Inspection on 17/05/05 for 2-4 St Ives Close

This inspection was carried out on 17th May 2005.

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

2-4 St Ives Close 17/06/09

2-4 St Ives Close 03/11/08

2-4 St Ives Close 25/06/08

2-4 St Ives Close 20/07/06

2-4 St Ives Close 04/10/05

2-4 St Ives Close 25/01/05

2-4 St Ives Close 06/09/04

2-4 St Ives Close 08/03/04

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Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

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Polesworth Group 64 Long Street

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 2/4 St Ives Close Leyfields Tamworth Staffordshire B79 8HL Lead Inspector Wendy Grainger Unannounced 17 May 2005 09:30 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. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 2/4 St Ives Close Address Leyfields Tamworth Staffordshire B79 8HL 01827 68517 01827 68517 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) Royal Mencap Society Mr David Nicholas Yates Care Home 9 Category(ies) of 9 LD registration, with number 1 LD(E) of places 5 PD 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 25 January 2005 Brief Description of the Service: 2-4 St Ives Close is owned by a housing association and operated by MENCAP. The home is located on an estate in Tamworth and is in walking distance of the town centre. The home provides services to eight service users that have a learning disability. Some service users also have sensory and physical disabilities and some exhibit some complex challenging behaviours.The home is divided into two separated living units with their own kitchen and communal areas. The two units share a laundry and the office. One unit accommodated five service users three of them that were wheelchair users and the other unit accommodated three male users who had some challenging behaviours and sensory needs. The home provided all the service users with single bedroom accommodation. Bedrooms all had a washbasin. The home provided a range of equipment including an assisted bath, level access shower, hoists and a vertical lift. The home had a large rear garden that was accessible to all the service users. The home had its own transport that was suitable for wheelchair users. The home was situated in a quiet area and was indistinguishable as a care home. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a proportion of a day during the 17th May 2005. Time was spent with the residents and staff on duty sitting in the kitchen where life evolves. The three residents in Number 2 were not spoken with as they were out with the staff at the sensory unit in Chelmsly Wood. The care manager over the unit provided written evidence, in respect of staffing, training, menus and care plans. On arrival two of the residents were in the kitchen, staff were assisting one of the residents prior to breakfast. One resident had gone to her day centre. The kitchen is the centre of unit 4, there was an extremely relaxed atmosphere all day with residents laughing and responding to the staff. Each of the residents were asked by various methods their choice of food for breakfast and lunch. While the home is separated into two units bedroom accommodation is on both floors accessed via the shaft lift or stairs. A risk assessment had been completed for the use of either route. At the time of this inspection the manager was involved in a possible placement of a resident. The person had visited and looked around the home with her family; remaining for a few hours. The vacancy would be in unit 4. The prospective resident is resident in a local authority home where her needs are not being met. Arrangements were in place for any of the residents to receive medical attention. This was confirmed during the inspection when one resident went into the Community to see her general practitioner. Each of the residents were provided with food of their choice after the staff had offered a selection of food for lunch. Breakfast for one resident was chosen from a selection of jams for her toast 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 6 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. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 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 standard(s) 2, 4. The home had an assessment system in place. No resident would be admitted to the home unless the needs of the person had been fully explored. Systems were in place to ensure new service users could visit the home prior to make a decision about moving into the home. EVIDENCE: There had been no new admissions for some time to St Ives. The management confirmed that they were processing an application for a new resident following interest in the home. The prospective resident had been to the home with her family, a tour of the premises and meeting with the other residents was part of the process. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 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 standard(s) 6,7,9 Appropriate care plans with detailed, information ensured that the resident’s needs were met. Risk assessments were appropriate and the care plans were evaluated on a regular basis. Staff had skills to communicate with residents in a sensitive easy relaxed style. EVIDENCE: Each of the residents had an individual plan of care; the format was to contain the evidence of daily and long-term needs in module form. From the sample of care plans seen there was evidence of the guidelines recorded being followed. Each of the residents had a key worker; chosen for their outlook, personality and interaction with individuals. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 10 One care plan identified a goal that had not been achieved after a long period of time. There were plans to set a new goal, which had not occurred, and needed re-reviewing. Risk assessments were carried out where required and were included in the care plan. With the limited communication skills of the residents other forms of communication was observed today. Residents were shown items to make a decision; they were asked which drink they preferred by clench fists one for tea one for coffee. The results were positive with each person making a choice. Residents were supported in their daily life style. One resident was independent when using the shaft lift; another resident used the stairs independently. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15,16,17, Each of the residents were protected and supported in their rights and daily lifestyle. The home recognised individuals’ social needs and responded in a robust manner. Arrangements were in place for the health of the residents to be monitored when necessary. Menus offered a variety of meals to suit the client group, served in a manner to encourage independence. EVIDENCE: No resident was part of an external work force; residents did go to the local colleges and day centre. With the change in management at the day centre the one resident enjoys the experience more. Each of the residents had the option to go into the community, evidence today was a visit to a general practitioner; three residents went to a local sensory unit and then for lunch. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 12 The homes management and staff recognised that each resident had different needs. Two residents were going to a chalet for four days. From the reaction of one resident this was being looked forward to very much. Mencap have given each resident £1000 for social activity’s/holidays. Where necessary an advocate had been arranged. Residents rights were respected and protected by the staff and via the families. Meals were very much based on residents likes and dislikes of individuals. Food was prepared in a manner to suit individuals needs. Records could have been completed on a daily basis. The care manager will address this. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 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 standard(s) 18,19,20. Appropriate arrangements were in place for the health and personal needs of each individual. The system for checking medication needs monitoring to ensure the correct amount of medication was received. EVIDENCE: There was evidence of the equipment provided for individuals needs. Three residents required a hoist to progress with their daily life style. Records evidenced that personal needs were recognised and addressed by the key workers and other staff. On going health care needs were recorded and observed during the inspection. All the residents had an annual check on their medication via their consultant. Policies and procedures were in place when administering medication. Observed in the system in unit 2 was an extra half a tablet in the monitored dose box. Records that should have been completed were evidenced not to have been checked by the staff responsible. The care manager will address this error. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 14 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) 22,23, The home had a complaints procedure that was displayed for any visitors. There was a system to assist residents to exercise their views. Staffing display an understanding of Vulnerable Adults Procedures. EVIDENCE: The management or staff had received no complaints. The complaints process was displayed in each unit. Staff training records evidenced that more Moving & Handling was planned. Part of the induction and further development includes courses for Respect & Protect, Respond & Respect Values. With the exception of NVQ training, training to meet the needs of the client group was available. One resident indicated that she would speak to one of the staff on duty if she had a concern. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 15 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) 24,25,26,27,29,30. St Ives provided an environment, which was attractive and suitable to meet the special needs of the residents. It was disappointing to observed second hand furniture being supplied for the residents lounges. EVIDENCE: St Ives provides a clean, well-maintained accommodation for the residents in both units. Within each unit was a lounge and separate kitchen. Accommodation for the residents was comfortable modern and provided a homely environment. At the rear of the home was a lawned area, a new garden swing had been purchased and displayed. Bathrooms located in each unit were fitted with a lock. The only facility shared was the laundry. Advice had been given for the use of Latex gloves, a risk 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 16 assessment was observed. It was recommended that gloves of this substance should not be purchased again. The inspector was told that as the homes budget had not been received the two second hand suites (origin known) had been purchased to replace the previous ones. The manager is advised to ensure these meet with the fire retardency regulations and they have evidence of this. Otherwise they should be removed from the home. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34,35,36. There is a need to pursue the NVQ training as reflected in Standard 32.6. Staff were competent and experienced to meet the needs of the residents. The registered care manager operated an open door policy and staff felt supported by the manager. EVIDENCE: Evidenced from the records identified that the staff were competent and qualified in areas pertinent to the care of the client group. Their experience was observed during the inspection. They were fully aware of the needs of the residents at home. Two of the staff were completing level II NVQ in Care. Mencap do not fully advocate NVQ training . Staff confirmed that they had received training but would like to be considered for NVQ training as part of their development. Policies and procedures were in place for the recruitment of new staff at the time of this inspection there remained 52 hr vacant. Adverts and interviews had taken place but no suitable candidate had been identified. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 18 Records evidenced supervision of the staff continued. Staff confirmed that they felt supported by the homes management. The area manager had not visited St Ives for a while or forwarded to the Commission a Regulation 26 as required to comply with the National Minimum Standards. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 19 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) 37,38,39,42. The registered manager where applicable ensures the health and safety of residents and staff. Risk assessments were part of the staff commitment to the residents. Staff felt supported and management was available at any time. EVIDENCE: The registered care manager ensured by his leadership skills that the residents all had a good quality of life. He was supported by willing competent staff that were aware of the daily requirements of the residents. The inspection was conducted in a relaxed manner with residents being involved throughout the day and contributing where possible. Mencap conducted a separate inspection based on the Standards annually. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 20 The registered managed ensured that the compliance with the relevant legislation and risk assessments were operational at all times. Evidenced in the documents were records for the fire prevention. One resident told the inspector how the bell sounded and confirmed he knew what it was for. 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 21 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 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 x 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 2/4 St Ives Close Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 3 x E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 22 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 20 Regulation 13(2) Requirement Timescale for action on going 2. 24 16 (c) 3. 32 26 (5) (a) the registered person shall make arrangements to ensure that medication is checked at all times when received into the home. the registered person shall on going provide adequate furnishings suitable for the needs of the residetns. the Responsible Individual shall a June 2005 least once a month make an unannouced visit in line with the items listed in Reg 26 and forwarded a report to the commission. 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 32 Good Practice Recommendations 50 of the care staff in the home should hold an care NVQ II incare (by 2005) 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Stafford Office - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 2/4 St Ives Close E51-E09 S5002 St Ives Close V227695 170505 Stage 4.doc Version 1.30 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. 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