Inspection on 20/10/05 for 48 Cedar Road

This inspection was carried out on 20th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

48 Cedar Road 30/08/07

48 Cedar Road 21/11/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 48 Cedar Road Dudley West Midlands DY1 4HW Lead Inspector Ms Linda Elsaleh Announced Inspection 20/10/05 10:00 48 Cedar Road DS0000063797.V255349.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 48 Cedar Road DS0000063797.V255349.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. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 48 Cedar Road Address Dudley West Midlands DY1 4HW 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) 01384 241877 TBA Mr S Ball Lucy Fallon Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Physical disability (8), Sensory of places impairment (8) 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: 48 Cedar Road is registered to provide care and accommodation for a maximum of eight adults, between the ages of 18 and 65, with acquired brain injury. Service users are offered 24-hour personal care and support, including waking night staff. The aim of the home is to provide medium to long-term support to service users to assist them to develop an independent lifestyle, according to their individual abilities. It works closely with external clinical specialists to enable the continuation of service users’ individual rehabilitation programmes. The home is a two-storey detached purpose built property situated in a residential area of Dudley, close to local shops, amenities and public transport. It has its own transport and off-road parking is available to visitors. It provides good access for people with limited mobility. The first floor can be accessed by a passenger lift. Communal facilities include lounge, kitchen with large dining area, activity room and private rear garden. There are eight single-occupancy bedrooms, two on the ground floor and six on the first floor. All are spacious, furnished to a high standard and have en-suite facilities. Service users have the option to use the bathroom, if they prefer, and additional toilets are situated close to communal areas. The home has an open visiting policy. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was registered in May this year and the announced inspection was carried out over a period of 10 hours on 20th & 21st October. The purpose of the inspection was to assess the home’s performance against selected key standards from the National Minimum Standards for Care Homes for Adults (18-65 years). Discussions with the manager and staff focussed mainly on care planning, provision of care and support and training for staff. Relevant records and documentation were examined. The questionnaires returned to the inspector by service users, relatives and others indicated an overall satisfaction with the service. Comments about the home included the following statements “…staff are very friendly and obliging.” “I am always happy with the level of care and always feel very welcome.” The inspector found the atmosphere within the home relaxed and friendly. Positive interaction was observed between staff and service users. What the service does well: What has improved since the last inspection? The home was registered on 13th May 2005 and the first service users were admitted in June. The manager has monitored the service’s progress and is reviewing the Statement of Purpose, Service User Guide and various policies, procedures and other documentation in light of her findings. Staff are proactive in exploring suitable techniques and activities that will assist service users with their rehabilitation. They are aware of their own developmental needs and have a positive approach towards training. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 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. 48 Cedar Road DS0000063797.V255349.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 48 Cedar Road DS0000063797.V255349.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, 2, 3 & 5 The home follows a robust assessment process to ensure it is able to meet the needs of prospective service users. However, the current Statement of Purpose and Service User Guide needs to be revised to ensure detailed information is available about the services provided and admission process. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The manager informed the inspector that both documents are in the process of being reviewed. A copy of both revised documents must be provided to current and prospective service users and the Commission for Social Care Inspection. Staff discussed the assessment process carried out by the home in respect of prospective service users. Service users’ files contain detailed information in respect of this process, such as assessment reports from the referring agency and other relevant professionals, discussions with the service user and, where appropriate, family and/or friends. The home produces an individual care plan based on the assessment process and provides written confirmation to the referring agent that the home is able to meet the needs of the prospective service user. Written confirmation must also be provided to the service user, or their advocate/representative, as required by Regulation 14 of the Care Homes Regulations 2001. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 9 The manager stated that service users’ contract/terms and conditions of occupancy (individual Licence Agreements) are currently being reviewed. All details required by the National Minimum Standards 5.2 must be included in these agreements. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 & 9 The home has a comprehensive care planning process. Service users are consulted about different aspects of service on an individual and group basis. They are supported to maintain independent lifestyles through person centred planning and appropriate risk assessments. EVIDENCE: Examination of a sample of care plans show how these have been developed from the home’s and care management assessments. They clearly identify any specialist requirements, how these will be met and by whom. Service users are provided with copies of their care plans in formats to meet their individual needs. Risk assessments are carried out and risk management strategies are put in place to enable service users to safely participate in their preferred activities. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 11 Some service users have very specific communication needs and use aids such as communication passports, reference cards, pictorial books or/and ‘lightwriters’ (electronic communication board). The home encourages service users to develop a wide range of communication. For example, work is being undertaken with specialists to extend the range of visual aids available within the home. One service user and member of staff are attending British Sign Language classes. Staff and service users congregate throughout the day in the kitchen/dining area where discussions take place on a variety of subjects. These include sharing their plans for the day, choice of meals and views about the home. The home also uses formal processes for consulting with service users and encouraging them to express their views about the running of the home, such as house meetings and questionnaires. One-to-one meetings with staff allow personal issues to be discussed in private. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 practical and emotional support to follow their individual lifestyles and maintain relationships with family and friends. EVIDENCE: The recordings kept by the home show service users are consulted about how they wish their care to be provided and their daily routines. Staff respect service users right to privacy and do not enter a bedroom without being invited. The inspector was informed that arrangements are made for each service user if they wish to be included on the electoral role. The home supports service users to maintain contact with their family and friends by developing effective communication systems that will enable family and friends to support them in improving their social and independent living skills. Care Plans include service users’ individual interests such as attending football matches & tea dances, bowling and playing cards. Suitable arrangements are made to enable service users to continue with these activities. The staff team have identified the need to extend the range of activities the home provides. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 13 Interest has been expressed by service users in using the internet, a request the home in looking into. During the inspection a service user was observed preparing the evening meal with staff. Service users are consulted about menus and records are kept of likes, dislikes and any specific dietary requirements. Recipe books are available for sugar free or soft diets. Records are kept of service users dietary intake, where appropriate, as part of the home’s monitoring process. Service users are involved in shopping for food and other household products. All staff are involved in the preparation of meals. Records show that four have attended Basic Food Hygiene training. Arrangements must be made for all staff to complete this training. The home does not have a written policy in respect of smoking and use of alcohol and substances by service users, visitors and staff. There is no evidence of how this information is provided to service users. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Suitable arrangements are made to ensure service users physical and emotional health care needs are appropriately met. Personal care is provided to service users by a caring and sensitive staff team and in accordance with their wishes. EVIDENCE: The sample of care plans examined detail service users’ individual routines and how their care needs are to be met. Staff demonstrated a sensitive approach to ensuring service users personal/intimate care needs are met in a manner that maximises the service user’s privacy, dignity and independence. Staff ensure service users have access to all relevant health care professionals and support them in attending appointments for which records are kept. Comments from health care professionals were positive about the service being provided by the home. Four staff hold current First Aid at Work Certificates and two are trained in Basic First Aid. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 15 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 The home has policies and procedures for promoting and protecting the welfare and rights of service users. However, a copy must be obtained of the local authority’s Vulnerable Adult Policy and a written statement on the use of physical intervention made available in the home. EVIDENCE: Comments, compliments and complaints forms are available in reception for use by service users and visitors to the home. However, there is no information about how these will be managed/responded. The home has a complaints procedure and this is referred to in the current Statement of Purpose and Service User Guide. There is no evidence that a copy of this procedure has been provided, or explained, to service users. There have been two concerns/complaints raised with the home. The records show that both have been appropriately managed by the home and to the satisfaction of the complainants. The home has written policies for protection and prevention of abuse, responding to bullying and whistle blowing. However, it must obtain a copy of the local authority’s Vulnerable Adult Policy. Training records show four staff have attended adult protection training. This training must be provided to all staff. A copy of the company’s policy on the use of restraint is available in the home. The inspector was informed the home operates a ‘no restraint’ policy, however, it does not have a written statement to reflect this. The manager stated that the company’s policy is under review and she is considering whether a localised policy needs to be developed for the home. Training has been arranged for staff in Non-Violent Crisis Intervention. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 16 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): These standards were not assessed. EVIDENCE: N/A 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 17 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): 31, 33, 35 & 36 Service users benefit from an effective staff team who are clear about their roles and responsibilities. To ensure the needs of service users are met by suitably trained staff a more planned approach needs to be applied to training and development programmes. EVIDENCE: Prior to service users being admitted to the home in June, staff spent time familiarising themselves with the aims of the home, policies and procedures and their individual roles and responsibilities. The staff team reflects the composition of current service users in terms of gender, age and life experience. The home does not employ ancillary staff. Service users are encouraged to participate in various domestic tasks, according to their abilities and, as identified in their individual care plans. The care plan for one service user identifies specific activities where one to one care is to be provided. Examination of service users’ records and staff rotas confirm that appropriate staffing levels are provided to ensure the needs of all service users are appropriately met. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 18 Discussions with staff show they are aware of their own limitations in knowledge and skills, and where necessary involve someone with more specific expertise. Staff meetings are held on a monthly basis and individuals contribute to the agenda. Minutes are kept of these meetings and include a record of attendees. Waking night staff do not attend these meetings and there is no formal process for their views to be included. This is an area that needs to be addressed. The home has a supervision schedule for staff that identifies six supervision dates during a twelve-month period. This meets with the National Minimum Standards. Newly appointed staff are provided with an Induction Work Book. This is discussed during supervision. When on duty, the worker is supervised by an experienced worker. However, there is no guidance on how the induction process is to be carried out. A planned work programme is required to ensure a comprehensive induction is provided and to enable the supervisor to assess and evaluate practice. The manager is advised to ensure the home’s induction process meets with the Sector Skills Council specifications. The home keeps a record of the mandatory and client-centred training courses attended by individual members of staff. Arrangements have been made for staff to attend Non-Violent Crisis Intervention, Infection Control and the Safe Handling of Medication in the near future. However, a more planned approach needs to be given to meeting the training and development needs of the staff team and individual workers. The manager is aware that 50 of the care staff team must hold at least a Level 2 National Vocational Qualification (NVQ) Certificate and is arranging for this training to be provided. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 19 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, 40 & 41 The organisational skills of the manager and a caring and supportive staff team ensure service users benefit from a well run home. The rights and best interests of service users are safeguarded through the home’s record keeping. There are a small number of areas that need to be addressed in respect of the home’s policies and procedures. EVIDENCE: The registered manager has several years experience of working with this client group in a residential setting. She is currently undertaking the Registered Manager’s Award. The manager reports a good working relationship with the registered provider and has suitable budgets to enable her to manage the service. There is an open, positive and inclusive atmosphere in the home. An ‘open door’ policy is operated by the home to enable staff and service users to speak to the manager and senior staff on a daily basis. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 20 Written policies and procedures are accessible to staff and, as applicable, are discussed in staff meetings and supervision sessions. Core policies are discussed with newly appointed staff as part of their induction. The manager is aware of the need for the company’s policies and procedures to be regularly reviewed with the aims of the home. Where applicable, more localised procedures must be produced. Those of particular interest to service users must be made available in suitable formats and/or evidence provided that staff have explained these to the service user. Service users’ records are well maintained and there is evidence to show some service users contribute to the upkeep of the information kept on them. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 21 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 4 2 X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 3 X 2 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 48 Cedar Road Score 4 4 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 X X DS0000063797.V255349.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? N/A 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, 5 Requirement The registered person must ensure a revised copy of the Statement of Purpose & Service User Guide is provided to: • Prospective service users • Current service users • Commission for Social Care Inspection The registered person must ensure written confirmation is provided to a prospective service user as to whether the home is able to meet her/his assessed needs The registered person must ensure each service user has a contract/statement of terms & conditions which includes all elements detailed in NMS 5.2 The registered person must produce a written policy in respect of smoking and use of alcohol and substances by service users, visitors and staff. The registered person must ensure a copy of the complaints procedure, in a suitable format, is provided to service users. The registered manager must obtain a copy of the local DS0000063797.V255349.R01.S.doc Timescale for action 10/02/06 2 3 14 13/12/05 3 5 5 13/01/06 4 16, 40 12 10/02/06 5 22, 40 22 10/02/06 6 23, 40 13 16/12/05 48 Cedar Road Version 5.0 Page 23 7 23, 40 13 8 33 18, 24 9 35 18 10 35, 17, 23 18 authority’s Vulnerable Adult Policy & Procedure. The registered manager must ensure there is a written statement or localised policy about the use of physical restraint. The registered person must provide suitable opportunities for waking night staff to contribute to discussions held at staff meetings. The registered person must ensure • newly appointed staff are provided with a suitable work programme • the home’s induction process meets the Sector Skills Council specifications The registered person must ensure staff are trained in: • Basic Food Hygiene • Adult Protection and • produce training & development programmes for the staff team and individual workers 13/01/06 10/02/06 10/02/06 10/02/06 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 Refer to Standard 22 40 Good Practice Recommendations The registered person is advised to make available to visitors information about the home’s policy for responding to their comments, compliments and complaints. The registered person should ensure policies and procedures of interest to service users are available to them in suitable formats. 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 24 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 48 Cedar Road DS0000063797.V255349.R01.S.doc Version 5.0 Page 25 - 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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