and that service users are supported by an effective staff team. EVIDENCE: Service users benefit from a stable staff group, therefore ensuring that staff is familiar with their needs and give the required support. Staff confirmed they were aware of their roles and responsibilities, and could give various examples of practice, they also stated that they continue to develop their roles to ensure they meet service users changing needs. N.V.Q. training was discussed with the manager who is an NVQ assessor. The home has seven care staff two of these staff have achieved NVQ level 2 or 3 courses, and four other members of staff have enrolled on N.V.Q courses, the home is aiming to achieve the 50 of the work force being NVQ trained. Training needs assessment is carried out for the staff team and all staff within the home has an individual training file, these show what training as been achieved and when updates are due. Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 16 Two staff has recently completed equality and diversity training. Since the last Inspection the homes as updated there induction package that meets sector skills council specifications. Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 17 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): 42 Records required by regulation are maintained, this ensure that service users health, safety and welfare are promoted and protected. EVIDENCE: Safe working practice was discussed with the manager, staff and records examined. Records show that all fire safety is checked and records kept. The home completes maintenance checks and records were available, documentation shows details of what is checked on either a weekly, monthly or quarterly basis all of which was up to date. Most of the staff has completed basic first aid training, and three members of staff have also completed the accredited course that only needs updating every three years. Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 18 Health and safety was discussed, all staff with the exception of the new member of staff has completed health and safety OCN level 2 certificate course. The home has appropriate Insurance cover in place and on display in the home. Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 19 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 3 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 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 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X 3 X Trafalgar Street DS0000059567.V284008.R01.S.doc Version 5.1 Page 20 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 YA20 Regulation 13(2) Requirement Medication; Secondary dispensing must cease and alterative arrangement must be made. (Timescale of 01/12/05 not met) All service users must have nutritional assessments completed. Timescale for action 30/04/06 2 YA17 16(2)(I) 30/04/06 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 Refer to Standard YA32 Good Practice Recommendations Ensure that staff has 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.V284008.R01.S.doc Version 5.1 Page 21 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.V284008.R01.S.doc Version 5.1 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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