Random inspection report
Care homes for adults (18-65 years)
Name: Address: 11 Bacup Street 11 Bacup Street Moston Manchester M40 9HF three star excellent service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sylvia Brown Date: 0 6 0 5 2 0 1 0 Information about the care home
Name of care home: Address: 11 Bacup Street 11 Bacup Street Moston Manchester M40 9HF 01613209060 Telephone number: Fax number: Email address: Provider web address: delia.murphy@nwcs.ltd.uk Name of registered provider(s): Name of registered manager (if applicable) Mrs Deborah Mary McAllister Type of registration: Number of places registered: Conditions of registration: Category(ies) : North West Community Services (GM) Limited care home 3 Number of places (if applicable): Under 65 Over 65 0 learning disability Conditions of registration: 3 The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 Date of last inspection Brief description of the care home 11 Bacup Street is a residential care home providing 24-hour care and accommodation for 3 persons with learning disabilities who may also have additional disabilities. The Manchester Methodist Housing Association owns the building. The North West Community Services, contracted by Manchester City Council, provide the day-to-day
Care Homes for Adults (18-65 years) Page 2 of 9 Brief description of the care home and managerial support. The home is situated in the Moston area of North Manchester and is close to local amenities and transport routes. The home is a purpose built bungalow sited on a residential street. All bedrooms are single occupancy. Communal and kitchen areas are large enough to allow a person with high mobility needs access to all these areas. At the rear of the house is a well-maintained garden. Care Homes for Adults (18-65 years) Page 3 of 9 What we found:
We conducted a random inspection of the service as part of our regulatory responsibility. We did this to see if there had been any significant changes in the delivery of the services provided and if any of those changes impacted negatively on the service users or affected the 3 Star Excellent rating given at the last Key inspection in June 2007. At the last key inspection the quality rating given to the service was 3 star. This means the people who use this service were experiencing excellent quality outcomes. Since that time we have asked the registered provider to complete an Annual Quality Assurance Audit (AQAA) each year . The AQAA is a self-assessment document that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We have also conducted an Annual Service Review (ASR) each year which means we looked at all the information we had on the service including the AQAA and completed a report of our findings. Since we last inspected the service a new manager has been appointed who also manages the day to day running of another service. She has successfully completed the registration process with us to become the registered manager of the service in 2008. At this random inspection we found that there was one vacancy at the service and that both service users currently living at the home had been there for some considerable time. As a consequence we looked at one file in depth which we call case tracking. We were able to meet the service user and view the support they received. We had a look at the medication administration records and daily care file for the other service user to gain an overview of how the service was continuing to support them. We spent 1hour 45 minutes at the home and were able to observe service users as they went about their day to day routines, we spoke briefly with the managerduring the inspection and again after the inspection to give feed back. We observed support staff as they assisted service users and completed other duties. We looked around the home and looked at a sample of servicing records to confirm information provided to us within the AQAA. We found that the home continues to be managed to a good standard which provides service users with excellent outcomes. The registered manager has good administration systems in place which were well organised enabling members of staff to provide us with all the information we asked for in a timely and prompt manner. For reporting purposes the terms we or our are used when referring to the Care Quality Commission CQC or inspectors acting on their behalf. What the care home does well:
Service users continue to live in a home that offers them personalised high quality support which is able to meet their individual needs and expectations.
Care Homes for Adults (18-65 years) Page 4 of 9 We saw that each service user was living as they desired . Staffing levels were such that service users received one to one support which means that they are able to have the day to day routines they wish. Service users preferred day to day routines were recorded in detail as were health care requirements , meals, activities and personal aspirations. This means members of staff were able to clearly and concisely gain information on how the service users required support and what was expected of them to promote service users independence, self worth and self esteem. Some daily records maintained by members of staff were not as throughly detailed as required. Though basic information about care and support was recorded, many aspects of the service users daily life were not. We have advised the registered manager to give due considerations to developing this aspect of the service with members of staff. Service users are supported to live as others within the community and were possible visit their own GP and clinics within the community rather than receive services at home. Meals and meal times were observed , we saw that one service user who required a soft diet received their meat and vegetables as one portion. The member of staff had not made sure that each food item had been softened separately and presented nicely for the enjoyment of the service user. We brought this matter to the attention of the registered manager who told us that some members of staff had received formal training whilst other were awaiting training . They had however received in house training. Assurances were given by the registered manager that she would address this matter with all members of staff to make sure meals served to service users were visually pleasing and tasty. The manager has improved links with community specialists who were provide support services to service users. Service users had their needs kept under review and records confirmed that statutory reviews were undertaken. Heath care action plans were also kept under review and the way this is completed has improved since we last inspected. Each service users medication is kept individually as are their records. Minimum stocks are held on the premises and record keeping to demonstrate good management of medication was in place. Service users have continued to have days away from the home and annual holidays. Staff training continues to be prioritised. The manager stated that due to the changes in the staff team currently two of the seven members of staff have achieved a National Vocational Qualification ( NVQ) at level 2 or above with a further two currently on the course and two awaiting the training. We spoke with three staff members who told us that they were either on the course or waiting to commence it. This means that the service did not meet the standard to have 50 of its work force trained at NVQ 2 or above. We have confidence that the statements made by the manager are accurate and that the service is working towards meeting the training target in the near future. The organisation has recruited a new training co-ordinator who has been working closely
Care Homes for Adults (18-65 years) Page 5 of 9 with the service to ensure regular training updates are made available. Such training includes the protection of vulnerable adults. Members of staff on duty confirmed that they have all received training in Adult Protection and complaints. One member of staff who had recently joined the team from another service run by the organisation stated that regardless of his previous experience he was again assessed when he moved to Bacup Street to make sure he was fully aware and competent at managing and administrating service users medication. All members of staff receive individual supervision, attend staff meetings, have training and development programmes in place and are appraised annually. This means service users are supported by members of staff who are trained, monitored and supported to a good level. Good monitoring systems are in place at the home, with the registered manager conducting her own spot checks and completing quality audits. In addition the service manager undertakes Regulation 26 visits each months which look at all aspects of the service, talks with and observes service users and members of staff , monitors the environment and looks at records. reports of these visits were recorded as were the outcomes. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 6 of 9 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 7 of 9 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 8 of 9 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 9 of 9 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
