Inspection on 15/11/05 for 55 Malvern Road

This inspection was carried out on 15th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

55 Malvern Road 15/11/06

55 Malvern Road 24/06/05

55 Malvern Road 16/02/05

55 Malvern Road 03/02/05

55 Malvern Road 10/02/04

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Polesworth Group Pooley Heights

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Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

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10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Malvern Road, 55 St John`s Worcester Worcestershire WR2 4LE Lead Inspector R McGorman Unannounced Inspection 15th November 2005 2:00 Malvern Road, 55 DS0000018662.V259733.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 Malvern Road, 55 DS0000018662.V259733.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. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Malvern Road, 55 Address St John`s Worcester Worcestershire WR2 4LE 01905 421787 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) New Era Housing Association Limited Ms Julie Joan Hodgetts Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is primarily for people with a learning disability but may also accommodate those with an additional physical disability. 24th June 2005 Date of last inspection Brief Description of the Service: 55, Malvern Road is registered to provide residential care for up to five adults who experience a learning disability, who may have a physical disability, and whose needs are complex and diverse. The premises is a large, detached property, situated in a pleasant residential area of St. Johns, approximately a mile from the City of Worcester, with easy access to public transport and a range of amenities and facilities. The home is owned and run by the New Era Housing Association Ltd., and is part of The New Dimensions Group, which, as the parent Company, provides strategic direction and a range of functional support services. The stated purpose of the organisation is, to work with people with learning difficulties, supporting them to make choices and to exercise control over their lives, and the main aim of the home is, to deliver a person-centred response to the needs and aspirations of the people we support. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine unannounced inspection was to follow up previous requirements and recommendations, and to monitor the care provision at 55, Malvern Road, Worcester, in relation to the stated aims and objectives. The inspection took approximately 3 hours, when time was spent with service users, and talking with staff. The care records of service users were inspected, and discussions held with the manager and staff about the content, as service users were unable to communicate verbally. The records kept in respect of the maintenance of equipment, and safe working practices were also seen. What the service does well: What has improved since the last inspection? The previous requirement and recommendations have all been met. A reorganisation of risk assessments has made the procedures more manageable. A review of the medication prescribed for service users has been very beneficial. A more structured approach to the administration of the home has been effective. New carpets have been fitted and the office is now more accessible. Malvern Road, 55 DS0000018662.V259733.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. Malvern Road, 55 DS0000018662.V259733.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 Malvern Road, 55 DS0000018662.V259733.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 Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. EVIDENCE: The Statement of Purpose and the Service Users Guide, provide detailed information for residents and their families, about the services and facilities available at the home. The documentation is produced in an appropriate format, and has been reviewed recently to ensure that it accurately reflects specific aspects of the care that can be provided. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 Service users living at the home are supported in making choices in all areas of their lives. Risk management strategies enable a responsible approach to the risks associated with the various activities of daily living. EVIDENCE: Care planning procedures are well developed at the home, and the Person Centred Approach is part of the philosophy of the care provision. The needs of every service user living at 55, Malvern Road are very complex, but their individual wishes are identified as far as possible, and their participation in daily life within the home is encouraged by all members of staff, working at the home. Risk assessments are completed, in relation to the premises, to the activities undertaken, and any restrictions imposed, and also in respect of every aspect of the life of each service user. The documentation that is maintained in respect of risk assessments has been reorganized and is now more manageable. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14,16 & 17 The opportunities made available to service users enable them to live as fulfilling a life as possible. The manner in which support provided by staff ensures that the rights of service users are respected and their independence is promoted. There is a flexible approach to the provision of a healthy diet, and services users are encouraged to decide what to eat and when. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 11 EVIDENCE: Service users living at the home are encouraged to follow an ‘ordinary’ life style as far as possible, by using the same facilities as other members of the community, and being involved in a range of leisure activities. Individual programmes for service users acknowledge their preferences, the daily routines revolve around each persons choice, and their rights are constantly respected. The arrangements regarding the provision of food reflect the preferences of each service user. General food stocks for the home are purchased each week, from which service users can choose, or an alternative can always be provided. Meals are discussed with everyone individually, and although service users are not always able to express their specific requirements, it is made very clear if something is not wanted. There may be four different meals, all provided at various times, although lunch is a light snack and the main meal is usually taken in the evening. Healthy eating is encouraged, and a record maintained of the food provided. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 21 Procedures are in place to ensure that the personal and health care needs of service users are appropriately met. The systems in place for the administration of medication ensure that the health of service users is promoted. Further development of the procedures to be followed in the event of the demise of a service user, will enable the appropriate action to be taken when necessary. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 13 EVIDENCE: The personal and healthcare needs of service users are well documented, and there is evidence to show how staff understand and respond to them in an appropriate way. Concerns had been discussed previously, with the Care Manager, regarding access to certain invasive treatments, which require the consent of the service user. Consultation with health professionals have not resolved the situation, therefore further enquiries are to be made. Medication arrangements at the home are satisfactory, although an issue was identified previously, regarding the service provided to the home by the local Pharmacy. The Pharmacist Inspector has arranged visit the home to help to resolve the situation. A review of the medication prescribed for each service user, was requested by staff at the home, which resulted in a reduction in some of the medicines taken, with a marked improvement in the quality of life for service users. A profile is also to be developed to include the side effects of each medicine, and a photograph of the service user is to be attached to their individual medication records. The issues relating to the ageing, illness and possible death of a service user, were discussed with the manager, and the need for training to be provided, to increase the awareness of staff, is to be considered. The wishes of service users, their family or representative, concerning terminal care and death, should be recorded when determined. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 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): 22 A satisfactory complaints procedure is in place at the home, and it enables everyone to express their concerns, views, opinions, and compliments. EVIDENCE: These standards were not inspected in detail, but were previously met. A clear procedure for the investigation of complaints has been produced and any issues are dealt with immediately. The document has been produced in a format that is understandable to service users. There have been no complaints to the home, since the last inspection. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 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): 24,25,27 & 30 The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of service users. The premises are suitable for their purpose and the accommodation is maintained to a satisfactory standard, providing service users with a comfortable and homely place to live. Failure of staff at the home to undertake weekly checks of the fire alarm system, potentially places staff and service users at risk. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 16 EVIDENCE: The premises at 55, Malvern Road is a large detached house with accommodation on two floors, which is maintained to a satisfactory standard, and is suitable for its purpose. The gardens to the rear of the property are mostly lawned. They are accessible to service users, and have benefited from further development recently. There are five single occupancy bedrooms for service users, which comply with the space requirements, although only four are in use at the present time. They are appropriately furnished, and personalised, and contain various types of sensory equipment, specific to the needs of individual service users. Adequate toilet and bathing facilities are provided. The bathroom wall tiles, which had previously become detached, have since been replaced. The home had not received a recent visit from the Environmental Health Officer or the Fire Safety Officer. The Fire Log Book was checked, but the weekly fire alarm test had not been recorded for the previous 3 weeks. The manager indicated that this would be rectified without delay. Malvern Road, 55 DS0000018662.V259733.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 & 35 The management support and supervision given to staff, enables a clear understanding of their roles and responsibilities, and ensures the promotion of the aims and objectives of the home. The extensive training programme available to staff ensures that they are competent in their work, and therefore able to provide appropriate care and support to service users. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 18 EVIDENCE: New Era provides relevant information for staff on joining the organisation, and also keeps them updated on new developments and any changes that take place. Each member of staff is given a Welcome Pack that contains details about the organisation, and its aims and objectives, an Employee Handbook that provides information about terms and conditions of employment and policies and procedures, and an Induction Checklist covering the first three months of employment. The staffing arrangements at the home were not inspected in detail on this occasion, although previously met. A training programme is in place at the home that includes Induction and Foundation training, the Learning Disability Award Framework (LDAF) accredited training, and the NVQ training. The training needs of staff are regularly reviewed, and care related courses are attended. A training record is maintained in respect of each member of staff. Malvern Road, 55 DS0000018662.V259733.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): 37,40,41 & 43 The management arrangements at 55, Malvern Road are satisfactory, and staff benefit from the positive leadership, and service users benefit from the person centred care they receive. The support provided to staff by the area manager, ensures the promotion of the aims and objectives of the home. The policies and procedures, and records maintained at the home, comply with legislative requirements and therefore help to safeguard the rights of service users. Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 Page 20 EVIDENCE: The Care Manager, Ms Julie Hodgetts has achieved the Registered Managers Award and the NVQ Level 4 qualification. She is also a NVQ Assessor. In addition she attends care related training courses, and ensures she is kept informed of the various developments relating to the care of people with a learning disability. The manager has many years experience working with this client group and has good communication skills, and a clear understanding of her role and responsibilities. The positive interactions observed between staff and service users are pleasing to observe. The records checked during the inspection had been completed to a satisfactory standard, with the exception of the Fire Log. (See Standard 24) Regular maintenance and servicing of equipment is done, and temperature checks are recorded. The accident records were seen to be in order, and Notifications under Regulation 37 are made to the Commission, when appropriate. Policies and procedures are produced by the Organisation, and staff confirmed they are familiar with the content. Specifically, an extensive health and safety policy and procedure is in place, and the Company employs an officer to advise on health and safety matters. Risk assessments in respect of all safe working practices are completed. A Business Plan is produced by the Organisation, which considers proposals for the next 5 years, and covers all aspects of the work of the New Dimensions Group. A copy of the Plan has been produced specifically for service users. Appropriate insurance cover is in place in respect of the business and the property. Malvern Road, 55 DS0000018662.V259733.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 3 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Malvern Road, 55 Score X 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 X 3 DS0000018662.V259733.R01.S.doc Version 5.0 Page 22 NO 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 YA24 Regulation 23 Requirement The registered person must take adequate precautions against the risk of fire – The fire alarm must be tested each week and a record maintained Timescale for action 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA19 YA20 YA21 YA21 Good Practice Recommendations Advice and guidance should be sought regarding the issue of consent for medical treatment to be provided Further development of the medication procedures should be taken, and should include a profile of side-effects, and a photograph of the service user Training should be provided for all staff at the home on death and bereavement Discussions should take place with service users, and their family or advocate, about their wishes concerning death Malvern Road, 55 DS0000018662.V259733.R01.S.doc Version 5.0 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. 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