Inspection on 16/06/05 for 73 Commonside

This inspection was carried out on 16th June 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

73 Commonside 15/05/07

73 Commonside 23/01/06

73 Commonside 16/11/04

73 Commonside 26/07/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 73 Commonside Pensnett Brierley Hill Dudley. DY5 4AJ Lead Inspector Cathy Moore Unannounced 16 June 2005 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. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 73 Commonside Address Pensnett Brierley Hill Dudley WEst Midlands. DY5 4AJ 01384 813670 01384 76265 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) Commonside Care Ltd. Ms Toni Quinn Care Home 6 Category(ies) of LD Learning Disability (6) registration, with number of places 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Nil Date of last inspection 16.11.04 Brief Description of the Service: 73 Commonside is registered to provide care to a maximum of six younger adults who have been diagnosed as having a learning disability . Commonside is located in Pensnett, which is situated between Kingswinford and Dudley. The home is in a fortunate position as it is situated in a residential area, but close to a main road where bus routes can be accessed to reach neighbouring areas. A number of shops and other amenities are in close proximity of the home. The home itself comprises of two floors and provides a dining room, newly built lounge, laundry, conservatory, office, four single and one double bedroom. The internal environment is appointed to a very high standard . The home is well maintained externally and has a generous sized, attractive rear garden. Ramped access is provided from the new lounge to the patio area in the rear garden. A path from the patio accesses the homes frontage. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector between 07.40 and 13.00 hours and was the first of the homes two routine statutory inspections for this inspection year. During the course of the inspection four residents were spoken to, two in detail. Two residents personal files to include daily notes and care plans were assessed. Two staff were spoken to, one in greater detail and two staff files were assessed. Health and safety records were scrutinised. The communal areas. Kitchen, laundry and one residents’ bedroom were viewed. What the service does well: What has improved since the last inspection? The home has increased its staffing complement by one support worker. The home has been awarded Investors In People accreditation. Remaining radiators that were not previously guarded have now been guarded. The home continues to maintain its environment to a high standard. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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) EVIDENCE: These standards were not assessed as no new residents, due to the home being full, have been admitted for nearly three years. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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 Care plans are in place but need further development. EVIDENCE: A written care plan was in place for each resident. The care plans seen were not detailed sufficiently to demonstrate that full needs of each resident or when and how care needs to be carried out or by whom. There was provision on the care plans for the resident to sign to demonstrate their involvement in the compilation but this section had not in all cases been completed. There was evidence available to demonstrate that the care plans are being reviewed regularly. From speaking to staff and residents it was determined that residents are encouraged with assistance to make as many decisions on how they want to live their lives as possible. However, one resident commented “ I would like to spend more time alone in my bedroom, it’s for my own good though that I don’t”. The manager stated that the home had brought the resident a CD player for her to use in her room when she wants to be alone and disagreed with what the resident had said. There was no evidence that any limitations imposed to protect residents’ health and well-being were agreed with them. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12,13,14,15, 17 Residents have appropriate opportunities for personal development, engagement in relationships, activities and the local community. Dietary provision is adequate. EVIDENCE: There was ample evidence to demonstrate that all residents have access to and do attend various educational facilities. Two of the residents confirmed that they would be going to day centre later. Another said, “ I go to centre two days, then I go in the kitchen at the school to work, I love that”. Residents access the local community on an on-going basis. The home has it’s own transport thus allowing trips and outings on a planned or impulsive basis. One resident said” We go out a lot, shopping, to the pub, for a meal and to the country. We have been to Stourport”. All resident’s bar one have just returned from an enjoyable all inclusive holiday in Turkey accompanied by staff. A holiday in this country is being arranged for 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 11 the one resident who was unable to go to Turkey. Last September a number of residents went to Florida, again accompanied by staff members from the home. In general all residents enjoy two holidays per year. The maintenance of contact with family and friends is very much encouraged. The majority of residents have some contact with their families. One resident said, “ I go home to see Mum and Dad every weekend on a Sunday”. Another sees her sister regularly at her day centre. Her sister used to visit the home for tea once a week, these visits have now been stopped. Food stocks in the home were seen to be varied. There was a selection of fresh salad, fruit, cheese, meat, cereals, a wide selection of tinned food and yoghurts. The home provides fresh semi-skimmed milk, brown bread and soda bread for one individual. A menu was on display detailing breakfast, lunch and tea not supper. In general residents take a`packed ‘ lunch with them to the centres for their midday meal, one does however, have a hot meal. Tea is served in the evening. One resident is on a weight reducing diet a food consumption monitoring chart was available for this person in the kitchen. A list of dietary likes and dislikes was seen in the kitchen. Staff were heard giving the residents choices at breakfast time. One resident said,” we can choose what food we like”. Residents are involved in menu planning, food shopping, preparation and cooking. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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) 19 Residents physical, emotional and healthcare needs appear to be adequately met. EVIDENCE: There was ample documentary evidence available although not all in one place, to demonstrate that the health care needs of the residents are being met. This included evidence of appointments with doctors, dentists, chiropodists the consultant for learning disabilities, blood screening and well women checks. In general residents access these health care services in the community rather than them visiting the home. Weight monitoring processes are in operation within the home. One staff member said” To enhance dignity I always make sure that the bathroom and toilet doors are closed when in use. I make sure that bedroom curtains are closed when residents are getting dressed and I always knock residents doors before I go into their rooms”. Greater diligence is required to ensure that all personal care delivered is recorded. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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) These standards were not assessed during this inspection. EVIDENCE: 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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, 25,26,27,28,29,30 The home provides a homely, safe environment, which is appropriate to the needs and lifestyles of the residents and is of a high standard. EVIDENCE: The home provides an ample living space for the six residents living there. This consists of a new lounge, separate dining room and conservatory. The bedroom viewed was of a good size with an en-suite providing a toilet, with hand basin and a walk-in shower. The resident occupying this bedroom said” I like my room, I think it is really nice”. The resident commented that she had not been given a key to her bedroom door. This resident has a shower chair and a raised chair for the kitchen to enhance her safety and independence. The home has four single bedrooms, two of which have en-suite facilities and one double bedroom. The home has a main bathroom which provides a bath and a shower a toilet and wash hand basin. Communal items examples being face cloths and sponges were seen in the bathroom. The home has a cleaning schedule, residents do undertake household cleaning with help and supervision from the 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 15 staff. The home overall appeared to be clean and orderly, no odours were identified. The laundry is separate and is located to the rear of the home. One washing machine and one dryer is provided. All residents washing is washed separately. Liquid soap and paper towels were seen in different parts of the home. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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 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 Staff numbers and presence require development and diligence. Recruitment policies and practices generally are acceptable but would benefit from attention to finer detail. EVIDENCE: On arrival at the home two staff were on duty. Neither staff member knew who was in charge, both only employed within the last year. Between 11.30 and 16.00 hours only one of these staff members remained to care for two residents, one of whom has intermittent epilepsy, the other requiring supervision and assistance with personal care. The staff group overall has increased its complement by one support worker since November 2004 Overall recruitment processes / staff records seen were acceptable. Staff CRB/POVA checks were available, but were held on the staff members personal files instead of being stored separately. Reasons for gaps in employment history had not been recorded. Staff files were seen to be securely stored. One resident commented, “the staff are nice and kind”. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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) 37,39,42 Generally the home is well run but requires attention to seeking the views of residents. Aspects of health and safety practices require greater diligence. EVIDENCE: The manager is also the registered owner of the home therefore having involvement in its day-to-day running. The manager was approved as a fit person in accordance with the Registered Homes Act 1984. The manager is continuing with the required work in order for her to attain the prescribed N.V.Q award. The home has recently has been awarded Investors In People accreditation. The manager is aware that gaps remain in the homes systems with regard to quality assurance and quality monitoring. Frequent Regulation 26 visit reports are received from the home by the Commission for Social Care Inspection. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 18 Health and safety records were briefly assessed as was the kitchen. Staff training was not assessed in full. A fire risk assessment dated 8/04 was available, the required health and safety poster on display in the kitchen. PAT tests were undertaken in November 2004, although it was unclear if the liquid oil lamp in (S.R) room had been tested. A gas safety certificate was on file dated 10/04. There was no evidence to demonstrate that the homes emergency lighting and fire alarm system have received a recent maintenance service from a qualified engineer. Overall the kitchen was seen to be satisfactory. It appeared to be clean and tidy. The kitchen windows do not have insect screens. Although the storage of food in general was acceptable, not all short life sauces had been labelled when opened. 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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 x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 4 3 x 3 Standard No 31 32 33 34 35 36 Score x x 2 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 73 Commonside Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 x E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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 YA6 Regulation 15(1)(2) Requirement The registered provider must expand care plans to ensure that the following is clear: The precise total needs of each resident including assessed risks, limitations, personal care, social care, medication, special instructions etc. What has to be done to meet these needs. Who has to to what to meet these needs, how and when. That the resident has been involved in their care plan production and review. The registered provider must ensure that where limitations are imposed that these are agreed with the resident and reflected in their care plan. Timescale of 30.11.04 not met. The registered provider must forward to the CSCI a copy of the social work minutes wherein it is detailed the decision making in respect of (D.B) sisters visits Timescale for action 16.07.05 2. YA7 12(2) 16.07.05 3. YA13 12(2) 16.07.05 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 21 being discontinued. 4. 5. YA17 YA17 17(2) Schedule 4, 13. 12(1) The registered provider must ensure that supper is added to the homes menu. The registered provider must ensure that only initals are used where private information is displayed about individuals such as the food consumption monitoring chart in the kitchen. The registered provider must improve health visit recordings to ensure that information can be retreived easily. and That personal care delivered daily is recorded in more detail according to assessed needs. 7. YA26 23(2) The registered provider must 01.07.05 ensure that a bedroom door key is offered to each resident. Where they refuse a key or one is not given to to risk factors then this must be recorded on the residents personal file. The registered provider must 01.07.05 ensure that personal items such as sponges and face towels are returned to the individual residents rooms after use. The registered provider must 27.06.05 reassess current staffing levels in accordance with residents needs, health, safety and well-being. The registered provider must ensure that sufficent staff are on duty at all times. The registered provider must ensure that fully competent and experienced staff are in charge of the home at all times. The registered provider must ensure that the person in charge 27.06.05 27.06.05 01.07.05. 01.07.05 6. YA19 17(2) 01.07.05 8. YA30 13(3) 9. YA33 18(1)(a) 13(4) 10. 11. YA33 YA33 18(1)(a) 13(4) 18(1)(a) 13(4) 18(1)(a) 12. YA33 24.06.05 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 22 13. YA34 17(2) 14. YA34 19(1) 15. YA39 24 of each shift is aware that they have this responsibility and that the persons name in charge is clearly denoted on the staff rota. The registered provider must ensure that staff CRBs/POVA list checks are held in a folder as per CRB codes of practice. The registered provider must ensure that any gaps in prospective staff members employment history are fully explored and recorded on their file/ application form. The registered provider must identify an appropriate quality assurance / quality monitoring system. Timescale of 02.01.05 not fully met. 24.06.05 01.07.05 01.09.05 16. YA42 23(4) Acknowlegement to the home being awarded Investors In People is made. 01.07.05 The registered provider must forward to the CSCI the following documents: Service certificate for the fire alarm system. Service certifcate for the emergency lighting supply. Weekly test records in respect of the fire alarm system. The registered provider must 01.07.05 forward to the CSCI evidence that the liquid oil lamp in ( SR ) room has been PAT tested. The registered provider must 01.08.05 provide appropriate insect screening to the kitchen windows. The registered provider must 27.06.05 ensure that temperatures of food containing meat or other high Version 1.30 Page 23 17. YA42 23(4) 18. YA43 16(2)(J) 19. YA43 16(2)(J) 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc 20. YA43 16(2)(J) 21. YA43 16(2)(J) risk foods are taken and recorded. The registered provider must 27.06.05 ensure that the food probe is collaborated regularly and that records to demonstrate that this is being done are made. The registered provider must 27.06.05 ensure that all short life products such as sauces and jams are date labelled when opened. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 73 Commonside E55 S24990 73 Commonside V233761 160605 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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