Inspection on 28/07/05 for 47-49 All Saints Road

This inspection was carried out on 28th July 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.

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 20/03/06

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 Debra Lewis Announced 28 July 2005 11:00 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. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 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 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 Trust NHS Trust Mrs Amanda Deborah Jeffries Care Home 5 Category(ies) of MD Mental Disorder - 5 registration, with number MD(E) Mental Disorder (over 65) - 2 of places 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration other than those referred to on the previous page. Date of last inspection 11th March 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 E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours on a Thursday. The aim was to look at what progress the home had made since the last inspection, when they had been asked to make significant changes. The inspector met with the registered manager and with some care staff. There were no service users in the home during the inspection. The inspector also checked records, care plans and policies. The home had 3 service users and 2 vacancies. What the service does well: What has improved since the last inspection? Much had improved since the last inspection. There were now enough staff to help service users with leisure activities. It was now clear how people could make a complaint. Staff were now aware of how to help protect the service users from abuse. The home was starting to regularly ask service users what they thought of the home. Health and safety was mostly being well managed. Staff employment records were now kept in the home. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 6 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. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 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 standard(s) 1, 2, 4 and 5 Most, but not all, required information was available to prospective service users. Individual needs and goals were assessed. Prospective service users could visit the home. Service users still did not have contracts. EVIDENCE: The inspector was given copies of the revised statement of purpose and service users’ guide. Both almost met the standard, but the statement of purpose did not include a statement of terms and conditions (currently unavailable from the Trust), and the service users’ guide did not include service users’ views on the home (not yet collated as part of the developing quality assurance system). Existing service users’ needs had been re-assessed by the home and the inspector was told that the home would always obtain a CCA (community care assessment) before admission of any new service user. The inspector was told of a prospective service user’s visiting the home. The Trust had not yet provided service user with a contract. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 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 standard(s) 6, 7 and 9 Service user plans contained the necessary information about their assessed needs and goals. Service user plans also showed that service users normally managed their own money, and made their own decisions e.g. about social activities, food choices. Service users were supported to take ordinary risks such as going out unaccompanied, and were given suitable training or advice to help them manage risks. EVIDENCE: The inspector sampled service user files and found they contained a comprehensive collection of information, including assessment of needs, goals, social activities records, individualised risk assessments, as well as ongoing care plans. There were signed forms where service users chose to manage their own money. Restrictions, e.g. on smoking, were agreed and recorded. Risk assessments included information about giving road safety training, and giving other advice relevant to risks taken. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.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) 12,13 and 14 The home had not yet completed work on looking at education and training opportunities for service users. The home was increasing service users’ involvement in the local community, though more could still be done. Service users now had much greater access to leisure activities, although more could be done and/or recorded. EVIDENCE: The home had much improved staffing levels, including normally 2 staff on duty during the evening. This enabled staff to accompany service users on leisure activities of their choice, e.g. going out for meal. Key workers (some of whom had moved to the home in January) had been focussing on finding out more about service users’ preferences for leisure. Staff who were keyworkers spoke of how they tried to encourage and enable service user to have more leisure activities. A holiday was planned for 2 service users (paid for from their own funds, as the placing authority’s payments did not include provision for holidays). The other service user did not wish to accompany them so his key worker was planning other activities with him e.g. meals out. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 11 The increased leisure was improving access to the community, though more could be done e.g. the main daily routines for service users were based on specialist daycentres / clubs. Access to local non-specialist colleges, libraries etc. could be encouraged. The home had not yet given full consideration to educational / occupational needs and wishes, as they had been focussed initially on improving leisure. The home was now keeping records of leisure activities for each service user, which was good practice. The records indicated a much improved, but not high, level of social activity e.g. for one person there were 2 activities recorded in June. The inspector advised the home to increase the number of opportunities offered, to record any opportunities which were declined and to record any “low key” activities such as going for a walk, choosing a video to watch, visit to library or shops etc. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.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) 18 and 19 Personal support, physical and emotional healthcare needs were being met. EVIDENCE: Service user plans included detailed plans for supporting service users with personal care, physical health and emotional well being. There were records of medical appointments, including psychiatric input. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.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) 22 and 23 The home had a suitable complaints procedure and kept records of complaints or compliments. The procedure had been provided to service users and relatives. There was a suitable policy on protection from abuse. Staff were due to receive training on this. EVIDENCE: The inspector saw the revised complaints procedure and the recording book for complaints (none recorded). Service user files included copies of letters to service users and relatives, setting out the complaints procedure. The inspector saw the policy for protection from abuse. Staff had signed copies, which were kept in their individual files. Staff had applied for training, but the training had been oversubscribed so they were on a waiting list. Staff who spoke with the inspector understood the reasons behind some challenging behaviour of one of the service users, and were supporting him appropriately. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.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) 24, 26 and 30 The home had sufficient space, and was clean, comfortable and homely. Bedrooms did not yet have locks, but these were due to be fitted this year. Laundry provision and the home’s infection control procedures were suitable. EVIDENCE: The inspector saw most of the shared areas of the home, which were clean, well maintained and free from odour. A smoke extractor was soon to be fitted to enable smoking indoors during the winter (at present the garden was used for smoking). Bedroom locks were due to be fitted, along with other work to be done from August. There were signed forms in service user files, in which service users had said they did not want all of the required items in their rooms, e.g. wash hand basins. The laundry was sited away from the kitchen and dining areas. The inspector saw a detailed risk assessment for control of infection. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.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) 33, 34, 35 and 36 The home was fully staffed to a suitable level. Regular staff meetings were held and the team was working well together. Staff recruitment normally followed good practice, although at the time of the inspection not all evidence was available. Staff had access to training, but there was not a clear record or plan for the team as a whole. There was not a suitable structure for foundation training. Staff were being supervised, but the manager had not yet been trained in supervision. Appraisals were being done. EVIDENCE: The inspector saw staff rotas, which showed sufficient staff on duty including during evenings and weekends. The inspector was told that staff meetings were well attended and staff felt able to participate. The inspector was told that the staff (some of whom had worked there for years, others had joined the team in January) had integrated well. It was clear that the staff team had functioned well during the registered manager’s recent absence on sick leave. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 16 The home had not recruited any new staff (some had moved from another Trust home in January). The inspector sampled staff records and found evidence of required pre-employment checks, apart from CRB (Criminal Records Bureau) disclosures. Some of these had been seen on a previous occasion and the registered manager assured the inspector that they had all been completed; the responsible individual was attempting to get hold of them from the Trust human resources department. The home had individual, but not team, training and development records and plans. They now had a suitable induction training structure, which complied with the TOPSS specification [TOPSS now called Skills for Care]. There was not yet a similar structure for foundation training. Standard 36 was not fully checked, but it was noted that the manager had not yet been trained in supervision. Appraisals were being done. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.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) 37, 39, 40, 41 and 42 The registered manager was experienced and was a qualified mental health nurse. She was doing her NVQ4 managers’ training, which was due to be completed by next year. The home had begun implementation of a quality assurance system, though it was not yet fully functional. There were suitable policies and procedures. Most records were kept well, with some omissions. Health and safety management had greatly improved and was now being generally well managed, with some details to be followed up by the registered manager. EVIDENCE: 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 18 The registered manager was suitably experienced and was a qualified mental health nurse. She has been doing her NVQ4 managers’ training, which was due to have been completed by the end of this year, but had now been delayed by a lengthy period of illness. She now expects to complete it next year. The home had developed a draft quality assurance system, shown to the inspector, and had begun using service user surveys. The home had a wide range of policies and procedures provided by the Trust. Those seen were appropriate for the home. Most records were checked and were in place. There were some omissions: there was not a statement of the procedure to be followed if a service user went missing, there were no photographs of staff in their files, and the accident book was not of the up to date style (i.e. that complies with the Data Protection Act). Most previously noted health and safety problems had now been addressed. The inspector asked the registered manager to pursue further evidence re. electrical safety and Legionella testing. 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 19 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 2 3 x 3 1 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x x x 3 Standard No 11 12 13 14 15 16 17 x 1 2 2 x x x Standard No 31 32 33 34 35 36 Score x x 3 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 47-49 All Saints Road Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 x 2 3 2 2 x E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 20 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 1 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 homes terms and conditions.) A Service User’s Guide, which includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service users and their families. (Specifically it needs to include service users’ views on the home and a standard contract.) (Previous timescales of 30.6.04 and 31.3.05 not met.) 3. 5 5 Service users must be provided with contracts which met the requirements of standard 5. (Previous timescale of 31.3.05 not met.) 4. 16, 26 12, 23 Locks, of a type specified by the 31.10.05 Page 21 Timescale for action 31.10.05 2. 1 5 31.10.05 31.10.05 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 CSCI and Fire Authority, must be fitted to the doors of all service users’ bedrooms. (Previous timescales of 30.6.04 and 31.3.05 not met.) 5. 34 19 The home must keep evidence of acceptable Criminal Records Bureau disclosures for all staff. The registered manager must prepare a training matrix for staff, showing what training they have already done, and what further training is needed. A copy of this should be provided to the Commission. A staff training and development programme must be put in place, to ensure that all members of staff receive foundation training to National Training Organisation specification within 6 months of appointment to their posts. (Previous timescales of 30.6.04 and 31.3.05 not met). 8. 36 18 The manager must receive training in supervision. (Previous timescales of 30.6.04 and 31.3.05 not met). 9. 10. 39 41 24 17 The draft quality assurance system must be implemented. 31.10.05 31.10.05 31.8.05 6. 35 18 31.10.05 7. 35 18 31.10.05 Required records must be kept, 31.10.05 specifically a missing person procedure, staff photographs and an accident book compliant with the Data Protection Act. The registered manager must ensure the home has evidence of E52 S61835 47-49 All Saints Road V240748 280705.doc 11. 42 13 31.8.05 Page 22 47-49 All Saints Road Version 1.40 up to date testing of electrical systems, electrical appliances and for Legionella, and that remedial action has been taken if defects identified. 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. 2. 3. 4. Refer to Standard 12 13 14 14 Good Practice Recommendations Service user plans should address service users’ needs and wishes regarding education, training or work. Service user plans should include ways of enabling service users to participate more in the community. Records should be kept to show that leisure activities are available to all service users on a frequent basis. Service users’ holidays should be funded from the home’s budget. (At present this is not considered possible as holidays are not included in the schedule of provision agreed with social services.) Any prospective service user should be offered the option of all items specified in standard 26.2, including a wash hand basin. Staff training should include equal opportunities and race equality.[This was carried forward from the last inspection in January 2005, and was not checked during this inspection] The registered manager should be trained in risk assessment. 5. 6. 26 35 7. 42 47-49 All Saints Road E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 23 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 E52 S61835 47-49 All Saints Road V240748 280705.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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