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Inspection on 30/12/05 for 120 Feckenham Road

Also see our care home review for 120 Feckenham Road for more information

This inspection was carried out on 30th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is able to provide good staffing levels. This enables the team to meet the day-to-day needs of individuals. Staff are able to provide support and assist individuals to develop and retain their skills. Appropriate care plans were in place. Individual`s needs are recognised and documented. Good attention is given to the assessment of risks and meeting individual health care needs comprehensively.

What has improved since the last inspection?

The home had employed new staff and this had improved the quality of care provided. Good systems are in place to meet health care needs and to address healthy lifestyles for individuals. The staff team had worked hard to address risks by ensuring proper safeguards are in place. Service users are now attending further educational colleges. Individuals are involved in work experience placements. Service users viewed this positively. Access to advocacy services is being promoted and staff are supportive.

What the care home could do better:

CARE HOME ADULTS 18-65 Feckenham Road, 120 120 Feckenham Road Headless Cross Redditch Worcestershire B97 5AG Lead Inspector Martha Nethaway Unannounced Inspection 30th November 2005 03:15 Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 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 Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 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. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Feckenham Road, 120 Address 120 Feckenham Road Headless Cross Redditch Worcestershire B97 5AG 01527 401974 01527 544064 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) www.mencap.org.uk Royal Mencap Society Mrs Bonita Ann Clarke Care Home 5 Category(ies) of Learning disability (5), Physical disability (3) registration, with number of places Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may also accommodate one person with an additioanl visual impairment. The Home may also accommodate one person with additional dementia illness. This home is for people with learning disabilities, but may accommodate up to 3 people with additional physical disabilities. 31 June 2005 Date of last inspection Brief Description of the Service: The care home at 120 Feckenham Road provides long term care for a maximum of five adults with learning disabilities. The conditions of registration also permit up to three service users with additional physical disabilities, dementia and/or visual impairment to be accommodated. Two people with mobility problems can be accommodated in ground floor bedrooms. The aim of the home is to support service users to lead as normal a life as possible with active involvement in the local community. The home was formerly a large family house that has been adapted for its present purpose. It is located in a pleasant residential area of Redditch and has a level, enclosed garden at the rear. Service users are accommodated in single bedrooms, two of which have an en suite bathroom or shower room. Golden Lane Housing Association owns the premises and the registered proprietor is the Royal Mencap Society. The responsible individual is Ms Janine Tregelles. The service manager is Mr T. Hickey who provides line management support and supervision to the registered manager. Bonita Clarke is the registered manager. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 2.5 hours. One inspector visited the home and discussions were held with the service users and management team. A random selection of records was examined. What the service does well: 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. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 6 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 Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 7 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): EVIDENCE: None of these standards were examined on this occasion. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 8 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): 9 Individuals are well supported and good arrangements exist to analyze and address areas of risks. EVIDENCE: The registered manager had introduced a comprehensive risk assessment process and all staff had been provided with training. Information on risk assessments was held centrally to assist with auditing and monitoring purposes. Discussions with senior staff indicated that service users involvement was sought where appropriate. Staff had also contributed and team meetings evidenced further discussion of risk assessments. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 9 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, & 17 The staff team enables individuals to achieve success with their work placements and further education. Service users spoke positively about their involvement with local community resources. The arrangements for meals ensure that dietary needs of individuals are being met. There is good access with the local advocacy organisation and one individual is using this service. EVIDENCE: Discussion with one service user indicated they accessed a good range of work placements and had developed and maintained good social networks. This included working at a local florist and a coffee bar. The comments made were positive about staff enabling this to happen and being supportive. Other service users are attending local mainstream adult education college. The courses being accessed included pottery, cake decorating, dance and Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 10 flower arranging. This was a significant improvement since the last inspection visit. Additionally a number of service users attend the local day service provision. The home allocated one day for each service user to focus on developing daily living skills. Staff provide one to one support and concentrated on areas to develop and extend skills. This included domestic daily living skills including shopping, cooking and cleaning. Individual’s dietary needs were documented in the care plans. Staff were familiar with the likes and dislikes of service users and information was available on all the files. Examination of the menu records evidenced choice and alternative meals were available. Service users were expected to prepare the evening meal as part of their ‘home based training day’. Staff support and supervise this process. On the evening of the visit the meal cooked was, fish in parsley sauce, vegetables and mashed potatoes. For dessert it was ice cream and strudel. The registered manager has been proactive about involving advocacy services. One service user now attends a sub group of the local advocacy group, Worcestershire Valuing People Board. The service user reported her involvement as beneficial. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: None of these standards were fully examined on this occasion except in relation to meeting the previous requirements. The previous short falls were now addressed in relation to medication monitoring and addressing health care effectively. Effective measures were in place to monitor and review records relating to medication that is administered to service users. All service users had a ‘health action plan’ that deals with all health care matters comprehensively. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: None of these standards were fully examined on this occasion except in relation to meeting the previous requirements. The registered manager is reviewing the complaints system. The manager had introduced a system that ensures all allegations and incidents of abuse, and actions taken are recorded. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: None of these standards were fully examined on this occasion except in relation to meeting the previous requirement. The home had now adopted an appropriate infection control policy. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 14 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): 34 & 35 Recruitment practices are sound and staff training is addressing the professional needs of the team. EVIDENCE: The homes recruitment practices were examined. Three files were looked at and these were found to be coherent and well organised. The files contained proper evidence relating to recruitment checks. Previous employers written references were available and checks by telephone reference had been completed. All employees are subjected to a six-month probation period with an initial 3-month review. The home has recruited three fulltime staff members and this had improved the staffing levels. Staff training was checked. The registered manager was in the process of organising a training file for each member. A number of the staff team are newly recruited and were completing their core mandatory training schedule. A system needs to be developed to ensure all staff receive continual professional development of at least five paid training and development days (pro rota) per year. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 15 Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 16 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): 39 Arrangements are in place to consult with individuals and the staff have the capacity to address issues raised. EVIDENCE: There are a number of mechanisms used to consult with service users. These include keyworker sessions, questionnaires, annual reviews and house meetings. The registered manager operates an ‘open door’ policy to enable service users to express their views when not satisfied. Mencap also integrates the findings from questionnaires into the ‘service development plan’. This enables areas for improvement to be identified and addressed at a local and organisational level. Royal Mencap are committed to responding to the views of service users and families and or relatives. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 17 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 x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Feckenham Road, 120 Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x x x DS0000018481.V270805.R01.S.doc Version 5.0 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA26 Regulation 12 Requirement Timescale for action 30/06/05 2. YA29 12 3. YA30 13, 16 A lock, with an appropriate override device, must be fitted to the door of the service users bedroom on the ground floor New timescale set Opportunities and/or equipment 30/06/05 must be provided to enable two of the service users to develop their communication skills. New timescale set Policies on the control of 30/06/05 infection must be drawn up to include the safe handling and disposal of clinical waste, dealing with spillages, provision of protective clothing and hand washing. New timescale set Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 19 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 YA24 YA39 Good Practice Recommendations A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented. A system must be developed to ensure all staff receive continual professional development of at least five paid training and development days (pro rota) per year. Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 20 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Feckenham Road, 120 DS0000018481.V270805.R01.S.doc Version 5.0 Page 21 - 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. 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