Inspection on 06/10/05 for 30 Brook Street

This inspection was carried out on 6th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

30 Brook Street 30/05/07

30 Brook Street 16/03/06

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 Christine Lancashire Announced Inspection 6th October 2005 10:00 30 Brook Street DS0000025044.V256186.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 30 Brook Street DS0000025044.V256186.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. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 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.V256186.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2005 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 17 years ago. It provides accommodation for 18 people. Residents’ accommodation is on the ground and first floors. There are 8 bedrooms on the first floor with 4 kitchenettes and 4 bathrooms/toilets. These are accessed by stairs. Residents who are more independent are accommodated on this floor but they can access any of the Home’s facilities including the main dining room, kitchen and laundry on the ground floor. There are communal lounges on both floors. 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 domestic type properties 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). 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection concentrated on key areas, with particular attention paid to those where requirements had been made in the last report. Those key standards not fully assessed will be covered at the next inspection. During the inspection the inspector examined selected records and spoke with the manager and staff. Four service users discussed their views of the home with the inspector and several others provided comments during a tour of the building. 18 service users and 3 visitors provided responses to the questionnaire and all provided positive comments. The overwhelming response from service users was that the home meets their needs. Comments included the following, ‘fantastic’, ‘excellent’, ‘nothing to change’, ‘It couldn’t be better’. What the service does well: What has improved since the last inspection? What they could do better: Care must be taken to ensure that all risk assessments are regularly reviewed and updated as necessary and that a record is maintained of the date of review. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 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. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 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.V256186.R01.S.doc Version 5.0 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 Prospective service users have appropriate information to inform their choice of home. EVIDENCE: The home has a detailed Statement of Purpose which has been amended since the last inspection. It includes the necessary details, including the philosophy, services and facilities, staffing and methods of making a complaint. This and the service user guide provide prospective service users and their representatives with appropriate information to inform their choice of home. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 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): These standards were not assessed at this visit. EVIDENCE: 30 Brook Street DS0000025044.V256186.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): 11,12,13,14,15,16,17 Service users are provided with opportunities for personal development and are encouraged to participate in activities, develop appropriate relationships and to be part of the community. Their rights are respected. They are enabled to have a healthy diet and to enjoy their meals. EVIDENCE: Service users told the inspector about a range of activities which are offered within the home and in the community. Service users may choose to organise their own time and they are also encouraged to make suggestions for activities at meetings. These include a theatre trip, the Ffestiniog railway, Newquay and the cinema. Recent holidays include Corfu and Newquay. Service users are all asked whether or not they wish to participate in a holiday and if so, whether or not they wish to go abroad. Their preferences are respected and staff organise arrange of trips to suit these. This sometimes involves 1:1 outings. There is a formal system for feedback after each activity. The most recent one seen was for a cinema trip and one resident had commented that they had been encouraged by staff to participate and they had enjoyed it. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 Page 11 Staff encourage service users to develop appropriate relationships and offer advice and guidance in this respect. Service users commented on the friendships which they had developed in the home and staff were seen taking an interest in the lives of the service users. Visitors made positive comments about the home and confirmed that they are made welcome. The menus show a variety of meals which appear to be well balanced in terms of nutrition and to offer choice. Service users said that they enjoy their meals. 30 Brook Street DS0000025044.V256186.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): 20 Service users retain their own medication where appropriate and are protected by the home’s policies and practice in this area. EVIDENCE: There are policies and procedures to guide staff in the storage and administration of medication. Those staff who administer medication have received appropriate training. The medication is overseen by a pharmacist, who last checked the system in July 2005. Examination of a sample of administration sheets revealed that they were appropriately completed. They have photographs of service users. Staff have access to information about the medication and the possible side effects. After risk assessment, several service users self medicate to varying levels, under the general supervision of staff. 30 Brook Street DS0000025044.V256186.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): 22,23 Service users’ views are valued and they are protected from abuse and harm. EVIDENCE: There is a clear complaints procedure which is explained in the home’s literature. The records show that there have been no recent complaints. Service users confirmed that they would know who to talk to should they wish to make a complaint, but added that they were happy at the home and did not wish to complain. One service user said ‘staff listen to you’ and added that he would tell his key worker if he was concerned. The records show complaints which have been responded to appropriately prior to the last inspection. There are policies and procedures to safeguard the welfare of the service users. The majority of staff have been trained in adult protection and this area is also covered as part of the induction. Allegations in connection with abuse are taken seriously and discussion with the manager revealed a good level of understanding of the course of action which should be taken in response to these events. 30 Brook Street DS0000025044.V256186.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): 24,25,28,30 Service users are provided with a homely and comfortable environment, where their bedrooms meet their needs and shared facilities are suitable for their needs. The home is clean and safe, but risk assessments need to be reviewed and updated on a more regular basis. EVIDENCE: The home provides a range of facilities to meet the needs of service users with varying needs in terms of support. The bedrooms seen were of a reasonable size and contained the necessary items of furniture. All areas were clean and well maintained. Since the last inspection, some areas have been decorated and the smoking and non-smoking lounges have been swapped. There are several areas where service users can meet and relax communally and these include pleasant seating in the garden. All reasonable steps are taken to maintain a safe environment and risk assessments are undertaken. However, there was no evidence that these had been reviewed recently. This must be addressed. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 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): 32,34,35,36 Service users are protected by the arrangements for recruitment and selection of staff. They are supported by competent staff who are appropriately trained and supervised. EVIDENCE: There are appropriate arrangements for the recruitment and protection of staff. References are taken up and the inspector saw evidence that all staff are checked through the Criminal Records Bureau. There is a system for formal supervision and discussions revealed that staff value this facility. However, the managers are available for discussion outside these planned times and informal advice is provided on a regular basis. There is a training officer to coordinate training and ensure that all staff have completed the necessary courses. Staff, including night staff, undertake an appropriate induction before undertaking further training. A matrix was supplied to the inspector and this demonstrated that staff receive training in a range of relevant areas, including rolling programmes of infection control, heath and safety and food hygiene and other more specialised areas such as mental health awareness and dealing with conflict, confrontation and disputes. 6 Service users were also included in the food hygiene training. There is a good proportion of staff who have completed NVQ training, with the manager having undertaken level 5, the deputy level 4 and 70 of support staff with level 2 or 3. There is a low turnover of staff. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 Service users benefit from a well managed home, with appropriate quality monitoring systems. There are suitable policies and procedures, safeguarding the service users’ best interests, personal safety and rights. EVIDENCE: The manager is appropriately qualified to run the home and has continued her professional development to include NVQ level 5. There is an open atmosphere in the home, with all staff having a good level of contact and communication with the service users. This was evident on the day of the inspection through observation and the comments of the service users. The home has systems for self-monitoring and representatives of the organisation make regular visits to assess the conduct of the home. These are sent to the inspector. Service users are provided with opportunities to supply their views on the running of the home and to provide feedback on activities. They confirmed that staff ask their opinion on a range of issues. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 Page 17 Policies and procedures are reviewed in the light of changes in legislation and good practice. Great efforts have been made to ensure that all the requirements made at the last inspection are met. There is a range of policies and procedures to guide staff. Records indicate that appropriate checks are made on services to and equipment in the home. There are risk assessments to cover relevant areas of the environment and the behaviour of service users, but there was no evidence that some of these had been updated recently. 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X 3 X 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 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 30 Brook Street Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X 3 X DS0000025044.V256186.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24YA42 Regulation 13(4) Requirement The manager must ensure that all risk assessments are reviewed and updated on a regular basis. Timescale for action 01/12/05 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 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 Page 20 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: 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 30 Brook Street DS0000025044.V256186.R01.S.doc Version 5.0 Page 21 - 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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