Inspection on 30/01/06 for 197 Henwick Road

This inspection was carried out on 30th January 2006.

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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

197 Henwick Road 03/11/06

197 Henwick Road 22/08/05

197 Henwick Road 14/03/05

197 Henwick Road 11/06/04

197 Henwick Road 15/03/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Henwick Road, 197 197 Henwick Road St John`s Worcester Worcestershire WR2 5PG Lead Inspector R McGorman Unannounced Inspection 30th January 2006 14:00 Henwick Road, 197 DS0000018659.V277723.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 Henwick Road, 197 DS0000018659.V277723.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. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Henwick Road, 197 Address 197 Henwick Road St John`s Worcester Worcestershire WR2 5PG 01905 429915 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) New Era Housing Association Limited Mrs Janet Elizabeth Lancaster Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is primarily for younger adults with learning disabilities but may accommodate one person over the age of 65 The Home may also accommodate people who have an additional physical disability. 22nd August 2005 Date of last inspection Brief Description of the Service: 197, Henwick Road is registered to provide residential care for up to four service users who experience a learning disability, who may have a physical disability, and whose needs are diverse. The home is also able to accommodate one person over 65 years of age. The premises is a large bungalow, situated in the St. Johns area of Worcester, approximately 1 mile from the city centre, with easy access to public transport and a range of amenities and facilities. The home is owned and run by the New Era Housing Association Ltd., and is part of the New Dimensions Group, which, as the parent company, provides strategic direction and a range of functional support services. The stated purpose of the organisation is, to work with people with learning difficulties, supporting them to make choices and to exercise control over their lives, and the main aim of the home is, to deliver a person-centred response to the needs and aspirations of the people we support. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine unannounced inspection was to follow up previous requirements and recommendations, and to monitor the care provision at 197, Henwick Road, Worcester, in relation to the stated aims and objectives of the home. The inspection took approximately 3 hours, when some time was spent with service users, although they are unable to verbally communicate their views. During discussions with staff, very positive comments were made about what it is like to work at the home. A tour of the building was also undertaken. The care records of service users were seen, and the records kept in respect of the maintenance of equipment, and safe working practices were also checked. What the service does well: The care that is provided at the home revolves around the service users who live there – person centred care is consistently demonstrated, and the respect and consideration that is afforded to residents at all times is very evident. The commitment of staff to their role in supporting and enabling service users is commendable, as they strive constantly to achieve the aims and objectives of the home. The success of the staff group at 197, Henwick Road, is achieved by genuine ‘team work’, and the invaluable support that every team member gives to each other, enables the service users to benefit. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 6 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. Henwick Road, 197 DS0000018659.V277723.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 Henwick Road, 197 DS0000018659.V277723.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): 1&3 Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. The assessment process is both detailed and thorough, to ensure that an appropriate decision is made, both by the home and the service user. EVIDENCE: The Statement of Purpose and the Service Users Guide, provide detailed information for residents and their families, about the services and facilities available at the home. The documentation is produced in an appropriate format, and retained by the service user, if this is their wish. Documentation is reviewed regularly, to ensure that it accurately reflects specific aspects of the care that can be provided. The admission procedure includes extensive assessment by staff from the home, and is being implemented for a service user who is to be admitted to the home in the near future. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. The key-worker system ensures that service users living at the home are supported in making choices in all areas of their lives. EVIDENCE: An individual plan of care is produced for each service user, based on the initial assessment undertaken during the admission process. These plans, which are retained by the service user, are very comprehensive, detailing their specific needs, and how these are to be met. The needs and individual preferences of every service user living at 197, Henwick Road are identified as far as possible, and their participation in the daily life of the home, is constantly encouraged. Two key-workers are assigned to each service user, and have responsibility for ensuring that appropriate care is provided. Monthly meetings are held, and ongoing assessment is also undertaken, any changes are monitored over a period of time, and amendments made when necessary. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 10 Henwick Road, 197 DS0000018659.V277723.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): 11 & 14 The opportunities made available to service users, enable them to live as fulfilling a life as possible. The involvement of each individual in planning their activities, both within and outside the home, means that they are able to choose what they wish to do, and that everything revolves around them. EVIDENCE: Service users living at the home are encouraged to follow an ‘ordinary’ life style as far as possible, by using the same facilities as other members of the community, and being involved in a wide range of leisure activities. Limited communication skills preclude involvement in paid employment or educational opportunities, but social activities are provided, and these may be undertaken in-house or in the community. Arrangements for holidays are made, and further weekend breaks are also being planned. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Procedures are in place to ensure that the personal and health care needs of service users are appropriately met. Advice and guidance is requested from the primary healthcare teams, and other professionals, to ensure that the health needs of service users are fully understood, and that appropriate responses are made. EVIDENCE: The personal and healthcare needs of service users, which are extensive, are well documented, and there is evidence to show how staff understand and respond to them in an appropriate way. Personal care is provided in privacy. The healthcare of service users is closely monitored, and additional specialist support and advice is sought from health professionals, when necessary. Health Action Plans have been implemented for all service users living at the home. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 13 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 A satisfactory complaints procedure is in place at the home, and it enables everyone to express any concerns, views, opinions, and compliments. EVIDENCE: These standards were not inspected in detail, but were previously met. A clear procedure for the investigation of complaints has been produced and any issues are dealt with immediately. The document has been produced in a format that is understandable to service users. There have been no complaints to the home, since the last inspection. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 14 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 & 29 The premises are suitable for their purpose. They are comfortable and clean, and ensure as far as possible that the safety and wellbeing of service users is promoted, although fire safety precautions need to be reviewed The standard of the accommodation is excellent. The décor and furnishings are in good condition, and provide service users with an attractive and homely place to live. The location of the house is convenient to local services and facilities, and the layout provides adequate communal space and equipment for the needs of service users. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 15 EVIDENCE: The premises at 197, Henwick Road is a large detached, bungalow, which provides a safe and well-maintained environment, and is suitable for its purpose. A dormer area has been developed which includes the office and sleeping area for staff, a bathroom, and also some storage facilities. The communal areas of the house are homely, nicely decorated and comfortably furnished, and sensory equipment is provided for the benefit of service users. There are three communal rooms, which include a pleasant lounge and a conservatory, and also a large kitchen/dining room. The proposals for new kitchen units to be fitted are not considered to be a priority, therefore these have not yet been actioned. The gardens, which are extensive, have been given considerable attention, and plans have also been produced for further work to be undertaken in the Spring. The proposed patio area will greatly improve facilities for service users. Several areas of the house are fitted with overhead tracking to assist with moving service users, although the design of the existing equipment has raised some issues in regard to health and safety. Consideration is being given to providing additional overhead hoists, therefore a review of the suitability of the present provision should also be undertaken. The Fire Log Book was seen, and appropriate checks have been undertaken with the required frequency. The following issues in respect of fire safety precautions were identified with the Acting manager: • staff to have fire awareness training every 3 months and • a fire drill every 6 months • the Fire Risk Assessment to be reviewed and • the Emergency Evacuation Contingency Plan to be updated Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 16 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): 31,33 & 35 The management support and supervision given to staff, enables a clear understanding of their roles and responsibilities, and ensures the promotion of the aims and objectives of the home. The home has an experienced and competent team of staff, who are able to ensure that the needs of service users living at the home can be effectively met, providing adequate staffing levels are maintained. The training programme available to staff ensures that they are effective in their work, and therefore able to provide appropriate care and support to service users. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 17 EVIDENCE: New Era provides relevant information for staff on joining the organisation, and also keeps them updated on new developments and any changes that take place. Each member of staff is given a Welcome Pack that contains details about the organisation, and its aims and objectives, an Employee Handbook that provides information about terms and conditions of employment and policies and procedures, and an Induction Checklist covering the first three months of employment. A review of the staffing arrangements at the home has been undertaken by the organisation, and the rotas indicate that there is some difficulty, at times, in maintaining staffing at a satisfactory level. There is a high incidence of sick leave, and a member of staff who left recently, has not been replaced, which has further compounded the problem. To ensure that the intensive care needs of the service users living at the home are appropriately met, a minimum of three members of staff should be on duty throughout the waking day. A training programme is in place at the home, although staff sickness has affected the availability of staff to attend some of the courses. The training needs of staff are regularly reviewed, and a training record is maintained in respect of each member of staff. The need for staff to have regular fire awareness training was identified. Henwick Road, 197 DS0000018659.V277723.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): 37,40,41 & 42 The home is well managed at present, but the acting manager needs to be registered in order to comply with legislation. The policies and procedures, and records maintained at the home, comply with legislative requirements and therefore help to safeguard the rights of service users. The support provided to staff by the area manager, ensures the promotion of the aims and objectives of the home. Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 19 EVIDENCE: The home does not have a registered care manager at present. The responsibility for the day-to-day management of the home is being undertaken by Ms Rebecca Edwards, and an application for registration is to be submitted to the Commission in the near future. Policies and procedures are produced by the Organisation, and staff confirmed they are familiar with the content. Specifically, a comprehensive health and safety policy and procedure is in place, and an officer is employed by New Era to advise on health and safety matters. Risk assessments in respect of all safe working practices are completed. The records checked during the inspection have been completed to a satisfactory standard, and they are securely kept. Regulation 26 reports are submitted to the Commission on a regular basis. Routine maintenance and servicing of equipment undertaken, and temperature checks are recorded. The accident books were seen, and clarification provided in respect of maintaining appropriate records, which now appear to be in order. Notifications under Regulation 37 are being made to the Commission, when appropriate. Henwick Road, 197 DS0000018659.V277723.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 3 2 X 3 3 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 2 25 X 26 X 27 X 28 2 29 2 30 X STAFFING Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 2 X X 3 3 2 X Henwick Road, 197 DS0000018659.V277723.R01.S.doc Version 5.1 Page 21 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 YA33 Regulation 18 Requirement Suitably qualified, competent and experienced persons must work at the care home in such numbers as are appropriate for the health and welfare of service users Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA24 YA24 YA28 YA29 YA29 YA37 Good Practice Recommendations Consideration should be given to upgrading the units in the kitchen The Fire Risk Assessment should be reviewed and the Emergency Evacuation Contingency Plan updated Further development of the garden area should be undertaken Consideration should be given to the provision of further sensory equipment for the benefit of service users The provision of overhead tracking for hoists should be reviewed An application for registration from the acting manager should be submitted to the Commission without delay DS0000018659.V277723.R01.S.doc Version 5.1 Page 22 Henwick Road, 197 7. YA42 Fire awareness training should be provided for staff every three months Henwick Road, 197 DS0000018659.V277723.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 Henwick Road, 197 DS0000018659.V277723.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!