Inspection on 15/02/06 for Charlotte Street

This inspection was carried out on 15th February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charlotte Street 29/06/07

Charlotte Street 21/07/05

Charlotte Street 07/12/04

Charlotte Street 02/08/04

Charlotte Street 05/03/04

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 Charlotte Street 28 Charlotte Street Chuckery Walsall West Midlands WS1 2BD Lead Inspector Lesley Webb Unannounced Inspection 15th February 2006 12:30p Charlotte Street DS0000020835.V282849.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 Charlotte Street DS0000020835.V282849.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. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Charlotte Street Address 28 Charlotte Street Chuckery Walsall West Midlands WS1 2BD 01922 616925 01922 722659 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) Caldmore Area Housing Association Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Charlotte House may accommodate three (3) named service users only over the age of 65 years (names recorded on variation application form - reference V10042). When any of the named service users leave Charlotte House the original age registration category (18-65) shall apply. July 2005. 2. Date of last inspection Brief Description of the Service: Charlotte House is a detached property situated within easy reach of Walsall town centre. The home is owned and managed by Caldmore Area Housing Association Limited and provides accommodation for eight people for reason of learning disabilities. It is conveniently situated for local amenities such as the shops, public transport, a local park and various forms of public transport. All bedrooms are single occupancy, some with en-suite facilities. There is one lounge, separate laundry room, kitchen and a large light conservatory that is used as a dining room. There are toilets and bathing facilities close to all service users bedrooms. The building is domestic in nature, which is in keeping with its surroundings. There is limited parking to the front of the building, and a secure and private garden area to the rear. Externally and internally the house is maintained to a high standard. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 12.30pm and stayed until 6.30pm. Time was spent talking to service users, interviewing staff and looking at records before giving feedback to the registered manager. Since the last inspection a new manager has completed the registration process. This person was previously employed as a deputy at the home. This is the second inspection to take place in twelve months and therefore both this report and the one published in July 2005 should be read when looking at how the home is achieving national minimum standards. By the end of the visit the inspector was satisfied that generally the home provides a good service and would like to thank everyone for the co-operation and assistance shown. What the service does well: The staff at this home have a very good understanding of supporting service users to maintain contact with families and friends, and in supporting them with their educational needs. As one member of staff explained, “we arrange transport if needed, help with telephone calls, read letters if they cannot understand. We only help them with anything they can’t do for themselves”. All the people who live at this home lead full and active lives participating in various community activities including accessing local colleges and work placements, using local shops, markets, hairdressers, restaurants and building societies. One service user informed the inspector that they had, “made a day of it” when going to pay their rent at the post office explaining, “we also had a look around the shops and then had a cup of tea in the café, it was great”. Practices observed throughout the visit and records seen confirmed that service users are offered daily choices in relation to what they wear, eat, where they wish to go and who they wish to spend time with, all of which encourage service users to take control over their lives. The home also has very good training system, which ensures people working at the home receive the appropriate support they require in order to fulfil their roles. This support includes training in adult protection, equal opportunities, disability awareness and violence and aggression. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed at previous inspection. EVIDENCE: Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed at previous inspection. EVIDENCE: Charlotte Street DS0000020835.V282849.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): 12, 13, 15 and 16. Staff have a good understanding of the educational needs of service users, promoting life skills based on each persons capabilities. Documentation needs to be implemented to support decisions made in this area. Community and family contact are well managed creating daily variation and interest for people living at the home. Practices within the home demonstrate that service users are encouraged to exercise choice and control over their lives. EVIDENCE: Records and discussions with service users and staff demonstrate that service users attend both college and work on a daily basis. The home uses the Links to Work scheme that provides suitable risk assessed work placement and fulltime employment. Service users make full use of local community activities. These include pubs, clubs, restaurants, cinema, theatre and local shopping complexes. Holidays are arranged both for individuals and groups depending on the service users needs and choice, and locations vary to include resorts abroad as well as in the UK. Staff arrange transport for service users Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 12 such as the Ring and Ride and local taxis companies, while other service users use local buses. As part of Caldmore Area Housing Association the home participates in a yearly carnival. This activity encourages service users to become part of, and participate in the local community and builds up relationships with other individuals living in the local community. When looking at the files of two service users living at the home the inspector found little evidence that care plans are completed that detail support people need with education including any specific aims and goals that people may want to achieve. The inspector explained that as everyone living at the home has specific training days where they are supported to increase their skills in areas such as washing, paying their rent, domestic tasks and feeding the cat care plans should be in place that detail how people are supported to achieve these tasks. Staff that were interviewed demonstrated understanding of their role in supporting people with educational needs, for example one member of staff explained, “when people are at home we help with letters e.g. reading to them. When doing training day for laundry we show how to use machines, we only do things that people can’t do for themselves”. The home has a visitor’s policy that restricts people from accessing the home after 10pm unless prior agreement is sought. Discussions with service users and practices observed by the inspector confirmed that service users are supported to maintain family links and friendships inside and outside of the home however no care plans were found to be in place to support people in relationships. The inspector witnessed service users completing agreed household chores as part of the homes daily routine. Service users all had keys to their own bedrooms, which some chose to use. Also, they all have a key to the front door, there is a keypad system fitted to facilitate service users access to the home. Staff do not open service users mail. A book is used to record all incoming mail and service users sign to say they have received their mail unopened. On the day of inspection staff were observed interacting with service users on a one to one basis and in groups, but never exclusively with each other. The home has a written policy regarding pets, giving service users the opportunity to keep a pet if this does not infringe on others living at the home. Service users that the inspector spoke to confirmed that routines are flexible, as one service user explained, “you can watch T.V in your bedroom or the lounge, its great here” and another, “staff ask us what we want to do, where we want to go”. A requirement identified in the previous inspection to ensure nutritional assessments are completed for all service users remains unmet, however the registered manager assured the inspector that this would be actioned before the next inspection. Charlotte Street DS0000020835.V282849.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. Personal support in this home is offered in such a way as to promote and protect service users, privacy, dignity and independence. EVIDENCE: It was noted by the inspector that previous requirements relating to hearing tests and self-medication risk assessments are now met. Service users have a choice in respect of the care they receive ensuring their privacy and dignity is respected and their independence is maintained. They each have a key worker who provides guidance and support where necessary. The home liaises with nurses and members of the primary health care team as required and where aids are required the G.P. is consulted. Records demonstrated that times for rising, going to bed, meals and other activities are flexible according to individual choices. All service users were dressed individually, with their appearances reflecting their personalities. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Staffs understanding of adult protection is good, providing safeguards for the people who live at the home. EVIDENCE: The home has comprehensive policies and procedures for all aspects of abuse that work in conjunction with Walsall’s Vulnerable Adults Procedures (placing authority for all service users living at the home). The majority of staff at the home have undertaken training in abuse and aggression in order to support individuals living at the home. Upon inspection of service users finances the inspector found that the practices undertaken by the home acceptable. All service users finances are recorded and stored appropriately. All staff that were spoken to demonstrated knowledge and understanding of adult protection and their role within this, for example one person stated, “you must report anything you are worried about straight away, it doesn’t matter who it is you have a responsibility to report things. If you don’t get satisfaction with the response you must take it higher, never let things go un-noticed”. The inspector was also pleased to find that every service user that was spoken to stated they felt safe living at the home. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30. Infection control measures require further attention to ensure staff and service users are fully informed and protected. EVIDENCE: Although the environment was not assessed at this visit it was noted by the inspector that a previous requirement to address all issues documented in the fire departments report have now been actioned. On the day of inspection the home was very clean and free from offensive odours. There is a separate laundry room with the appropriate laundry equipment in place to control the spread of infection apart from liquid soap and disposable gloves. Policies and procedures for the control of infection including the safe handling and disposal of clinical waste, dealing with spillages, provision of protective clothing and hand washing were not to be found on the day of inspection, with management stating these are in the process of being formalised. The inspector instructed that hand washing instructions be prominently displayed, in appropriate formats, as aids to education for both staff and service users. All staff (including management) have recently undertaken infection control training that is accredited. Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 16 Charlotte Street DS0000020835.V282849.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): 35. The arrangements for the training of staff are good, enabling and empowering staff to care for the people who live at the home appropriately. EVIDENCE: The inspector was pleased to find that two of the six staff working at the home are enrolled on LDAF training and that other staff will participate in this on a rolling programme basis. The home has a training and development plan; training budget and HR department that is responsible for ensuring all training is arranged. All new staff undertake a corporate induction as well as completing an induction specific to the home. In addition to this all staff have a training assessment completed that details courses undertaken and those required. Information from the individual training assessments is used to plan future training for the home (as documented on the unit training and development plan). Training that staff undertake includes violence and aggression, HIV awareness, equality and diversity, lone working and disability awareness. Charlotte Street DS0000020835.V282849.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): 42. Generally health and safety is adequately managed at this home. Further work will provide further safeguards to those living and working there. EVIDENCE: Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 19 Previous requirements relating to quality assurance are in the process of being actioned. The views of service users have been obtained with a report due to be published (including pictorial), and the home is in the process of devising a relative’s questionnaire in order that their views can be sought. All records relating to gas, central heating, water heating checks for compliance with Legionella and electrics were found to be in order and up to date. The inspector did however find that the emergency call system has not been serviced since August 2002 and the burglar alarm June 2003. COSHH data sheets were viewed and found to contain corresponding checklists completed by the home. In the main these were found to be acceptable with only actions to be taken to eliminate or reduce risk required. Safe working risk assessments were found to be in place for the majority of working practices within the home. The inspector did however instruct that assessments be completed for the animals that either live or visit the establishment. Mandatory training was found to be in place for the majority of staff with only moving and handling and fire required. The inspector instructed that fire be given priority as this has arose in previous inspections. Charlotte Street DS0000020835.V282849.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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 4 14 X 15 2 16 4 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X X X 2 X X 2 X Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 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 YA12 Regulation 16(2) Requirement Timescale for action 31/05/06 2 YA15 16(2) 3 YA17 16(2) 4 YA30 13(3) Care plans must be completed that detail both short and longterm goals/aims for service users educational needs and/or support. Care plans must be completed 31/05/06 that detail both short and longterm goals/aims for service users in personal relationships. Nutritional assessments must be 30/04/06 completed for all service users – Requirement originally made July 2005. 31/05/06 The homes infection control policies and procedures must be formalised with evidence that all staff have read these documents. Hand washing instructions must be prominently displayed in the laundry. These must be in an appropriate format for service users. Liquid soap and disposable gloves must be provided in the laundry. All staff must use Learning Disability Award Framework accredited training – Part met. DS0000020835.V282849.R01.S.doc 5 6 YA30 YA35 13(3) 18(1) 16/02/06 31/05/06 Charlotte Street Version 5.1 Page 22 7 YA39 24 Requirement originally made December 2004. The home must ensure the quality assurance system is based on the views of service users, staff, families, friends and stakeholders in the community – Part met. Requirement originally made December 2004. The home must be able to demonstrate that findings from service users and others are analysed, that the findings are published and are linked to the annual review of the homes development plan – Part met. Requirement originally made December 2004. 30/04/06 8 9 YA42 YA42 13 13 The home must be able to demonstrate a systematic cycle of planning, action and review for quality assurance – Part met. Requirement originally made December 2004. All staff must undertake two fire 28/02/06 training sessions a year (one of which can be in-house). The nurse call and intruder alarm 31/05/06 must be serviced. COSHH check lists completed by the home must include any actions to be taken to eliminate or reduce risk. Risk assessments must be completed for the animals at the home. All staff must undertake moving and handling training Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Charlotte Street DS0000020835.V282849.R01.S.doc Version 5.1 Page 25 - 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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