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Inspection on 07/07/05 for 180 Bromwich Road

Also see our care home review for 180 Bromwich Road for more information

This inspection was carried out on 7th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

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

What the care home does well

Service user`s health care needs were well catered for and care plans were well implemented. Staff spoke proudly of their work in supporting service users with a diverse range of disabilities. The atmosphere was friendly and open. The standard of cleanliness was high and the premises was well maintained.

What has improved since the last inspection?

Since the last inspection the registered manager had sought extra funding from one placing authority to assist with meeting a service user`s needs better. Two additional part-time support worker roles have been identified to increase the numbers in the staff team. This will help to ease the existing strain on staff resources.

What the care home could do better:

The home needs to implement an infection control policy to ensure appropriate safe working practices. The care plan documents should be visibly reviewed. The provider needs to improve the system for quality control and service users should be able to access questionnaires that are user friendly. Recruitment practices must be more robust to ensure all the necessary paper work has been gathered. Personnel files should be more structured to ensure auditing and monitoring of the system can be achieved.

CARE HOME ADULTS 18-65 180 Bromwich Road 180 Bromwich Road Worcester Worcestershire WR2 4BE Lead Inspector Martha Nethaway Unannounced 7 July 2005 7:15 am 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 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 Stationary 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. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 180, Bromwich Road Address 180 Bromwich Road, Worcestershire, Worcestershire WR2 4BE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01905 428030 Royal Mencap Society Mrs Joanne Hartland Care Home 6 Category(ies) of LD Learning disability both genders (6) registration, with number of places 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 February 2005 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. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 7:15am. It took place over 5-½ hrs and the inspector visited the home to observe the early morning routine. Three of the service user’s files were examined and other records were sampled. The deputy manager discussed the operation of the home and the care needs of the residents. Three staff were spoken to and one staff member was interviewed to discuss their experience of working at the home. One of the service users gave a guided tour of the home. Another service user shared their views and opinions about the home. The remaining service users were less well able to talk due to shyness or limited verbal communication. Therefore, observation and discussion was a key feature of this inspection with the care staff on duty. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The home’s practices ensured that assessment and admission processes offered prospective service users appropriate placements. EVIDENCE: The home had a clear admission criteria. Records illustrated information had been obtained from the placing authorities. This included a formal assessment and supplementary information about assessed needs. Primary carers were given information and were consulted as part of the admission process. Any new admission was subjected to a three-month trial. One file demonstrated good information existed about the service user’s needs including using computer graphics and photographs. Evidence was available of trail visits including opportunities to meet the existing service users living at the home. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 7 Proper arrangements existed to ensure social and health care needs were identified and met. The home provided a good level of support to facilitate choice and decision-making but links should be established with a local advocacy service. EVIDENCE: Each service user had a written care plan that provided information about their background which assessed their needs including social skills and health care needs. Plans were easy to read and determined individual needs. This was then supplemented with a range of risk assessments that related to living at the home and using facilities in the community. Staff discussed how care plans facilitated people’s involvement in making choices and in receiving individualised care. Keyworkers were responsible for reviewing care plans but this was not always recorded. Daily records showed that staff supported people with personal hygiene, communication, leisure activities and developing life skills. One service user discussed how he had changed the menus and the home has arranged one take away to be delivered monthly. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 9 One service user’s needs were progressively changing and the manager had approached both the placing authority and health authority to increase resources to match the service user’s assessed needs. Consideration should be given to developing links with an external advocacy service. Discussions with staff identified this would be beneficial for one service user living at the home in particular. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 10 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 standard(s) 13, 15 & 16 People were enabled and supported in accessing local community resources on a regular basis. Service user’s individual choices and lifestyle were preserved and self-help skills were promoted. Regular contact with families and relatives was maintained and facilitated at the home. EVIDENCE: Each service user had a scheduled activity planner that included attending social education centres, college courses and social clubs. Two of the service users spoke positively about the college courses they participated in and one person showed examples of their pottery work. Discussions with services users revealed that trips out to the pub and cinema were a regular feature of their recreation time. The location and accessibility of the home was viewed as helpful to accessing leisure centres and shopping facilities. Service users had regular contact with their families. The home had areas that allowed families to meet in private without disturbing the existing resident group. Service users were encouraged to keep their bedrooms tidy and staff supported individuals with household tasks. This was consistent with information on individual care plans. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Good arrangements existed to monitor and promote health. Clear systems existed for the administration of medication and training of staff. EVIDENCE: The home used Worcester Primary Care Trust, ‘Health Action Plan’ and all the service users had this plan. There were excellent examples of health care planning and monitoring. Two individuals had particular complex health care needs and staff were diligent with monitoring these. Good links had been established with community health based services. Each care plan clearly detailed service user’s current medication. The home had available a policy, procedure and training for the administration of medicines. The dispensing of medication records was checked and it was well managed and followed the home’s policy. Records relating to staff medication training were up to date. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 The home had suitable arrangements in place to protect residents from abuse. EVIDENCE: The home had a policy on Abuse Prevention and clear guidance on the Protection of Vulnerable Adults. Staff discussions indicated that they were familiar with the Adult Protection procedure. Mencap’s training department organised periodical refresher training to reinforce staff awareness. There were no live issues related to vulnerable adults. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 The home was well maintained to a good standard of cleanliness. The home needed to implement an infection control policy and contact the water board to ensure the facilities comply with Water Fitting regulations. EVIDENCE: The home employed a domestic cleaner and the premises was maintained to a high standard of cleanliness. The home does not have an infection control policy and this should be considered in relation to staff maintaining safe care practices. The manager should contact the local Health Protection Agency for further advice and guidance. Appropriate risk assessments were available relating to the environment. The registered manager needed to make contact with the water board to ensure that the services and facilities fully comply with Water Supply (Water Fitting) regulations 1999. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 The personnel files did not provide evidence that recruitment practices were following the home’s own operational policy. There must be improvements to ensure that recruitment procedures provide proper safeguards for service users. EVIDENCE: Recruitment was organised centrally by Mencap personnel department but the home retained information about staff on the premises. Four staff personnel files were examined in relation to staff recruitment practices. The files were unstructured and did not contain all the necessary paperwork relating to the recruitment process. Some files required employers written references, job descriptions, probationary period and in one case a full copy of the job application. This needs urgent attention. All the files contained full CRB checks. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 No further progress had been made in relation to developing a proper quality assurance programme that was accessible to service users. A suitable team plan that interfaced with the providers operational plan had not yet been established. EVIDENCE: As identified in the previous inspection the provider had begun to establish a quality assurance programme although this was considered ineffective. No further progress had been made in adapting this process further for those individuals with differing communication needs. The manager was currently working with the staff team on the development plan that would interlink with the Mencap business operational plan. The home had consulted with parents and or relatives and the main findings related to concerns about insufficient numbers of staff on shifts given the diverse needs of individuals. Discussions with staff indicated that some of the resident’s needs were high and allocation of staff resources had not been matched. This had been formally taken up with the placing authority and health authority. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 2 Standard No 11 12 13 14 15 16 17 x x 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 180 Bromwich Road Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 1 x x x x E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 17 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement Timescale for action 30/1/06 2. YA43 25 3. 4. YA30 YA34 16 7,9 & 19 A quality assurance system appropriate to the needs of these service users must be established and a report of the outcome provided to the Commission (Timescale of 31/5/2005 not met). A business and financial plan for 7/10/05 the home must be prepared. (Timescale of 31/5/2005 not met). The registered manager must 7/10/05 implement an infection control policy. The registered manager must 7/10/05 ensure that Personnel files contain all the required information in accordance Schedule 2. 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. Refer to Standard YA7 Good Practice Recommendations Consideration should be given to the value of advocacy services in helping service users express their views of the E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 18 180 Bromwich Road 2. YA30 3. 4. YA34 YA6 service and any concerns they might have. The registered manager should make contact with the water board to ensure that the services and facilities fully comply with Water Supply (Water Fitting) regulations 1999. The personal files should be organised in a suitable format to ensure that information can be easily audited. Keyworkers should demonstrate that care plans are periodically reviewed. 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 19 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 180 Bromwich Road E52 S18636 180 Bromwich Road V237608 070705.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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