Inspection on 08/03/06 for 164 Walker Road

This inspection was carried out on 8th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

164 Walker Road 24/02/07

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 Mrs Mandy Beck Unannounced Inspection 8th March 2006 8:50 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 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.V286042.R01.S.doc Version 5.1 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.V286042.R01.S.doc Version 5.1 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 Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the homes first inspection 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. There is a large garden to the rear of the property with access for all service users. The home is well maintained and pleasantly decorated; it is situated near to local amenities, Walsall Arboretum and town centre. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the first one since the home opened last year. It began at 08:50 and was completed 13:30 and was undertaken by one inspector. Most of the key standards were assessed and judgments made within this report are based upon discussions with the manager and other care staff, a tour of the building, examination of staff files, the home’s policies and service user files. None of the service users were available to talk to on the day of inspection. The inspector would like to thank everyone at the home for a very positive inspection and their hospitality throughout. What the service does well: What has improved since the last inspection? What they could do better: This was a very positive inspection with few requirements. The company/manager needs to develop the home’s quality assurance systems within the home and demonstrate the involvement of the service users within this process. A nutritional screening tool needs to be introduced and service users weights must be recorded on a monthly basis. The manager needs to develop a training and development programme for all staff, this will include both mandatory and specialist training subjects. The adult protection policy needs to be updated and training secured for all staff. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 6 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. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 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.V286042.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users can be assured that their needs will be thoroughly assessed prior to admission to Walker Road EVIDENCE: All of the service user files seen contained a comprehensive assessment of need that had involved the service user, care manager, psychiatrist and home manager. This means that service users can be assured that their needs have been assessed and that the home will have a detailed understanding of how to meet those needs once they move in. The assessment also contained information on therapeutic needs and provides the basis for the individual service user plan. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Service users are supported in their daily lives to make choices, and their service user plan reflects this. Information and assistance is given to enable service users to make decisions about their own lives. EVIDENCE: Each service user has in individual plan that details how there needs are to be met. It was pleasing to see that all of the risk assessments and care plans had adopted a person centred approach to their planning and gave a clear picture of each service users needs. There are clear guidelines for the management of challenging or aggressive behaviour and these are reviewed regularly, although the home manager needs to explore ways to demonstrate service users involvement in this process. Service users are encouraged to make choices in their daily lives, some service users do have restrictions placed upon them, these have been identified as part of ongoing vulnerable adults agreements and are documented within the file. Staff were able to demonstrate a detailed understanding of all of the service users and knew how to promote their strengths and support them with the weaker elements of their capabilities. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 10 There are comprehensive risk assessments in place for all service users these are reviewed regularly and amended as required. Each risk assessment has a an identified management plan that indicates how risks are to be minimised. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Service users are actively encouraged to continue their education, maintain their links with the local community and have appropriate family and personal relationships. The home offers a well balanced diet to all service users based upon their cultural and dietary needs and their individual preferences. EVIDENCE: All of the service users at Walker Road are either in full time education, attending day centres or have structured programme of activity. Two of the service users are due to leave school in July 2006 and they have expressed at wish to continue their education, the manager is helping them find out about further education and the possibility of attending college. There is no formal activity programme within the home but there is evidence that all service users make use of local facilities, going out shopping, visiting the cinema and leisure centres. Service users have the choice of what they want to do. On the day of the inspection one service user had taken the opportunity to visit Cadbury World. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 12 Risk assessments are in place for all service users when using public transport although most of the service users prefer to use the home’s own transport when they go out. There was evidence to show that the home actively fosters relationships for each of the service users, family and friends are welcome and service users have the choice to see visitors in the privacy of their own rooms. Service users are offered a nutritious and varied diet, the menus can be planned up to four weeks in advance and have been agreed by service users and based upon their likes and dislikes, dietary requirements and cultural needs. Staff have received food hygiene training and prepare meals freshly at the home. In addition to this the staff are working with service users to produce a pictorial menu to make food identification and choosing easier for service users. At present there is no nutritional risk screening tool in use at the home and the manager should address this and also the monthly recording of service users weights. The kitchen was seen during the inspection but not thoroughly inspected this will looked at in more detail at the next inspection. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Service users do receive personal care in a way that they prefer and their physical and emotional needs are met. Medication is administered in a satisfactory manner and the home has adequate policies and procedures in place when dealing with medication. EVIDENCE: Service users at Walker Road are able to receive personal care in a way that they find acceptable to them. Their individual care plans are detailed and leave the reader in no doubt as to how care is to be delivered. All service users have en-suite facilities in their own bedrooms this helps to ensure that intimate care is carried out in private. There is evidence that service users receive additional support from specialist services should they require it and there are aids and equipment around the home to maximise service users independence. There is on service user who is unable to access the bath at present and the company needs to consider ways to make this possible for them as this was an area of personal care they had enjoyed prior to living at Walker Road. All service users have access to NHS healthcare facilities in the locality and are supported to attend out patients and other appointments. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 14 Medication is generally administered in a safe manner, there has been one drug error, which did not result in any harmful effect to the service user and the manager was able to demonstrate effective strategies to ensure that the risk of error is reduced in future. All staff are now enrolled with Wolverhampton University and are currently completing the safe handling of medicines training, the manager has also introduced a comprehensive in house training package for all staff. Records are kept of all receipts, returns and administration, there were gaps on some of the Medicine Administration Record (MAR) sheets and the manager needs to take steps to ensure that all MAR sheets are completed there must be no gaps and appropriate codes must be used. There are no facilities at Walker Road for the cold storage of medicines although at present they are not required. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service users views will be listened to and acted upon, the adult protection policy needs updating to ensure that service users will be protected from abuse. EVIDENCE: The home has not received any complaints since it was registered in August 2005, the complaints policy needs amending to include the correct address for the Commission for Social Care Inspection and all of the information required in the national minimum standards. Consideration should also be given to providing information for service users in a way that they understand. The home does have a policy for the protection of vulnerable adults but this needs to be updated to include details of the Protection of vulnerable adults register and the conditions staff will be referred for consideration for inclusion to the register. The manager also needs to ensure that all staff receive training in Adult Abuse Awareness. Most of the staff at the home have completed training that enables them to understand and to deal with physical and verbal aggression in the best interests of the service user. At present there is no policy that addresses the protection of service users finances, this needs to be rectified so that service users can be assured their monies are in safe hands at all times and staff have clear guidance when dealing with service users money. Despite the lack of policy the home has robust procedures in place, every transaction is recorded and receipts are provided. Each service user has their own locked money box and this is kept within a locked cabinet. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 16 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): 24,30 The home is very well presented and is clean and tidy EVIDENCE: A tour of the premises was undertaken, the home is airy and bright and free from offensive odours. Service user bedrooms were seen and were all pleasantly presented with many of their possessions on display, rooms are of a good size and all have en-suite facilities, only one room does not have a bath or shower. The kitchen is of a domestic style and well maintained as was the laundry. The home has a sluice where mops and cleaning equipment is stored. The manager must ensure that mop heads are stored inverted and that they are washed on a daily basis not in the sluice sink. Laundry is washed at appropriate temperatures to control the risk of infection, there are prominently sited hand washing facilities and there is ample protective clothing and gloves. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 17 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 Staff are recruited in a way that safeguards service users and in accordance with the homes policies and procedures. Staff receive induction training and their training needs have been assessed to ensure staff have the necessary skills to meet service users needs. EVIDENCE: The home generally recruits staff in a safe manner, the recruitment process requires some fine tuning to ensure that it meets all the required standards. Staff files were examined and generally included all required information, the manager must make sure that all gaps in employment history have been explored and documented. Relevant checks had been completed these included POVA/CRB disclosures and obtaining two written references. The home has a structured induction programme in place this includes safe working practices, the particular needs of the service users and medication training. In addition to this staff working at the home us Learning Disability Award Framework accredited training to underpin their knowledge. The manager has worked well in organising training for all of the care staff but now needs to complete a training needs assessment for all the staff team and develop an individual training and development profile for all staff. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 18 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): 39,42 The health, safety and welfare of all the service users is promoted by the homes safe working practices. There is currently no working quality assurance system within the home EVIDENCE: The manager has been in post since December has made good progress in arranging training for all staff in moving and handling, fire safety training, first aid and food hygiene. Infection control, health and safety training remains outstanding and the manager is taking steps to rectify this. The home is well maintained and certificates were seen that indicated that all equipment is regularly checked, electrical equipment and systems, water regulation, boilers and central heating systems have all been recently inspected. All staff are receiving training on safe working practices during their induction. At present the manager is the process of developing a quality assurance system that will form the basis for self monitoring and further development of the homes service based on the service users views. 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 19 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 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 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X 1 X X 2 x 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 20 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 YA6 Regulation 15 Requirement The manager must demonstrate service users involvement in planning and reviewing of their service user plan, where this is not possible it must be documented within the service users file. The manager must ensure that nutritional screening is completed for all service users and that a record of their weights is regularly documented The manager must ensure that MAR sheets are completed in all cases and there must be no gaps, appropriate codes must be used. The manager must amend the complaints policy to include the correct name, address and telephone number of the Commission 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 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 21 Timescale for action 01/05/06 2 YA17 17(1)(m) 01/05/06 3 YA20 13(2) 01/04/06 4 YA22 22(7)(a) 01/04/06 5 YA23 13(6) 01/05/06 6 YA34 19(b) sch 2 The manager must ensure that all staff files include of the required documentation, in this case a recent photograph. The manager must ensure that all gaps in employment history are accounted for and documented The manager must complete a training and development plan for all staff The manager must develop an effective quality assurance system. The manager should involve the service users and staff at Walker Road in this process. The registered provider must complete visits in accordance with regulation 26 The manager must ensure that all mandatory training is arranged for all staff to undertake 01/04/06 7 YA34 19 sch 4 01/04/06 8 9 YA35 YA39 18(c)(i) 24 01/06/06 01/07/06 10 9 YA39 YA42 26 18(c) (i) 01/04/06 01/07/06 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 3 Refer to Standard 20 30 42 Good Practice Recommendations It is recommended that a suitable facility be provided for cold storage of medication It is recommended that all mop heads are stored inverted and are machine washed daily It is recommended that a moving and handling assessment be completed for staff in respect of the low bed for one of the service users 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 22 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: 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 164 Walker Road DS0000064983.V286042.R01.S.doc Version 5.1 Page 23 - 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!