CARE HOME ADULTS 18-65
Duke Street Bungalows 21/23/25 Duke Street Wednesfield Wolverhampton West Midlands WV11 1TH Lead Inspector
Gurinder Cheema Announced Inspection 24th October 2005 12:00 Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 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 Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 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. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Duke Street Bungalows Address 21/23/25 Duke Street Wednesfield Wolverhampton West Midlands WV11 1TH 01902-553356 01902-553356 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) Wolverhampton City Council Miss Margaret Mary Whelan Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 21 Duke St - 6 people, 23 Duke St - 6 people, 25 Duke St - 8 people as described in the Statement of Purpose. 17th November 2004 Date of last inspection Brief Description of the Service: The three purpose-built bungalows in Duke Street came into operation in November 1996. The bungalows are situated close to Wednesfield Shopping Centre and other local facilities. The bungalows provide residential care for a total of twenty adults with learning disabilities who have various levels of dependency. Bungalows 21 and 23 accommodate six people in each bungalow. Bungalow 25 accommodates eight people. Bungalow 21 provides a service to people with a learning disability who are physically active. Bungalow 23 provides a service to people with a learning disability who have challenging behaviour. Bungalow 25 provides a service to people with a learning disability who also have physical and sensory disabilities or who are in other ways physically vulnerable. The bungalows are appropriately furnished and equipped to meet the needs of the service users. There is a garden and outside amenity space that includes a car parking facility. Bungalows 21 and 23 each consist of six single bedrooms, two bathrooms, two WCs, a small office, a kitchen, a dining room, and a lounge. Bungalow 25 consists of eight single bedrooms, two bathrooms, two WCs, an office, a staff sleeping-in- facility, a kitchen, a dining room and a lounge. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first annual inspection of the year. Care homes are inspected at least twice a year. The inspection was announced and took place on 24th October 2005 between 12:00pm and 2:30pm. The manager, staff on duty, and the service users, who were mostly available, were all very welcoming and helpful throughout the inspection. All of the National Minimum Standards inspected were met identifying that the overall quality of care provided is very good. Written comments and feedback via questionnaires were sought prior to the inspection from a number of individuals. These included: Service users, staff, General Practitioners, Health and Social care professionals and service users’ carers. Only questionnaires from relatives were received back and these were all found to be very positive. The care home has a history of meeting national minimum standards and providing a good service for people; consequently on this occasion mainly those standards identified as “key” by CSCI have been inspected. What the service does well:
Information available for service users is good. Some information is also written in other languages such as Punjabi, Hindi and Urdu. Personal care needs are assessed and met, with each service user having their own care plan, which were found to be regularly reviewed. These are detailed and appropriately documented giving clear instructions to staff on service users individual care needs. These are also accessible to all service users. A number of service users were met and appeared content with the care they were receiving. Four relatives were also spoken to during the inspection. Comments received were all very positive and included: “The premises are kept clean and tidy” “Excellent manus that are varied” “We are told about everything that’s going on” “We are over the moon about the care planning that takes place here” “Staff are courteous and informative” “Staff send relatives flowers for special occasions” Risk assessments are comprehensive and information regarding individuals is provided to staff before they begin caring for the individual. There is a clear and accurate complaints procedure that is also available in different languages and in and in a format appropriate to the Service user group.
Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 6 In regard to the general administration of the home, the inspection revealed that there is a commitment to providing accurate and relevant records. The Care Manager and staff are commended for their efforts to maintain good standards of care and comfortable environment for the service users. 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. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 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 Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Pre admission assessments are appropriately carried out to ensure that the home can meet the needs of the individuals moving into the home. EVIDENCE: Most of the current service users residing in the home are longstanding residents. The placing authority implement an assessment and the home then generate a plan of care that is done over a period of 3 months. A review is then conducted at a 3 monthly stage and then 6 monthly. The care plan shows that the interests and needs of family carers are taken into account subject to the service user’s agreement. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Most of the current service users are unlikely to be able to contribute to the assessment process due to the nature of their disabilities. Despite that, appropriate service user plans, decision making processes and risk assessments have been developed to identify service users’ wishes and needs and safe ways to meet them. EVIDENCE: Three files were sampled during this inspection. These contained comprehensive care plans and regular monthly reviews / summaries and formal six monthly reviews. The home has largely a dependent service user group - who have mostly been residing at the home for some time. There is, however, a key working arrangement in practice in order to encourage residents on an individual basis to be involved in decision-making on a daily basis. All service users have thorough individual risk assessments. These are regularly reviewed depending on individual circumstances. Risk management strategies are recorded in service user plans and service users are always accompanied whilst out.
Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 10 Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 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): 12,13,15,16 and 17 The lifestyle of the service users living at this home is excellent and through a framework of activities, independence, personal and social skills they are encouraged to develop. EVIDENCE: Service users are mostly very dependant however the home arrange access to a number of local resources such as adult training centres, day centres and places of worship which includes those of ethnic minorities. Staff were seen to spend time with, and provide support for service users outside of the home. Flexibility is also provided for staff at evenings and weekends to provide such support. Care plans evidenced that service users participate in a wide variety of activities that includes groups and individual activities depending on the wishes and abilities of the service users. There was also evidence to show that the home support service users to maintain family links and friendships, inside and outside the home in
Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 12 accordance with their Care Plans. Discussions with relatives provided information that the home welcome families and friends and the service users see them in either in their own rooms or lounge/dining rooms. The Home has policies and procedures on personal relationships and sexuality. There was again evidence seen of multi-cultural events being organised such as Diwali. Due to the disabilities of the service user groups the daily routines and house rules are quite structured within the home. All the mealtimes and activities are organised to meet the individual needs of the residents. The home also has rules in relation to drugs, smoking and alcohol for both residents and staff. Each bungalow has a separate dining room where meals prepared differently according to service users preferences. Clear records are maintained for all meals eaten by service users. Each service users file contains information regarding their likes and dislikes pertaining to food. On examination of this it was established that a number of ethnic minority service users had expressed preferences to Asian foods. This was seen to be offered on a regular basis. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 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): 18,19 and 20 The personal and health needs of service users are well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis. EVIDENCE: The home appeared to provide an environment that is flexible and respects service users privacy and dignity. Most of the current group of service users are dependent in most aspect of their daily living however there is consistency and continuity of support through the key working arrangements practiced by the home. From the sample of files viewed it was evident that service users health care needs are monitored closely. The home has is well supported by the local GPs, and other paramedical services when necessary. From the examination of the medication procedures it was evident that the home has policies and procedures for the receipt, storage, handling, recording, administration and disposal of medicines. The Registered Manager also ensures that only staff appropriately trained administer medication. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 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): 22 and 23 The home has policies and procedures in place to ensure that Service users are protected and relatives are able to air their concerns. EVIDENCE: The Inspector evidenced the Home’s Complaints Procedure, which appeared to be detailed. The local authority has now devised the complaints procedure into other ethnic minority languages and a pictorial format that is more appropriate to the service users groups. The home has policies in place for dealing with abuse, violence towards staff, whistle blowing, and dealing with service users finance. Service user finances were inspected and found to be kept within a safe and accurately recorded. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 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): 24 and 30 The standard of the environment is good providing service users with a homely and comfortable place to live. EVIDENCE: The home is within easy access of local amenities. During the day of inspection it was found to be clean, bright, airy and decorated and furnished to a good standard. The areas identified during the last inspection as needing attention such as worn carpets in certain areas and unkempt areas within the garden have now been attended to. The home has a satisfactory policy and procedure in respect of hygiene and infection control. There were cleaning schedules throughout the home and on the day of inspection the home was clean and free from odour. There is a satisfactory induction-training programme for all the staff in respect of hygiene and infection control. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 16 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): There appeared to be satisfactory numbers of competent staff on duty to meet the identified care needs of the residents. EVIDENCE: These standards were not inspected fully on this occasion. However, there appeared an adequate number of staff on duty and those spoken showed knowledge and understanding of the needs and wishes of the residents. Relatives spoken to all commented positively about the staff and stated that they are very caring and responsive to their needs. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 17 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 Health, safety and welfare of service users and staff are promoted by safe working systems in place. EVIDENCE: There is evidence of regular checks and maintenance of the equipment used in the home including electrical wiring and Gas Safety. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 18 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 x x x Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Duke Street Bungalows Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x DS0000036162.V255492.R01.S.doc Version 5.0 Page 19 No 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. 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 Refer to Standard YA29 Good Practice Recommendations It is strongly recommended that the Registered Provider address’s the risk assessment identifying the need for emergency call systems. Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 Duke Street Bungalows DS0000036162.V255492.R01.S.doc Version 5.0 Page 21 - 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!
