Inspection on 19/12/07 for Inspirations

This is the latest available inspection report for this service, carried out on 19th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Inspirations 12/09/05

Inspirations 02/06/05

Inspirations 24/08/04

Inspirations 18/05/04

Inspirations 06/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Westmead

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Inspirations Inspirations 171 Tettenhall Road Wolverhampton West Midlands WV6 0BZ Lead Inspector Martin George Key Unannounced Inspection 19th December 2007 09:45 X10015.doc Version 1.40 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 Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 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 Older People. 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. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inspirations Address Inspirations 171 Tettenhall Road Wolverhampton West Midlands WV6 0BZ 01902 710938 01902 566067 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) Mrs Patricia Hayward Mrs Patricia Hayward Care Home 15 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (15) of places Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Females aged 60 years and above and males aged 65 years and above. No number division between categories. Maximum number of Service Users is Fifteen (15). The maximum number of service users with dementia that can be accommodated at any one time is fifteen (15). The category of DE (dementia) is for Mild Dementia only. Thematic - 21st December 2006 Key – 13th July 2006 Date of last inspection Brief Description of the Service: Inspirations is a care home providing accommodation for 15 older people. It is a large, semi-detached building, situated on the Tettenhall Road, about one and a half miles from Wolverhampton city centre. The accommodation is arranged over three floors and there is a passenger lift to each floor. There are various amenities nearby, including churches, pubs, a library and shops. West Park is a short distance away. There is limited parking to the front of the property and a larger car park at the rear. All bedrooms are single, seven having an en suite facility. The registered persons operate an ongoing programme of routine maintenance and renovation that keeps the property in good order throughout. The home is tastefully decorated. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by a single inspector between 09:45 and 14:45. As part of the inspection all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’ were inspected. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home through their annual quality assurance assessment (AQAA). The views of a number of people living at the home and staff working there were also acquired, both through on site surveys and discussions during the inspection. Information was analysed prior to inspection and helped to formulate a plan for the visit and helped in determining a judgement about the quality of care the home provides. On the day of the inspection we spoke to staff and service users, relatives of service users, Chair of the resident’s association as well as the registered manager and deputy manager, and observed practice and this provided evidence in support of the records that were also checked on the day. What the service does well: What has improved since the last inspection? The front living room has been furnished with new seating and there is a big flat screen television on the wall. The layout provides ample space for the service users to relax and gives good sight of the screen. The ongoing work to provide a new conservatory dining area is well underway and this will give a very pleasing environment in which to eat. There will also be a hatch directly through to the kitchen, making service user food choices easier to respond to. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is excellent. Pre-placement assessments of need ensure that service user needs are met and subsequent assessments incorporate acquired knowledge to help service users achieve their potential. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user records that we checked provided evidence of comprehensive, pre-placement assessments of need for those who are funded by the Local Authority and for those who are self funding. Funded placements have multidisciplinary assessments and those service users who are self funding have assessments completed on the comprehensive in-house model, which includes all areas of need identified in National Minimum Standard 3.3. Records also evidenced that there is recognition of the need to focus on achieving positive outcomes for service users. The contracts given to service users fully explain Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 9 what is provided by the home, and all those we checked were signed and dated. Information provided to staff about daily living needs, arising out of the assessments of need, is easily accessible and understandable, leading to staff who are well informed and able to meet the diverse needs of service users. All the residents are permanent. The home does not provide intermediate care. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. Care plans are well constructed, identifying a comprehensive range of service user needs. The frequency of reviews ensure needs continue to be assessed and met. Medication practices safeguard service users from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a comprehensive care plan for each service user, based on the initial assessment. These are kept up to date and are reviewed weekly by the keyworker. Care plans cover mobility and personal care, continence, diet/fluid intake and output, safety, communication needs, emotional/social needs, strengths and skills, medical/physical needs and challenging behaviour issues, ensuring that service user needs are fully met. Each file contains an ongoing information sheet and a review sheet. All service user files are laid out Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 11 identically, making it easier to navigate to the necessary information, leaving staff with more direct contact time with service users. The home uses Pool Activity Level (PAL) sheets to assess the level of ability a service user has in a number of practical areas and these provide very useful information for staff to enable them to support service users in being as independent as their physical and cognitive abilities allow. Records provide evidence of regular monitoring of weight and nutritional intake. There is also evidence of regular visits by, and liaison with, GP’s and other health professionals. Records show that the assessment of need and admission forms cover the issue of whether a service user wishes, and/or is able, to self medicate. The medication administration and recording practices are well established and effective. Both the internal and external monitoring (through the pharmacist) show a high level of awareness to potential harm in medication matters. Staff are trained in the safe handling of medicines before administering medication. The deputy manager provided a very clear explanation of how it is managed, satisfying us that service users are safeguarded in this area of practice. Service users, through our discussion with them and in surveys submitted to us, rated the home very highly in terms of respect, dignity and sensitivity. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. The home listens and responds well to service user preferences with regard to meals and activities and encourages the involvement of relatives. Community involvement is seen as important and service users gain evident benefit. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The routines and activities within the home are flexible and consistent with the needs and preferences of service users. Several service users expressed high levels of satisfaction with the variety and quality of meals. Family members we met also spoke very highly about how well their relatives were catered for. The building work underway will create a new dining area with direct access to the kitchen, making it easier to respond to service user food choices. There are numerous activity options, both within the home and in the wider community. The manager explained that she tries to encourage all service users to engage in activities to minimise the risk of those who are normally Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 13 less sociable, becoming isolated from the other residents. The manager is very receptive to ideas, expertise and good practice from other sources, such as the Alzheimer’s Society, and there is evidence of how these are utilised by the home. The home has a good relationship with representatives from the local church, St. Jude’s, who visit the home occasionally to meet with service users. The home also encourages young people from a local school to undertake occasional work experience at the home, which helps maintain a constructive link between the generations. The home is very proactive in trying to engage the relatives of service users as much as possible. Events such as parties and outings are seen as ideal opportunities to involve relatives. Key in this function is the Chair of the resident’s committee, who works tirelessly to ensure service users benefit fully from what the home is able to offer. At the time of the inspection he was organising a trip to a pantomime in Wolverhampton. Another key role he undertakes is auditing the finances for all service users. These records were checked by us and found to be clearly laid out and well managed. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home has a good complaints procedure, widely available and clearly understood by service users, their relatives and staff. Safeguarding is given high priority in terms of training and service users feel well cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints are a rare occurrence at the home and although there is always a risk that the reason for this is that service users are afraid to make a complaint, we are totally satisfied that in the case of this home the reason for the absence of complaints is due to very high levels of satisfaction with all aspects of the care provided. This was expressed to us by several service users, relatives and the Chair of the residents association. The complaints procedure is understandable and is available to all service users and their families. Service users and relatives spoken to would be happy to raise concerns if they had any. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 15 Knowledge of safeguarding of vulnerable adults is good amongst the staff team and training in this area is of good quality and consistent with Skills for Care knowledge sets. Service users consistently reinforced, through discussion and surveys, how well they were cared for. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23 and 26 Quality in this outcome area is good. Service users benefit from a well maintained and decorated environment. Changes to the living environment are evidence of how the home listens to service users and their families. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the bedrooms have their own character and are all tastefully decorated and personalised to the service user’s preference. One bedroom on the second floor has no window and the only natural light is through the fire door, which has opaque, wired glass in the top half. Unfortunately this does not afford the service user a view of the garden. The manager explained previous discussions she has had with the fire officer about types of glass that may meet Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 17 regulations and also provide a view. This will be pursued again with the fire officer. In several areas of the home the original, stained glass window panes have been retained and this not only keeps the character of the home but is also reflective of the style familiar to many of the service users. To further enhance the comfort and amenities for service users the home would like to install an additional toilet with disabled access. The attention to the needs of those with physical disability is evident throughout the home and a new ramp is being installed as part of the ongoing building work to provide a conservatory, which will incorporate the new dining area. The laundry area is in the basement, down some rather steep stairs. Safeguarding is evident here though, with a key code lock on the door at the top of the stairs to restrict entrance to those capable of using the stairs. The washing and drying machines are of good quality, suitable for the quantity of laundry. There is a designated area for the disposal of clinical waste. The environmental health certificate we saw is valid until 01/04/09 and the home is currently rated 4 star (very good). The most recent fire service visit was in May 07. Three minor issues were raised and addressed immediately by the home. Training and practice in the area of infection control is very good. We checked the quality audit file which evidences how and when the necessary checks are carried out. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. The attention paid to the recruitment and development of staff helps to ensure the highest quality of care is provided to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several staff files were checked, covering new starters and longer serving staff, across all grades. All files were well ordered and provided evidence of all necessary recruitment checks. There was also evidence of good quality induction, signed and dated when completed. Terms and conditions of employment were on file and signed. All staff have or are receiving a good range of training, covering both mandatory topics and additional practice areas. Training carried out in the last year has included health and safety, manual handling, protection of vulnerable adults, food and hygiene, dementia care, fire prevention, first aid, safe handling of medication, infection control and falls prevention. The quality of recruitment practice helps to safeguard service users and the range of training helps staff to meet their diverse needs. Supervision for all staff meets or exceeds the frequency required by National Minimum Standards, ensuring that staff feel consistently supported and are Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 19 therefore better placed to continue meeting the complex needs of the service users. The rotas provide evidence of sufficient cover for all times, day and night. There is a good system of management on-call to ensure staff feel fully supported at all times, giving them the confidence to meet service user needs even when difficulties arise. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area is excellent. Good leadership and clear levels of accountability support a well trained staff team who provide competent and confident care to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is managed by a team of managers who have proven competence through the achievement of the registered manager award. In addition to this the manager is a registered mental nurse and holds the diploma in management studies. This knowledge is filtered down through the team in a Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 21 well defined hierarchy of accountability, giving staff confidence to carry out their roles and more effectively meet the needs of service users. The manager is very open to ideas and is regarded as being very approachable. In order to help her keep abreast of best practice she chairs a meeting of a group of providers. We acquired evidence of how the home recognises the importance of equality and diversity issues. Recent meetings have addressed several areas and this has resulted in a document titled the “Dignity Challenge”, identifying targets that the home has set itself and what they are doing to meet them. Throughout the document there is evidence of the priority given to the needs of service users and how they can be helped to achieve their potential. The Chair of the resident’s association undertakes auditing of the finances for all service users. These records were checked by us and found to be clearly laid out and well managed. Health and safety issues are given high priority, both in terms of training for staff and in how that training is translated into practice to ensure service users are properly safeguarded. Day to day practice around care of substances hazardous to health (COSHH), infection control and the management of falls are very good. Records show that all necessary checks are carried out and any actions identified and rectified. Maintenance checks and actions are also well recorded. Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x 3 x 3 x x 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 4 x x 4 Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Inspirations DS0000020893.V351789.R01.S.doc Version 5.2 Page 25 - 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!