Inspection on 13/09/05 for Arbor Way

This inspection was carried out on 13th September 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 but made no statutory requirements on the home.

Other inspections for this house

Arbor Way 03/10/06

Arbor Way 07/03/06

Arbor Way 14/03/05

Arbor Way 10/06/04

Arbor Way 29/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Arbor Way 78a Arbor Way Chelmsley Wood Solihull B37 7LD Lead Inspector Donna Ahern Announced 13 September 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. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Arbor Ay Address 78A Arbor Way Chelmsley Wood Solihull West Midlands B37 7LD 0121 788 1937 0121 788 1945 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) Royal Mencap Housing Support Gill Cox Care Home 5 Category(ies) of Learning Disability (5) - Physical Disability (1) registration, with number of places Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents are under the age of 65 years. Date of last inspection 14 March 2005 Brief Description of the Service: 78a Arbor Way is a 5-bedded detached property located in a quiet side road in Chelmsley Wood. The Home is registered to provide long-term placements for adults with a learning disability and physical disability. The residents receive accommodation; full board, twenty-four hour care and supervision as required. The property is owned by Bromford Carinthian Housing Association who are accountable for major works and the external maintenance of the building. The Home and staff are managed by MENCAP. MENCAP also take responsibility for general internal decoration, carpets, furniture and so on. The Home, which blends in with its surroundings, is easily accessible by bus and close to local amenities such as shops, library and Doctors surgeries. Services are organised on a group living basis. Communal space includes a sitting room, dining room, conservatory and good-sized garden. Whilst all four of the bedrooms on the first floor are fitted with wash-hand basins, bathing and toilet facilities are shared, the only bedroom with an en-suite is located on the ground floor. There is a stair lift providing access to the 1st floor. The arrangements for storage are poor and required review. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one long day. The inspector met and spoke to all the residents. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were inspected. Staff records were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the manager and two care staff. Due to the needs of residents it was not possible to gain their views and opinion about their home. The inspector spent time observing care practice and interactions between residents and staff. Four comment cards were received from relatives who made only positive comments and raised no concerns. What the service does well: What has improved since the last inspection? The previous inspection in March 2005 raised 15 requirements. It was really positive that progress had been made on 13 of the requirements. The two outstanding requirements which were to provide suitable storage and to update the organisations Adult Protection Policy were not within the manager’s control and had been referred by the manager to the organisation for attention. The acting manager was approved as the registered manager of the home (September 2005). Residents care plans and risk assessments had been developed and there was ongoing work to these. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 6 Referrals had been made to the Speech and Language and Occupational Therapy service. 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. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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 Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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) 1, 3 Information was available about the home and had been produced in a suitable format for residents; some minor updating was required so that the information was current. EVIDENCE: The Statement of Purpose required minor updating. There was evidence that both the Statement of Purpose and Service User Guide are kept under review as required. The Service User Guide had been produced in a format that was more accessible to the people that live at Arbor Way and was also available on audiotape. One of the residents had just reached the age of 65 years. The manager was in the process of having their needs reassessed to ensure that the home is still suitable for their needs. A copy of the care plan and an application to vary the homes registration to accommodate a resident over the age of 65 must be forwarded to CSCI for approval. The Statement of Purpose must be up dated to reflect the changes and demonstrate the homes capacity to meet the resident’s needs. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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, 9 Further development of residents care plans was required so that an up to date plan of care is in place for all residents. Some further development of risk assessments was required so that the home can evidence that the risk residents face are well managed. EVIDENCE: Two care plans were sampled. Progress had been made on revising residents care plans and updating their support plans. The plans sampled were clear detailed documents that state how best to support the resident with their care needs. Where relevant care plans had been cross-referenced to risk assessments and policies and procedures. The manager was in the process of ensuring that all five residents care plans were to the required standard. A number of risk assessments were in place and had been reviewed. The manager was revising some of the assessments so that they were more specific about the risk to the resident and the required action by staff. Sampled files had detailed of reviews with the placing authority, which were Solihull Social Services, and Northampton Social services. One residents review Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 10 was outstanding and Birmingham Social Care and Health were the responsible funding authority. The manager stated that a request had been made to the relevant area office for a review to take place but nothing had been forthcoming. It was advised that the manager makes this request in writing. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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 standard(s) 12, 14, 15 Residents are supported to have a meaningful lifestyle, engage in appropriate activities and maintain contact with their relatives. EVIDENCE: Residents attend local day centres. One resident had recently started at a local college where they undertake classes in information technology, art, and living skills and keep fit session. The indications were that this had been a positive development for the resident. Two residents had been on holiday to Spain and three went to Malta. Photographs were available from different holidays and days out. The manager said that a lot of thought and planning go into the residents holidays and days out so that they are appropriate for each resident. Staff stated and records indicated that where appropriate residents are supported to maintain contact with their relatives. Care plans had details of relative contact arrangements. A comment card received from one relative stated “I am kept informed of any changes in my relatives care”. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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) 18, 19, 20 Residents receive a good level of support with their personal care and healthcare needs. Guidelines must be implemented for gender care. EVIDENCE: Residents were well dressed and there was good attention to people’s personal care. There is a walk in shower and a bathroom with a bath chair. The portable hoist required servicing. There is a core team of staff who knew residents needs well and there was a keywoker system in place. The need to review gender care practice was required. The manager must ensure that the practice is in line with the organisations procedure on gender care and protects resident and staff. Guidelines for gender care must be in place. The manager and staff had recently implemented Health Action plans that had been supplied by Solihull P.C.T (Primary Care Trust). A number of different professionals are involved with the care of residents including Consultants, Psychiatrists, Speech and Language Therapists, Occupational Therapists and Dietician. Two residents in particular have changing needs and health issues that was requiring very close monitoring by the manager and staff team. A Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 13 community Nurse was involved with reviewing one resident’s epilepsy management. The storage and administration of medication was satisfactory. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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 standard(s) 22, 23 The home had a complaints procedure that was available in different formats for residents. The Adult Protection Procedure required some further development so that residents are fully safeguarded. EVIDENCE: The Adult protection Policy required some amendments as raised at previous inspections. The policy must make it clear what the staff role is in the reporting of abuse (section C of the organisations policy). The No Secrets document and the Multi Agency Guidelines were available. There was a complaint procedure and log. The procedure had been updated since the last inspection so that it reflected the change in responsible CSCI office from Coventry to Birmingham. Residents would not be able to verbally raise a concern or a complaint they are reliant on the staff team to promote and protect their well being. The manager discussed some of the work in progress with the staff team and a change in culture towards complaints. The manager said that they would be actively looking at how the staff team can support residents to communicate their views and feelings about the home and demonstrate the Organisations commitment to take appropriate action. Progress will be monitored at future inspections. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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 standard(s) 24, 30 Residents live in a homely, comfortable environment. The storage arrangements must be reviewed so that potential hazards to residents’ safety are removed. EVIDENCE: Arbor Way is a domestic style home. It was clean and was very homely and comfortable. Residents own bedrooms are lovely and are well kept with lots of personal items. There is good communal space with a pleasant conservatory at the rear of the house and a well-kept garden. Four of the residents use a wheelchair all can transfer and have varying degrees of mobility. Manoeuvrability of wheelchairs within the house is restrictive. A stair lift provides access to the first floor. As raised in previous report the storage of essential items such as wheelchairs and a mobile hoist has the potential to cause a hazard. These items were observed stored under the staircase blocking the fire extinguisher and in the entrance hall where again it is a potential hazard. Adequate storage must be provided. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 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, 35, 36 Staffing levels must be reviewed so that the home has an effective staff team, in sufficient numbers to meet resident’s needs. EVIDENCE: Rotas indicated and the manager confirmed that there is two staff on shift at core times and at night there is one person on a waking night shift. The manager stated that there were 40 care hours vacant, which she was in the process of appointing to with two 20-hour support worker posts. The home has a flat line management structure with a team of support workers. There is no senior support worker or deputy manager. If and when the manager is on leave there is no one in a senior role to take a lead. These arrangements must be reviewed with CSCI so that the home has an effective staff team, with sufficient skills and experience to meet the needs of residents. The manager was due to take a period of leave shortly after the inspection took place. It was requested from the operations manager that CSCI receive confirmation of the management arrangements whilst the manager is on leave. It was proposed that a deputy manager from another registered service would provide support. A formal response was required regarding how the organisation plans to address this matter on a long-term basis. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 17 Due to the changing and deterioration in residents needs the manager recognises that there was a need to keep staffing levels under review to ensure that there is adequate staff on duty to meet residents needs at all times. It was noted from observations at the inspection that meal times and morning routines are a particularly busy time and it is important that a staff member is always present during and just after meal times due to the particular needs of residents. The staff training records were examined and indicated that mandatory training is provided to all staff. Some updates and refreshers were required and these were said to be in hand and are scheduled to take place over the forthcoming months, so that staff have the up to date knowledge and skills to support resident’s needs. Three staff files were examined and these contained the required information including application form, references, CRB check and proof of identity. A copy of Job descriptions must be issued to staff and only part of the application form for the new starter was on file. Details of a health declaration must be available on all files. The manager agreed to request a full copy from the organisation Human Resource Department. Supervision records were assessed and indicated supervision does take place the manager was on target to achieve at least six sessions per year. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 18 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, 42, 43 Health and Safety matters were generally well managed. Adequate storage must be provided and potential hazards removed. Staffing levels must be kept under review so that the well being of residents is fully promoted and protected. The Organisation must fulfil its duty and responsibilities to evidence that it has overseen and monitored the care provided in the home. EVIDENCE: The acting manager was successful in her Fit Person application and interview to become the registered manager of Arbor way in September 2005. Throughout the inspection process the manager presented as open, positive and inclusive. A number of required records were examined including risk assessments for the environment, COSHH, fire records, and health and safety checks and were all found to be in good order. Evidence of the hard wiring check that took place in February 2005 must be available in the home. Records of fire drills must include staff names so that the manager can monitor staff involvement in the Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 19 drills and ensure all staff including night staff are involved. The fire procedure must include how to support residents to evacuate in the event of a fire and any specific information regarding their needs such as mobility issues must be documented. As raised in previous report and under standard 24 the storage arrangements required review and adequate storage must be provided. Staffing levels must be kept under review as raised in previous reports and in section 33 of this report. Risk assessments regarding the care and support of residents required some further development as raised under standard 9 of the report. The accident procedure had been revised since the previous inspection to incorporate the date protection requirements. The home was still using loose sheets for the recording of any accidents or incidents. The use of loose sheets is problematic as there is the potential for information to become misplaced. It was strongly advised that this system is revised and consideration given to the using of a bounded accident book with numbered pages. The Reports of owner’s visits were examined and records indicated that visits had not been undertaken monthly as required. A report was available for a visit in March 2005 and the manager said that another visit had taken place recently but no report of this visit was available in the home. The organisation must fulfil its duty and responsibility to undertake such visits. Failure to do so is a breach of the regulations. CSCI were particularly concerned about the lack of evidence to monitor and support this service as the manager was in a temporary position until September 2005. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 3 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x 3 3 x x Standard No 31 32 33 34 35 36 Score x x 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Arbor Way Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 1 E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 21 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 1 Regulation 5 (1) (a) 4(1) c schedule 1 14 (1) (2) Requirement Minor updating of the Statement of Purpose was required. A variation application and a copy of the residents care plan is required for the resident who is 65 years. Further development of residents care plans required. Timescale for action 30 november 2005 30 November 2005 2. 3 3. 4. 5. 6. 6 9 18 18 15 (1) (2) 13(4)abc 13 (6) 12 (1) 23 (2) c 7. 23 13 (6) 8. 24 and 42 23 (2) L 9. 33 18 (1) a 31 December 2005 Further development of residents 30 risk assessments was required November 2005. Guidelines for gender care must 30 be implemented. September 2005 The mobile hoist must be 30 serviced and records of the September service must be available in the 2005 home. The Organisations Adult 30 November Protection policy required review. (Previous requirement 2005 31/5/05) Attention was required to the 31 October arrangements for storage in the 2005 home. A formal response to this matter is required. (Previous requirement 30 April 2005) Staffing levels and the staff 30 Version 1.40 Page 22 Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc 10. 11. 34 42 7,9,19, Schedule 2 23 (2) b 12. 42 23 (4) c (e) 13. 42 23 (4) c iii 14. 43 26 (2) (3) (4) structure for the home must be formally reviewed with CSCI. Staff files must contain all of the required information as stated in schedule 2 Evidence of the hard wiring check that took place in February 2005 must be available in the home. Records of fire drills must include staff names so that the manager can monitor staff involvement in the drills and ensure all staff including night staff take part in the drills. The fire procedure must include how to support each resident to evacuate in the event of a fire and any specific information regarding their needs such as mobility issues must be documented. The organisation must fulfill its duty and responsibility to undertake visits. November 2005 november 2005 13 october 2005 13 0ctober 2005 13 october 2005 31 October 2005 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 42 Good Practice Recommendations The home was using loose sheets for the recording of any accidents or incidents. The use of loose sheets is problematic as there is the potential for information to become misplaced. It was strongly advised that this system is revised and consideration given to the using of a bounded accident book data protection compliant, with numbered pages. Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Arbor Way E54 S4494 Arbor Way V244377 130905 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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