CARE HOME ADULTS 18-65
8 Stickley Lane Lower Gornal Dudley West Midlands DY3 2JP Lead Inspector
Ms Linda Elsaleh Unannounced Inspection 08/02/06 15:00 8 Stickley Lane DS0000025016.V276147.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 8 Stickley Lane DS0000025016.V276147.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. 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 8 Stickley Lane Address Lower Gornal Dudley West Midlands DY3 2JP 01902 662076 NONE 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) Langstone Society Clive Lingard Care Home 6 Category(ies) of Learning disability (4), Physical disability (2) registration, with number of places 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24/05/05 Brief Description of the Service: Stickley Lane is a purpose built residential home owned by Black Country Housing and operated by the Langstone Society. The home is registered to provide 24-hour care to a maximum of six people with a learning disability including two with additional physical disabilities. Accommodation is provided over two floors; the main staircase accesses the upper floor. On the ground floor are two bedrooms, bathroom with bath chair and walk in shower, lounge, dining room, kitchen and laundry. A further four bedrooms are on the first floor along with the main office, bathroom with shower and toilet, and a further toilet. There are a few parking spaces at the front of the property and a landscaped garden at the rear. The home is situated in a residential area of Lower Gornal and is in keeping with other properties in the area. Local shops and other amenities are within walking distance and a bus service is easily accessible. A private mini bus is also available to service users and the ring and ride can be used if needed. 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 8th February 2006 during the late afternoon/early evening. The purpose of this inspection was to focus on some key standards and report on the home’s progress in addressing requirements made at the previous inspection in order to meet the National Minimum Standards for Care Homes. The inspection process included observations of care practices and discussions with staff. Short discussions were held with services users who indicated they were satisfied with the service being provided. What the service does well: What has improved since the last inspection?
The home maintains an excellent standard with regards to the environment, with the exception of the work required on bedroom and bathroom for service users on the ground floor, in order to meet minimum requirements. Redecoration of the hallway was taking place at the time of this visit. In order to ensure any complaints the home may receive about the service written guidance has been provided for staff and a system implemented for recording the nature of, action taken and outcome of any complaints they may receive. Additional information has been included in the Infection Control Procedures in respect of the use of the sluice facility. 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 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. 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 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 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 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): These standards were not assessed. EVIDENCE: N/A 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 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): These standards were not assessed. EVIDENCE: N/A 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 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): 11, 12, 13, 14, 15, 16 & 17 Service users pursue their own activities and pastimes with encouragement and support from staff. Where an interest has been expressed in trying a new activity, or developing further knowledge and/or skills in current interests, staff support them to access the relevant local facilities and services. Service users rights to make their own decisions are respected. Staff provide advice and guidance, with due consideration to the individual’s level of understanding, to enable them to make informed choices about the lifestyle they wish to follow. Service users are encouraged to view mealtimes as a social occasion and are provided with meals of their choice. 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 11 EVIDENCE: The service users at Stickley Lane have their own routines. They attend various Adult Training Centres, colleges and social centres depending on their interests. Transport to and from these venues is arranged to meet their individual needs. The home has its own vehicle and transport is also provided by the Adult Training Centres. Staff support one service user to access transport through the ‘Ring & Ride’ service. The service user also uses public transport for some journeys. During this visit service users and staff were observed enjoying each others company discussing the day’s events, the evening meal and other activities. Individual discussions also take place between service users and their support worker. These meetings provide opportunities for service users to express their interest in new activities. For example suitable arrangements have been made by the home to enable service users to attend cooking and computer classes at local colleges. Service users have a varied social life. They regularly attend different social clubs and enjoy going to concerts to watch their favourite artists. One service user demonstrated a good knowledge of events happening within the local community. The inspector was informed that various, short-break holidays are arranged throughout the year. Service users and staff spoke about the previous holidays they enjoyed and their favourite locations. The manager stated that appropriate funding for holidays is provided by the organisation. Service users are encouraged and supported to maintain positive links with family and friends. The home arranges social events for family and friends to attend throughout the year. Where applicable, they are encouraged to participate in the development and implementation of the service user’s care plan. For example one service user has progressed to visiting family unescorted. This was achieved through regular discussions and risk assessments to ensure the service user’s safety. The relaxed atmosphere within the home encourages service users to express their individual choices about the food they wish to eat, drinks and what activities they wish to participate in. At the time of this visit a service user returned from a visit to a garden centre where they and staff had had lunch. 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 12 Service users are supported to keep their rooms clean and encouraged to participate in other household tasks, such as assisting staff to prepare meals, laying the dining table and washing the dishes. Staff are responsible for carrying out laundry tasks; such as washing and ironing. However, the inspector was informed that service users are encouraged to take their washing to and from the laundry room. Service users are encouraged to view mealtimes as social occasions, although arrangements are made for service users who wish to dine alone. The staff are responsible for ensuring service users are provided with healthy, nutritious meals. They prepare, cook and carry out all duties associated with meeting the dietary needs of the service users and have completed Basic Food Hygiene training. As previously stated, service users are encouraged to participate in some of these tasks. Service users choose their meals on a daily basis. Nutritional assessments have been completed for all service users and staff monitor dietary intake, weight and disposition, where there are any concerns the relevant specialist is contacted. Staff respect service users right to privacy and service users are able to move freely around the home. At the time of this visit one service user chose to spend time on their own in their bedroom and another was observed wandering between their bedroom and the lounge. 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 13 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): These standards were not assessed. EVIDENCE: N/A 8 Stickley Lane DS0000025016.V276147.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): These standards were not fully assessed. However, the home has addressed two of the requirements made at the last inspection in respect of standard 22 & 23. EVIDENCE: The home has produced written guidance for staff in receiving complaints and developed a system for recording the nature, action taken and outcome of the home’s investigation. It is not possible to comment on the implementation of the guidance or the recording system as the home has not received any complaints. The system for use by service users to make direct contact with the organisation about any concerns they may have has yet to be revised. The Whistle-blowing Policy has been revised and includes a statement that staff will not face disciplinary action should they contact CSCI with regards to any concerns they may have. 8 Stickley Lane DS0000025016.V276147.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): These standards were not fully assessed. However, the inspector can report the home has addressed the requirement made in respect of its Infection Control Procedures. EVIDENCE: At the time of this visit the hall was in the process of being re-decorated. Following the installation of a sluice last year, the home needed to incorporate guidance with regards to the use of this facility in its Infection Control Policy. This has been addressed. The manager reported that little progress has been made with regards to implementing plans to improve bedroom and bathroom facilities for service users on the ground floor. Details of the proposed changes and programme of work are to be formally submitted to CSCI prior to commencement. 8 Stickley Lane DS0000025016.V276147.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): These standards were not assessed. EVIDENCE: N/A 8 Stickley Lane DS0000025016.V276147.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): These standards were not assessed. EVIDENCE: N/A 8 Stickley Lane DS0000025016.V276147.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 X 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 X 23 X 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 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5 Requirement Develop a contract covering all the requirements under this standard and 16.11 in a suitable format.
Not assessed at this inspection Timescale for action 13/09/05 2. YA6 12 The registered manager must ensure strategies for managing unacceptable behaviour are relevant to the situation and staff are provided with written guidance on keeping themselves safe and their responsibilities when managing such behaviour.
Not assessed at this inspection 13/09/05 3. YA22 22 The responsible person must revise its method for enabling service users to contact the organisation about complaints.
Original date for compliance 13th September 2005 not met. 05/05/06 4. 5. YA34 YA35 19 18 All staff must have a recent photograph. 01/05/05 01/05/05 Not assessed at this inspection An induction and foundation policy and procedures to be implemented. Not assessed at this inspection 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 20 6. YA39 24 The home must maintain an effective quality assurance and monitoring system. 01/05/05 Not assessed at this inspection 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 YA25 Good Practice Recommendations It is recommended that should the ground floor room that is below the minimum standard of 12sq metres become vacant it should not be used for a service user who uses a wheelchair or has complex medical needs. Consideration should be given to locating more storage space for wheelchairs and hoists. The inspector recommends the registered manager monitors individual supervision agendas to ensure all the issues detailed in this standard are discussed on a regular basis. 2. 3. YA25 YA36 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 21 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 8 Stickley Lane DS0000025016.V276147.R01.S.doc Version 5.1 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
