CARE HOME ADULTS 18-65
73 Commonside Pensnett Brierley Hill, Dudley West Midlands DY5 4AJ Lead Inspector
Mrs Cathy Moore Unannounced Inspection 23rd January 2006 07:35 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 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 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) Commonside Care Ltd Ms Toni Elizabeth Quinn, Ms Pauline Nicklin Ms Toni Elizabeth Quinn Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16/06/05 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 DS0000024990.V279703.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out on one day by one inspector during 07.35 and 12.05 hours. The inspection was a ‘short notice’ inspection whereby the owner was given less than one week to prepare. It was carried out as the second of the homes routine inspections for this inspection year. With their permission the inspector for a period of one hour and 10 minutes sat, observed and talked to all six residents residing at the home. Two residents were spoken to in more detail. One staff member was also spoken to the registered person/manager was involved in part of the inspection process. The inspection focussed on core National Minimum Standards for Younger adults that were not assessed during the last inspection and previous requirements made. This included examining resident and staff files, policies and procedures medication processes and general maintenance and safety. Not all standards were assessed during this inspection. For a full overview of service delivery this report should be read together with the last inspection report dated 16 June 2005. What the service does well:
The home provides and maintains the overall premises to a high standard. Both joint owners’, one of whom is also the registered manager have day to day involvement in the running, functioning and monitoring of the home. Conversation with residents’ continues to demonstrate contentment and happiness. It is clear from observation that all residents have a good relationship. Interactions and banter between all over the breakfast table was very positive. A number tend to ’mother’ others. It was one of the residents’ birthdays. She was very excited. All residents who were able wished her a ‘happy birthday’ and sang to her.
73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 6 Choice is given to residents wherever possible in respect of activities, food, menus and past times. One resident said;” I choose my hair. Always choose clothes”. Another said; “ Always, always choose clothes”. One staff member commented;” This is the best home I have worked in. It is well run the residents’ are looked after. They get what they want and do what they want “. Holiday, leisure time activities and stimulation provided by the home is exceptional. All residents are given the opportunity to have more than one holiday per year. Many go on holiday abroad with the home. Over the past years they have visited Paris, Spain, Turkey and the USA. Plans for this year’s holiday suggest that one venue will be Tenerife. What has improved since the last inspection? What they could do better: This home offers a high standard of service to the residents in their care. Only a few requirements have been made following this inspection which included the need to improve in respect of medication systems, the recording of residents money held in safe keeping and policies and procedures in connection with adult protection. Overall quality assurance/ monitoring systems must be finalised and fully put into operation. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 7 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 DS0000024990.V279703.R01.S.doc Version 5.1 Page 8 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 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 9 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): 2 Prospective residents’ individual aspirations and needs are assessed. EVIDENCE: Due full occupancy no new residents have been admitted to the home for a number of years. There was evidence available to demonstrate with the last resident to be admitted a rigorous assessment of need process was used. Input was gained from members of the multi-disciplinary team and the resident’s two sisters. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 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): 9 Residents’ are supported to take risks as part of an independent lifestyle. EVIDENCE: Documentary evidence was available to demonstrate that residents are at times supported to take risks to enable their choice of lifestyle. At least three residents visit their relatives for day or overnight stays. Residents’ who want to participate in various sports an example being swimming. Written risk assessments were available pertaining to various activities inside and outside of the home. The home has a missing persons procedure dated 3/05. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 11 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): 16 Residents’ are respected and responsibilities recognised in their daily living. EVIDENCE: Daily routines in the home do promote independence. During the week residents generally do have to get up at certain times in order for them to engage in their centres or ‘work’. Residents are given opportunities to attend different educational and other facilities in the local community. Staff do not enter bedrooms unless they have knocked the door. One residents care plan viewed stated “ Knock on door before entering bedroom”. This process was confirmed by two residents spoken to. Interaction between staff and residents was positive. Staff engaging with residents asking them questions and giving them choices. At times residents’ do choose to spend time alone in their bedrooms one resident said;” I like to put my music on loud in my bedroom when I am on my own”. Residents have full use of the home. They can access all areas except the office when un-staffed or each others bedrooms unless invited.
73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20. Residents receive personal care in the way they prefer. Improvements are needed in respect of medications to ensure that they are safe. EVIDENCE: Guidance for staff on providing personal care is detailed in individual care plans. One staff member said; “ All residents can attend to some of their personal care. We encourage independence and only do what they can not”. One resident commented when asked; “ I choose my hair. It has been washed today. Toni has blow-dried it”. Another confirmed when asked; “ Always I choose what I want to wear. I go shopping and get my clothes”. Some aspects of medication were good. The staff member giving medication to one resident stayed with that person to ensure that she had taken it. Medication is recorded in the individual residents care plan. One resident has to have one tablet at 07.00 hours; this too is incorporated into the care plan to ensure that it is given at the correct time.
73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 13 The homes medications are stored in an under stairs room. The temperature of this room is monitored daily. The home has a dedicated medication fridge with a lock. This is not used very often. The home does not keep an excess stock. It is positive that oral and topical medications are stored separately. No staff initial/signature gaps were identified on the medication records which is also positive. A number of shortfalls were identified. The home medication policy requires a review to ensure that all aspects of medication safety are included. The home at the present time does not record in-coming medications. Photographs are not attached to medication records. Not all staff have received medication training. Medications are generally only managed by senior staff. Medication training is in the process of being confirmed. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Processes are in place for residents to air their views in respect of complaints. Literature however, needs a review. Processes must be reviewed to ensure that residents are fully protected. EVIDENCE: The home has a written complaints procedure. It is positive that a copy of this documented is included on each resident’s personal file. The procedure however, has been produced in type print only not in a format to aid understanding to all. Neither the home nor the Commission for Social Care Inspection have received and concerns or complaints about the home. Not all staff to date have received abuse awareness training, this is in the process of being arranged. The home has internal abuse procedures for staff to follow and a copy of Dudley Council’s guidance ‘Safeguard and Protect’. These documents must be mirrored. There was no evidence available to suggest that staff have read Dudley Council’s guidance. Two residents’ money was checked. There was a shortfall in both involving small amounts of money. Residents’ inventories are not at the present time being updated when they have new possessions. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Nil No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35. Further developments are needed to ensure that residents individual and joint needs are met by appropriately trained staff. EVIDENCE: The home has an overall training matrix/programme. Training where needed has either been confirmed or is in the process of being confirmed. This applies to all training including mandatory training. It is positive that the majority of staff have achieved the LADAF award. Few however, at the present time have attained N.V.Q. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 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 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): Nil No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 2 x x x x x x x x 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 19 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 YA20 Regulation 13(2) Requirement The registered person must revise and expand the homes’ medication policy to include all aspects of; Ordering; Receipt; Storage; Administration; Medication errors; Retention after death(7 days). Controlled medications; Key safety and handover. Royal Pharmaceutical Society of Great Britain guidance titled; ‘The Administration and Control of Medicines in Care Homes and Children’s Services’ must be obtained to aid this review. Telephone 0207 572 2409 or Email rpsgb.org.uk 2 YA20 13(2) The registered person must ensure that all medications coming into the care home are counted and recorded. 15/02/06 Timescale for action 23/02/06 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 20 3 YA20 13(2) 4 5 YA20 YA20 13(2) 13(2) 6 YA20 13(2) 7 YA22 22(2) 8 YA23 13(6) 17(2) Sh4(9ab) 9 YA23 13(6) 17(2) Sch 4/5 The registered person must ensure that an up to date pharmaceutical guide (No older than 12 months is available on site at all times. The registered person must request a new contract from the homes providing pharmacy. The registered person must ensure that all medication records that are handwritten are, verified by two staff. The registered person must ensure that a photograph of each resident is attached to their medication record. The registered person must ensure that complaints procedures are produced in a format appropriate to all, for example pictures/symbols. The registered person must investigate to determine why the shortfalls regarding RM’s and SR’s money held in safe keeping by the home occurred and what is to be done to prevent future occurrences. The outcome of which must be provided to the CSCI. The registered person must ensure that all residents’ personal inventories are kept updated to reflect current possessions. This to include electrical items. 15/02/06 15/02/06 15/02/06 15/02/06 23/02/06 23/02/06 23/02/06 10 YA23 13(6) The registered persons’ must ensure that; The flow chart giving guidance to staff and leaflet from Dudley M.B.C’s ‘Safeguard and protect’ is copied and held with the home’s abuse policy. All staff read, sign and date 23/02/06 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 21 Dudley M.B.C’s adult protection guidelines’ Safeguard and Protect’. 11 12 YA35 YA39 18(1)(a) 24 The registered person must ensure that staff continue with their N.V.Q training. The registered provider must identify an appropriate quality assurance / quality monitoring system. Timescales of 02.01.05 and 01/09/05 not fully met. Acknowledgement to the home being awarded Investors In People is made. The registered person must ensure that a certificate to evidence the servicing of the emergency lighting is available. Or if evidence is to be provided on another document that it can be easily determined that the emergency lighting supply was serviced and is in good working order. 23/01/06 01/04/06 13 YA42 23(4) 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 73 Commonside DS0000024990.V279703.R01.S.doc Version 5.1 Page 22 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
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