Inspection on 28/08/07 for 180 Bromwich Road

This inspection was carried out on 28th August 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

180 Bromwich Road 04/07/06

180 Bromwich Road 06/03/06

180 Bromwich Road 07/07/05

180 Bromwich Road 22/02/05

180 Bromwich Road 14/09/04

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 Bromwich Road, 180 180 Bromwich Road Worcester Worcestershire WR2 4BE Lead Inspector Christina Lavelle Key Unannounced Inspection 28 August 2007 12.15-7.15 th Bromwich Road, 180 DS0000018636.V343451.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 Bromwich Road, 180 DS0000018636.V343451.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. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bromwich Road, 180 Address 180 Bromwich Road Worcester Worcestershire WR2 4BE 01905 428030 01905 429731 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 Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This service is for people with a learning disability but may accommodate one person with an additional physical disability. The home may also accommodate one named person with an additional mental disorder. 4th & 5th of July 2006 Date of last inspection Brief Description of the Service: Bromwich Road is run by the Royal Mencap Society, which is also a registered charity and is one of the largest providers of services for people with learning disabilities in the United Kingdom. Mencap’s mission statement for its service users is “To fulfil our ambitions, experience lots of things and make our mark in the world”. The registered manager has recently left the home and the deputy manager (Ms Jane Tudor) is currently taking the day-to-day management responsibility for the service. Bromwich Road was converted to a home in 1990 and provides accommodation with personal care for up to six people. The stated aim of the service is to provide a long-term home for adults with learning disabilities. Service users may also have physical disabilities, a sensory impairment and communication difficulties and some may use behaviours that could challenge a care service. 180 Bromwich Road is located in a residential area of Worcester less than two miles from the city centre. Public transport, shops and leisure facilities are within easy reach. The home is a traditional detached house and has a parking area, patio, and large gardens at the back. It offers six single bedrooms (none with en-suite facilities) two being on the ground floor. One bedroom is suitable for wheelchair users, as it has wide doors one leading straight into a bathroom with an assisted bath. The home also has three shared bathrooms, a lounge, dining room, conservatory, kitchen, laundry room, an office and staff room. Information about the service is provided in a statement of purpose document and a service users’ guide. This guide is available in an easy read format and includes photographs of the home, staff and facilities in the house and the local community. The fee for the service is as agreed by Mencap and service users’ funding local authority. People who live at the home have to pay in addition for their own clothes and toiletries, social activities, college fees, luxury items, some travel expenses and the cost of holiday accommodation and transport. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a key inspection of the service provided at Bromwich Road. This means all the Standards that can be most important to people who live in care homes were checked. This inspection visit was made without telling anyone at the home beforehand. Time was spent talking with the people who live there and to some of the staff. The way the home is being run and any changes made since the last inspection were also discussed with the deputy manager. Survey forms were left at the home for some staff and people who live there asking what they think about the service. Other surveys were sent to their families and four health or social care professionals involved with their care. Seven surveys were returned and their views are referred to in this report. An annual self-assessment form was also completed before this visit. This asks managers to say what they feel their home does well, what it could do better, what has improved and about their plans to improve the service. It includes information about the people living there, staff and other aspects of the home. Various records kept by the home were checked and the house looked around. All information received by the Commission about Bromwich Road since the last inspection is also considered, such as events affecting people living there. What the service does well: Bromwich Road is homely and friendly and the people who live there seem well settled and to get on with staff. One relative says ”The general atmosphere is of a happy inclusive family. Individual traits appear to be much catered for”. Each person living at the home has a care plan they are involved in making. Plans show all their needs, likes and dislikes, possible risks and some of their personal goals. They help staff know how to support them and keep them safe. People living at the home can make choices about what they do each day and staff encourage them to be independent and develop their life and social skills. They are also supported to take part in activities they like and to go out and mix in the community. One relative says that the home “Helps residents live happily and socially. Joining in activities, doing jobs for themselves around the house, keeping interested and fulfilled and as independent as possible”. Staff make sure that all the personal and health care needs of people who live at the home are met. They also manage their medicines safely on their behalf. 180 Bromwich Road is an ordinary house, which helps people living there fit in with the community. It offers them a secure, well-kept and comfortable home and is in a good place near Worcester city and to local shops and facilities. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 6 Staff receive training so they know how to keep the home and people safe and understand and have the skills to meet their special needs. Necessary checks are taken up to help ensure new staff are suitable to care for vulnerable adults. The homes provides good individual care for people who live there. The quality of the service is checked and plans made to keep improving it for their benefit. 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. The summary of this inspection report can be made available in other formats on request. Bromwich Road, 180 DS0000018636.V343451.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 Bromwich Road, 180 DS0000018636.V343451.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. This judgement has been made using available evidence including this visit to the service. Thorough assessment and admission procedures are in place to help to ensure the home could suitably meet the needs and wishes of potential service users. EVIDENCE: The required information documents are provided, which include a statement of purpose and a service users’ guide. The guide for the home is available in a user-friendly format. It includes photos of the house, staff, facilities in the local community and some that show how the home promotes the independence, dignity and privacy of people living there e.g. by knocking their bedroom doors and enabling them to manage their own money and choose their menus. There are guidelines available for the assessment of prospective service users’ needs and admission procedures. Although no one has moved into Bromwich Road for more than four years the deputy manager confirmed the assessment and introductory processes the home will follow should a referral for a possible placement be made. They would first receive a community care assessment completed by a social worker. The manager would then visit the prospective service user at their current residence to meet them and assess their needs. Following this at least three or four introductory visits to the home would be arranged and if these were successful they could move in for a trial stay. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 9 Their needs would have been discussed with the staff team, who would also be involved in the assessment process during their visits and trial stay. The importance of monitoring and obtaining the views of people already living at the home about possible new residents is clearly recognised. The manager is responsible for ensuring that the new individual would fit in with existing residents as well as confirming the home could appropriately meet their needs. Relevant other people (e.g. families) would be fully involved in the assessment and introduction of a new person to the home. A review meeting would be held at the end of the trial stay to make a decision about the suitability of the placement (including compatibility with other people living there), which would involve the new people themselves, their family, social worker and home staff. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. People who live at the home all have a care plan showing their needs, likes and dislikes with risk assessments to minimise safety risks. Whilst they can make choices in their daily lives and routines (as far as they are able) plans should focus more on their goals and the support needed to ascertain and meet them. EVIDENCE: A sample of care records kept for each person living at the home was looked at. They include their photograph, information about their background and family, a detailed life story and a description of their home. There is also an assessment of their needs and skills and a list of their likes and dislikes. They all have a care plan showing their needs (based on their skills assessment) and any support they need in respect of relevant areas such as personal and health care, communication, behaviours, medication, finances, shopping and cooking. The home has adopted an appropriately “person centred” (PC) approach to care planning. This aims to involve individuals in planning their own care and Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 11 making choices as far as they are able to. The PC plans had been drawn up with their involvement when possible and through consulting significant others, such as their relatives. Plans are being reviewed six monthly as they should be and it is good that individuals can choose who they wish to invite to attend a more formal annual review and where they are held and if they want to participate themselves. keyworkers are also allocated to each person from the staff team and who give them more individual support. Their role includes care planning and reviews and they help them complete a pre-review questionnaire. Some personal goals are set as part of the PC plans, although it is good that the home plans to focus more on setting and achieving goals. When plans are reviewed they should also reflect if their goals are being achieved with the outcomes detailed and any benefits to each person (or not). To assist the goal setting process more staff are to receive training on effective communication techniques. Pictorial support plans are also to be introduced and photographs and objects of reference used more to promote choice making. One person already uses a communication board so they know which staff will be coming on duty and there are pictures of meals to enable them to choose the menus. The home has a clear risk assessment policy in place to help keep people safe, whilst not restricting their freedom unless their safety could be affected due to their vulnerabilities. Risk assessments are being carried out and do primarily relate to minimising safety hazards such as falls, accessing the community and managing their own finances. Some people also have behavioural management plans to guide staff as to how to diffuse and/or deal with any aggressive or self-harming behaviours. Risk management should also however be directly linked to their PC plans and focus on promoting an independent lifestyle. Regarding issues of equality and diversity the home’s philosophy and practice appropriately focuses on the individuals’ needs. Whilst there are no specific or cultural differences amongst current residents gender issues are considered in relation to staff supporting then with personal care. The induction programme for new staff includes a module called “Value Me” and staff will be attending a session on the Mental Capacity Act. This should ensure the home is clear about the process of setting up best interests groups and how to ensure decisions are made by appropriate others when a person cannot make informed choices. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. People who live at the home are supported to take part in activities they enjoy and to mix in the community and maintain links with their families. Staff also respect their individuality and encourage development of their social and life skills. The home provides food people like whilst healthy options are promoted. EVIDENCE: Everyone who lives at the home has an activity plan with records kept of their activities and outings. Activities should also be linked to their interests and assessed social & developmental needs and so some people have specific goals which include exercises, language practice and washing and shaving at their wash hand basin. There is evidence that action is being taken to meet and to achieve these personal goals and that their goals and outcomes are reviewed. It is positive that staff are making efforts to find and facilitate a variety of new individualised social and leisure and adult educational activities. This has been Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 13 helped by the home having two vacancies however because staff have had more time available to support them. The implications on staffing would need to be considered should a referral be received for a prospective service user. Since day service provision in the area was cut staff have found alternatives such as projects in horticulture & animal care and music therapy. Some people are enrolled on college courses such as cookery, arts & crafts and life skills. Most of them go out somewhere every day, including to a hydrotherapy pool and snoozelen sensory centre. They choose their own holidays and outings and can go out for drives in the home’s minibus (which has a tail lift) or they use taxis and public transport. One person had been on a cruise this year and another to visit museums because they like engines. Some people can walk or use a wheelchair to visit local pubs and shops and go to Church. It is good that staff report some people’s behaviour has improved significantly since their admission and that their community integration and activities have increased. Staff also aim to encourage independence, life skills development and making choices in respect of their daily routines. However although some people are involved in household tasks and meal preparation (although this may just be observing) the manager does acknowledge that this could be extended. This would be good and could help them to further develop their daily living skills as well as take more responsibility for the day-to-day running of the home. It is confirmed that people living at the home are supported to maintain links with their families. Most people who live in the home have regular input from relatives and a record is kept of any contacts and visits. One relative made very positive comments about the home (as quoted in this report summary) and says they are always kept up to date about important matters. It is good the home has considered trying to find an advocate for one person but this has proved difficult because of their complex needs and limited communication. Regarding food provided by the home weekly menus are drawn up and staff have started to obtain pictures of menu dishes to help people who living at the home choose their own meals and decide what shopping will be needed. Staff either ask or know their individual preferences and any special dietary needs. The home previously had input from a Dietician to check the home’s menus and one staff member is to attend a course on healthy eating to provide more guidance. Meanwhile staff promote such as fresh fruit & vegetables, wholemeal options and make home made soups etc. The main meals are eaten together with staff and the inspector was kindly invite to join them all for their evening meal. This was a very nice, relaxed and social occasion with a tasty, healthy meal, which we all helped ourselves to. One person chooses to eat in their own bedroom and it is good that this flexibility and choice is supported. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. People who live at the home are supported to meet their personal and health care needs and staff make sure that appropriate health care input is obtained. Their medicines are also managed safely in the home for them by trained staff. EVIDENCE: Plans show the personal support each person living in the home needs (which for most is a high level of assistance) and their preferred morning and night time routines. Daily records are kept of the actual support they have received. Everyone was seen to be well presented and appropriately dressed and they are supported by their keyworkers to choose and shop for their own clothes. Care records include information for staff about specific and general health related conditions and each person has a Health Action Plan, as recommended by the Department of Health for people with learning disabilities. Records are kept of all visits, input sought and/or treatment received from a variety of health care professionals e.g. GPs, nurses & dentists and specialists (such as a Psychiatrist, Dietician, Speech Therapist and Physiotherapist). One health care professional confirms that the home always seeks their input and acts upon it Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 15 commenting that “Advice and open communication is one strengths” and “Individual health care needs are always met”. instruction is arranged for staff when it is needed to help them manage particular health issues of people who are living at the of this home’s Training and/or understand and home. Ongoing reports are made by staff when possible health problems arise and some charts relating to physical checks that could affect a person’s health are kept (e.g. weight and headaches). Whilst it is evident from discussion that staff are proactive in dealing with health care issues it should be ensured that records reflect that they continue to monitor them and/or the outcomes. For example when one person was noted to have sore skin and another a problem with their foot there did not seem to be any follow up action in the reports. Also any charts that cannot be maintained consistently should not be kept and other protocols to manage any possible problem areas put in place. Regarding medication the home has a clear medication policy & procedures that have been updated recently. Staff have also set up a new medication file with information on medicines prescribed as and when required and protocols for safe administration. Each person has details in their personal file of all the medication they are prescribed and their consent to treatment and medication as would be agreed by them (if they are capable) or their relative or relevant person on their behalf. No one living at the home currently can self-administer. Medicines are kept in the home and administered by staff using a monitored dosage system. The home’s practices in relation to ordering, administering and medication records are monitored and audited and an external Pharmacist also checks the system regularly. There are suitable arrangements for the storage of medication and records of administration are maintained appropriately. There is a list of signatures of all staff designated to administer and all these staff have attended accredited training on safe handling of medicines following instruction received in-house during their induction. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The home has processes to enable people living at the home to express their views and concerns and frameworks are in place to manage complaints about the service for their welfare and protection. This would be enhanced if the home ensures staff are clear about multi-agency adult protection procedures. EVIDENCE: Mencap introduced a new complaints and compliments procedure last year. This includes a more user-friendly system called “I’m talking are you listening” that is designed to enable all service users to use a complaints process more effectively and through questionnaires. It can also be used to pick up health issues and indicators of abuse of people with profound learning disabilities and limited communication skills through audits. The process involves home staff, families and relevant other people who should note any behavioural and other changes with an indication of underlying causes by comparing them to their “normal” behaviour. If there are any concerns and issues arising the procedures shows how and where they should report them. Two people living at the home said they feel able to discuss any concerns with staff and the deputy manager. One relative confirms they would know how to make a complaint and the home had always responded appropriately to any concerns, commenting that “The service is transparent and caring”. There has not been any complaints or issues that could affect the safety of vulnerable adults raised with the Commission since the last inspection. When needed a record is kept detailing any complaints and the investigations, with outcomes. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 17 All staff are required by Mencap to attend a training session as part of their induction about safeguarding vulnerable adults called “Protect and Respect”. There are policies provided in relation to service users’ protection that includes whistle blowing. Whilst the deputy manager and staff are clear about their responsibility and duty for the protection and welfare of people who live at the home they must also ensure they are familiar with multi-agency procedures for Protection of Vulnerable Adults. This clarifies how and to whom they should refer any suspicion or incidence of abuse or neglect of service users. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The accommodation suitably meets the needs of people living there and offers them a comfortable, safe and well-kept home. Appropriate arrangements are in place to promote good hygiene and to keep the house safe, tidy and fresh. EVIDENCE: 180 Bromwich Road is situated on the outskirts of Worcester and is on a main bus route into the city. Shops, Churches and other leisure facilities are within easy reach. It was first opened as a care home in 1990 and was originally two police houses, with a kitchen extension. The home is a traditional detached house and has a parking area, patio, and large gardens at the back. It offers six single bedrooms (none with en-suite facilities). Two are on the ground floor, one of which is suitable for a wheelchair user and has wide doors one leading into a bathroom with an assisted bath. The home has three bathrooms, a lounge, a separate dining room, conservatory, kitchen and laundry room for everyone to share. There is also an office and another staff room. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 19 Most of the house was seen and the overall impression is comfortable and reasonably well decorated, furnished and maintained, although some carpeting and bathrooms looked a bit utilitarian/bare. There is a five-year renewal plan for the premises and ongoing servicing/maintenance is designated and the manager can also authorise emergency repairs as and when needed. Bedroom doors do not have locks, although current residents are not able to manage a lock and/or hold their own key and presumably arrangements would be made if a new person moving in could do so. Bedrooms seen are well personalised. The home employs a separate domestic for communal areas and all areas of the house were observed to be clean, tidy and fresh. Day and night care staff staff keep records and charts of cleaning tasks completed. Keyworkers are also expected to help people who live at the home to keep their bedrooms tidy etc. and they plan to try to involve them more in domestic tasks and cooking to help them develop their daily life skills. The gardens were a bit overgrown (partly due to the weather) although apparently care staff have to find time for maintaining the garden. It is good however that one staff member has a particular interest in the garden, including making a vegetable bed that they know one person living at the home is interested and could be involved in. A comprehensive infection control policy is in place and suitable arrangements are made for the disposal of soiled waste. It was previously confirmed that the home had adopted the Food Standards Agency’s procedures for safe handling of food on the premises and various charts are displayed to reinforce good practice. Some staff have received specific infection control training, although most have undertaken food hygiene and general health & safety procedures and practices are covered as part of their induction. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 20 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, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. People living at the home are supported by sufficient and suitably trained and supervised staff who work well as a team to provide an individualised service. Thorough recruitment procedures also help to make sure that only suitable staff are working at the home, for the protection of the people who live there. EVIDENCE: It is confirmed staffing levels are being maintained at an appropriate level to meet the personal needs of the four people who currently live at the home. There is a 4-week set rota and there is always three staff on duty during the day with one awake at night (with another on call). The manager was working 9-5s weekdays in addition but as she has left the deputy manager is working some designated shifts to manage the home. It is reported however that since there have been two vacancies people living at the home have benefited from having more staff time to support them 1 to 1 and with activities. Mencap would therefore need to review staffing levels with funding authorities if and when a prospective service user is referred. The home has had a fairly low staff turnover, and although a few experienced staff left this year they have relief staff to cover the home and now have a better ratio of male/female staff. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 21 Mencap provides robust policies & procedures for the selection and recruitment of care staff. Records seen of a new staff member confirm that a police (CRB) check and two written references are taken up (one from their last employer) and that these checks are obtained and must be satisfactory before new people are allowed to start work at the home. Copies of relevant documents are also held and application forms completed, including a full employment history (with any gaps explored) and a statement about their health. All new staff undertake a probationary period before their employment is confirmed. During this time they complete Mencap’s comprehensive induction programme in their first six weeks followed by six months foundation training. This takes them through all aspects of supporting service users and this induction process is appropriately accredited to the Learning Disability Award Framework (LDAF). This ensures that all staff have underpinning knowledge relating to the care of people with learning disabilities. A new staff member confirmed they were going through this process and had covered topics such as valuing people, confidentiality, communication and protection. They had also received training in fire safety, health & safety, medication and moving & handling and were soon to do food hygiene. They had worked alongside existing staff until they were confident in their role and felt well supported. Staff then move onto do an NVQ qualification and service user specific training topics such as autism awareness, epilepsy and for management of challenging behaviours. Although only eight of the current staff team now have NVQ another four are 4 working towards it, which will mean that over half the team will then be qualified as the Standards specify. It is positive that the manager planned to continue to arrange courses to increase the staff teams’ skills and knowledge and to do more in house training as part of their staff meetings. Each staff member has a training & development plan and any shortfalls are discussed in individual supervision sessions. Mencap also operate an appraisal system and regular staff meetings are held with minutes kept, when care, house, staff and any other issues are discussed. The new person feels that staff are open and that communication is great within the team. Staff were open and welcoming and appear to be well motivated and to work together in the best interests of the people living in the home to enhance their lifestyles. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 22 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, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Suitable management arrangements are in place so the home continues to run well whilst there is not a registered manager. Service quality is monitored and reviewed so it continually develops as people living at the home wish and for their benefit. Whilst overall the environment and staff practices protect the people who live and work there if Mencap’s policies & procedures were being reviewed and updated more often it would ensure they reflect legislation and current good practice guidelines that inform the way homes run and staff work. EVIDENCE: The deputy manager (Jane Tudor) is currently taking day-to-day responsibility for the home’s management and is suitably experienced and qualified. This key inspection confirms that staff are committed to providing a good service and there is a good team work ethic with an open and positive approach. Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 23 Mencap provide their service managers with relevant training such as diversity, managing performance, appraisals, personal development and absence management. External management arrangements for the home were changed last year so the home’s line manager would have more involvement and a better overview of the service at an operational level. It was considered that this could be more supportive and make Mencap more responsive to service users’ needs locally. Whilst this was not discussed during this inspection visit staff feedback indicated they do not feel they are always kept informed about management changes and/or input and so this may need further consideration. Mencap operate a formal system to monitor service quality. This includes the required monthly visits from an area manager when all aspects are checked and/or audited periodically and a continuous improvement plan is made with actions specified. These visits include talking to staff and the people who live at the home. Their views must be reflected in the service’s development plan and so questionnaires have been sent to them, their families and other stakeholders. This has all resulted in a business plan that includes short, medium and long-term objectives and how they will be met, with timescales specified. Another part of the quality assurance and monitoring process is that Mencap provides comprehensive polices & procedures to inform staff working practices. The home’s self-assessment shows however that many of these documents had not been reviewed for at least five years. This should be addressed so that they reflect current legislation and good practice guidelines. Regarding health & safety staff training is arranged in all the mandatory topics i.e. first aid, food hygiene, fire safety and moving & handling, although some were due for update. The following was also confirmed:• Electrical & PAT tests are carried out. • Staff undertake all required fire safety checks at the specified intervals. • Fire safety system and hoists etc serviced regularly. • Heating system & gas appliances are serviced regularly. • Risk assessments are carried out (including COSHH) There were also no safety hazards identified during these visits. . Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 24 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 2 3 X Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered persons meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered provider must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the registered provider to consider carrying out. No. 1 Refer to Standard YA23 Good Practice Recommendations The home should make sure that all staff know about and understand and/or receive instruction in relation to multiagency procedures for the Protection of Vulnerable Adults. This would help to make sure that they would know how to report any suspicion or incidence of abuse or neglect of people who live at the home, for their protection. Policies & procedures should be regularly reviewed and updated if necessary, as one aspect of quality assurance and monitoring. This is because they inform staff working practices in the home, which should always reflect current legislation and accepted good practice guidelines. 2 YA41 Bromwich Road, 180 DS0000018636.V343451.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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