Inspection on 09/03/06 for 267 Walmersley Road

This inspection was carried out on 9th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 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 31/10/05

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 9th March 2006 09:30 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 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.V265624.R01.S.doc Version 5.1 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. 31st October 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.V265624.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place at 8.30am on a Thursday morning. The inspector spoke with the registered manager and briefly two service users, looked around part of the building and at paperwork. Please see previous reports for further information about this service. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose needs to be looked at and amended to reflect the service. The building is looking tired in parts and needs repainting. Quotes to carry out this work have been sought by the service. More attention needs to be paid to control of infection and deep cleaning. The staff team needs to be strengthened to ensure that it can meet the specialist needs of the service users and withstand any future staff changes within the team. Staff members need to undertake training in adult protection as soon as possible after starting work at the Home. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 6 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.V265624.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The statement of purpose needs to be updated so that prospective service users have correct information to make an informed decision about the service. EVIDENCE: The Home’s statement and purpose must to be reviewed and revised to reflect the current service provided by them. Due to changes to the registration certificate the Home no longer accommodates children. Once amended a copy of the statement of purpose and the service user guide must be forwarded to the CSCI. The service also provides an outreach service to six service users on a regular and ad hoc basis. A meeting with the provider will be arranged in the near future to discuss whether this service needs to be registered under the Domiciliary Care Regulations. It was noted that one of the service users is seventeen years old and therefore legally a child. There have been no new admissions to the Home since the last inspection. 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. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed at this inspection. Please see previous reports. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 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 17 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: Two service users are currently undertaking college courses in hospitality and catering and psychology and sociology. Another service user is working. 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. Service users are encouraged and supported to pursue 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 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 11 Service users 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. One service user is looking to move on from the Home to live more independently with the local area. The kitchen was checked and found to be clean and tidy and well stocked with food, including fresh fruit and vegetables. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 The staff team are able to meet the specific needs of individual service users through very detailed care plans and good knowledge and understanding of their needs. Some improvements to the medication system is needed. EVIDENCE: Service users need varying levels of support from the staff team and this is reflected in their care plans. The support needed by service users can be highly detailed and must be applied in a consistent way to ensure the emotional wellbeing of service users is maintained. Staff members have access to very good written guidance to do this and permanent long term staff members have good background knowledge, skill and experience. All service users are registered with a local G.P, dentist and optician and were necessary specialist healthcare professionals such as psychologist to help develop behavioural strategies. Records of appointments are maintained. The medication system was checked. Some issues were raised around recording systems and shelf life of medication. A request has been made for the CSCI pharmacist to audit the system. First aid boxes need to be checked and fully equipped so that they are effective if needed in an emergency. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 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 a complaints procedure. No complaints have been investigated by CSCI about the service. The inspector was made aware that there are issues currently being addressed in respect of the financial arrangements of one service user. The Home has both an Adult Abuse policy and a Whistle Blowing policy. There is also a copy of No Secrets. The registered manager has recently attended a course that enables her to provide training to the staff team. This training is due to take place in the near future. The inspector viewed the training content. The registered manager must ensure that the training makes clear links with both internal policies and external local authority policies and POVA to ensure that staff members receive accurate information. 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. One service user has an advocate. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 The property is large, spacious, comfortable and homely. 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 tastefully furnished to a good standard reflecting the age group and the needs of those living there. The inspector asked that a sofa on the landing be removed, as it is a fire hazard. Since the last inspection parts of the house have been repainted. Quotes have been received for the work to be undertaken by a contractor to carry out work to the hall and stairs. This work must be completed. The inspector noted that the Home felt warm and comfortable and observed that an acceptable standard of hygiene and cleanliness, but could do with a spring clean. More attention needs to be paid to control and infection practices with the use of liquid soap and paper towels in communal areas. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 15 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 35 Care needs to be taken to ensure that the increased staffing demand of the outreach service does not compromise the needs of the service users living within the registered service. EVIDENCE: The level of need of the current service user group remains complex. As identified at the last inspection the originally high ratio of staff to service users has been reviewed and reduced over time. There remains an experienced core staff team, which includes the manager, a new deputy who has worker at the Home as a support worker for sometime and two other staff who have recently become seniors. There is one full-time vacancy at the Home, which has been advertised and a suitable candidate has been identified. There has been less of a reliance on agency staff recently and existing staff members are working any extra hours that are available. The inspector continues to be mindful that the service also runs an outreach service, which has recently increased to six service users and the registered manager has a dual role, which stretches staffing further. 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 and that the outreach service does not compromise the 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 16 service to those living at the Home. The registered manager said that she was happy with the present staffing arrangements. An on-call system is in place. The deputy manager is enrolled on NVQ Level 4, two staff members hold NVQ Level 3, with a further two staff members enrolled for NVQ Level 3. Two staff members undertaking NVQ Level 2. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 17 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 The registered manager’s level of knowledge, experience and skill is key to the 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 now completed NVQ Level 4. The registered manager is in her final year of a part time MA in Autism course at Sheffield University. An internal review of the quality of the care provision which covers care plans, health, support needs, etc is carried out every three months. Health and safety records and recording were checked. A PAT test of all portable electrical equipment must be undertaken and records of health and safety checks must be kept up to date. 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 18 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 2 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 4 X 3 X X 2 X 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 YA1 YA20 Regulation 4 13 Requirement That the statement of purpose is reviewed and revised and a copy sent to CSCI. That following a visit from the CSCI pharmacist that any requirements made are complied with and first aid boxes are complete. That following a review of relevant policies and procedures that all staff members receive updated adult protection training. That the building is repainted throughout. (Outstanding in part) That the sofa on the landing is removed as it compromises means of escape. That attention is paid to control and infection issues and cleaning. 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. (Ongoing). DS0000062679.V265624.R01.S.doc Timescale for action 30/04/06 31/05/06 3. YA23 13 31/05/06 4. 5. 5. YA24 YA24 YA30 23 23 16 30/06/06 31/03/06 30/04/06 6. YA32 18 30/06/06 267 Walmersley Road Version 5.1 Page 20 7. 8. YA42 YA42 13 17 That a portable appliance check is undertaken. That all records in respect of health and safety checks are properly maintained. 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 267 Walmersley Road DS0000062679.V265624.R01.S.doc Version 5.1 Page 21 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.V265624.R01.S.doc Version 5.1 Page 22 - 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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