Inspection on 24/02/07 for 164 Walker Road

This inspection was carried out on 24th February 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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

164 Walker Road 08/03/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 164 Walker Road Blakenhall Walsall West Midlands WS3 1BZ Lead Inspector Ms Linda Elsaleh Key Unannounced Inspection 24th February 2007 09:45 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 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 164 Walker Road DS0000064983.V329757.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 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. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 164 Walker Road Address Blakenhall Walsall West Midlands WS3 1BZ 01922400073 01922400077 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) enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Sarah Ann Pickard Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2006 Brief Description of the Service: Walker Road is a care home for younger adults. It provides a home for four service users who have a learning disability and challenging behaviour. The property has four bedrooms all with en - suite facilities. There is a spacious lounge and dining room, a fully equipped kitchen and separate laundry. A large garden is at the rear of the property. This is accessible to all service users. Off-road parking is available at the front of the premises. The home is well maintained and pleasantly decorated and is situated near to local amenities, Walsall Arboretum and town centre. The fee for this service ranges from £1400 to £2040.10 per week. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 24th February 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults (18-65) and report on the progress made to address requirements made at the previous inspection. The inspection process included information received about the home, comments received from relatives, discussions with staff, observations of care practices and examination of relevant documentation and records. The home has addressed six of the ten requirements made at the last inspection and a further four requirements have been made. The inspector would like to thank everyone at Walker Road for their cooperation and hospitality throughout this visit. What the service does well: What has improved since the last inspection? The home has provided alternative bathing facilities to meet the individual needs of one service user. Pictorial images have been developed further to support service users in expressing their views and improving their communication skills. Nutritional screening has been completed to ensure all the service users dietary needs are being met. Medication Administration Record (MAR) sheets are fully completed and, where applicable, appropriate codes are being used. A staff training and development plan has been produced that includes various mandatory and client-centred courses. 164 Walker Road DS0000064983.V329757.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. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. Prospective service users can be assured their individual needs and aspirations will be assessed by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions since the previous inspection. The previous report confirmed comprehensive assessments are undertaken of prospective service users’ needs. The service user, relatives, home manager and relevant professionals are involved in this process. The home has produced an individual plan of care each service user All service users’ care plans are regularly reviewed by the home. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. Service users assessed and changing needs and personal goals are reflected in their individual care plans. They are supported to make choices in their daily lives and, wherever appropriate, assisted to take responsible risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans examined during this visit contained detailed information of how their individual needs are to be met. Clear guidelines are provided for the management of challenging behaviour. Since the last inspection staff have attended training in care planning and managing challenging behaviour. The service user’s progress is discussed at staff meetings and regularly monitored and reviewed by her/his key worker. Service users are consulted on a regular basis about their care. A written statement is available of service 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 10 users who are unable to participate fully in this process. The reviewing process must involve significant professionals, family/friends and advocates, with the service user’s agreement where possible, at least once every six months. Service users are encouraged to make choices about their daily lives, such as how they wish to spend their leisure time. Some service users have restrictions/limitations placed on them. This is based on their ability to make informed decisions and the need to keep them safe. In such circumstances a record is kept on the service user’s file. Comprehensive risk assessments are in place for each service user detailing how risks are to be minimised. These are included in the regular reviews carried out by the home. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. Service users are encouraged to maintain relationships, continue learning, develop interests and participate activities in the local community. Service users are supported to make their own choices and their right to privacy is observed. The home offers a varied and balance diet based on dietary and cultural needs and personal preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has her/his own routines and includes education placements and/or day centres during the week. Service users are supported to follow their own routines such as getting up/going to bed and when they wish to be 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 12 alone or in company. Service users may have a key to their bedroom, if they wish. Staff are able to gain access if they are concerned for a service user’s safety. Service users are encouraged to make their own choices about how they wish to spend their leisure time. One service user attends a weekly luncheon club. During this visit one service user went shopping with a member of staff, one spent time in the lounge and another chose to spend some time in her/his bedroom listening to music. The home arranges for service users to go on holiday and last year included stays at Blackpool and a holiday centre in Nottinghamshire. The written policy that refers to service users’ holidays does not meet Standard 14.4 of the Care Homes for Adults (18-65) National Minimum Standards or reflects the home’s practice. Therefore, the policy must be revised and service users’ contracts reviewed to ensure all relevant information is included. Nutritional screening has been completed for all service users. They are encouraged to follow healthy eating programmes. The menus show nutritious and varied meals are provided that meet service users’ needs and likes and dislikes. The menu for the day is displayed in the dining room and service users are supported by pictorial images to assist in their selection of meals. Snacks and drinks are provided throughout the day. All staff are trained in basic food hygiene. Service users are provided with opportunities to shop for food supplies with staff. Staff support service users, wherever appropriate, to maintain positive relationships with family and friends. The home welcomes visitors to the home and service users are able to choose if they wish to see visitors in the privacy of their own home. Relatives, who chose to comment, were complimentary about all aspects of the home. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. Service users receive personal care from staff that are familiar with their physical and emotional needs and individual preferences. There are policies and procedures for the safe handling of medication. Medication is administered by staff who have been suitably trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff provide personal care to all service users in accordance with the individual care plan and preferences. Additional support is provided by relevant specialists when required and aids and adaptations are provided/installed to meet service users needs and to promote independence. All bedrooms have en-suite facilities and there is also a spacious bathroom on the first floor. The shower in the en-suite facility for one service user is in the process of being replaced with a bath that better meets her/his individual needs and preference. Staff training in manual handling has been booked for 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 14 this month and will include the use of the hoist fitted to the new bath. A risk assessment has also been completed for the low bed provided for one service user. All service users have access to NHS healthcare facilities in the locality, regular appointments are made for routine checks and records are kept of all their health care needs and how these are to be met. These are closely monitored enabling any concerns to be addressed promptly. The home manages all medication on behalf of the service users. There are suitable procedures for the receiving, storing, administering and returning medication. Additional information and guidance is also available to staff. The Medication Administration Record (MAR) sheets are appropriately completed. The service user’s GP or consultant regularly reviews her/his medication and written guidance is provided for medication that is administered when required and for homely remedies. A facility for the cold storage of medication has been provided since the last inspection. Staff training in the safe handling of medication is provided by Wolverhampton University and the manager provides an in-house programme. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. Service users views are listened to and acted upon. The home must review its policies to ensure service users will be fully protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has received two complaints since the last inspection. The manager is in the process of investigating these. In response to the last inspection report the manager has referred the complaint policy and protection of vulnerable adults policy to the company’s policy co-ordinator. This needs to be completed and updated policies made available to staff. Training in the protection of vulnerable adults is scheduled for May and June of this year. In the meantime the manager confirms that adult protection issues and procedures staff must follow in the event of an allegation/observation of abuse has been discussed with them during planned supervision. Service users’ personal allowances are managed on their behalf by the home and held separately in a secure facility. Each transaction is recorded and 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 16 receipts retained. However, finances and/or personal allowances managed on the service user’s behalf must be discussed and agreed by all significant people and detailed arrangements included in her/his care plan. The home’s policy for managing service users finances, dated August 2006, must be reviewed to ensure compliance with current legislation, the Care Home’s for Adults (18-65) National Minimum Standards and the Service Users’ Contracts. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is excellent. Service users are provided with a homely, comfortable and safe environment to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is good access to the property with some off-road parking available for visitors. The home is bright and cheerfully decorated and well furnished. Service users have access to a spacious lounge, dining room and rear garden. The kitchen is of a domestic style and well equipped. Service users are encouraged to participate with some tasks such as simple preparations for meals and washing up. For safety reasons service users are not allowed unsupervised access to the kitchen. The laundry is also well equipped. Cleaning equipment and protective clothing and gloves are stored here. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 18 Service users’ bedrooms include en-suite facility, of which three include a bath or a shower. The position of the toilet in the en-suite of one bedroom is close to a facing wall and consideration needs to be given to whether this can be resited. There is a spacious bathroom on the first floor. Bedrooms seen were well decorated and furnished to a good standard. Service users possessions are pleasantly displayed and reflect the their personality and interests. Policies and procedures for health & safety practices such as infection control and control of substances hazardous to health are available in the home. The home is pro-active in identifying areas for improvement and reporting repairs. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is excellent. The staff team are competent and trained in meeting the individual and joint needs of the service users. The home completes safety checks on prospective staff to ensure service users are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager and deputy were not on duty during this unannounced visit. Therefore, the inspector was unable to examine the staff files. At the last visit the inspector was able to confirm systems were implemented to ensure POVA/CRB (Protection of Vulnerable Adults & Criminal Record Bureau) checks were completed on all staff prior to employment. Information provided by the manager prior to this visit confirmed shortfalls identified in the last report have been addressed. Staff files will be examined fully at the next visit. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 20 Staff demonstrated a good knowledge of the needs, interests, likes and dislikes of service users. Care was provided in a positive and caring manner. Service users were encouraged to communicate their wishes and supported to do through the use of pictures and symbols, where applicable. Over 50 of the Care staff team hold a National Vocational Qualification Level 2 (or equivalent). Two staff are in the process of completing this training and one is waiting to receive her/his certificate. Staff have also attended courses for working with clients with autism and the use of makaton. A member of staff who has been employed since the last inspection spoke positively about the home’s induction process for new staff. This included becoming familiar with the home’s policies, procedures and practices, ‘shadowing’ workers to get to know service users and attendance on mandatory training courses. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. Service users benefit from a well run home. The health, welfare and safety of service users is promoted by the home’s safe working practices. The home’s performance will be further enhanced through the implementation of an effective quality assurance system. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post since December 2005 and the Commission for Social Care Inspection (CSCI) has approved her application for registration. There are suitable policies and procedures in place for regular servicing and safety checks to be carried out on appliances and equipment. Staff have 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 22 received training to ensure the home continues to be a safe place for service users. Since the last inspection the home has continued to improve systems for supporting service users to express their views, for example, pictorial menus. The home has yet to fully produce and implement a quality assurance system for self-monitoring. However, systems are in place for obtaining the views of service users, relatives, visiting professionals and staff as part of this process. The registered provider’s monthly reports on the conduct of the home were not available at the time of this visit. 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 2 X X 3 X 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The manager must ensure the care plan is reviewed at least once every six months with significant professionals, family/friends and advocates as agreed by the service user or where applicable The policy that refers to service users’ holidays and service users’ contracts must be revised The manager must amend the complaints policy to include the correct name, address and telephone number of the Commission Previous date for compliance, April 2006, not met The manager must review the adult protection policy to include Protection of Vulnerable Adults (POVA). The manager must provide all staff with training in vulnerable adult abuse awareness Previous date for compliance, May 2006, not met Timescale for action 13/07/07 2. 3. YA14 YA22 12 22 18/05/07 18/05/07 4. YA23 13 18/05/07 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 25 5. YA23 15, 12 Arrangements for managing finances/personal allowances on behalf of a service user must be detailed in her/his care plan The home’s policy for managing service users’ finances must be reviewed to comply with legislation, NMS and service users’ contracts The toilet in the en-suite of one bedroom needs to be re-sited to ensure appropriate access for the user The manager must develop an effective quality assurance system. The manager should involve the service users and staff at Walker Road in this process Previous date for compliance, July 2006, not met The registered provider must complete visits in accordance with regulation 26 Previous date for compliance, April 2006, not met 18/05/07 6. YA24 23 18/05/07 7. YA39 24 18/05/07 8. YA39 26 18/05/07 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 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 164 Walker Road DS0000064983.V329757.R01.S.doc Version 5.2 Page 27 - 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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