Inspection on 03/03/07 for 20 Waterloo Road

This inspection was carried out on 3rd March 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

20 Waterloo Road 17/02/09

20 Waterloo Road 12/01/06

20 Waterloo Road 27/07/05

20 Waterloo Road 13/02/05

20 Waterloo Road 26/07/04

20 Waterloo Road 15/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Waterloo Road, 20 South Yardley Birmingham West Midlands B25 8JR Lead Inspector Nancy Johnson Key Unannounced Inspection 3rd March 2007 09:30 Waterloo Road, 20 DS0000017091.V324719.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 Waterloo Road, 20 DS0000017091.V324719.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. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waterloo Road, 20 Address South Yardley Birmingham West Midlands B25 8JR 0121 707 4673 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) Mrs Manju Mohan Mr Rajeshwar Mohan Mrs Manju Mohan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 12th January 2006 Brief Description of the Service: 20 Waterloo Road provides accommodation, care and support for three people with learning disabilities. The house is a three bedroom terraced property situated in the South Yardley area of Birmingham. The home is well served by public transport and is in close proximity to community facilities and amenities. The Registered Manager is also the co-owner of the property with her husband, and both work as part of the care team along with their son and another support worker. On the ground floor is a front lounge, which gives access to the street via the front door of the house. There is a further lounge / dining room leading through to the kitchen at the rear of the property. The bathroom and toilet are also situated on the ground floor, and these are accessed through the kitchen. On the first floor are three single bedrooms, only one of which meets current National Minimum Standards for floor space. The staircase is quite steep, so this house would not be suitable for people with significant mobility problems. To the rear of the property is a long garden, with a lawn and patio area with seating. Parking space is generally available on the road at the front of the house. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection over seven hours. The inspector was pleased to meet with the residents, staff on duty and the Manager. The inspector looked at all the communal areas of the premises and most bedrooms. The Inspector spent time talking to service users and observing support and interaction between them and the staff. The Inspector looked at the records of care and the care plans for three residents and sampled two staff files. Other records including fire safety records, rotas, staff supervision and training were inspected. Information was provided by the Manager on the CSCI pre-inspection questionnaire. What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that the quality assurance tool that is currently being developed is fully implemented. The home should develop a reward system linking achievements of personal goals identified in service user’s care plans. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Waterloo Road, 20 DS0000017091.V324719.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 Waterloo Road, 20 DS0000017091.V324719.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provides individual contracts which is now in accordance with Standard 5.2. EVIDENCE: As required by the last inspection contracts have been rewritten in line with National Minimum Standard 5.2. The service users contracts now clearly stipulates what fees are to be paid, what these cover and who should be paying them. Individuals rights and responsibilities are also clearly outlined. The service users care plan has been developed to link with the individual contracts and service users expectations are reviewed on a monthly basis. Care plans are comprehensive with specific care and support needs coupled with risk management plans where appropriate. Since the last inspection staff have received training in care planning and risk assessment using the Mulberry House Care Planning electronic tool and work manual. The home has a statement of purpose based on the philosophy of the home for life. This was available both in written and picture format. There have been no new admissions since the last inspection. All service users have been there for a number of years and are a settled and stable group. Referrals are made Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 9 only by social services for new admissions and they would follow a phased admission policy prior to moving into the home. Upon referral the prospective user would be given the opportunity to test drive the home. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Substantial work has been undertaken to fully develop service users care plans and to update risk assessments. EVIDENCE: The home has undertaken substantial work to develop the residents care plans. The manager and staff had received training to assist them to review the care plans. All plans are now detailed and specific areas of need are identified, what support and how this support is required, who is responsible to provide the support and timescales. Individual goals are reviewed as part of the keyworking arrangements. Service users are encouraged and supported to develop domestic skills. Three residents files were sampled and one of the files indicated that the resident attended a day centre five days a week, they also help around the home and was encouraged to take part in other activities such as attending the cinema. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 11 All service users have a daily record sheet which indicates what they have done which is signed and dated by both the staff and service user. The inspector had the opportunity to audit the residents financial records and found these to be in order. Two of the service users have their own building society accounts and the manager is the appointee for those accounts. It is recognised that due to degree of the service users learning disabilities they are not able to manage their finance. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,14,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are engaged in a range of activities and are encouraged and supported to help around the home. EVIDENCE: The last inspection recommended that one of the residents were supported to develop their domestic skills around the home. The records indicate that this has commenced and that a particular resident was developing domestic skills in the kitchen and was making tea and toast. All service users are encouraged to assist with making their beds and to keep their bedrooms tidy. Activities are planned for residents on a weekly basis that involves attending the cinema, museums, libraries and going out for meals. All activities are documented in a daily record. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 &21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by recently reviewed medication and PRN policies and general good practice. EVIDENCE: There was clear documentation regarding daily records and monthly evaluations sheets for all health care appointments that the service users attended including GPs, opticians, chiropody and dental appointments. The service users diet is monitored regularly. All medication is appropriately monitored and policies are reviewed and actioned accordingly. The medication administration records (MAR) were sampled for all service users. All documentation was satisfactory and records were up to date. It was recommended at the last inspection that the PRN policy was reviewed and this was completed March 2006. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 14 Case tracking of three sampled files indicated that medication was dispensed and recorded in line with policies. Staff have received recent training in the administration and recording of medication. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. General practice within the home is good which protects service users from abuse, neglect and self harm. EVIDENCE: The homes complaints procedure was last reviewed in May 2006 and amendments have been made. The home was also in the process of updating the Hygiene and Food Safety policy. It was recommended at the last inspection that one of the residents was encouraged to sign for money received throughout the week in order to promote his independence. This has been implemented since the last inspection. Two staff files were sampled and records were up to date. Each file contained CRB check, photo ID, job application, contract of employment, staff assessments, supervision records and records of training. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a warm and homely environment where their safety and well-being is promoted. EVIDENCE: The home has good access to local facilities and transport. The home was clean and had a welcoming environment. The service users bedrooms were personalised and were equipped according to their needs and promoted independence as far as the service users are able. One service user informed the inspector that although their room was only decorated two years ago arrangements have been made with the managers to change the décor. There are sufficient washrooms and toilet facilities for all service users. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 17 The inspector had the opportunity to check safety records in relation to appliances, utilities and smoke detectors and these were all in order. The fridge temperature was also checked on a daily basis. There is a cleaning schedule in place outlining areas for daily, weekly and monthly cleaning. Since the last inspection new laminate floors have been laid in the dining room and lounge. Damaged furniture identified at the last inspection had been replaced. A maintenance schedule has been drawn up and budgeted for an annual period. The COSHH store is now securely locked as required at the last inspection. All hazardous substances kept in the home is accompanied by the manufacturers data information sheet. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care team is appropriately qualified and competent. EVIDENCE: The home is a family run business. Both of the managers are qualified to NVQ Level 4 and hold Registered Managers Awards. Supervision has improved since the last inspection and regular supervision was evidenced by sampled staff files. Staff had also received extensive training in 2006 using the Mulberry House Electronic Tool and Training manual covering a broad spectrum of social care, protection and related issues which is ongoing. All policies have been reviewed since the last inspection and have been signed and dated. Waterloo Road, 20 DS0000017091.V324719.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. EVIDENCE: It was required in the last inspection that a Quality Assurance systems be developed with particular attention being placed on ensuring that the views of the people using the service are taken into account. Since the last inspection the home has developed systems through Practical Quality Assurance System for Small Organisations. Part of that self evaluation meant that a plan was drawn up to include an annual review of policies, consultation with service users and safety checks. The inspector was informed that the managers found this feedback useful as a tool for improving services and the home environment. Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 20 Waterloo Road, 20 DS0000017091.V324719.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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 4 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 3 3 3 3 3 3 3 3 Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 22 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39 Good Practice Recommendations Manager to devise a questionnaire for relatives, friends and professionals involved in residents care. Do a detailed analysis of the activities undertaken by individuals. Use the results of both of these to develop an appropriate quality assurance system for the home. (Work on this has been partly met) Waterloo Road, 20 DS0000017091.V324719.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Waterloo Road, 20 DS0000017091.V324719.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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