Inspection on 20/03/06 for 47-49 All Saints Road

This inspection was carried out on 20th March 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

47-49 All Saints Road 18/09/08

47-49 All Saints Road 19/03/08

47-49 All Saints Road 01/12/06

47-49 All Saints Road 28/07/05

47-49 All Saints Road 11/03/05

47-49 All Saints Road 13/01/05

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 47-49 All Saints Road 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ Lead Inspector Julian Mason Draft Unannounced Inspection 20 March 2006 10:30 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 47-49 All Saints Road Address 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ 01527 579520 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) Worcestershire Mental Health Partnership NHS Trust Mrs Amanda Deborah Jeffries Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 Brief Description of the Service: 47-49 All Saints Road is a traditional two storey detached house in a residential street within a mile of Bromsgrove town centre. Each of the five service users has their own bedroom, individually decorated and furnished, with a shared lounge, dining area and kitchen. Local shops, public transport, the Mental Health Resource Centre and voluntary sector day centres are nearby. The home aims to provide a domestic environment promoting independence and dignity. Service users receive care and support to live as ordinary a life as possible in the community. The registered manager at the home is Amanda Jeffries. She was registered as the manager of the home in January 2005. The registered provider is the Worcestershire Mental Health Partnership NHS Trust. The responsible individual is Ms Ann Bennington. The Trust has been the registered provider since July 2004. Before this date, they were the staffing provider only. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, it started at 10.30am and finished late afternoon on the same day. One inspector visited the home and observed some of the events and routines of the day. A member of staff gave a tour of the building and the inspector met all of the residents in the home. Two residents files were examined and a range of records were sampled. The inspector also met a number of staff and had discussions with the care manager and a visiting field social worker. The inspector also participated in the lunchtime meal with residents and staff. Eleven “Key” National Minimum Standards were assessed and the progress on addressing the previous requirement and recommendations was also examined. This report should be read in conjunction with the previous inspection report because together the reports will cover the 20 “Key” Minimum Standards to be inspected in a 12-month period. What the service does well: What has improved since the last inspection? What they could do better: The home must provide residents with an agreed contract that sets out the terms and conditions of the service. The administration of medication policy needs to be reviewed and updated. All staff vetting checks must be completed to the required standard. The manager needs to develop and implement a comprehensive quality assurance system. Some health and safety process need to be completed 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The service must produce and agree individual contracts between residents and the home. EVIDENCE: Residents do not have individual written contracts or statements of terms and conditions in relation to the accommodation and services to be provided. This is a longstanding requirement that has been highlighted in previous inspection visits. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were inspection in this section, [See previous inspection report – 28 July 2005]. EVIDENCE: 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 & 17 The home continues to develop and promote education and training opportunities for residents. Staff support residents to access local activities and facilities. Residents are able to participate in the daily life and routines of the home that are consistent with their individual preferences and needs. The food and mealtime arrangements are good. EVIDENCE: Some residents attend various educational and /or occupational settings on a full or part-time basis. The home’s staff are sensitive and understanding in relation to individual residents wishes and needs. The manager demonstrated a good awareness of potential issues of discrimination and social inclusion that could affect access to services. The home continues to develop and explore opportunities for residents to engage in occupational, therapeutic and learning experiences. Support is also available to residents in relation to benefits and financial matters. The home is mindful of the differing needs and choices of residents in relation to accessing community activities and venues. The staff continue to promote 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 11 and develop its service in relation to community involvement and accessing local facilities. The home’s case records highlighted that residents participated a range of activities and outings. A newsletter had been produced by the home encouraging residents to make suggestions and comments about the service. The newsletter is a good example of the home’s commitment to consulting with the home’s residents, promoting choice and involvement. Staff have supported residents to choose, plan and organise their own holiday. [Paid for from their own funds, as the home did not include the cost of this in the fees paid by placing authority]. The home is based on a group living arrangement and is managed to ensure the service is inclusive without compromising each resident’s identity and personal needs. Residents are able to exert choice in relation to their involvement and participation in the daily living and social routines of the home. Sensitivity and care is taken when promoting domestic responsibilities for individual residents, the staff role is one of enablement and support. The arrangements for meals and mealtime routines are well established. The home organises mealtimes to suit the circumstances of residents. The dinning area is organised in a way to ensure that meals are eaten in comfort. The home uses a rolling menu that accounts for the known choices and preferences of residents. Special diets are also accounted for in menu planning and the home promotes a balanced and varied diet for all residents. The lunchtime meal was a hot snack, which was prepared and served with the help of a resident. The atmosphere was relaxed, friendly and unhurried. Drinks and snacks were available between meals and throughout the day and evening. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The administration of medication is being carried out appropriately. The policy and guidance needs to be reviewed and updated to ensure the health, safety and wellbeing of residents continues to be promoted. EVIDENCE: The current policy and practice guidance for the administration of medication needs to be updated. The policy document is a generic NHS policy that was produced in 2002, with a review date of October 2004. The policy review should be comprehensive enough to cover all administration and practice standards required in a residential setting. The Royal Pharmaceutical Society of Great Britain provides a template model for the administration of medication in residential homes, which can be adapted for a specific service. Staff who have responsibility for the administration of medication have received accredited training. Residents case files demonstrated that the health and wellbeing of residents is being monitored in relation to their medication and clinical reviews are being completed. The home uses an administration of medication record sheet to ensure prescription drugs are recorded at the point of receipt, administration and disposal. The records demonstrated that the delivery and recording of the administration of medication is being carried out appropriately. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 13 The home was not administering any Controlled Drugs at the time of the inspection. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 14 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): No standards were inspection in this section, [See previous inspection report – 28 July 2005]. EVIDENCE: 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 15 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): No standards were inspection in this section, [See previous inspection report – 28 July 2005]. EVIDENCE: 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 16 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): 34 & 35 The vetting of staff is nearly completed to the required standards. Staff are receiving a good range of training appropriate to their learning needs and professional development. EVIDENCE: The recruitment and selection processes at the home follow an established procedure. Staff personnel files are appropriately stored and secured in the manager’s office. A sample of personnel files for staff working at the home was made available to the inspector. The files demonstrated that nearly allappropriate checks are being undertaken in relation to an individual’s employment and the role to be undertaken. CRB checks [Criminal Record Bureau] did not include POCA checks [Protection of Children Act] as required by the vetting standards. All existing employees whose CRB checks are three or more years old should be renewed. All new staff only start working at the home after all the necessary checks have been completed. The manager was able to provide a profile of all training events and development activities and that the staff team had attended. The profile demonstrated that a wide range of training and learning opportunities had been organised and delivered. Some core training had yet to be undertaken 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 17 but this has been planned into the forth-coming training programme, which included anti-discrimination practice training, manual handling and fire safety. Managers have also received specific training to support their role and responsibilities. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 18 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): 39 & 42 The home is managed effectively but better use of quality assurance systems is needed to ensure care and support is maintained to the appropriate standards. Appropriate standards of health and safety are met in nearly all areas. EVIDENCE: The home did not have a comprehensive formal quality assurance and monitoring system. The home did have some plans in place but they were not part of any systematic cycle of planning, action and review. The and and and home does consult with residents and others about day-to-day matters the running of the home. Views and opinions are considered about care support but the range and methods of consultation need to be expanded included with in a wider framework of quality assurance. Information from resident surveys and stakeholder feedback is not gathered on a frequent or regular basis. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 19 The manager expressed a commitment to develop and improve the quality assurance systems in the home. The home’s policies and procedures covered many areas in relation to the health, safety and welfare of residents and staff. The registered manager should carryout a full audit against the National Minimum Standards to ensure the home’s policies fully comply with the relevant health and safety legislation. Fire drills are taking place with the frequency required. Testing of emergency lighting, fire alarms and fire fighting equipment is also taking place within appropriate timescales. Staff are due to attend a fire safety training course in the near future. Nearly all required utility checks and installations are tested and / or serviced with in required timescales. Electrical appliance safety checks need to be renewed. The home has completed a range of environmental risk assessments to ensure hazards are known and risks are minimised. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 20 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 X 2 X 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 2 X X 2 X 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The statement of purpose must be amended so that it includes all the information detailed in Regulation 4 and Schedule 1. [Specifically, it needs to include the home’s terms and conditions]. Previous timescale – 31/10/05 – not met. Service users must be provided with contracts, which meet the requirements in Standard 5. Previous timescales – 30/6/04, 31/5/05 & 31/10/05 – not met. The home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines must be reviewed and updated. All staff Criminal Record Bureau checks must include Protection of Children Act List checks. Effective quality assurance and quality monitoring systems must be in place to measure success in achieving the aims, objectives and statement of purpose of the home. Electrical appliance safety checks must be carried out. The registered manager must DS0000061835.V281268.R01.S.doc Timescale for action 31/07/06 2 YA5 5 31/07/06 3 YA20 13 31/07/06 4 5 YA34 YA39 19 24 31/07/06 31/07/06 6 7 YA42 YA42 23 23 31/07/06 31/07/06 Page 22 47-49 All Saints Road Version 5.1 carryout a full audit against National Minimum Standard 42.4 to ensure the home’s policies fully comply with the relevant health and safety legislation. 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 All existing employees whose Criminal Record Bureau checks are three or more years old should be renewed. 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 47-49 All Saints Road DS0000061835.V281268.R01.S.doc Version 5.1 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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