Inspection on 04/10/05 for 2-4 St Ives Close

This inspection was carried out on 4th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 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

Similar services:

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 Announced Inspection 4th October 2005 09:00 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 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.V254654.R01.S.doc Version 5.0 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.V254654.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 2/4 St Ives Close Address Leyfields Tamworth Staffordshire B79 8HL 01827 68517 01827 68517 h6029@mencap.org.uk 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) Royal Mencap (Housing & Support Services) 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.V254654.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 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 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 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 some of whom 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. Since the last inspection the home had appointed a second care manager to manage Number 4. The existing registered care manager will manage Number 2. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was completed on the 4 October 2005 by one inspector, the residents, staff and management assisted by providing relevant information. The registered care manager had completed the pre inspection questionnaire. Documents records and reports were provided based on the National Minimum Standards. The residents were either in the bathroom, lounge or bedrooms. One resident had gone into Tamworth to the Day Centre. The Commission had received no comment cards from relatives or residents. The majority of the residents do not have vocal communication skills; during the inspection residents were observed with the staff. Communication and body language identified that the residents were comfortable and relaxed with their life style and with the intervention of the staff. Arrangements were being undertaken to fill the vacancy in Number 4 with a residents from another home located in Stafford. This person had had a full assessment of her needs and been involved in a visit to the home. A second care manager had been appointed since the last inspection she will manage Number 4. The registered care manager Mr Yates will continue in his role and manage Number 2. The Statement of Purpose will reflect the change in management and qualifications. Residents accommodation is located on two floors accessed via the stairs or shaft lift. Observations made by the inspector were that the home was clean, tidy and maintained by the staff to a high standard. While this standard was maintained the bathroom and shower floors would only benefit from a deep commercial clean. Arrangements were in place for meeting the health and personal needs of individuals, details were recorded in the care plans. Regular daily normal social activities were promoted. There were no arrangements for external entertainers to visit the home. Residents were provided with a choice of meals, staff were aware of the likes and dislikes and arranged meals to suit the residents. This was evidenced from the menus provided. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 6 The complaints process was displayed in the hall and contained the appropriate information. Residents representatives would be the prime advocates to raise concerns with the management or Commission. Two new relief care assistants had been employed, the staff at the home were experienced and competent to provide the appropriate care for the resident group. Appropriate recruitment procedures were in place and each person prior to employment had a Criminal Records Bureau and POVA check. The inspector was surprised that the place used for staff interviews was not at the home but in the Job Centre, it is felt that this is a retrograde step and while the residents privacy and home life needs to be respected the prospective staff need the opportunity to meet with the existing staff and residents which may ally any concerns by being aware of the client group. Standard 8.3 iii states that residents should have the opportunity to be “involved in selection of staff and of other service users “ This issue was also raised by the Regulation Manager at a meeting with senior managers of Mencap recently. What the service does well: What has improved since the last inspection? What they could do better: This report makes two requirements and three recommendations, each one was discussed at feedback with the care managers. One of the requirements (No 5) was beyond the registered care manager’s control and was outstanding from the previous inspection completed in May 2005. 1. To ensure that at all time residents were only administered medication prescribed for them personally. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 7 2. 3. 4. 5. To consider further fire training in particular for the night staff. To ensure the temperatures of food cooked was recorded. To pursue the idea of a commercial firm to deep clean the bathroom and toilet floors. The Responsible Individual shall at least once a month make a visit to the home to comply with Regulation 26 and forward a report to the Commission. The Commission was aware of the difficulties in recruiting new staff for the establishment. The inspector was conscious of the fact that interviews were not conducted at the home. Prospective new staff were not aware of the client group, and while it is their home it may, be beneficial for a prospective employee to have an awareness of the residents, before committing to employment. This practice may prevent the turn over of staff soon after commencement. 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.V254654.R01.S.doc Version 5.0 Page 8 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.V254654.R01.S.doc Version 5.0 Page 9 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): 1,2,3,5 The home maintained a Statement of Purpose this document can be accessed freely. Time and consideration was given to ensure that any placement was right for the individual. EVIDENCE: The long process of assessing a prospective resident continued; the person had visited the home to meet the other residents. The funding had yet to be agreed so further visits have been postponed as it was identified that the travelling was upsetting the resident. The manager had assessed the resident identifying that the staff and facilities at Number 4 can meet her needs. Following the placement the terms and conditions agreement will be completed. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 10 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): 6,7,8,9,10 The care plans and risk assessments were informative, detailed and evaluated to ensure that daily routines and needs were met. The staff promoted the relaxed family atmosphere, residents responded to this and the sensitive manner in which they were approached. EVIDENCE: St Ives is divided into two units one care plan was seen in each unit. From the evidence in each of the plans and evaluations, the staffs were setting realistic goals. Records identified reviews with the resident and staff responsible for their care. Staffs at St Ives were competent and committed to the care of all the residents. With the exception of one resident who has two key workers each resident had a key worker. Mencap, were planning to have the plans more person centred, in the form of a new format. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 11 Residents were seen to be encouraged to complete tasks within their capabilities during the inspection. Where necessary risk assessments had been completed these were personalised to individuals, the detailed plan of action was evaluated with the care plan. Residents were observed to be offered choice during the inspection. One resident was taken into town for lunch. The staff were fully aware of the need for confidentiality and respected the choice and opinions of the residents who had verbal communication skills. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 12 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): 11,12,13,14,16,17 Staff recognised, respected and supported an individuals personal development. The residents were part of the community and were offered a full social life experience. Arrangements were in place for the residents to access external professional agencies. Residents were provided with a balanced diet to suit individual’s tastes. EVIDENCE: Personal development was part of an individuals care plan; one resident in Number 2 did not attend any form of day centre/college. They show no interest in using the facility. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 13 Residents in Number 4 attended the local day centre and college during the week. All the residents had been away on holiday this year; staff accompanied individuals in numbers to meet their personal needs. Menus for Number 2 & 4 were written to meet the likes, dislikes and ability of the residents. The residents in Number 2 were independent when dining and had a good appetite. The residents in Number 4 had different needs, which were respected by the staff assisting them. There was a need to continue recording the food temperatures. Other records required were current. No special diets were provided. Arrangements were in place for all the residents to access their own general practitioner. One resident had daily visits from the district nursing service. External clinics for the residents well being were accessed where appropriate. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 14 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 Arrangements were in place to meet the personal health needs of the residents. There was a requirement for the staff to follow the safe handling and administration of medication. Prescribed medication should not be administered to another person. Medication issues were a requirement in the previous report. It may be that staff need further awareness training. EVIDENCE: Residents were supported in their personal and health needs daily by the committed staff team. The residents responded to the staff in a relaxed comfortable manner. Equipment for personal use had been provided when necessary. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 15 The inspector had concerns in Number 4 when it was identified that medication had been administered to one resident from another residents prescribed medication. The management could offer no explanation as to the concerns raised. The registered care manager would investigate and ensure via the new care manager that this did not occur again. Medication prescribed should only be administered to the named person. This report makes this a requirement to comply. The previous report of May 2005 made medication a requirement to comply with, the inspector was told by the registered care manager that medication issues had been dealt with. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 16 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 The homes complaint process was accessible to any person visiting and residents living within the home Staff via training and experience ensured that residents were protected from any form of abuse. EVIDENCE: The Commission had received no complaints. The registered care manager had not recorded any complaints. The complaints process was available and displayed for ease of access. Staff training records and from the information recorded in the pre inspection questionnaire ensured that mandatory and relevant training was current. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 17 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): 24,25,26,27,28,29,30 The staff and management provided an attractive homely environment; residents had freedom of space and movement. The home was maintained to very high standards throughout. EVIDENCE: The residents at St Ives were provided with a comfortable individually furnished home. Each bungalow was different in style. Bedrooms were decorated and had tactile lights to suit individuals needs. Accommodation was located on two floors accessed by the stairs or shaft lift. The inspector viewed all the bedrooms each one was different in style and colour, personalised to suit a residents taste. Bathrooms and toilets were located throughout the home, there was need to deep clean the very stained flooring in these areas. The staff collectively maintained a very high standard of hygiene throughout the home. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 18 The only shared facility was the laundry and freezer area. At the rear of the home was a lawned area with an additional white gravelled part for ease of access there were no ramps or steps at any exit. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 19 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): 31,32,33,34,35,36 The staff team employed in numbers were meeting the needs of the resident group. These vacancies have been identified in previous reports, while staff continued to fill the shifts; further staff would benefit all concerned at St Ives. Each member of the staff team were committed via experience and training to the care of the residents. EVIDENCE: The management had recruited more staff earlier in the year. Two new relief staff were part of the team as was a new care manager for Number 4. The registered care manager was responsible for the staffing levels and rotas, which were displayed in the offices. Due to the physical dependency of the residents in Number 4 staffing levels increased by one during the morning shift. One waking person plus sleep-in completed the staff team. Mencap did not employ ancillary staff. At the time of this inspection there were 70hrs vacant over both units. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 20 Via the staff training, residents were supported by a staff group who, were committed knowledgeable and committed to the needs of individuals. Policies and procedures were in place for the recruitment and employment of staff. The Commission was aware of the difficulties in recruiting new staff for the establishment. The inspector was conscious of the fact that interviews were not conducted at the home. Prospective new staff were not aware of the client group, and while it is their home it may, be beneficial for a prospective employee to have an awareness of the residents, before committing to employment. This practice may prevent the turn over of staff soon after commencement. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 21 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): 37,38,40,41,42,43 The registered care manager and the staff where applicable and practicable ensured the health & safety of the residents. St Ives had a relaxed comfortable environment where residents were cared for and supported in their chosen life style. Policies and procedures provided the complete guidelines for the staff, based on the National Minimum Standards. EVIDENCE: The registered care manager will complete his Managers Award at the end of the year. His leadership skills for management promoted a relaxed atmosphere in each unit. Staff felt supported by the manager, he operated an open door policy. The home was operated in the best interests of the residents. The inspection was relaxed with the staff and the residents. Five of the staff were interested in NVQ Level II two staff were undertaking NVQ Level III in Care. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 22 A residents survey was conducted with the help of the staff. The home had a formal quality assurance document. A person from Mencap undertook reviews of the service and audit annually. The management and staff at all times so far as practicable promoted the health and safety of the residents. Records evidenced, identified that the registered care manager or person nominated needed to ensure that all the night staff had been involved in a fire drill. Professional fire training was planned for November 2005. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 23 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 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 4 4 4 3 3 3 4 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 4 4 3 4 4 CONDUCT AND MANAGEMENT OF THE HOME 3 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 4 3 3 3 3 3 DS0000005002.V254654.R01.S.doc Version 5.0 Page 24 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 24 Regulation 16 © Requirement Timescale for action 31/10/05 2 20 13 (2) The Responsible Individual shall at least once a month make an unannounced visit to the home to comply with Regulation 26 and forward the homes report to the Commission. This is outstanding from the previous inspection report. The registered person shall 20/10/05 ensure that only the prescribed medication is administered to the named person. 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 Refer to Standard 17 27 42 Good Practice Recommendations To continue with the temperature records in respect of food cooked within each unit. To pursue the suggestion of a commercial firm to deep clean the bathroom and toilet flooring. To ensure that all the night staff had been part of a fire drill. 2/4 St Ives Close DS0000005002.V254654.R01.S.doc Version 5.0 Page 25 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.V254654.R01.S.doc Version 5.0 Page 26 - 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!