Inspection on 21/07/05 for Charlotte Street

This inspection was carried out on 21st July 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but 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 15/02/06

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 21 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Charlotte Street Address 28 Charlotte Street Chuckery Walsall WEst Midlands. WS1 2BD 01922 615761 01922 722659 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Caldmore Area Housing Assoc. Ltd. Mrs Jennifer Holloway Care Home 8 Category(ies) of LD Learning Disability (8) registration, with number of places Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named service users over the age of 65. 2. When any of the named service users leave Charlotte House the original age registration category (18-65) shall apply. Date of last inspection 7th December 2005. 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 E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 1.30pm and stayed until 8.00pm. On arrival there were three service users at home (one of which was going out shopping), with the remaining people out at various day centres and places of further education. During the visit the inspector was able to either interview or talk to all the service users and obtain their views and opinions on the care and support provided within the home, as well as interviewing a member of staff and looking at records, before giving feedback to the Registered Manager. Since the last inspection CSCI has received an application to register the Deputy of Charlotte House as manager, in order that the present Registered Manager can undertake other duties for Calmore Area Housing Association. It is hoped that this application will be completed within the next three months. As in other visits to the home, the inspector was made to feel very welcome and would like to thank all the service users for their co-operation and assistance. What the service does well: When asked what is the best thing about living at Charlotte Street all the service users commented positively about the staff. For example one person stated, “ it’s a nice place to live, the staff are kind to you” and another, “the staff are friendly and care about you”. Observations throughout the day by the inspector confirmed these comments where everyone was treated with respect by staff and management. Service users are encouraged and supported in the compilation and reviewing of their care plans with weekly meetings taking place with their key workers in order that their views can be sought and issues discussed. Lots of different sorts of meetings are regularly arranged in order that the views of service users can be obtained when making decisions about the home and service. For example one service user stated, “ we have meetings to talk about new staff, meals, holidays and money. Sometimes we have our meetings in the pub which is nice”. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 6 The home has a good complaints system and everyone that the inspector spoke to was able to name staff that they felt comfortable talking to if they wished to make a complaint. Everyone that the inspector spoke to said that the management team was good and that they support people to be independent. Practices witnessed throughout the visit confirmed these comments, where service users were observed to make choices within a risk managed framework. 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4. Comprehensive assessments are completed by the home that ensure prospective service users can be satisfied that the home can meet their needs and aspirations. Service users are able to visit the home prior to making the decision to live there. EVIDENCE: The inspector talked to the newest service user to move into Charlotte House who confirmed that management from the home had visited them prior to their move to the home to find out what help and support they required. Records and discussions with management confirmed that comprehensive assessments are completed by the home before decisions are made as to whether a place can be offered. The manager also confirmed that they complete their own assessments even when the relevant social work teams have supplied Community Care Assessments in order that as much information can be gathered about individuals and to ensure the home can be satisfied that they can meet the needs of potential service users. Discussions with service users, staff and records also confirmed that potential service users visit the home prior to making a decision on its suitability, with one service user stating, “my social worker told me about this place so I came to have a look around”. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. There are clear and consistent care planning systems in place, which adequately provide staff with the information they need to satisfactorily meet service users needs, within a risk managed framework. The systems for service user consultation in this home are good with a variety of evidence that indicates that service users views are both sought and acted upon. EVIDENCE: All service users files sampled contained comprehensive care plans that detailed aims and goals for individuals along with corresponding risk assessments. The member of staff that was interviewed demonstrated knowledge of the contents of service users care plans and was able to give specific examples of aims including going out in the community, increase mobility and domestic tasks. Service users confirmed that they discuss their records and the contents of their care plans on a weekly basis with their key workers and in monthly reviews with management. Records relating to these meetings were found to be detailed and signed by both service users and staff. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 10 When asked if they are involved in decision making relating to their own lives and regarding the home every service user spoken to informed the inspector that they have residents meetings where they discuss new furniture, meals, and outings. In addition to this one service user stated, “ we have meetings and tell staff what new furniture we want, but sometimes the budget has to be checked. We also talked about the new person who was going to move in, to see what we thought of them”. After looking at the records of the residents meetings and subjects discussed the inspector was pleased to find an abundance of evidence that issues raised were then discussed in the staff meetings with action taken and followed through. Some service users also told the inspector about the Best Value day that the home has, where all service users and staff go to a hotel to talk about things that could improve at the home and agree these changes. The inspector was shown documentation from the Best Value day that included information in picture format and large print, both of which were used as additional aids to involve everyone in decisionmaking processes. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: All service users stated they are offered a choice of meals with comments received including, “its very nice, we have different things. On Saturdays we have a cooked breakfast” and “ its very nice, my favourite is Steak and Ale pie”. Records and discussions with service users and management confirmed that service users are offered choices and that menus are discussed in the residents meetings in order that they are involved in the planning and choices offered. When looking at records the inspector found that service users are weighed monthly and specified dietary needs catered for when identified but that practices within the home were reactive rather than proactive. The manager stated that the dietician had recently visited the home to give advice about meals but that nutritional assessments and screening were not presently undertaken as part of the care planning process. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 12 The inspector spent time at the home when service users were having a meal and found the atmosphere to be relaxed, with staff and service users sitting together to eat their meals. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 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 standard(s) 19 and 20. Generally, the health needs of service users are well met, with evidence of good multi disciplinary working taking place on a regular basis. In the main medication at this home is well managed promoting service users independence. EVIDENCE: Records and discussions with service users and staff confirmed that the physical and emotional health needs of service users are monitored with the appropriate action taken. Service users informed the inspector that they either attend health appointments at various surgeries by themselves if able or with staff if required. In addition to this one service user stated, “when I get ill the staff keep an eye on me and phone for the doctor”. Annual health checks for opticians, dentists, medication and chiropody were found to be recorded in all files sampled, with only hearing missing for some. The manager stated that they were experiencing difficulties for some service users in this area, as the surgery they were registered with did not offer this facility. No service users presently manage their own medication. When the inspector asked service users why this was responses included, “I might take too many tablets” and “ I might get muddled up with taking them”. All files sampled contained risk assessments based on each person’s abilities that are reviewed Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 14 as part of the care planning process. The inspector did however find that for one service user their risk assessment stated that they self medicated but after talking to the individual concerned and management found that this was no longer the case. It was also noted that this assessment had not been reviewed since 2003. The home has recently had an incident regarding the misadministration of medication. After looking at records and talking to management the inspector was satisfied that all appropriate action had been taken. Apart from this incident all records and practices relating to the recording, storing and administration of medication were found to be in order. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 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 standard(s) 22. The home has a good complaints system with evidence that service users feel that their views are listened to and acted upon. EVIDENCE: When asked if they knew someone they could talk to if they were unhappy or wished to complain every service user named individual staff members, including their key workers and management. When asked why they would approach these people again everyone said, “Because they listen and sort things out”. Records demonstrate that service users raise issues in the regular residents meetings; weekly key worker meetings and the monthly care plan reviews. The member of staff interviewed confirmed their role in supporting service users to complain stating, “I make time to listen to them, advise them of their rights to complain and would help them write official complaint if that was what they wished. It’s my duty to report complaints to the manager and check that it is sorted”. The home has comprehensive policies and procedures that are displayed throughout the home advising service users of their rights to complain. Since the last inspection there have been no complaints against the home, however an investigation was undertaken by the management team after comments were made unofficially by professionals involved in the care of a particular service user regarding care practices – resulting in staff being given additional supervision. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 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 standard(s) 24. The standard of the environment within this home is good providing service users with an attractive and homely place to live, that is also safe. EVIDENCE: The home is maintained to a very high standard. Records and discussions with staff and service users confirmed that everyone is involved in making decisions relating to decoration and the purchase of furniture. Many service users told the inspector that it feels “homely” with one person adding, “we all take turns to keep the place clean and do jobs around the house”. Since the last inspection the Fire Department have inspected the premises with one of the two Requirements still outstanding. The manager stated that this was not being ignored, but the most appropriate and cost effective resolution was still being sought. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards not fully assessed at this inspection. EVIDENCE: It was noted by the inspector that since the last inspection the home has partly addressed a Requirement identified in a previous inspection to ensure staff use Learning Disability Award Framework accredited training. Two of the six staff working at the home have now achieved certification in this area. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39 and 41. The manager is supported well by her senior staff in providing clear leadership throughout the home, creating an open and inclusive atmosphere in which service users live. Quality assurance systems are not based on the views of service users and their representatives and therefore have no value to the people who receive the service. Generally record keeping within the home ensures services users are protected. EVIDENCE: All service users spoken to praised the management team within the home confirming how they encourage and support people to develop and be involved in decision making. Throughout the inspection the management team were witnessed interacting with service users in a friendly and open manner, encouraging them to share views and opinions. As mentioned earlier in this report systems such as residents meetings and Best Value days are tools used by management to ensure service users are not excluded from the day to day Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 19 running of the home. Praise for the management team was also received from a member of staff who stated, “I am allowed to make decisions and I feel respected”. No progress has been made regarding Requirements identified in the previous inspection relating to obtaining the views of service users families and other interested parties. Although the inspector could find no evidence that this was having a detrimental effect on service provision, management were instructed that the Requirements must still be addressed to further enhance the quality monitoring systems presently in place at the home. Since the last inspection monthly visits to the home by a representative of the organisation have been occurring in line with Regulation 26 of the Care Home Regulations 2001. After scrutinising the reports of these visits the inspector commented on the format used, this being based on looking at records and not the views of service users and their representatives. It was also noted that nearly every visit had occurred at 12.00pm when the majority of service users are not at home. In addition to this CSCI had not received copies of the reports as required by legislation. Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 4 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x 2 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Charlotte Street Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score x 4 2 x 2 x x E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 21 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. 2. 3. Standard YA17 YA19 YA20 Regulation 16(2) 12(1) 13(2) Requirement Nutritional assessments must be completed for all service users Hearing tests must be arranged for all service users Service users medication risk assessments must be accurate, reflect the needs of the individual and regularly reviewed All Requirements made by the Fire Department must be complied with All staff must use Learning Disability Award Framework accredited training (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 (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 (REQUIREMENT ORIGINALLY Timescale for action 31/10/05 31/10/05 31/10/05 4. 5. YA24 YA35 16(1) 18(1) 31/10/05 31/10/05 6. YA39 24 31/10/05 7. YA39 24 31/10/05 Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 22 MADE DECEMBER 2004) 8. YA39 24 The home must be able to demonstrate a systematic cycle of planning, action and review for quality assurance (REQUIREMENT ORIGINALLY MADE DECEMBER 2004) Copies of Regulation 26 reports must be sent to CSCI every month 31/10/05 9. YA41 26 31/10/05 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 YA41 Good Practice Recommendations It is strongly recommended that the format for recording Regulation 26 monthly visits to the home be reviewed in order that these evidence that the views of service users are the basis for these visits. it is also strongly recommended that these visits occur at various times, paying particular attention to when service users are at home Charlotte Street E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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 E55 S20835 Charlotte Street V238765 210705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!