Inspection on 30/05/07 for 30 Brook Street

This inspection was carried out on 30th May 2007.

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 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

30 Brook Street 16/03/06

30 Brook Street 06/10/05

30 Brook Street 22/02/05

30 Brook Street 14/09/04

30 Brook Street 02/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 30 Brook Street Wordsley Stourbridge West Midlands DY8 3XF Lead Inspector Ms Linda Elsaleh Key Unannounced Inspection 30th May 2007 2:00 30 Brook Street DS0000025044.V332400.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 30 Brook Street DS0000025044.V332400.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. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 30 Brook Street Address Wordsley Stourbridge West Midlands DY8 3XF 01384 480770 01384 860507 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) Wordsley Housing Society Ms Karen Lesley Barr Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2006 Brief Description of the Service: Wordsley Housing Society is a voluntary organisation providing housing, support and practical help to adults with long-term mental health problems. There are three units within this registration. The main house, at 30 Brook Street, is a purpose built two-storey property, which was opened 18 years ago. The home provides accommodation for 18 people. Residents’ accommodation is on the ground and first floors. There are communal lounges on both floors. There are 8 bedrooms on the first floor with 4 kitchenettes and 4 bathrooms/toilets. The first floor is accessed via the stairs and residents who are more independent are accommodated here, but they can access any of the home’s facilities including the main dining room, kitchen and laundry on the ground floor. The ground floor has a range of toilets and bathrooms including one walk in shower, plus a small conservatory that is used by residents for growing flowers and plants. The main office is also on the ground floor. Attached to the home is an activities room with kitchenette and Manager’s office. The home also provides 1 respite bed, funded by the Local Authority. This is in the main house on the ground floor. There are patio areas for seating to the front and the rear and an ornamental fishpond at the front. Car parking is at the front of the property. There are also two smaller houses located in the adjoining street (6 & 9 Sutton Street). These are 2 bed-roomed properties with lounge/dining room and kitchen with a garden to the rear. These are used for people who wish to be more independent but also still require some level of support. Residents from these 2 houses are able to access facilities in the main complex and participate in-group activities arranged by staff, should they wish to do so. All properties are leased to the society by C.H.A.D.D. (Church Housing Association Dudley District). The basis weekly fee for this service is £333.00. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 30th May 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Adults. The inspector’s findings are based on the information received by the Commission for Social Care Inspection (including responses to questionnaires sent to service users and relatives/visitors to the home), a tour of the premises, examination of relevant records and documents and discussions with the manager, staff and service users. Service users and relatives commented positively about the staff and the service provided. Below is a selection of comments made to the inspector: “Staff are always there to help me” “I enjoy being able to help with the cooking” “I am looking forward to going on the holiday arranged by the home” “An excellent service” “The home makes every effort to empower the service users” What the service does well: Service users are provided with a good living environment. Relevant information about the service and how service users needs may be met are provided and suitable systems are in place for assessing the needs of prospective service users. Arrangements to visit the home are made to suit the individual’s needs and wishes. Care is provided by staff that are trained in meeting the needs of service users and supported in carrying out their duties through regular supervision and team meetings. Service users are encouraged to contribute to the development of their care plans and express their views and personal preferences at her/his key worker session and at house meetings. Regular reviews take place with service users to ensure plans continue to meet their needs and personal preferences. Suitable health and safety checks are carried out on the premises, appliances and equipment. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 30 Brook Street DS0000025044.V332400.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 30 Brook Street DS0000025044.V332400.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 Quality in this outcome area is good. Prospective service users are provided with information to enable them to make an informed choice about the home. The home consults with service users about their individual needs and aspirations as part of the assessment process and introductory visits are arranged. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a Statement of Purpose and Service User Guide that contains details of the home’s philosophy, its services and facilities. It also provides information about how issues can be raised and the process for making a complaint. Service users and their representatives stated they had been provided with this information. Prospective service users’ needs are assessed by the home and s/he is invited to make introductory visits to meet other service users and staff. Staff work closely with other health professionals to facilitate this process. Once a placement has commenced staff continue to assess the service user’s needs to 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 9 ensure a detailed care plan is produced. Service users are consulted and involved at each stage of the assessment process and settling-in period. The home is reviewing the assessment formats used to ensure the information is provided in a format that is accessible to service users. 30 Brook Street DS0000025044.V332400.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 Quality in this outcome area is excellent. Service users know their assessed needs and personal goals are reflected in their care plans. The home’s consultation and review processes supports them to take appropriate risks and make their informed decisions about their individual lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user is allocated a key worker and care plans are developed following her/his assessment. The records show the home continues to consult with the service usersd about their needs and personal goals. Regular reviews are held with the service user, relevant health professionals and their relative/representative, where applicable. Care plans are amended accordingly. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 11 Service users meetings are held to discuss the day-to-day running of the home, such as menus and activities, and other issues. Discussions have taken place about the annual holiday for this year. Some service users have opted for a holiday at an English resort, while others have chosen to go the Canary Islands and a few wish to remain at home with the option of a few day trips or more local activities. Minutes are kept of each meeting. Key workers inform service users who choose, or unable to attend a meeting, of the discussions held and seek their views. At the time of this visit one service user was observed consulting with others and staff about arrangements for the next meeting. Staff encourage and support service users to take controlled risks by providing them with advice and guidance. Relevant risk assessments are available on each file and include the measures to be taken to minimise and/or manage risks. The records show service users are at different stages of independence and are appropriately supported by staff. The information kept of service users progress and the discussions held with service users demonstrate the home’s commitment to enabling service users to reach their full potential. 30 Brook Street DS0000025044.V332400.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): 11,12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent. The home provides service users with opportunities for personal development and to participate in a wide range of activities. Service users are supported to maintain appropriate relationships with family and friends. A healthy and varied diet is provided in an environment that allows service users to enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users and their key workers identify suitable opportunities to enable the individual to live a more independent lifestyle. The records show 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 13 discussions about how communication and independent living skills may be improved and the benefits of external support programmes. Service users are encouraged to develop individual interests. The home also offers a range of group activities such as board games, arts & craft sessions and discussions groups. There is a well-equipped games room with pool table, tennis table and darts board. The music equipment and dance floor enable service users to celebrate special occasions such as birthdays with a party to which guests are invited. Other ‘at home’ activities include DVD evenings and relaxation sessions. Most service users travel independently. However, the home also provides transport for activities such as the regular visits to a social club in Stourbridge, shopping malls and places of interest. Activities also take place on a 1:1 basis between a service user and their key worker. There is a formal system for service users and staff to provide feedback on each activity so an assessment can be made on the service users enjoyment and interest. The majority of service users commented positively on the activity programme provided. Two service users were looking forward to their different choice of holiday and were making arrangements to go shopping for new clothes. Relatives commented positively on different aspects of the home such as their inclusion in activities and celebratory events. Service users are encouraged to maintain contact with family and friends and spoke positively of support provided by staff. Relatives are welcome to visit the home and reported a friendly response from staff. Relatives, where applicable, are included in discussions and meetings held with service users in respect of her/his progress and review of the care plan. The overall comments received from relatives were complimentary about the facilities and care afforded to the service users. Since the last inspection the home has implemented a more pro-active approach to healthy eating. The manager and staff said this had had a positive affect on service users health and resulted in a reduction of prescribed medication for some service users. Service users assist staff to prepare communal meals and some service users cook their own meals. The inspector joined some service users for their evening meal. Three different options were provided. The chicken curry and boiled rice was well presented and tasty. The inclusion of more fresh fruit and vegetables has become popular with most service users. Fruit juices and ‘smoothies’ are available through out the day. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. Service users receive personal support with their physical and emotional health needs in the way they prefer and require. Service users retain their own medication, where appropriate, and health and welfare is protected through the home’s policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relevant health professionals are involved in all stages of the service user’s care plan. Service users are consulted about the support to be afforded them. Service users request for a specific key worker is accommodated where possible following discussions. All service users are registered with a GP and the home reports that working relationships with the surgeries and other health care professionals continues to be good. Records contain details of appointments and any support a service 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 15 user requires during these consultations. Some service users prefer to manage their own appointments. This arrangement is recorded on their files. There are policies, procedures and guidance for staff in the storage and administration of medication. Training has been provided to staff that have responsibility in this area. The inspector observed medication being administered. This was carried out appropriately and suitable recordings made on the individual’s medication administration record sheet (MARS). A photograph of the service user is available these sheets to avoid errors. Some service users manage their own medication to varying levels, for which risk assessments have been carried out. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. Service users views are listened to and acted on and suitable arrangements are made to protect them from abuse and harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints procedure that is explained in the home’s Statement of Purpose and other literature. The records show the home has received one complaint since the last inspection and has been appropriately responded to. Service users and relatives confirmed that they know whom they would approach if they wish to make a complaint. They also stated general satisfaction with the service provided and reported that any issues raised are addressed appropriately by the home. No concerns were raised about the welfare and safety of service users. There are suitable policies and procedures available to staff and training in adult protection issues are provided as part of the induction process for newly appointed staff. Update training is provided when applicable. Staff demonstrated awareness of this procedure and their responsibility for ensuring service users are protected from abuse. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. Service users are provided with a homely, comfortable and safe environment in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a range of facilities to meet the various needs of service users. There are several communal areas where service users can relax to watch television, listen to music or chat and play board games. A smoking is room is provided for those who wish to smoke. There is also a pleasant garden with suitable outdoor seating. During this visit service users were observed making use of all these facilities. Regular risk assessments are carried out on the premises, appliances and equipment to ensure a safe environment is maintained. The home has 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 18 improved is recordings for the assessments of the environment. The home has a lead person for Infection Control issues. He attends meetings with other professionals, such as the NHS Infection Control Nurse. Up to date information is provided to staff and the home’s procedures are revised, where applicable. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. Service users are supported by competent staff who are suitably trained and supervised. The home follows good recruitment procedures and needs to develop a policy for Students on Placement to ensure the welfare of service users is fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records examined show care continues to be provided by a stable team of staff who bring with them different life experiences. The manager confirmed that 70 of the team hold a National Vocational Qualification Level 2 and above. Arrangements are made for newly appointed staff to register for this training. The recruitment files for three staff were examined and found to be well organised. The home ensures that Criminal Record Bureau checks are completed prior to an applicant commencing employment and a minimum of two written references are sought. A discussion was held with a senior worker in respect of the process for verifying references. The home does not use the 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 20 services of volunteer workers, but does accept students on placement. To ensure both parties are clear about what is expected of them the home needs to produce a policy detailing the roles and responsibilities of the staff and student. Newly appointed staff are provided with induction training and arrangements made for them to attend the home’s mandatory training courses, such as health & safety, fire safety, basic first aid and basic food hygiene. The home continues to provide staff with good training programmes that includes clientcentred issues. Staff stated there are good opportunities for them to improve their knowledge and skills and to attain nationally recognised qualifications. The home has a structure for providing supervision and annual appraisals with all staff. Staff stated they receive regular supervision and found these meetings beneficial. The home also holds regular staff and senior staff meetings. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Quality in this outcome area is excellent. Service users benefit from a well managed home that has robust quality monitoring systems. Service users are confident their views underpin all selfmonitoring, review and development of the service. The policies and procedures in place at the home ensures service users rights and best interests are promoted and safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 22 The manager has the relevant qualifications and experience for running the home. Service users, relatives and staff commented positively on how the home is run. The home has comprehensive systems for obtaining the views of service users, their relatives/representatives and other stakeholders. A member of staff is arranging for questionnaires to be given to service users to assess the home’s healthy eating programme. An annual action plan is produced to address issues identified through the home’s monitoring and review processes and to develop the service. This information is made available to all interested parties. The home has relevant health and safety policies and procedures. Regular checks are carried out on the premises, appliances and equipment and the records for environmental risk assessments have been improved. Staff are provided with appropriate training on health and safety issues. Documents and records kept by the home are appropriately stored. Service user files continue to be well compiled. A content sheet is provided at front of the file to enable the reader to access information easily. Service users are aware that records are kept by the home on their progress and they are encouraged to sign their individual records. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 3 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X 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 3 3 3 X 4 X 4 3 X 3 X 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 24 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. 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 YA34 Good Practice Recommendations A policy and procedure for the roles and responsibilities for students on placement needs to be produced to ensure service users well being is safeguarded and their care needs continue to be appropriately met. 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 30 Brook Street DS0000025044.V332400.R01.S.doc Version 5.2 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!