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Inspection on 19/09/05 for 44 Manorford Avenue

Also see our care home review for 44 Manorford Avenue for more information

This inspection was carried out on 19th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

44 Manorford Avenue is a real home to the 2 residents that live there. They are fully involved in any decisions made and assist with all daily living tasks. There have been no admissions or discharges for over 2 years and both the management and small staff group are very stable.

What has improved since the last inspection?

Of the 11 outstanding requirements 4 have been fully met and work is underway to make further improvements, including the fitting of a new kitchen. The manager has continued to review and refine information to ensure the residents understand it.

What the care home could do better:

The main outstanding requirement is to improve the garden area including making safe the garage door and window, which has been poorly repaired. Further work is required to ensure all policies and procedures are implemented and relevant to the home.

CARE HOME ADULTS 18-65 44 Manorford Avenue West Bromwich West Midlands B71 3QH Lead Inspector Mike Kirton Unannounced 19 September 2005 th 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 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 Stationary 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. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 44 Manorford Avenue Address 44 Manorford Avenue, West Bromwich, West Midlands, B71 3QH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 532 2749 Optimum Care Services Tracey Rayers Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th January 2005 Brief Description of the Service: 44 Manorford Avenue is a small residential home, registered to care for three people with a learning disability between the age of 18 and 65. The detached four-bedroom property is situated at the end of a cresent within a residential area close to bus routes into West Bromwich town centre. There as a small garden and parking space at the front and extensive gardens to the side and rear. The ground floor consists of front porch, hallway, lounge, dinning room, kitchen, laundry, and shower and toilet. Upstairs are the four bedrooms, toilet and bathroom. Care is provided on the basis that it is the service users home and they are involved in all decisions that are made. The size of the home enables staff to provide a high level of support and interaction with each service user to promote independence. Frequent use is made of outside agencies including day centres and advocacy services. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 hours and included discussions with the manager and the 2 service users. Staff records for the 2 employees were examined and a care plan inspected. Additionally the medication records and the homes policies and procedures were examined. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The home has clear and detailed information about the services provided in appropriate formats. Although there have been no admissions in recent years a good admissions procedure is in place. EVIDENCE: The home has a statement of purpose and service users guide, which contain all the information required, and includes visual aids and a complaints procedure on audiocassette. They are contained in a visitor’s folder with additional details about the home and services available. There have been no admissions to the home for over 2 years and there are no plans to change this arrangement. There is however a detailed admissions procedure which will be followed if this ever occurs. Residents have an individual statement of terms and conditions, which is reviewed annually and signed by them. This includes all the information required by the minimum standards. Both have the use of an advocate who visits them at the home. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,&9 Residents have a comprehensive plan of care describing in detail how their needs are met. It is excellent that they feel these belong to them and they are aware of there content. The manager is committed to making sure that they are fully involved in the running of their home. EVIDENCE: A care plan was examined with the resident present. They were aware of the information held on them and were able to understand the plan with the inclusion of a variety of picture aids. The plans were detailed and precise about their assessed needs and the actions required to meet them. Any restrictions on their lifestyle were recorded including the reasons why. They also contained a comment card completed by them to demonstrate whether they were happy with their care and a personal goal sheet for the coming year. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 9 The structure of these plans were well laid out, regularly reviewed and updated, and contained an index sheet. They included a personal history and a weekly planner for preferred daily routines, activities, and housework responsibilities. All social, physical, and mental health needs were clearly identified and planned for, and likes and dislikes recorded. Residents are fully involved in the planning of daily activities and the running of the home. This is supported both by feedback received from them and their plan of care. Both have an appointed outside advocate who visits them. Risk assessments for activities inside and outside the home are completed and reviewed at least annually. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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 standard(s) 11,12,13,14,15,16,&17 The home provides good opportunities for activities both inside and outside the home and promotes independence and further learning. Residents are encouraged to make their own decisions and their views are respected. EVIDENCE: Residents engage with a variety of activities both inside and outside the home in which they have opportunities to develop their independent living skills. They attend both college and day services where they have a wide choice of courses that they can enrol on including computing skills, animal care, line dancing, cookery, music, life skills and self-advocacy. These along with housework responsibilities are recorded on their weekly planner. Encouragement is given for residents to follow their own interests and activities with support provided by staff on a 1:1 basis. They have just returned from a week’s holiday in Bournemouth where they stayed in a hotel. This is covered by the basic contract price, and is planned by the users. There are also facilities within the home such as a TV, a video and board games. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 11 The home is very much in keeping with other properties in the road. They have a good relationship with their neighbours. Use is made make of the local amenities and public transport. The home has links with Sandwell Advocacy Service from where a worker visits every Friday. Contact with family and friends is encouraged and a visitors folder is available to provide information about the home and its services. Service users have the option of a key to their own room and all bathrooms have locks fitted to ensure privacy. These have an override devise that can be used in an emergency. All mail is delivered unopened, their preferred form of address is used, and rules and responsibilities are clearly stated in the individuals file. Staff, as on previous inspections, were seen to interact well with the service users and appeared to enjoy each other’s company. Service users are fully involved in the planning of the homes menu. They assist in the preparing the shopping list and attend with staff to fetch the required items. The nature of the home allows for mealtimes to be flexible and unhurried. All health and hygiene requirements were met including the storage and preparation of food. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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 standard(s) Standards were not fully assessed on this occasion. EVIDENCE: 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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 standard(s) Standards were not fully assessed on this occasion. EVIDENCE: 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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 standard(s) Standards were not fully assessed on this occasion. EVIDENCE: 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,&36 The home has a small staff team (Manager and 3 care staff) who are able to build good relationships with the 2 residents and are aware of their individual requirements. Training needs are identified and action is being taken to meet them. EVIDENCE: During the day and night there is always one staff member in the home if there are residents present. Otherwise they are out supporting them with activities such as shopping and medical appointments. Management time is also provided in addition to normal care hours. There have been no appointments since these standards were last inspected. All staff files previously contained all the required information including proof of identification, criminal record check (CRB) and 2 satisfactory references. Interviews for a vacant post will take place shortly with applications already short-listed. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 16 The home does not have a recruitment and induction procedure however a checklist has been implemented to ensure all the correct information is received. An induction plan is in place and staff are required to enrol for NVQ 2 in care, if this is not already held. All staff members have an individual training plan which shows when the course was completed and when it needs to be reviewed. The manager showed evidence that she was regularly referring staff for training however sometimes courses were over subscribed. Outstanding training needs still need to be met including safe handling of medication. The manager must ensure that staff have formal supervision at least 6 times a year followed by an annual appraisal. These sessions can be used to discuss work practices, training needs, or implementation of policies and procedures. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 Improvements are required to ensure that all the required policies and procedures are available and implemented in the home. EVIDENCE: The homes policies and procedures were inspected. Several were found to be missing including the appointment and induction of new employees, ordering of medication, and mental health. Others required updating or made relevant to the home. They should be signed and dated by the manager and a record made that staff have read and understood them. 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 44 Manorford Avenue Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x 2 x x x E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 19 Yes 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 24 Regulation 16,23 Requirement The kitchen cupboards had several doors missing, were looking dated and need replacing. The garage side door and window that is no longer used needs boarding up securely. The upstairs bathroom requires work to replace the bath sealant. These are outstanding requirements from the last inspection. staff should have a statement of terms and conditions and are subject to a 3-month probationary period. This is an outstanding requirement from the last inspection. The gaps identified in the individual staffs training programme must be met particularly in relation to the administration of medication. This is an outstanding requirement from the last inspection. All staff should receive an annual Timescale for action 01/12/05 2. 34 18 01/12/05 3. 35 18,19 01/12/05 4. 36 18,19 01/12/05 Page 20 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 appraisal. This is an outstanding requirement from the last inspection. The manager should be qualified to level 4 NVQ in management and care. This is an outstanding requirement from the last inspection. The homes policies and procedures must be signed and dated by the manager and a record made that staff have read and understood them. Procedures for the ordering of medication, appointment and induction of staff, and mental health policy must be implemented. 5. 37 9 01/03/06 6. 40 12,13 01/01/06 7. 8. 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 Good Practice Recommendations 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen 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 44 Manorford Avenue E55 S4785 Unannounced Manorford Avenue V248378 190905 Stage 4.doc Version 1.40 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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