Inspection on 29/06/07 for Charlotte Street

This inspection was carried out on 29th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charlotte Street 15/02/06

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 Mrs Kathryn Marks Key Unannounced Inspection 29th June 2007 09:30 Charlotte Street DS0000020835.V344170.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 Charlotte Street DS0000020835.V344170.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. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 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 Janice Hooper Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 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. 15th February 2006 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. Information gained from the Senior Support Worker in charge at the time of inspection identified that the current fee’s charged are £387.05. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced Inspection was carried out on 29/06/07 and covered all of the core standards. The inspection took place over one visit totalling 6.5 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. A tour of the home took place with staff and four people who use the service who were present in the home. The inspection included an examination of records, indirect observation, with the people living here and conversations with them and staff on duty. Case tracking of three-service users care plans took place. Staff’s records were not examined at this visit as identified in the main report. Observations were made of positive warm interaction between staff and people who use the service during the day and when others came home from day services. Information was obtained from people who use the service, in relation to their views of the service provided at Charlotte Street. Discussions with the service users confirmed their satisfaction with regards to the service provided and the support and assistance offered by the staff team. What the service does well: As at the previous visit staffs at this home are generally of long standing and have a good understanding of people who use the service. Individuals are encouraged to maintain contact with family and friends and staffs support them with educational, health and social needs. If an individual can complete a task unaided then they do so. All people who use the service lead full and active lives participating as previously in various community activities. Individuals were observed to be in and out of the home attending appointments or day placements as they wished. Taxis seem to be the Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 6 preferred transport with individuals being treated respectfully by various drivers collecting them and staff today. Observations throughout today’s visit were that individuals were offered daily choices in relation to what they do, where they go, what they wear and what they eat encouraging people who use the service to take control of their daily lives. 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. The summary of this inspection report can be made available in other formats on request. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2 have been reviewed at this visit. Quality in this outcome area is excellent. The homes Statement of Purpose and Service Users Guide provides prospective people who use the service with details of the services Charlotte Street has to offer enabling an informed decision about admission to be made. Full assessment of the needs of people who use the service is carried out and their contract tells them about the service they will receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Charlotte Street has in place a detailed Statement of Purpose and Service Users Guide that provides individuals with information about the home enabling an informed decision to be made by them and their relatives about admission to the home. Prospective people who are to use the service are admitted following a full assessment of needs to ensure staffs at the home are able to meet those needs. Six people who use the service are of longstanding at the home and a further person has been at Charlotte Street for approximately 18 months. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 9 A pre admission visit was made to the home where the individual met other people who use the service and had a meal with them. Detailed pre assessment and ongoing assessment was seen on file providing a lot of information with excellent recording in place. A copy of a letter to the individual confirming the outcome of the assessment was also on file. Charlotte Street DS0000020835.V344170.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): Standards 6,7,9 were reviewed at this visit. Quality in this outcome area is excellent. Observations of personal care plans, people who use the service and risk assessments in place-evidenced individuals are involved in decisions about their lives. Systems in operation promoted service user involvement with regards to the management of the home and key decisions in areas affecting their lifestyle and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The changing needs of people who use the service are assessed and personal goals are reflected in their care plans. Individual care plans are detailed and up to date three people who use the service care records were reviewed. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 11 Care Plans are in a modular format and contain: Information sheets, Missing person profile, Daytime Activities, General Notes, Medical Notes, Financial Information, Risk Assessments, Personal Profile, Current Review, Daily Care Plan, and Key Worker Goals. There are also agreements on file for allowing staff to access bedrooms to clean them. People who use the service were observed to be making decisions about their lives with assistance as needed. Choices were being made about how much cash they wanted, holidays they are going to Blackpool from choice in September, days out to various venues the current one being Rhyl. People who use the service were making decisions with people who knew them that they were comfortable with. One person who uses the service has an advocate to assist them however all individuals spoken with knew they could have someone to help them. Individual finances were sampled cash balanced with records maintained. People who use the service are supported to take risks as part of their lifestyle. Individual risk assessments were in place for people who use the service providing comprehensive information relating to potential hazards and details of measures to reduce or eliminate the risk. The Senior Support Worker confirmed that these risk assessments were reviewed on a regular basis. Risk assessments also in place for “Sam” the homes cat. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 12 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): Standards 12 13 15 16 17 were reviewed at this visit. Quality in this outcome area is excellent. People who use services are able to make choices about their lifestyle, and are supported to develop their life skills. Social, educational, and recreational activities meet individual’s observed expectations. This judgement has been made using available evidence including a visit to this service and discussions with individuals. EVIDENCE: Observations during this inspection were that all people who use the service are enabled to take part in age, peer and culturally appropriate activities and attend various venues to suit their preferences and abilities. These venues include Links to Work factory, Hawbush Day Centre, North Gate Day Services, Brewer Street Day Services, Walsall College, One person who uses the service accesses the Blind Centre in Walsall. One person has just been accepted to do volunteer work in Charity Shop in Walsall. (Risk Assessment being done.) Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 13 Individuals access venues in the community via Taxis, Ring and Ride, Community Transport, some relatives visit Charlotte Street, some individuals maintain contact by visiting relatives at home. All people who use the service are encouraged to bring their friends to Charlotte Street. One person who uses the service has diverse needs and attends venue of their choice to meet those needs, at all times needs are met via discussion. Observations of the Inspector were that choice independence freedom of movement is respected. Access to the bedrooms of people who use the service is with individual’s permission and there is a protocol in place for cleaning bedrooms. All people who use the service have a front door key and where an individual cant use the key then there is a front door key fob that they hold the key up to and it opens. All receive their own mail and are assisted by staff if unable to read mail. Menu seen varied diet people who use the service shop with staff assistance and basically decide on a daily basis what they would like to eat. Inspector observed this happening. Individuals said they “enjoyed their food” and “loved living at the home” “staff help you” “ You can do what you like” Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 14 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): Standards 18 19 20 were reviewed at this visit. Quality in this outcome area is excellent. The health and personal care that people who use the service receive is based on their individually assessed needs. Observations were made of principles of care being promoted ensuring that respect, privacy and dignity of individuals are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As at the previous inspection 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 time 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 including Walsall football supporters. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 15 Two people who use the service are currently self-administering medication under staff supervision. Details are on the Medication Administration Sheet and risk assessments have been carried out. All medication is stored in a locked Metal Cabinet secured to the wall. The pharmacist from boots pharmacy visited today to carry out the 3 monthly audits of medication and procedures. All was found to be in order. Staffs administering medication are all trained in the management of medication. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 16 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): Standards 22 23 were reviewed at this visit. Quality in this outcome area is good. This judgement is based on the examination of the complaints policy and some records relating to the homes recruitment procedure. The complaints procedure was accessible to all service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service that were spoken to said they felt that they were listened to and if they were unhappy about something that staff would deal with it. There is a complaints procedure in place that is displayed in the hallway is given to people who use the service and their relatives and is explained to them. The home has in place a record book to record complaints and any action taken to deal with them this was seen at the inspection. People who use the service are safeguarded from abuse by staff observations and training. Appropriate recruitment all staff had Criminal Records Bureau checks and Protection of Vulnerable Adults checks numbers were seen. There is a vulnerable adults policy in place at the home. There is also a handbook in place for people who use the service this contains the range of services, last report, aims of the home, various policies and procedures, and the service users guide. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 17 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): Standards 24 30 were reviewed at this visit. Quality in this outcome area is good. The home was suitable to meet the needs of people who use the service with adequate communal space, sufficient bathing and shower facilities and single occupancy bedrooms. This enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service live in a comfortable safe bright environment that is suitable for its stated purpose. It is homely with individuals bedrooms being personalised and reflecting the personality of the person occupying the room. All radiators have been guarded to ensure the safety of people who use the service. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 18 The home has a planned maintenance and renewal programme with records being maintained. The property is in a residential area and is in keeping with surrounding properties. 28 Charlotte Street is well maintained both internally and externally and was clean and odour free. The wet room on the first floor the folding seat needs to be on cleaning schedule to ensure that it is cleaned or replaced if stained. Overall the home provides a homely environment where individuals come and go as they choose. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 19 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): Standards 34 35 were reviewed at this visit. Quality in this outcome area is good. Robust recruitment procedures are in place with appropriate checks taking place. Staffs at the home are trained and sufficient in numbers to support the people who use the service ensuring the safe running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspecting Officer was unable to review the staff files on this visit, as the key was not available to access them. The Care Manager being on holiday and Senior Support worker was unable to access the key. However records of Criminal Records Bureau and Protection of Vulnerable Adults checks were e-mailed to the home from head office and were seen by inspector. Staffs are recruited via Human Resources Department of the company. Training and development records were in place staff being involved in National Vocational Training and Learning Disability Award Framework Training. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 20 Observations of staff on duty evidenced that they were aware of the needs of people who use the service in their care and that those needs were being met. Staff spoken with confirmed that they had received all mandatory training and took part in on going training on a rolling programme. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 21 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): Standards 37 39 42 were reviewed at this visit. Quality in this outcome area is good. The management and administration of the home is based on openness and respect and has now developed an effective quality assurance system. Staffs demonstrate an awareness of their roles and responsibilities, ensuring that the health, safety, and welfare of residents are observed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is qualified and competent to run the home. She has been at Charlotte Street for 16 years and worked with people who use the service with a Learning Disability since 1985. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 22 The Registered Manager has the Registered Managers Award and is responsible for Charlotte Street only. The Registered Manager takes part in training with her staff to update her own knowledge. There are Quality Assurance systems in place via questionnaires to people who use the service and their relatives. Annual development plans were in place and seen by Inspector. As at previous inspection all records sampled relating to gas, central heating, and water, heating checks for compliance with legionella and electrics were found to be up to date and in order. Risk assessments were in place. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 23 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 4 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 X 3 X 3 X X 3 X Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard YA30 YA9 Good Practice Recommendations Monitor seat in wet room for cleaning or replacement if stained. Ensure that all risk assessments are signed up to date. Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Local Office 28 Charlotte Street Chuckery Walsall West Midlands WS1 2BD 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 Charlotte Street DS0000020835.V344170.R01.S.doc Version 5.2 Page 26 - 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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