Inspection on 02/08/07 for Bromsgrove Road, 5

This inspection was carried out on 2nd August 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bromsgrove Road, 5 10/11/09

Bromsgrove Road, 5 28/06/06

Bromsgrove Road, 5 07/12/05

Bromsgrove Road, 5 12/09/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Bromsgrove Road, 5 5 Bromsgrove Road Droitwich Spa Worcestershire WR9 8LR Lead Inspector Sue Davies Key Unannounced Inspection 2nd August 2007 2.30 Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 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 Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 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. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bromsgrove Road, 5 Address 5 Bromsgrove Road Droitwich Spa Worcestershire WR9 8LR 01905 774263 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.macintyrecharity.org MacIntyre Care Susan Elizabeth Margaret Dubif Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 Brief Description of the Service: 5 Bromsgrove Road is registered to provide residential care for up to 4 adults who have a learning disability, and may accommodate one person with an additional physical disability. The premises is a semi-detached property, situated on the main road on the outskirts of Droitwich Spa, within easy access of the town centre, and various amenities and facilities. The Registered Provider is MacIntyre Care, who has recently taken over this responsibility from the Royal Mencap Society. The stated purpose of the organisation is, ‘to be recommended and respected as the best provider of services for people with learning disabilities throughout the United Kingdom’. Information provided states current weekly fees for this service range from £400.32 to £567.80. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection focussed on how the service at 5 Bromsgrove Road is developing for the benefit of the people who live there. This included following up requirements and recommendations from the previous inspection, and considering management and staffing arrangements, staff training, and the service users’ experience of the care and support they receive. Preparation for the inspection included looking at previous reports, the recent service history and contact with the Commission, and the annual quality assessment return completed by the manager. The inspection was undertaken on 2nd, 8th and 16th August 2007 at different times of the day and evening, and was unannounced. Time was spent talking with the manager, all members of staff and the four service users. One service user wanted only brief contact. More time was spent with the other three people and included a meal, providing opportunities to talk and observe. One service user provided a guided tour of her home and talked about her experience of life there. Two service users care records were sampled and delivery of care and support was discussed with their key workers and other staff members. Samples of the home’s written policies and procedures were also checked, together with a selection of management and administration records. The time and cooperation given by everyone in the course of the inspection was much appreciated. What the service does well: The home has a warm and welcoming atmosphere. The inspection was carried out at times when service users were at home, and their busy lives, enthusiasm and ready smiles provided evidence of the continuing progress being made in this service. Everyone has a varied programme of college, day placement and leisure activities. They are encouraged to take part in the everyday activities of the home and to express their views and choices, which are respected. The staff are committed and well motivated, morale is good, and they provide a high standard of support for service users. Staff are receiving regular Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 6 supervision, are encouraged and supported to achieve relevant training and possess a very good understanding of service users needs. Staff are clear about their roles and responsibilities. There have continued to be some changes but full staffing is almost achieved, there is a relief team so agency staff are no longer used, and staff are working well together as a team. Staff feel well supported by their new manager, who is strongly committed to their personal and professional development. There is a strong emphasis on developing sound communication skills reflecting the service users’ needs and abilities, and staff are making progress beyond basic skills with real benefit to service users. What has improved since the last inspection? The staff team is now almost complete, and the manager is registered. Staff are working through or have completed induction training and are all being encouraged to progress to a full programme of skills development through National Vocational Qualification programmes and some specialist training. The records system has been reorganised and most records are fully up to date. The care planning process is much improved with evidence service users take a full part in working on their plans with their key workers. Plans are person centred and work is continuing to make sure they reflect the service user’s life, important people and events. Health Action Plans have been completed and are being kept up to date, with careful attention being paid to preventative health care and forward planning. The Statement of Purpose, the Service Users Guide and the Terms and Conditions of Residence are all now in place. These are clear, informative, and fully reflect the providers’ philosophy and aims. The service users each have their own signed and dated copies of the service users guide and contract in an accessible form. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 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 Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are carefully assessed and they have good, detailed information to help them decide whether this is a place they would like to live. EVIDENCE: Although no new service users have moved in since the last inspection, personal files showed needs assessments had been done before the people here moved in. However, assessments carried out by social workers for service users who moved in many years ago now need updating so that they show their current needs, and the manager has asked placing bodies for this to be done. The statement of purpose, the service users guide and the terms and conditions of residence are all now in place. These are clear, with a lot of helpful detail, and show the providers’ philosophy and aims very well. The service users each have their own signed and dated copies of the service users guide and contract in a form they can understand. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users plans show their needs, wishes and goals and how these are to be supported, including what is needed to help them understand and manage any risky situations they may face in their day to day life. However existing written risk assessments all need to be updated. Service users are supported to contribute to the life of their home, and to make decisions about their own lives. EVIDENCE: Service users are benefiting from the better way their plans are being written. These have improved considerably since the previous inspection, so that they are better constructed and more consistent. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 11 Staff have been getting to know service users well and working with them on their plans, with evidence of good recording practice. Each service user now has their own key worker, and good progress has been made in developing service user plans with them, so that they are more integrated and person centred. The manager and staff are keen to continue this to ensure the plans fully show each service user’s life from their own point of view. Photographs are being collected together with other mementoes to help bring plans alive for service users. Service users all have assessments carried out by the previous provider, showing how they understand and deal with risky situations in their everyday lives. The manager knows these are getting out of date, and is now planning as a priority for the next month to update and integrate them into service user plans in a person centred way. Staff have received risk management training and will be involved in this process. This will mean service users can look forward to extending their opportunities as staff support them to understand and deal with risks they may face, for example by helping them learn new skills. This is already happening in practice. For example, during the inspection a service user was being supported to take a short train journey to determine how she would cope with this, in preparation for a planned longer trip. Records and observation of practice show service users are well supported to make their own choices and decisions about their daily lives. For example one service user was delighted with the new colour scheme in her recently redecorated bedroom, and explained how she had chosen the décor. All service users are helped to choose their own meals and plan the meals for the week, and are supported to choose the activities they follow. Service users are supported to express their own views as staff continue to work on improving communication. This is being extended to make sure service users have ready access to all the information they need about the day to day life of their home, such as staff on duty, so they have more opportunity to choose what they want to do and who with. A key working system is now in place and staff are committed to improving their own skill and understanding through training, to help service users’ enjoy a good quality of life. Staff and service users get on well showing each other patience and respect, and interactions are characterised by warmth and humour. Communication is a significant issue for most service users here. There has been very good progress in addressing communication needs. Service users with limited communication have individual communication assessments, and staff training is ongoing to develop sound communication skills. This is already enabling them to communicate more effectively with service users, but it is recognised this is an ongoing process. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 12 Staff are proud of their developing skills and an example was given of the way this is benefiting all the service users. One service user learnt Makaton as a girl but this lapsed as no-one in her life had this skill. Now staff here are learning to use Makaton it has given her renewed confidence to use it again, and she has also begun to speak. Other service users are benefiting too, and are also using Makaton symbols to communicate with staff and with each other. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16, and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users generally have good contact with their families, and enjoy a variety of individual and group activities both within and outside the home, which are appropriate to their age and interests. They enjoy learning new skills and taking part in the life of the home, for example in cleaning and taking care of their home, gardening and the planning and preparation of meals, and enjoy a healthy balanced diet. EVIDENCE: Each service user is being supported to develop a fulfilling lifestyle based on who they are and how they want to lead their life. Where service users have progressive needs they are being supported to sustain a fulfilling life compatible with their needs. Most service users have lived here for some time, have made their home together and know their local community well. They are being well supported to explore the range of opportunities available to them, extending skills and Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 14 building confidence, and widening their circle of friends and acquaintances. They lead varied lives with a wide range of activities in and outside the home in keeping with their interests and abilities. Holiday destinations include the Isle of Wight and Greece, and one service user is looking forward eagerly to next year and a sixtieth birthday cruise. Service users spend their time on a mix of activities including college, day centres, work and leisure pursuits such as line dancing, out to the pub and for meals, visiting attractions and places of interest, or at home watching television, playing music and games, knitting and crayoning or ‘ladies nights in’ when pampering nail care and make-up sessions are a favourite treat. They have supportive personal and family relationships and their rights are respected. They take part in meals planning shopping and preparation, with a healthy and nutritious diet tailored to individual health requirements where needed. A relaxed and sociable evening meal was observed where service users and staff sat down together. This showed service users were able to eat at their own pace and supported sensitively as needed. The meal was plentiful, nourishing and appetising, and reflected service users’ personal preferences. In keeping with the focus on developing a total communication approach in this home, a system has been devised for everyone to communicate the meals they would like. This is based on a large collection of photographs showing main meal ingredients service users can use to make their own choices and help plan meals. Following discussion during the inspection, a big communication board has been set up in the dining room to show important people and planned and possible activities. This had already met with service users approval and was promising to be very successful. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported sensitively and effectively by staff who have the information, knowledge and skills to meet their needs in the way they prefer. EVIDENCE: Service users’ plans have been upgraded to be sure that staff have a full picture of their needs and how they are to be met (see outcome group 2, Individual needs and choices). Plans now provide staff with clear up to date information about service users’ personal needs and preferences, including daily routines, to enable them to support service users in the way they need and prefer. It is evident talking to staff and observing care practice, that they have a good understanding of service users as individuals, their day to day care and support needs and personal choices. Health action plans have been fully completed, and service users are now using them each time they attend healthcare appointments. There is evidence Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 16 in records that service users access NHS services and receive regular optical, dental, and hearing check ups, as well as specialist services such as support for mental health needs. Records are designed to support good health care practice and integrate information so that service users have the support they need. There is very good liaison with and support from health care agencies to promote sound health, particularly in recognising the needs of older service users. There is much evidence of good practice. As service user plans have been updated they now include more systematic evidence that known health needs are kept under review, input and progress is monitored and recorded, and attention is given to preventative health care. Information on health outcomes is being integrated with personal care so that any impact on service users lives is clear and can be acted upon promptly. There is a commitment to extend staff training as needs arise, to make sure every staff member has the specialist skills needed to support service users, for example with epilepsy and mental health problems. In view of service users’ ages, the manager has arranged staff training in understanding both the normal ageing process and dementia. The manager has relevant experience and skills in working with people who have diagnosed mental health needs. This has been valuable in establishing effective liaison with relevant professional agencies. It has enabled her to achieve a highly supportive network for one service user, with evidence that this support is of real benefit to the person concerned who is beginning to turn her life around. There is a suitable medication policy and procedure in place. This is carefully and conscientiously followed so service users can be confident their well being is safeguarded. Observation of one experienced staff administering medication showed a clear understanding of the procedures, with a sound approach to the management, storage and administration of medication supported by clear and effective records. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and encouraged to express their views and opinions. There are robust policies and procedures to safeguard service users interests. All staff have undertaken relevant training in protecting people from abuse and neglect. EVIDENCE: No complaints have been made to the Commission. One incident had occurred since the previous inspection that needed to be recorded as a complaint, this was discussed during the inspection and guidance was provided. Three service users had been anxious about an incident compromising their privacy. The service had responded promptly and appropriately. The incident highlighted the need to ensure service users understand they can lock their bedroom doors, with support provided if they wish. It also showed that bedroom door locks needed to be upgraded, advice has been sought on this and locks are due to be replaced. A satisfactory complaints procedure is in place at the home, and service users are also encouraged and enabled to express their views and opinions in their day-to-day dealings with staff and in their service user meetings. This procedure is available in an alternative format, and imaginative consideration is being given to how this might be achieved in a format specifically suited to Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 18 these service users abilities. It would also be good practice for the complaints procedure to acknowledge how staff look for and respond to other indicators that service users may be distressed or have concerns. In view of the communication difficulties faced by some service users, consideration is also being given to the benefits of advocacy, and explored with local advocacy services. Staff show they understand the issues relating to abuse and know how to protect service users, with an ongoing programme of training including the management of challenging behaviour and use of restraint. Training provided ensures staff understand the local procedures for responding to suspicions of abuse. Staff recruitment practice is robust and designed to safeguard service users from the appointment of staff who might put them at risk. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and comfortable home that is benefiting from improvements. EVIDENCE: This house is close to the centre of the town so service users can easily reach the shops and leisure facilities on foot, and access public transport. There is a bus stop nearby and a station in Droitwich for trips further afield, as well as use of a house vehicle. Service users are able to enjoy living in a home that is clean and fresh, decorated in a bright modern style and comfortably furnished. They have a pleasant lounge/dining room, recently refurbished and redecorated to their choice. The communal areas are spacious and provide different areas for alternative activities, although service users have no separate area other than their own bedrooms to receive visitors in private. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 20 Service users share one bathroom and two separate toilets, one on the first floor and one on the ground floor, the latter being also shared with staff. The bathroom is to be refurbished and the old bath replaced with a more modern bath with shower very soon, so service users who are getting less mobile will be able to use it more easily. The stairs are somewhat steep and consideration should be given to how service users with limited mobility might manage these in future. For example at present there is only one handrail so the benefits of a second rail could be assessed. Bedrooms are comfortable, personalised and individually decorated according to service users’ personal choice. All now have washbasins installed, so service users’ washing facilities are improving generally. Outside is a steep terraced garden and level patio. The garden is on a bank so it is not easily accessible to service users, but they do enjoy using the paved patio area in fine weather and one service user enjoys caring for the plants. Although some facilities are not ideally suited to their needs service users benefit from living in a house that is well maintained and safe, with sound fire safety and hygiene measures in place. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a balanced staff team, who are trained to understand their complex and varied needs. Sound recruitment practice is followed. EVIDENCE: Service users now have almost a full team of staff to support them, and benefit from the continuity and stability this provides. There is a relief staff team who know service users well so there is no longer reliance on agency staff. Service users have the support they need in personal care and activities within their home, and can be spontaneous in their choice of activities outside the home, because there are enough staff that are deployed flexibly and effectively. The manager is attentive to the possibility some service users may need more support as needs progress and is keeping staffing needs under review. The manager has worked hard to recruit a full team of staff able to provide Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 22 service users with the support they need. She is currently interviewing candidates so expects to appoint one more staff soon to complete the team. Service users have taken part in meeting and helping select staff, and one service user has attended a service user group working to enhance service users’ role in this process. Records showed robust recruitment practice is followed. The manager was reminded that summary recruitment information needs to be available in the home for inspection should the manager not be present. Service users were observed relating to staff in a relaxed and comfortable way. Staff were seen using a variety of communication methods and it was particularly encouraging to see service users and staff communicating readily with Makaton. All staff spoken to during the inspection were keen and well motivated. They show both a good general understanding of service users needs as well as specific skills reflecting their special needs and the relevant training provided. One new staff member met during the inspection is already trained and experienced, adding more skills to the staff team. Staff spoken to were enthusiastic about the training and support they receive, and very clear about their roles and responsibilities. There is a full programme of basic and specialist training planned. Staff have completed foundation training, progressing through the Certificate in Working with People with Learning Disabilities and onwards to the National Vocational Qualification programme. The aim is for all staff to complete National Vocational Qualification programmes. Mandatory safe working practice training is ongoing and training has been completed or is planned, to keep everyone up to date. A record of completed training is maintained with certificates on file. The manager has been advised on recording staff training in a way that is easy to monitor and deliver in a timely way. Annual appraisals are due to begin soon and full staff training profiles are to be established at this time. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41,42 and 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a registered manager in post and satisfactory management arrangements, to ensure service users benefit from a well run service that listens and responds to their views. EVIDENCE: Service users are benefiting from an improving service placing them at the heart of service planning. The acting manager in post at the last inspection has now been registered. She is qualified and experienced, with NVQ4 in care management and the Registered Managers Award, and an extensive background of working with people who have a learning disability and mental health problems. There is ample evidence from this inspection showing that she has worked hard over the past year to re-establish a sound service and Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 24 begin the process of service development. She is doing so creatively and with a strong commitment to service users having a key role in this process, and this is reflected throughout this report. Service users are enjoying themselves and making real personal progress in their lives. They are included in decisions about their home and are beginning to have a real voice of their own as a result of the determined focus on improving communication. There is a cheerful and relaxed atmosphere in the home and staff morale is high. Inclusion, participation and sound communication are valued and encouraged at all levels informally and through regular staff meetings and supervision, and service users’ meetings. The manager and staff share a strong commitment to providing a quality service that listens to and reflects service users’ views, needs and wishes. The introduction of a formal quality assurance process is an important next step. This is now being planned with careful consideration being given to facilitating advocacy services, to provide the support service users need to enable them to express their own views. Policies and procedures are in place and accessible, and care is being taken to ensure staff are familiar with these. Record systems have been rationalised and brought up to date. These are important steps to make sure people who live and work at 5 Bromsgrove Road can depend on a service that is well managed and effective. This has included attention to health and safety measures and staff training in safe working practices, to make sure sound procedures are in place and service users health and well being is safeguarded. Records sampled show significant improvements. Correct procedures are being followed, for example the fire safety risk assessment has been updated, regular fire safety checks and procedures are being maintained and staff training has been completed, water hygiene legionella checks and safeguards are in place, and the manager reported that food hygiene systems were recently praised by the health and safety officer on a recent inspection. The manager has sound support from MacIntyre’s local area manager who makes monthly monitoring visits on behalf of the provider, and she values links with manager colleagues. Copies of the monthly visit reports are provided to the Commission. This confirms the focus on developing this service in service users’ best interests, with sound oversight of service development. Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 25 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 3 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 x 3 3 3 Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 26 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. 9. Standard YA9 Regulation 13 Requirement Risk assessments must be carried out, kept under review and updated as part of an enabling risk management strategy which supports service users to develop skills and achieve optimum independence Timescale for action 08/12/07 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 YA6 Good Practice Recommendations Work should continue on the development of Person Centred Planning so that information is easy to use, and makes sense as a picture of the whole person, their hopes and plans, and the help they need to live life to the full. Consideration should be given to including a statement in the complaints procedure, showing how behavioural indicators of concern are responded to A suitable advocacy service should continue to be sought for service users with limited communication 2. 3. YA22 YA22 Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 27 4. YA24 Consideration should be given to the possible future need for facilities to assist service users with restricted mobility, such as additional rails An individual training profile should be established for each member of staff A full quality assurance system should be introduced and implemented, with a copy of the report on the outcome of any surveys made available to the Commission 5. 6. YA32 YA39 Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Bromsgrove Road, 5 DS0000064301.V347875.R01.S.doc Version 5.2 Page 29 - 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!