CARE HOME ADULTS 18-65
11 Bacup Street 11 Bacup Street Moston Manchester M40 9HF Lead Inspector
Steve OConnor Unannounced 31 May 2005 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 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 Stationary 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. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 11 Bacup Street Address 11 Bacup Street Moston Manchester M40 9HF 0161 681 9455 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Delia Murph: North West Community Services (GM) Limited Sharon Louise Dixon CRH Care home PC Care home only 3 Learning disability 3 Category(ies) of LD registration, with number of places 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A maximum of 3 service users with learning disabilities (excluding mental disorder and dementia) may be accommodated. 2. The service must,at all times,employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 14 December 2004 Brief Description of the Service: 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 building is owned by the Manchester Methodist Housing Association with the North West Community Services contracted by Manchester City Council to provide service user 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 people with high mobility needs access to all these areas. At the rear of the house is a well-maintained garden. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 31st May 2005. During the inspection, time was spent talking with the manager and staff on duty and examining people’s files, records and the homes policies and procedures. The inspection also included a tour of the building. The three people who live at the home have little verbal communication and so although they were not able to express their views directly, time was spent observing how staff talk to and support people. The Commission for Social Care Inspection (CSCI) had not received any complaints about the home since the last inspection. There was just one requirement identified as a result of the inspection in December 2004 and work had been carried out to complete this. As this inspection only looked at a limited number of standards this report should be read together with the previous and any future reports to gain a full picture of how the service is meeting the needs of the people living there. What the service does well:
The home places a lot of importance in providing people with a place to live that is well maintained, decorated throughout and has a homely and relaxed atmosphere. Although it was not possible to find out directly how this affects the people who live at the home, it was clear that it has a positive impact on the way the staff feel about the home and this was reflected in the positive way they work with people. To be able to support people in a way that best meets their needs and goals it is important to be able to clearly understand and show what is important to each person. The home have worked with each person to get to know them and to try to understand, as best they can, what is important for that person. This is shown through the way the home has developed each person’s care plan. If you visit the home for the first time you would be able to read a ‘story’ about each person telling you in detail how they want to be supported. For example, the care plan will tell you how a persons likes to be helped in their personal care, which people are important in their lives and how they like to enjoy themselves. Another important area that is needed when supporting people with little verbal speech is to be able to understand what people are saying through their body language, behaviour and emotions. To understand what people are saying means that they can be offered greater choice, make decisions and so
11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 6 have greater control over their lives. The home has developed detailed guidance in the way that people communicate and this information is used to find out peoples reactions to situations and new activities to allow them to express themselves and be understood. Another area that the home does well is in identifying and supporting people to stay healthy. There is a good understanding of each person’s health needs and the home work closely with healthcare providers such as G.P’s, district nurses, occupational and speech and language therapist. The home has a manager who, since being appointed, has improved the standards of care and support people receive. They have the skills, motivation and values to put into place her ideas and belief in the role the home has in offering people a full and valued life. What has improved since the last inspection? What they could do better:
Although it has been mentioned that the home is well maintained, decorated and furnished the home and the housing association have not developed and agreed a planned programme of renewal and replacement which would allow better planning and use of resources. The laundry facilities need to be able to cope with the high level of use to maintain a safe and clean environment. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 7 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. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 2 People’s individual needs and goals were assessed prior to admission and on an ongoing basis. EVIDENCE: People were placed with the home through Manchester Children, Families and Social Care and Community Care Assessments were provided along with the Care Management Care Plans. The procedure for assessing a person’s needs prior to admission would be to ensure that a full Community Care Assessment and Care Plan had been developed and provided by the purchasing authority. The person would be visited as part of the pre-admission assessment process. This information would then be used to establish whether the home was able to meet the person’s needs. The assessment process continued through the post-admission stage where the home would undertake a in-house assessment to fully clarify the person’s needs and goals. Since the last inspection the home has re-assessed people’s social and leisure needs and goals and identified new activities and opportunities for people. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 6, 7 and 9 The home has identified people’s goals and aspirations and offers them the opportunity to make meaningful choices in relation to their day-to-day lives based on a through risk assessment. EVIDENCE: People’s Care Plans were seen and it was found that the service had developed a style of care planning that was descriptive, informative and set out people’s needs, goals and the support required to meet those goals from a person centred focus. This was recorded from the person’s point of view and written in the 1st person. The goals identified corresponded clearly with the assessment of need and included personal and healthcare goals, behavioural issues, mobility, medication, finances and social/leisure needs. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 11 The purchasing authority had introduced an ‘Essential Lifestyle Planning’ process for the home to develop that reflected the ‘Person Centred Planning’ agenda of the Government’s White Paper ‘Valuing People’. This work was now completed. The purchasing authority undertook annual multi-agency Care Management Reviews. The home also undertook informal monthly reviews of people’s support needs at staff meetings. Changes in people’s needs and goals had been identified and clearly recorded. The service had introduced its own formal six monthly review process. However, despite their efforts the home was finding it difficult to get other agencies involved in these reviews. Through discussions with the manager it was highlighted that the narrative style of Care Planning could be added too to make clear a person’s individual needs and goals so that these could form the basis for the review process in evidencing the progress made in achieving those goals. It was recommended that the home could further develop the care planning process to clearly identify and evidence the progress of achieving people’s goals. Over the past 12 months previous restrictions of people’s access to areas such as the kitchen had been removed. People had full access to all areas based on agreed risk assessments. People were encouraged to make decisions about their day-to-day lives through choices and through the home developing detailed guidance to help staff understand people’s body language and behaviours. People are encouraged to take part in the daily domestic activities of the home according to their ability and choice. The home has developed an extensive range of risk assessments that are reviewed and updated according to people’s changing needs. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15 and 16 The home offers people the opportunities and support to participate in valued social, leisure and household activities. Family relationships are supported and maintained and people take an active role in the home’s daily routines EVIDENCE: The home was supporting people to access new in-house and community based activities and were clearly recording people’s reaction to these activities to obtain their views and opinions. The home has worked towards establishing a structured base of activities that a person can access such as specialist day services. In addition they have identified with each person areas of activities that they do or may enjoy. This ‘menu’ of activities will allow people to choose and decide what they want to do. In addition the home is working to further the role of the staff team in developing their relationship and understanding of people and to encourage spontaneity in offering opportunities to add to the quality of their lives. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 13 The home encourages and supports people to maintain contact and relationships with their families and welcomes the involvement of family members. The home has a relaxed and informal routine. People are encouraged to take part in domestic tasks as much as possible. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 18, 19 and 20 The home supports people to maintain their personal and healthcare needs in the way they prefer and has a medication administration policy, procedures and system that protects people and maintain their wellbeing. EVIDENCE: The home had developed individual Care Plans that contained information and guidance that focused on the experience of the person regarding the personal care support required and was written in the 1st person. The home had re-assessed the moving and handling needs of people as their needs changed using both the organisations and specialist health provider input to develop clear risk assessments, guidance and training for the staff team. The appropriate equipment had been provided and through discussions and observation of the staff it was demonstrated that they were competent in moving and handling techniques. The home’s medication administration system was clear, accurate and contained an auditing and monitoring process. People’s use of medication was reviewed on a regular basis with the relevant healthcare professionals.
11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 15 The home undertook regular monitoring and recording of specific events in relation to people’s weight, epilepsy and emotional health on an ongoing basis depending on their health needs and the advice of relevant health providers. The home recorded detailed information of people’s health needs and access to health providers such as G.P., optician, dentist, chiropodist and other relevant specialists such as community nurses, speech and language therapists. The outcomes of all health appointments were clearly recorded. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 16 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 standard(s) 22 and 23. The home has policies, procedures and systems in place to raise concerns and to protect people from abuse and neglect. EVIDENCE: The Complaint Policy and procedure was seen during the previous inspection and found to contain clear guidance including the stages and timescales of the process. The policy covered all of the North West Community Services service. Evidence was seen that the complaints leaflet the service produced had been reviewed and updated to make it clear to people and their representatives that they can contact the CSCI at any time about their worries and concerns. The home had adopted the Manchester Multi-Agency Adult Protection Procedures and its own Adult Protection Policy was clear and related directly to the ‘No secrets’ guidance. Staff had read and had access to the policy which they had signed and dated. In-house adult protection training was provided by the organisation, for its staff through the induction process and training events. The organisations training plan was seen and showed that two training events had been planned for 2005. At the time of inspection not all the staff had attended specific adult protection training and it was not part of the ‘core’ training for each staff member. It was recommended that specific adult protection training form part of the core training provided to all staff. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 17 The ‘Whistleblowing’ Policy had been seen during the previous inspection and evidence showed that this policy was made available to the staff during their induction training. The policy relating to managing people’s personal finance was found to be comprehensive and provided a clear procedure and audit process. The balance personal spending money was checked and found to be accurate. The Physical Intervention Policy was seen at the previous inspection and found to have a clear procedure and guidance to assist staff in this area of their work. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 18 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 standard(s) 24 and 30 The premises were clean, homely, comfortable and safe but did not have the equipment in place to address issues of cross infection. EVIDENCE: The home’s premises was well decorated, maintained, comfortable and provides people with a homely environment. The main areas of the premises had been redecorated and refurbished to a good standard. The previous requirement relating to redecoration had been addressed. The issue of ongoing maintenance, replacement and decoration was discussed with the manager and found that there was still no formal agreement between the home and the Housing Association for a planned maintenance and renewal programme for the fabric and decoration of the premises. The home must ensure that it has developed such a programme with the housing association. The home support people with a high level of continence needs and has to clean soiled clothes and linen every day. The home has a domestic washing machine and this has broken down at least three times in the last six months. The home must ensure that it has the laundry facilities that can meet the high level of use and has the ability to meet standards of disinfection.
11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 The home’s recruitment and training policies and procedures ensure protection of people as well as providing sufficient well trained staff who receive regular job supervision and appraisal of their performance and training needs. EVIDENCE: The staff team consisted of the manager and six full-time support workers. The home provides 231 hours of direct support with between two and three staff on duty through-out the day and evening. There is sleep-in cover during the night. The staffing levels were sufficient to meet the needs of the people living at the home. The identification documents required under Schedule 2 of the Care Home Regulations 2001 and staff references were seen. The staff team Criminal Record Bureau (CRB) disclosure certificates and evidence that applications had been made to the CRB were seen at the previous inspection. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 20 The organisation provided an initial induction orientation programme and then a range of mandatory training for all staff that included First Aid, Moving and Handling, Health and Safety, Food Hygiene and Epilepsy awareness that was based on the Learning Disability Awards Framework. The organisation’s training programme for 2005/2006 was seen. Individual staff training and development plans were developed through the job consultation process and co-ordinated by the Training Manager. Through this process additional training needs were identified and relevant courses arranged and provided either in-house or through a training provider. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 and 39 People living at the home benefit from having a manager with the ethos and management skills to provide a quality service and the home has the systems in place to help people express their views and influence change in the service they receive. EVIDENCE: Since August 2005 the manager has taken responsibility for managing both Bacup Street and another of the organisations registered care home. During this time there has been significant improvements in the quality of the service people receive and in achieving the National Minimum Standards. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 22 She has shown that she has the skills, values and commitment to providing an open and transparent service that encourages innovation and creativity amongst the staff team. Senior managers within the main organisation (NWCS) undertook Regulation 26 inspections of the home every month. In addition, the Housing Association undertook a three-month maintenance audit of the premises. The purchasing authority had also undertaken a quality audit of the home. . People were involved in the monthly house meetings where issues affecting the house were discussed and actions agreed. Senior management were provided with the minutes from these meetings and would be used as part of the quality assurance process and the development of an annual plan for the organisation. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
11 Bacup Street Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x x x F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 24 No 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 24 Regulation 23 Requirement Timescale for action 1st September 2005 2. 30 16 A formal agreement between the home and the Housing Association must be developed for a planned maintenance and renewal programme for the fabric and decoration of the premises The home must ensure that it 1st has the laundry facilities that can September meet the high level of use and 2005 has the ability to meet standards of disinfection. 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. 2. Refer to Standard 6 23 Good Practice Recommendations It is recommended that the home sould develop further the care planning process to clearly identify and evidence the progress of achieving people’s goals. It is recommended that specific adult protection training form part of the core training provided to all staff. 11 Bacup Street F55 F05 s21701 Bacup Street v230818 D310505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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