Inspection on 31/10/05 for 267 Walmersley Road

This inspection was carried out on 31st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

267 Walmersley Road 14/07/09

267 Walmersley Road 03/10/08

267 Walmersley Road 08/10/07

267 Walmersley Road 20/03/07

267 Walmersley Road 09/03/06

267 Walmersley Road 26/02/05

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 267 Walmersley Road 267 Walmersley Road Bury BL9 6NX Lead Inspector Julie Bodell Unannounced Inspection 04:00 31 October 2005 st 267 Walmersley Road DS0000062679.V250732.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 267 Walmersley Road DS0000062679.V250732.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. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 267 Walmersley Road Address 267 Walmersley Road Bury BL9 6NX 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) 0161 737 7339 0161 737 3907 Pendleton Care Ltd Miss Wendy Shepherd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 6 service users to include: up to 6 service users in the category of LD (Adults with learning disabilities) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th February 2005 Date of last inspection Brief Description of the Service: 267 Walmersley Road provides a specialist residential facility for up to six young people who have Asperger’s Syndrome or associated communication impairments. Pendleton Care offers support to services users on an educational, employment and recreational level as they make their personal transition from childhood to a more independent lifestyle. The house is sited on a main road, has good public transport links and is accessible to community facilities. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on a Monday afternoon. The inspector spoke with two service users, the deputy manager, two members of permanent staff, stayed for tea, looked around the building and at paperwork. A follow up visit to speak with the manager was made later the same week. 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. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 234 A lengthy assessment is carried out before a young person moves into the Home to ensure that their needs can be met. Young people have the opportunity to visit the Home during this period. EVIDENCE: The registered manager completes an extensive and thorough needs assessment, with potential service users, which takes place over a thirteenweek transitional period. This includes looking at the suitability of accommodation, personal support, meaningful education, training or occupation to be provided, risk assessment and management, mental health, specialist input etc. The organisation also has a behavioural psychologist who will become involved in the assessment process, where appropriate. The inspector had no concerns about the ability of the staff members to meet the needs of the service users at the time of this inspection. There is one potential service user currently going through the assessment process. The service user has visited the Home, met the other service users and members of staff. If the assessment proves successful and funding is made available, then the service user will be able to stay overnight before agreement of a permanent placement is agreed. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Service users have very detailed care plans and risk assessments in place and are involved in the development of them. Both documents give support workers clear information as to how they will support the service users. EVIDENCE: Each service user has a detailed care plan. The inspector examined two service user plans. Plans are developed throughout the assessment period and reviewed and updated as the placement progresses. Information is gathered from as many sources as possible during the assessment process such as the family, social worker and other people who have involvement in the service users life. The plan includes arrangements for care that cover a wide area including personal details, personal profile, behavioural profile and support strategies, risk assessments, individual learning plan, communication abilities, activities for daily living and a child protection statement and strategy where appropriate. Service users are asked to sign the plan. The plan is reviewed on a 3 monthly basis. There is a key worker system in place. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 9 Service users are encouraged to lead a full lifestyle with support from staff as and were necessary. On the service user’s file examined by the inspector written risk assessments, covering all areas of potential risk, were in place. Risk assessments are detailed and specify the action required by members of the staff team to ensure that each identified risk is minimised and handled in a way that would not aggravate the service users level of anxiety. Any restrictions are recorded on the care plan were risks are identified. Risks are assessed prior to admission in order to determine whether an individual’s needs could be met within the established service user group. It was clear from discussion with staff members that they had a good knowledge and understanding of the service users behavioural needs and possible triggers to behavioural changes. Staff members said that they found written information on the working files to be good, clear and informative. Care plans and risk assessments matched the information that the inspector gathered during discussions with both service users and staff members. Service users have SMART (Specific, Measurable, Achievable, Realistic and Time-scaled) goals in place to help them manage any behavioural issues that they may have and help them move on. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 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): 11 12 13 14 15 16 Service users are supported by the staff team to live full and active lifestyles, which is based on each individual’s needs and choices. EVIDENCE: The service is specifically centred around personal growth, which includes the development social and emotional awareness and improving communication with others, particularly on consequences of behaviour. It also promotes independent lifestyles with support as required. Service users are involved in household tasks such as washing and ironing, preparing snacks and keeping their own rooms clean in their preparation towards independence. Two service users are currently undertaking college courses in hospitality and catering and psychology and sociology. Another service user is working at a college as a cleaner. The service users have both individual interests and can be involved in-group activities if they wish. Service users are encouraged and supported to pursue 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 11 their own interests. One service user attends drama, Aspirations and Aikado on a weekly basis. Another service user has also purchased a bike and rides to local countryside areas. Other service users needing more support have very busy lifestyles and are given the opportunity to experience new activities such as using the trampoline, swimming, crazy golf, bike riding Service users particularly enjoy music, especially the digital music channel, art, writing, the Internet and computer games, as well as DVD’s and videos, particularly science fiction and cartoons. All service users have contact with their families. Two service users go to stay with their families regularly and on occasion one service user visits and stays with a friend. It was clear from discussion that the rights of service users to have control over their lives. Examples such as management of service users time in areas such as going to bed and getting up, respect for privacy of their rooms and confidentiality were discussed. This can at times create interesting and difficult debates around the conflicts of respecting service users rights and the staff team adhering to responsibilities of duty of care. Conversations and documentation both areas were given the utmost consideration by the registered manager. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 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): EVIDENCE: Not assessed at this inspection. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 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): 23 Mandatory training is available to the staff team to ensure that they have the knowledge to protect service users from abuse. EVIDENCE: The Home has both an Adult Abuse policy and Whistle Blowing policy, a copy of No Secrets and The Protection of Children Act. The Home has a copy of the local Area Child Protection Committee Procedures. There have been no child protection inquiries. Adult protection training is available to all staff through mandatory training. Staff members receive physical intervention training and there have been times when techniques have had to be used. There are no physical interventions being used on an individual basis at the Home at this time. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 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 25 26 27 28 30 The property is large, spacious and homely. It suits the needs of the service users and a relaxed atmosphere prevails. The house is looking tired in parts and needs repainting. EVIDENCE: 267 Walmersley Road is a comfortable, homely, spacious detached property situated on a main road. It is not distinguishable as a care home thus promoting ordinary life principles. It is tastefully furnished to a good standard reflecting the age group and the needs of those living there. There are two large lounges and a spacious dining room available to service users. At the point of registration the building was plastered then painted throughout. Fine cracks have appeared during the settlement period of the plaster. The building is now looking tired in parts and needs to be repainted. The registered manager is aware of this and there are plans for the support workers to take on the project and involve service users. This is good practice, however the task is so big both in terms of the height and size of rooms, that in this case the inspector is not convinced that within current staffing ratios 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 15 that this is achievable and that it might be better that the job be done swiftly by a suitably qualified person. Each service user has there own large bedroom that is suitably equipped to meet their needs. The bedrooms are the service users private area and the support workers respect this. The bedrooms have locks to the doors. The degree as to which service users look their rooms differs markedly with each individual. There is a bathroom situated on the first floor, which contains a bath/shower, a hand basin and a toilet and two bathrooms on the second floor with the same facilities. There is a small car park to the front of the house and a very large elevated and enclosed rear yard. A large park is situated near by. Staff members sleeping in use a sofa bed that is in the office and have separate toilet and shower facilities. There is no smoking inside the house. The inspector noted that the Home felt warm and comfortable and observed that an acceptable standard of hygiene and cleanliness was achieved. Carpets have been cleaned recently. The damp through condensation in the laundry room appears to be better controlled and this will be checked again at future inspections. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 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): 32 33 34 36 EVIDENCE: The level of need of the current service user group remains complex. The inspector spoke to a new member of staff who confirmed that she had received induction training and had been shadowing other staff members and that this would continue until she felt confident to work unsupervised. The staff member said that she had received weekly supervision and felt that she had been well supported by the management and staff team, and that the atmosphere was comfortable and relaxed. She had also been given lots of useful reading material relating to Asperger’s Syndrome. The originally high ratio of staff to service users has been reviewed and reduced. There remains an experienced core staff team, which includes the manager, a new deputy and two other staff who may become seniors. However, there has been a high staff turnover below this group since the last inspection, with the very experienced and knowledgeable deputy and another member of staff moving to another home, whilst others have been made redundant or have left. There are two full-time vacancies at the Home. There is a heavy reliance on agency staff, though the manager does her best to ensure consistency by arranging block contracts. Given the specialist needs of this particular client group and the knowledge base needed by staff members to carry out the task, this is an area of weakness that must be addressed. The inspector is mindful that the service also runs an outreach service to four 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 17 service users and the manager has a dual role, which stretches staffing further. As already stated in Standard 23 the staffing issues have impacted on the staff teams ability to attend mandatory training. Both mandatory and NVQ training will be looked at in more detail at the next inspection. The inspector is aware that recruitment drives have taken place and that the quality of the applicants has been poor. Ways of retaining good staff members must also be looked at. However the registered provider must ensure that there is enough suitably qualified, experienced and skilled staff in place to meet the specialist needs of the service users at the Home at all times. The rota has now changed. The staff team are now working a longer day, which improves consistency for the service users and also reduces the need to have more regular handovers. There are on-call arrangements in place. Prospective new recruits attend a formal interview. The inspector examined a staff recruitment record, which was found to contain, an application form, two references, an induction checklist and a contract of employment and evidence of a CRB check being undertaken. 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 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 The registered manager’s level of knowledge, experience and skill is a key factor into success of this specialist service. EVIDENCE: The registered manager has a degree in psychology and has over seven years residential care experience. The registered manager has resumed undertaking NVQ Level 4 which will be completed in the near future. The registered manager is undertaking a part time MA in Autism course at Sheffield University which will take 3-6 years to complete. The manager also acts as regional manger for the Bury and Rochdale area, conducting monthly audits to ensure consistancy throughout the organisation. At the last inspection there were plans pending to appoint a new registered manager to the Home to free the present registered manager to carry out her regional duties. This situation has changed and the manager has continued in both roles. Care must be taken given the concerns about the staffing 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 19 arrangements that this dual role does not impact on the Home in a detrimental way. A new deputy manager is now in place. Service users and staff members said that the registered manager was always approachable if they had concerns or ideas about the service and said “the atmosphere was very friendly.” 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 4 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 X 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 N/A 3 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 X 2 2 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 267 Walmersley Road Score X X X X Standard No 37 38 39 40 41 42 43 Score 4 3 X X X X X DS0000062679.V250732.R01.S.doc Version 5.0 Page 21 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 2 Standard YA23 YA32 YA33 18 Regulation 23 Requirement That the building is repainted throughout. That the registered provider must ensure that there is sufficient numbers of suitably qualified, experienced and skilled staff in place to meet the specialist needs of the service users at the Home at all times. Timescale for action 31/03/06 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 267 Walmersley Road DS0000062679.V250732.R01.S.doc Version 5.0 Page 23 - 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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