Inspection on 20/07/06 for 2-4 St Ives Close

This inspection was carried out on 20th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

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 04/10/05

2-4 St Ives Close 17/05/05

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 Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

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 Mrs Wendy Grainger Key Unannounced Inspection 20 July 2006 09:00 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2/4 St Ives Close Address Leyfields Tamworth Staffordshire B79 8HL 01827 68517 F/P 01827 68517 h6029@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) Mr David Nicholas Yates Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1), Physical disability (5) of places 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 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 within walking distance of the town centre. The home provides services to nine 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 separate living units, which are known as Unit 2 and Unit 4, with their own kitchen and communal areas. The two units share a laundry and the office. One unit accommodated five service users, some of whom were wheelchair users and the other unit accommodated three male service 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 residential area and was indistinguishable as a care home. From the information provided in the pre-inspection questionnaire, the current fees were £1,046.50 and £1,091.50. The pre-inspection questionnaire indicates that there were no additional charges made to the residents. Each resident received their full personal allowance. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed on the 20 July 2006 with the registered care manager. The home continued to be well maintained. Staffing levels at the time of this inspection were satisfactory to meet the needs of the residents in both units. There had been a change in the management structure, with the nonregistered care manger transferring to another area. The inspection was completed from the details in the pre-inspection questionnaire; three comment surveys, speaking to the staff on duty and from observations of the residents’ interaction and limited discussions with the residents where possible. A tour of the home identified one concern with a carpet. The external parts of the homes were safe and secured. What the service does well: What has improved since the last inspection? What they could do better: There was an urgent need to replace the flooring in Unit 2’s kitchen at the time of this inspection as it was a potential hazard to the residents and the staff. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 6 The first floor landing carpet is a potential hazard which needs re-stretching or replacing. While the home has to rely on the Council or landlord to attend to the garden, the shrubs outside the lounge in Unit 2 would benefit from pruning. It was identified during the tour of the home that a number of the fans in the bathrooms and toilets were not working, despite the light showing alternatively. While the fans are not working, the bathrooms were airless and may be liable to mildew. 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 DS0000005002.V303689.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including speaking to management. The Statement of Purpose reflected the recent changes in the management structure. The information provided was current. Every effort is taken to ensure that the placement is the right one, this was via the admission procedures and assessments. EVIDENCE: The Statement of Purpose had been amended to inform any person that the management structure had changed to one main registered manager. There are procedures in place to assess and welcome a prospective new resident to the home. Trial visits have been part of this; at the time of admission there will be a further assessment of the equipment the person will require. Each of the residents were provided with the terms and conditions of the home. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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): 6,7,9, Quality in this outcome is good. This judgement has been made using available information including viewing a sample of the care plans, observing the staff and residents. Care plans continue to provide relevant information to facilitate the staff in providing the appropriate care for vulnerable residents. EVIDENCE: There had been a change to one person’s medication; this had been recorded and staff informed to watch for any changes that may occur. This and other relevant information was recorded in the sample of the care plans seen. It was difficult for residents to make comments regarding their care due to their lack of communication skills. Each resident would be part of the evaluation, often not always stopping with the staff for very long. One resident does make a more informed comment. Risk assessments were part of the regular evaluations; one resident was involved in pouring his own tea. It was a pleasure to observe the staff working and supervising the residents who they know and understand so well. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15,16,17, Quality in this outcome area is good. This judgement was made using available evidence, checking the records, speaking to staff on duty. Arrangements were in place for any resident to access external professional agencies. Residents were part of the local community, using facilities in the Tamworth area. Staff on duty were supportive to individuals, recognising each resident’s personality and needs. EVIDENCE: No resident or their family had identified that their relative had a spiritual interest. Residents from Unit 4 residents were able and interested in attending the local college, and day resource centre during the week. The residents in Unit 2 have a different lifestyle, going out with staff on a regular basis. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 11 Residents in Unit 2 were planning to have a holiday in Centre Parks and the Darby Dales. Unit 4 holidays had been discussed but nothing had been decided yet. One of the residents is facilitated to exercise his option to vote. The home has two vehicles adapted to accommodate wheelchairs when necessary, the vehicles are not always in working order due to their age but they do have MOT certificates. Residents where able are encouraged to be independent and to do small personal and household tasks. Each one would be accessed on their ability. Each resident had various needs, which were recognised by the staff. Meals were different in each unit. There was a need for the staff at Unit 4 to ensure that the food records and temperature records were current. The meals in Unit 2 were observed as part of the inspection; portions were ample and residents appeared to enjoy the lunch. It was decided that a casserole would not be suitable on the day due to the weather; an alternative would be prepared. Residents in Unit 4 were physically less able and needed more support when dining. There was a need for a member of the staff to contact the day resource service to ensure that they forward current menus weekly, to ensure residents were not provided with a duplicate meal on their return home. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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, 19,20 Quality in this outcome area is good. This judgement has been made using available evidence including inspecting records, speaking with the management and staff, and observing the interaction between staff and residents. The medication system, training and storage were satisfactory. Residents’ personal needs were met in a sensitive manner by staff committed to their care and daily routine. EVIDENCE: Each of the residents had full access to other professional agencies. One resident had routine visits from a consultant at the home. The staff were exploring the possibility of a “well man’s clinic”. The interaction of the staff and residents was a pleasure to observe. Residents with no communication had the support of staff in all aspects of their daily routine and care based on the care plans and the knowledge of each individual. Where applicable residents that can verbally make a choice were listened to. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 13 The system for medication and the records used in conjunction were accurate. The registered care manager was aware that some routine health checks were no due for two residents. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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 the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including checking documents, speaking with staff and where possible residents. The homes complaint process was available to any person coming to the home. The staff receive training, updating and improving their knowledge to ensure residents are protected from abuse. EVIDENCE: There had been no internal complaints received. The company had updated the complaints system for the residents. A copy plus a tape were contained in each of the care plans. Staff confirmed that they had received training via Mencap, to recognise any form of abuse. More training was due September 2006. For the new staff recruited this would be part of their induction training. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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 the following standard(s): 24,25,26,2729 30 Quality in this outcome area is good. This judgement has been made using available evidence including a tour of the home. Both units were well maintained hygienically to a high standard. The home in most areas was safe for residents’ use but there were a couple of areas where this was not the case and formed a potential danger to the residents. EVIDENCE: There had been two new dishwasher fitted since the previous inspection. A new cooker had been purchased for Unit 2. Following the closure of a satellite house No 2 unit has been provided with a quality leather suite. There was a need to urgently replace or repair the flooring in the kitchen of Unit 2 as the flooring is a potential hazard for residents and staff. During the tour of the home it was identified that the extractor fans were not working. This needs to be addressed, as the bathrooms were airless and may be subject to damp forming. The carpet on the first floor had become a potential hazard where it had become uneven. This needed replacing or re-stretching. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 16 Outside the lounge in Unit 2 there was a need to consider pruning the shrubs to enable the residents to have a clear view. The entire home was maintained to a high standard, bedrooms had been rearranged to provide one resident with more space. Personal items were encouraged as were observed during the tour. There are plans following a discussion with the prospective resident that the vacant rooms furniture will have to be stored when she brings her own furnishings in. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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): 32 33 34 35 36 Quality in this outcome area is good. This judgement had been made using available evidence including reviewing the rota, speaking and observing the staff. The staff team were committed, experienced, and trained to provide appropriate care to vulnerable adults. EVIDENCE: Since the recent inspection the registered care manager had been involved in the recruitment of three new staff. Mencap had not taken on board the advice in the previous inspection report with prospective employees being interviewed at the home; to get a perception of the residents and the accommodation. The staffing levels were acceptable to meet the needs of the residents. The number of vacant hours had reduced. At the time of this inspection the manager was waiting for the CRB checks of 3 staff to be returned before commencing their employment. The records of the staff needed reviewing to ensure the safety of the residents they were a little fragmented in the required details. This was discussed with the registered manager and he will address it with the relevant staff. Staff training supported the residents in their personal, social and life style. The obligatory training was current. There was a need for the registered care 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 18 manager to comply with the National Minimum Standards pursue infection control for 2006. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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 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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available information including accessing records, speaking with the staff and manager. Training implementation continued to further support the residents life style. The manager and his staff generated a relaxed atmosphere throughout the home. EVIDENCE: The registered care manger generates a relaxed ambience; the staff team support the residents with the same approach. The registered care manager will complete his Registered Managers Award later this year. Staff confirmed that they were supported by the registered care manager and that they received supervision. Four of the staff had NVQ II in Care and three staff had NVQ III. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 20 The audit for the fire risks, tests and drills were current, from the information and records provided. The company had devised questionnaires to obtain feed back from other professional agencies. Mencap review and create policies and procedures when necessary. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 4 26 4 27 3 28 3 29 3 30 4 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X X 3 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered 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 YA24 Regulation 13 (4) (a) Requirement The registered person shall ensure that al parts of the home to which residents have access are so far as reasonably possible free from avoidable hazards to their safety Timescale for action 20/08/07 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 YA34 YA17 Good Practice Recommendations To ensure that records required in Schedule 2 are current for all the staff To maintain accurate records for Unit 4 for meals served and food temperatures taken. 2/4 St Ives Close DS0000005002.V303689.R01.S.doc Version 5.2 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 DS0000005002.V303689.R01.S.doc Version 5.2 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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