CARE HOME ADULTS 18-65
Wensley Street 142 Wensley Street Sheffield South Yorkshire S4 8HN Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 19th January 2006 10:00 Wensley Street DS0000003025.V274201.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 Wensley Street DS0000003025.V274201.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. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Wensley Street Address 142 Wensley Street Sheffield South Yorkshire S4 8HN 0114 242 4359 0114 244 8418 iris.macdonald@sct.nhs.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) South Yorkshire Housing Association Ms Iris McDonald Care Home 30 Category(ies) of Learning disability (30) registration, with number of places Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One Service User who has a learning disability but who is also over 65 can be accommodated on the ground floor. 13th July 2005 Date of last inspection Brief Description of the Service: Wensley Street is a care home providing personal care and accommodation for thirty service users with learning disabilities. The home consists of six modern houses, each providing places for five service users. The houses are clustered together around accessible pleasant green areas. All rooms are single. The home aims to meet the needs of service users on an individual basis and encourages their independence. The home is situated near to shops at Firth Park and near to public transport. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Jayne Barnett - Middleton carried out this unannounced inspection over five hours. Opportunity was taken to make a tour of the premises, inspect a sample of records and policies and talk to staff and residents. The inspector had the opportunity to speak to most of the staff on duty. It was not possible to formally interview any of the residents, due to their high support needs but the inspector spoke to several residents informally. What the service does well:
The Staff were friendly, approachable and relaxed to talk about the care that they provided. Positive and appropriate relationships were observed between staff and residents. The majority of residents had opportunities to access appropriate activities, including day centres, luncheon clubs and visiting amenities within the community. Activities were provided within the home including crafts, games and music. Residents confirmed that they were encouraged and supported to maintain positive relationships with their families and friends. Residents confirmed that their relatives were welcome to visit them. Resident received personal support, which promoted their privacy, dignity and independence. Residents seen were well dressed in clean clothes and had received a good standard of personal care. The garden areas were well maintained, safe and accessible to residents. A sensory garden, which was being built by a community group, was almost completed. This will provide a pleasant area for residents to use when the weather is warm. All houses were very clean, tidy and odour free, which provided a hygienic and homely environment for residents. Many of the staff employed have worked at the home for many years and therefore know the residents well and can offer them a consistent service. All staff said that there was good team work and spoke positively about the support that they received from the management team. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Wensley Street DS0000003025.V274201.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 Wensley Street DS0000003025.V274201.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): 2. Needs assessments were available on the residents files checked. They contained appropriate information about the residents care needs, which ensured that the home was able to meet their needs. EVIDENCE: A full needs assessment was carried out for residents prior to their admission. This confirmed that the service was appropriate for the resident, and provided staff with the information to formulate an individual plan of care. Wensley Street DS0000003025.V274201.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 and 9. Person Centred Plans were being developed. The care plans that were checked were very detailed and showed how the residents wished to be supported and what their future aspirations were. The care plans had been reviewed regularly. All residents had risk assessments, which enabled them to take risks as part of an independent lifestyle. Those that were checked had been reviewed on a regular basis. EVIDENCE: Care plans checked set out in detail the action that was required by staff to ensure that all aspects of resident’s personal, social support and healthcare needs were met. Records checked confirmed that care plans were reviewed on a frequent basis to reflect the resident’s current needs. The care plans checked were of a good standard and information was accessible and easy to track. There were plans to develop person centred plans for some residents. The staff said that they needed more time to ensure that this work could be carried out appropriately.
Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 10 Resident files contained risk assessments relating to all aspects of residents lives both inside and outside the home. They identified the individual risks that were presented to residents on a daily basis and the action required to reduce the risk, which enabled residents to live an independent lifestyle. Wensley Street DS0000003025.V274201.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): 12,13,15,16 and 17, Some of the residents had regular opportunities to access age, peer and culturally appropriate activities. Residents regularly accessed community day services and leisure activities. Others with higher support needs had limited opportunities, as they need 1- 1 staff support, which was not always available. The deputy manager said that the sponsoring authorities had been approached and that the manager was in the process of attempting to secure extra staffing hours. Opportunities were provided for residents to engage in activities within the home and maintain links within the local community. The daily routines within the home were flexible and promoted independence, individual choice and freedom of movement. Residents were supported to have appropriate relationships with their peers and relatives. A choice of menu was offered and individual dietary needs were catered for. Residents were encouraged to eat a healthy and varied diet. Some residents had healthy eating plans to support them to maintain a healthy weight.
Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 12 EVIDENCE: The majority of service users had opportunities to access appropriate activities. Care plans checked and discussions with staff demonstrated that residents had access to activities including day centres, luncheon clubs and visiting amenities within the community. The staff confirmed that residents with high support needs had limited opportunities to access activities as they required 1:1 or in some cases 1:2 staff support and that the staffing levels were not always appropriate. The manager was in the process of attempting to secure extra staffing hours. The deputy manager said that once extra hours were available, each team would be involved in planning how the extra hours would be used to enable equal opportunities for all residents. Activities were provided within the home including crafts, games and music. A sensory garden was in the process of being built. The residents in one house described how they were in the process of deciding what type of plants to purchase and how they would enjoy planting them. Residents and staff spoke positively about a recent Christmas Show that they had organised and presented. The staff said that they had received good support from relatives and that the show had been a great success. Residents confirmed that they were encouraged and supported to maintain positive relationships with their families and friends. Residents confirmed that their relatives were welcome to visit them. One resident was supported to independently visit their relative on a regular basis. Residents were offered and encouraged to eat a healthy diet. A varied menu was provided. Details of the resident’s preferences and special needs were maintained. One resident said that the food was “ always good”. The staff had a good knowledge of individual needs and was able to describe residents individual preferences. Several residents had chosen to take part in a healthy eating plan to help them maintain a healthy weight. The staff and residents said that this was proving successful and described how they planned and prepared healthy meals. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 13 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 and 20. Resident received personal support, which promoted their privacy, dignity and independence. Residents seen were well dressed in clean clothes and had received a good standard of personal care. Resident’s physical and emotional needs were met. The Care plans contained detailed information about how the resident’s personal support should be met by staff in order to meet their individual needs. The staff said that the residents received good support from local G.P’s and health support teams. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. EVIDENCE: The resident care plans detailed how personal support should be offered to each individual. This included the times that they rose and retired and what level of support they required to wash and dress. All residents seen appeared very well cared for, they were clean, hair and nails had been attended to and male residents were shaved.
Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 14 The staff said that the residents received good support from the local healthcare professionals who visited them. There were records to evidence that residents were receiving regular visits from healthcare professionals dependent on their needs. Two residents spoke in detail about the healthcare visits that they received. Nutritional screening was undertaken for residents on admission and weight monitoring records were in place. One weight monitoring record checked demonstrated that the resident had been weighed in September and had lost weight. However there were no subsequent records to demonstrate that the residents weight had been monitored. The staff were able to demonstrate a good knowledge of the residents current health and potential reasons for the weight loss. However, the resident should be regularly weighed to ensure that their healthcare needs can be monitored. The deputy reported that there were plans to develop ‘ Health action plans’ which would enable the staff to work with residents in further identifying their specific health care needs. There was a medication policy and procedure to ensure that staff adhered to safe practices. Medication was checked on a sample basis. On the whole medication systems were good and procedures were in place to ensure that medication was appropriately administered. Some gaps were noted on Medication Administration Records (MAR) checked, where medication had been administrated and not signed for. Care is needed to ensure that administration records are well maintained, to ensure the safe administration of medication to residents. Medicines were securely stored and staff responsible for administering medication had received training to promote the safety of residents. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 15 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 and 23. The homes complaints procedure was clear and accessible, ensuring that any complaints made by residents and their relatives would be listened to and action taken to deal with complaints promptly. There was an adult protection procedure, which promoted the protection of service users. Resident’s financial interests were safeguarded by the procedures at the home. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. All staff said that the manager was “approachable” and were confident that any concerns would be listened to and appropriate action taken. There was an adult protection policy and procedure that promoted the protection of residents from harm or abuse. Staff had received Adult Protection training enabling them to identify and report any allegations or incidents of abuse to residents. Arrangements were in place for residents who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that tenants were able to access their monies for personal items as they wished. Systems were in place to protect residents from financial abuse and daily checks of resident’s monies were carried out. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 16 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 and 30. The houses were well maintained, odour free, well decorated and homely. The patio and the gardens were well maintained. A sensory garden is being built and is almost completed. The resident’s bedrooms were comfortable, individually personalised and furnished to meet their needs. EVIDENCE: The houses were well maintained, pleasantly decorated and furnished in a homely manner. A previous requirement to replace the floor covering in the kitchen areas had been met. The staff reported that new trap doors had also been fitted, promoting a clean and safe environment for residents. The garden areas were well maintained, safe and accessible to residents. A sensory garden, which was being built by a community group, was almost completed. This will provide a pleasant area for residents to use when the weather is warm. Residents said that they liked the new garden and were in the process of choosing the plants that they would like.
Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 17 Resident’s bedrooms were comfortable, individually furnished and personalised to meet their needs. It was evident that residents had been encouraged to personalise their bedrooms with photographs and ornaments, which encouraged residents to retain their own identity. Housekeepers were employed to maintain a good level of cleanliness. It was evident that this arrangement worked very well. All houses were very clean, tidy and odour free, which provided a hygienic and homely environment for residents. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 18 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 and 36. Many of the staff employed have worked at the home for many years and therefore know the residents well and can offer them a consistent service. Staff had received training to meet the resident’s general and specific needs. A good range of training was available for staff. The home operated a recruitment procedure that promoted the protection of residents. The staff team said that they received good levels of support from the manager and team leaders. Plans were in place to ensure that the staff received formal supervision and appraisals at the required frequency. EVIDENCE: The Staff were friendly, approachable and relaxed to talk about the care that they provided. Positive and appropriate relationships were observed between staff and residents. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 19 A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Staff confirmed that they had received a good range of training that included Moving and Handling, First Aid and Health and Safety. Since the last inspection several staff had completed the Learning Disability Award Framework, (LDAF) award, which will give them a recognised induction into supporting the residents who live at the home. Several staff were working towards the NVQ2 care award. A recruitment policy and procedure was in place. Two files checked contained a range of information including two references, declaration of health and qualifications/training. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of residents. The staff team said that they received good levels of support from the management team. The deputy confirmed that all staff had been allocated to a senior member of staff and it was anticipated that regular formal supervision would commence within the near future. The senior staff said that they had recently attended training and that all staff would be supported to complete a Personal Development Review twice per year. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 20 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 and 42. The staff said that they were well supported by the management team. Forums were in place, which enabled residents and staff to contribute to the day-to-day running of the home. The health, safety and welfare of residents was promoted and protected. EVIDENCE: The registered manager had many years experience within the caring profession which, enabled her to contribute to the care of service users and communicate a clear sense of leadership to staff. All staff spoke positively about the support that they received from the management team. South Yorkshire Housing Associations quality assurance officers visited the home on a regular basis to carry out monitoring of the service to ensure that the home was working within the law and their policies and procedures. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 21 A resident representative from South Yorkshire Housing visited residents on a regular basis, which enabled residents to voice their views and to suggest how the service could be improved. All houses were well maintained which promoted a safe living environment for residents. The staff had received regular training to promote the health, safety and welfare of residents and their colleagues. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 22 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 3 23 3 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 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X X X X X 3 Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 23 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 Regulation Timescale for action A review of each service users 01/04/06 opportunities to access daily and leisure activities within the community must be carried out.( Timescale of 31.10.05 not met) A review of the staffing levels 01/04/06 must be made to ensure there are sufficient numbers of support staff to enable the residents to access activities within the community. (Timescale of 31.12.05 not met) Service users must be 01/03/06 weighed on a regular basis and monitoring records maintained. The administration of 01/03/06 medicines must be accurately recorded. Requirement YA14YA13YA12 12,16 2. YA33 18 3. YA19 12 4. YA20 13 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 24 No. 1. 2. 3. 4. Refer to Standard YA32 YA37 YA19 YA6 Good Practice Recommendations 50 of care staff must be trained to NVQ Level 2. The manager must be qualified to NVQ Level 4 in care and management. All service users should have as a minimum an annual health check. Al service users should have the opportunity to devise a person centred plan. Wensley Street DS0000003025.V274201.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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