Inspection on 06/03/06 for 180 Bromwich Road

This inspection was carried out on 6th 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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

180 Bromwich Road 28/08/07

180 Bromwich Road 04/07/06

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 Martha Nethaway Unannounced Inspection 6th March 2006 11:00 Bromwich Road, 180 DS0000018636.V286431.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 Bromwich Road, 180 DS0000018636.V286431.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. Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bromwich Road, 180 Address 180 Bromwich Road Worcester Worcestershire WR2 4BE 01905 428030 01905 429731 H5M021 johartland@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mrs Joanne Hartland Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 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 additonal mental disorder. 7th July 2005 Date of last inspection Brief Description of the Service: 180 Bromwich Road is a traditional detached house situated in a residential suburb of Worcester. Shops, public transport and leisure facilities are within easy reach. The home provides care for up to six people with moderate to severe learning disabilities and occasional challenging behaviour. The registered manager is Jo Hartland. The responsible individual is Ms Janine Tregelles but line management and supervision is provided to the registered manager by Tony Hickey, service manager. Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced inspection, taking place over two and half hours. One inspector visited, to observe the midmorning schedule for service users. Most of the service users were met and one service user provided a guided tour of the premises. Discussions were held with staff and the acting manager. A random selection of records was examined. What the service does well: What has improved since the last inspection? What they could do better: • • The home needs to develop a strategy plan to address the shortfall with the declining resources available for day centre provision. The development of advocacy input should be considered to ensure best practices are continually updated and adopted. Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 6 • Minor improvements need to be implemented to ensure all the necessary records are being kept in respect of each service user. 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. Bromwich Road, 180 DS0000018636.V286431.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 Bromwich Road, 180 DS0000018636.V286431.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): EVIDENCE: None of these standards were assessed on this occasion. Bromwich Road, 180 DS0000018636.V286431.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): 9 The assessment of risks are given careful consideration. Staff receive training from key professionals. Extra resources are addressing service users changing needs. EVIDENCE: The management team assesses each service user’s risks. Written risk assessments are incorporated within the Person Centred Plans. The main area of risk relate to the stairs. One service user requires close supervision and staff support, when using the stairs. The management team had ensured input from the physiotherapist to assess and train staff. Another service user requires staff support in relation to meal times and ensuing that meals are cut to bite size chunks and pureed where necessary. All risk assessments were reviewed within the agreed time scales. There were a number of risk assessments relating to the onset of dementia the continual decline related to health matters. Specific support is required from the staff team. The staffing arrangements have increased to provide extra input with two service users. Service users who are assessed as competent with travelling independently and accessing local amenities are clearly outlined in their care plans and risk Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 10 assessment. Staff protocols were in place to ensure safety issues were thoroughly addressed. Risk assessments are now discussed at each team meetings. The registered manager ensures that two assessments are discussed in depth. Any actions or changes with staff practices are fully outlined at the team meetings. This ensures that all staff are continually reminded of the necessity to reduce risk to vulnerable individuals. Bromwich Road, 180 DS0000018636.V286431.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 & 17 Service users participation at college courses is being organised but is limited. Declining resources with day provision from the local authority is having a impact on the home. It is stretching the homes resources, in relation to staff and transport arrangements. A strategic plan needs to be developed to address with day provision from local authority. Menus reflect the choice of service users. Healthy eating is promoted. EVIDENCE: Since the last inspection visit in May 2005, of day-care provision has changed significantly. Increasingly, local authority day services are being rationalised and placements at day centres are at a premium. There were difficulties with accessing Worcester College Adult scheme with a limited number of college courses available. The manager met with a representative from Worcester College and further courses are being planned to start after the Easter holidays. The home has good links established with, Kidderminster College who are able to organise courses related to service users ability. The staff group and the Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 12 management team consider the transport arrangements as problematic as it can impact on the day-to-day running of the home. The registered manager is reviewing this with the external line manager. Service users are accessing Snoozlen facilities that offer sensory input and a hydrotherapy pool. The home is also spot purchasing services, for example pottery sessions. The home is aware of the staffing implications for the medium and long term. College courses do not run for 13 weeks of the year and there is a lack of alternative options. It is recommended that the senior external line management address these concerns both in terms of service provision and future planning of the home. A more strategic approach needs to be adopted. The home has available a policy relating to the promotion of a healthy lifestyle. The speech and language therapist was consulted in relation to three risk assessments for eating and drinking. As a result staff will attend a refresher course on eating and drinking. This provides extra input for new staff that had joined the existing staff group. Mealtimes are staggered across the day according to individual schedules. The main meal is served at lunchtime and the evening meal is a light teatime snack. Service users are encouraged to prepare and cook light snacks and sandwiches. Discussions with service users and staff indicated that meal times are considered sociable events. The registered manager is in the process of purchasing a new set of dining room furniture that will be more durable. Bromwich Road, 180 DS0000018636.V286431.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 Adequate arrangements exist to provide care and support that reflects the assessed needs of individuals. The development of advocacy input should be considered to ensure best practices are continually updated and adopted. EVIDENCE: The home provides a clear policy and procedure outlining how staff will support intimate care with service users. Service user’s personalised care needs are addressed in their care plans. Service users receive both direct support and supervision by care staff. Staff encourage service users to retain self-help skills as far as practicable. The health authority has provided extra staff for one service user with continuing care needs. The home also has access to an excellent assessment tool that provides a clear baseline to assess self-help and social skills. This ensures comprehensive assessments of needs are carried out. The staff team composition has changed and two new male workers are employed. This is redressing the gender balance issues within the staff group. Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 14 The home operates a keyworker system and where possible service users are consulted when choosing their keyworker. Good relationships are promoted with families. Good relationships exist with the local church and the church ministry visits the home regularly but the management team recognise that advocacy services are underdeveloped. Bromwich Road, 180 DS0000018636.V286431.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 Good arrangements are in place to deal with complaints. EVIDENCE: The home had a policy and procedure in place for dealing with complaints. The manager had liaised with the speech and language therapist. The home intends to adopt ‘I’m talking are you listening’ devised by a profound multiple disabilities group. Information is available in the ‘Service Users Guide’ and the ‘Statement of Purpose’. Records examined showed that no complaints were entered into the complaints procedure since the last inspection. Bromwich Road, 180 DS0000018636.V286431.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 The home was maintained to a good standard of cleanliness. EVIDENCE: The home employed a domestic cleaner and the premises is well maintained to a high standard of cleanliness. One service user provided a guided tour of the home and all areas are domestic in style and proportion. Bedrooms are decorated to the preferred taste of service users. There is a rolling programme of renewal for the fabric and decoration of the building. As mentioned earlier the dining suite will be replaced. New carpets are being ordered for the communal hallways. The two bathrooms are to be redecorated. In addition, two-service users bedroom flooring is to be replaced. The kitchen floor requires maintenance to the floor surface to ensure proper cleaning can take place and infection control standards are maintained. Bromwich Road, 180 DS0000018636.V286431.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): 35 Staff receive appropriate levels of training and professional development plans are underway. EVIDENCE: The registered manager ensures a full development programme is available for all staff. Newly appointed staff, complete a six-week induction plan. All have core mandatory training completed including first aid, fire safety, moving and handling, basic food hygiene and the administration of medication. All staff are receiving five days training per year. The registered manager is currently developing a personal development plan for each staff member. It is intended to link this with the strategic business plan for the home completed in February 2006. Bromwich Road, 180 DS0000018636.V286431.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): 42 Good arrangements are in place to promote and ensure health and safety is effectively managed. Minor improvements need to be implemented to ensure all the necessary records are being kept in respect of each service user. EVIDENCE: Mencap has available extensive guidance and procedures in relation to health and safety matters. The home completes health and safety audits and remedial action is always followed up. The home has a system in place to corroborate that domestic installations and equipment are checked and serviced. Records were examined for electrics, gas and fire checks and were found to be up to date. There is a staff protocol in place to address infection control. The registered manager intends to train two additional staff to cascade good models of practice to the staff team. Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 19 Over the next 12 –18 months the registered manager is aiming to ensure that all staff have attended training on the assessment of risks. This will enable care staff to take responsibility for completing risk assessments in relation to service users. Accident records were available and complied with Data Protection. It is recommended that all accident records should be kept in service user’s files, in line with the expectation of record keeping under Schedule 3 of the national minimum standards. It is recommended the registered manager conduct a self-audit of Schedule 3. Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 20 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 x 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 x ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x x x x x x 2 x Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes, but Standard 39 was not assessed on this occasion. New timescale set. 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 YA39 Regulation 24 Requirement A quality assurance system appropriate to the needs of service users must be established and a report of the outcome provided to the Commission (Timescale of 31/5/2005 & 30/01/06). The accident records in respect of each service user must be kept in accordance with the expectations of schedule 3. In addition the manager must conduct a self-audit to ensure full compliance. Timescale for action 30/06/06 2. YA42 17 (1) a Schedule 3 30/06/06 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. Refer to Standard YA7 YA12 Good Practice Recommendations Consideration should be given to the value of advocacy services in helping service users express their views of the service and any concerns they might have. A more strategic approach should be developed to fully DS0000018636.V286431.R01.S.doc Version 5.1 Page 22 Bromwich Road, 180 3. YA24 address the declining resources with day care provision from the local authority. This will prevent the overstretching of the homes resources. The kitchen flooring should be repaired to ensure proper cleaning can take place and infection control standards maintained. Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bromwich Road, 180 DS0000018636.V286431.R01.S.doc Version 5.1 Page 24 - 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. 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