Inspection on 07/03/06 for Arbor Way

This inspection was carried out on 7th March 2006.

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

The inspector found 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Arbor Way 03/10/06

Arbor Way 13/09/05

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 West Midlands B37 7LD Lead Inspector Donna Ahern Unannounced Inspection 7th March 2006 13:20p Arbor Way DS0000004494.V286400.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 Arbor Way DS0000004494.V286400.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. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Arbor Way Address 78a Arbor Way Chelmsley Wood Solihull West Midlands B37 7LD 0121 788 1937 0121 7881945 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) www.mencap.org.uk Royal Mencap Society Mrs Gillian Cox Care Home 5 Category(ies) of Learning disability (5), Physical disability (1) registration, with number of places Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To complete NVQ Level 4 and the Registered Manager’s award by July 2006. One named service user over the age of 65 years. Date of last inspection 13th September 2005 Brief Description of the Service: 78a Arbour 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. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and undertaken by one inspector. This was the second of the statutory inspections for 2005/2006 and not all of the National Minimum standards were assessed. This report should be read in conjunction with the inspection report of 13th September 2005. The inspection included observation of care practice and interactions between residents and staff. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were assessed. Some Health and Safety records were inspected. The inspector had the opportunity to talk to the manager, five residents and two staff members. What the service does well: What has improved since the last inspection? The manager completed an action plan within agreed timescales to implement requirements identified in the previous inspection report. Good progress had been made on requirements. Twelve had been actioned in full; evidence of progress had been made on the remaining two. The Statement of Purpose had been reviewed. A variation to the homes registration had been completed and processed so that the home can continue to support a resident who is over 65 years. The providers policy on gender care had been made available to staff and the implications discussed with staff members so that residents receive the appropriate support with personal care. The mobile hoist had been serviced as required. Storage in the home had been reviewed and items from under the stairs had been removed so that there is clear access to the fire extinguisher. Staff files had been audited so that all the required information was available. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 6 The fire procedure had been developed so that specific information on how to support residents is documented. 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 DS0000004494.V286400.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 Arbor Way DS0000004494.V286400.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): 2 The organisations procedures indicate that prospective residents needs would be fully assessed prior to admission. EVIDENCE: There have been no admissions since the previous inspection. The home had no vacancies. The organisation has an admission criteria to follow in the event of any new referrals to the home. It includes visits to the home and overnight stays. The manager demonstrated a good understanding of the required practice regarding any new referrals to the home. Arbor Way DS0000004494.V286400.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): 6, 7 Further development of residents care plans was required so that an up to date plan of care is in place for all residents. EVIDENCE: The previous inspection report found that residents care plans were detailed documents that state how best to support residents with their care needs. Where relevant care plans cross-referenced to risk assessments and policies and procedures. The manager said she was in the process of reviewing all residents care plans. The needs of one resident had deteriorated considerably and their care plan was assessed at this inspection. The manager was in the process of reviewing the care plan to address the change in need. New guidelines had been implemented for staff to follow regarding the changes in support. The manager had consulted with a number of professionals regarding the resident’s change in needs and evidence of these discussions and outcomes were documented on their care plan. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 10 Resident’s files had details of their finances. This includes income, personal account and personal allowance details. Resident’s appointee details were also documented. Arbor Way DS0000004494.V286400.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): 13, 17 Residents are supported to have a meaningful lifestyle, engage in appropriate activities and enjoy a healthy diet. EVIDENCE: Residents attend local day centres. One resident attends a local college where they undertake classes in information technology, art, and living skills and keep fit session. Sampled records and conversations with staff indicated that residents are supported to go out for meals, and to the theatre and cinema. The manager said that the staff team are exploring leisure opportunities for residents and have been researching local clubs in the area that residents may be interested in joining. Menus seen indicated that residents are offered a healthy and nutritious menu it included details of fruit and vegetable served daily. Residents are asked at the weekly resident meeting what they would like on the menu. Pictures and menu books are used to assist residents with their choice. A menu board was in use and displayed the evening meal in pictorial format. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 12 The dietician service is involved with two residents and one residents dietary needs are reviewed by the G.P. There was a good supply of food available including fresh fruit and a range of drinks and snacks. Arbor Way DS0000004494.V286400.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): 18, 20 Residents receive a good level of support with their personal care. Manual handling assessments must be implemented so that residents are guided, supported and moved in a way that meets their needs. 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. Which meet the needs of resident’s current needs. Mobility issues for specific residents had been risk assessed. Manual handling risk assessment must be implemented for each resident. Minor amendments were required to the risk assessment for the use of a lapbelt on a resident’s wheelchair. Wheelchairs and lapbelts must be used in accordance with manufactures guidelines. As lapbelts are a form of restraint if they are in use the reasons and circumstances must be documented on the care plan. The previous inspection report required the need to review gender care practice. This had been actioned and the provider’s policy on gender care had been made available to the staff team. Issues in relation to the implementation of the policy were discussed with the manager and staff at the time of the inspection. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 14 The storage and administration of medication was satisfactory. An incident involving an error with the administration of medication occurred a few days after the inspection. The manager and staff concerned took appropriate action. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 15 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 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). A memo from the provider’s service manager was in place to address some of the shortfalls as a temporary measure. The No Secrets document and the Multi Agency Guidelines were available. No complaints had been received since the previous inspection. 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 DS0000004494.V286400.R01.S.doc Version 5.1 Page 16 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): EVIDENCE: Not assessed at this inspection. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 The staffing structure must be reviewed so that residents benefit from an effective staff team. EVIDENCE: There is 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. The previous inspection report required that 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. This remained outstanding and the provider is again required to review the staffing structure. Due to the changes in need of one resident staffing levels had been increased from two to three staff members on duty at core times. One 30 hour and one 20 hour position for care staff had been appointed to subject to satisfactory CRB checks. Residents received good support from staff who demonstrated that they had a good understanding of resident’s individual needs. Staff on duty presented as interested and motivated. Staff engaged well with residents and supported them to engage in one to one activities. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Resident’s benefit from a well managed home. Health and Safety matters were generally well managed. EVIDENCE: The manager was registered with CSCI in September 2005 and was working towards completing the registered managers award which she anticipates completing by July 2006. An action plan was received within agreed timescales to implement requirements identified in the previous inspection report. Good progress had been made. There was evidence that the manager and staff liaise with resident’s relatives and other professionals. Quality monitoring systems were not assessed. Fire records were in good order with required tests and checks undertaken. Guidelines on how to support each resident in the event of a fire had been implemented and a detailed fire evacuation was in place. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 19 The previous report raised the need for storage under the stairs to be reviewed this had been actioned. The hoist had been serviced 27/09/05. Evidence of the landlord Gas certificate and the electrical hard wire test were required. Bromford Carinthian Housing Association who are the homeowners holds this information. The manager was able to evidence that letters had been sent to Bromford requesting this information. 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. Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 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 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 3 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 3 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X 3 X 3 3 X X X 2 X Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 21 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 YA6 Regulation 15(1)(2) Timescale for action Further development of residents 31/05/06 care plans required. Progress made further work required. Manual handling risk assessment 30/04/06 must be implemented for each resident. Minor amendments were 14/03/06 required to the risk assessment for the use of a lapbelt on a resident’s wheelchair. The Organisations Adult 30/04/06 Protection policy required review. Previous requirement 31/05/05. Staffing levels and the staff 30/04/06 structure for the home must be formally reviewed with CSCI. Previous requirement 30/11/05. Evidence of the hard wiring 30/04/06 check that took place in February 2005 must be available in the home. Previous requirement 13/10/05. Evidence of the Landlord Gas 30/04/06 safety check was required and a copy of the certificate must be available in the home. Requirement 2 3 YA18 YA18 13 (5) 13 (4) 4 YA23 13 (6) 5 YA33 18(1)(a) 6 YA42 23(2)(b) 7 YA42 13(4)(a) Arbor Way DS0000004494.V286400.R01.S.doc Version 5.1 Page 22 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 YA42 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. 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