Inspection on 13/10/05 for Emscote House

This inspection was carried out on 13th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Emscote House 30/01/07

Emscote House 21/03/06

Emscote House 08/03/05

Emscote House 01/12/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Emscote House Emscote Drive Wylde Green Sutton Coldfield West Midlands B73 5NE Lead Inspector Gerard Hammond Unannounced Inspection 13th October 2005 10:00 Emscote House DS0000016726.V259365.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 Emscote House DS0000016726.V259365.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. Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Emscote House Address Emscote Drive Wylde Green Sutton Coldfield West Midlands B73 5NE 0121 382 1463 0121 382 1463 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) Norman Laud Association Mrs Lesley Pamela Somerfield Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years Ms Somerfield completes the Registered Managers Award and NVQ 4 in care within 18 months of the date on this registration certificate. 08 March 2005 Date of last inspection Brief Description of the Service: Emscote House is registered to provide accommodation, care and support for up to eight people with learning disabilities, who may also have additional physical disabilities. This is a respite care service, aimed generally at serving the needs of younger adults. The property was purpose built: all respite accommodation is provided on the ground floor of the building, in single bedrooms. Rooms are designed to meet a varied range of support needs. The Home has well equipped standard and specialist (assisted) bathrooms, offering bathing and shower facilities. The kitchen links two roomy dining areas: both these rooms also double as areas for tabletop activities. There are also two well-furnished lounges that include televisions, video / DVD, stereo, and computer games console. The newly built conservatory also offers additional space for games, snooker table, parties and so on. There is an extensive private and enclosed garden to the rear of the property. At the front are shrub borders and parking spaces. The Home is situated at the end of a cul-de-sac in the residential area of Wylde Green. Local amenities include shops, library, medical centre, places of worship and a range of leisure and recreational facilities. The area is well served by public transport, including rail and bus routes. Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Sample checking of records including personal files, previous inspection reports and safety records, were used for the purposes of compiling this report. The Inspector formally interviewed the Deputy Manager, and met briefly with the registered Manager, who was not on duty that day. Unfortunately there were no people who use the service in residence during the inspection visit, so it was not possible to seek their views directly. A tour of the building was also completed. Throughout this report, people who use the service are referred to as “guests”, as this is the preferred title. What the service does well: What has improved since the last inspection? Clear attempts have been made to comply with requirements made at the time of the last inspection. Proper use is now being made of the visitors’ book. Staff files now contain necessary documentation, and all COSHH items are stored securely. Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 6 Improvements have also been made to fire safety precautions, in keeping with the recommendations of the local Fire Officer, following a recent visit. The new conservatory is now complete and in use. This has created valuable additional communal space in the house. 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. Emscote House DS0000016726.V259365.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 Emscote House DS0000016726.V259365.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&4 Prospective users of the service have their needs and aspirations assessed appropriately, and have the opportunity to visit prior to choosing whether to stay or not. EVIDENCE: The service has a thorough admissions procedure, which includes a full assessment of prospective guests’ needs and the provision of opportunities to visit, prior to any decision being made about offering a placement. Sample checks of records confirmed that assessments were in place, and on arrival at the Home, the Inspector met briefly with a young man who was just leaving following an introductory visit. He was clearly happy with the process and went away to discuss this further with his family and social worker. Conversations with the Deputy Manager provided further evidence that much thought is given to who comes into the Home, and when, so that a good “mix” of people can be achieved if possible. Emscote House DS0000016726.V259365.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 & 9 People’s assessed and changing needs are included in their support plans, but plans need to be developed to include more detail about how support should be given, and also to reflect their personal goals. There is evidence to show that people using the service are consulted appropriately. Responsible risk-taking is encouraged so as to enhance people’s independence. EVIDENCE: Personal records were sampled, and found to contain appropriate care plans, referred to as “Guest Profiles”. It was noted in the last inspection report that individuals’ disabilities often prevent their direct involvement in developing their plans. However, families are given the opportunity to complete plans, so that they can pass on detailed information to help staff support their relative during their stay. There was evidence that plans are updated and reviewed regularly, and are supported by risk assessments as appropriate. The Organisation is at present considering ways of improving the risk assessment process to see if it is possible to update it on a daily basis. Conversations with staff demonstrated that there is a positive attitude to risk assessment, one Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 10 that sees responsible risk-taking as providing opportunities for learning and development rather that creating obstacles. Some development of care plans is needed, so that sufficient detail is included to instruct the reader exactly about how support should be given. For example, one plan said “regular checks throughout the night” – this should indicate how frequently and the agreed intervals between checks. “Requires assistance” should say exactly what this means, and in detail (e.g. requiring assistance to dress might mean just a tidy up at the end, or might mean help to choose the right clothes for the weather / season, able to put things on but not manage buttons or zips, actually needing to be dressed completely, and so on). Care plan guidance should be specific. Plans should also include goals with outcomes that can be measured, so that they can be properly evaluated when the plan is reviewed. It is also recommended that consideration be given to ways of introducing personcentred approaches, in keeping with the aspirations of the Government White Paper “Valuing People”. It is further recommended that detailed communication guidelines be placed in a prominent position in people’s care plans for guests who have communication support needs. One person’s plan said “we use signs if he knows them”, but gave no indication of what signs he did know, or how these were actually used. Unfortunately, there were no guests in residence during the course of the inspection visit, so it was not possible to directly observe or to ask guests about their experiences of being able to make decisions and choices. However, the Deputy Manager advised that guest meetings are held every week, and “mini-meetings” on a daily basis, as well as personal one to one discussions individually, in order to support people make choices and decide what they want. There was plenty of evidence of material around the Home specifically designed for people with communication support needs such as pictorial aides and Makaton sign books. Emscote House DS0000016726.V259365.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, 14, 15 & 17 People using the service are able to take part in appropriate activities of their choosing, and to be a part of the local community. Guests are supported to maintain contact with their families and friends, in accordance with their wishes. Guests are offered a balanced and nutritious diet and enjoy their meals. EVIDENCE: During their stays at Emscote House, guests are encouraged and supported to attend their usual day activity placements if they have them. Should guests not have regular daytime placements, then the service can structure a programme of activities to suit individual needs. Guests can access local facilities including pubs and restaurants with support, using public transport or the Home’s own vehicle, as appropriate. Day trips are also arranged on a regular basis, and the Deputy Manager advised that an outing to the safari park was scheduled for later in the week. In addition to being able to go out for recreation, guests can chose to stay in and make use of the range of Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 12 equipment and facilities available to them in the Home. The service is a wellestablished feature of the local community. Guests are supported to keep in touch with families and relative in accordance with people’s wishes. As people using the service are generally only there for short periods of time and return to live with their families, this is not really considered to be especially significant. At the last inspection it was reported that mealtimes were lively and pleasant social occasions, with people able to have a choice of what they ate, and stating that the food was good. Choice is supported by the use of pictorial aides for people who cannot communicate verbally. An examination of food stocks revealed a plentiful and varied supply, including fresh fruit, vegetables and salad items. The Inspector was also advised that the service is able to provide culturally appropriate food, according to what people want. Emscote House DS0000016726.V259365.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 & 20 People receive support in accordance with their requirements and preferences, and their healthcare needs are met appropriately. General practice in the storage, handling and administration of medication affords people using the service with protection. EVIDENCE: As reported earlier, it was not possible to observe guests in receipt of care and support directly. However, this standard was met in full at the last two inspections. Any particular healthcare needs are assessed prior to admission, and monitored thereafter. It was noted on one guest’s profile that an epilepsy management plan was in place. Contact details for GP’s are held on each person’s records, and other essential information is clearly presented and readily available. Previous inspection reports have highlighted the good standards of practice in relation to the management and administration of medication in the Home. The MAR (Medication Administration Record) was examined and found to have been appropriately completed. A sample audit of medication stocks also tallied Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 14 with records held. Medication was securely stored as required. The Inspector was advised that several members of staff are scheduled to begin medication training shortly, once their training packs have arrived. Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 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 the following standard(s): Positive efforts are made to ensure that people using the service have opportunities to make their views known, and these are listened to and acted upon appropriately. General practice affords guests with protection from abuse, neglect and selfharm. EVIDENCE: There is a clear and effective complaints policy and procedure in operation. In the foyer by the Home’s main entrance is a “post box” with pens and forms for guests or visitors to register any comments they may wish to make about the service. The complaints procedure is also prominently posted in Urdu and Punjabi and is available in a Makaton format for guests. There have been no formal complaints since the last inspection. In addition to formal procedures, there is a “grumbles book”, which gets used when people do not wish to register formal complaints, but to express minor concerns. The book also details the response and outcome. This represents good practice and should be commended. It was noted that the local multi-agency guidelines for adult protection were incorporated into the service’s own policy and procedure, and it is recommended this should now be updated (minor adjustment) to include the latest edition of these guidelines. From information available on the day of the inspection visit, two members of staff have yet to complete training in the protection of vulnerable adults from abuse, and this should be addressed. (See Standard 35 also.) Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 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 the following standard(s): 24 & 30 Emscote House is safe, comfortable and homely for the benefit of guests who stay there. The house is kept clean, tidy and hygienic. EVIDENCE: Emscote House provides guests with a living environment that is warm, welcoming and homely. The building is decorated, fitted and furnished to a very high standard, and it is clear that much thought has gone in to providing good facilities for people with a wide range of support needs. The house is accessible throughout for people using wheelchairs. There are washing and bathing facilities for people requiring full assistance, and fully accessible toilets also. The Home is well supplied with specialist equipment including mobile hoists for lifting and handling (with a range of different slings) and grab rails in toilets and bathrooms. Since the last inspection the new conservatory has now been completed and is fully in use. This is a very flexible space and offers guests a range of possibilities for activities and social gatherings, providing welcome additional communal room to supplement the Home’s two lounge areas. The dining areas are also used creatively outside of mealtimes for other activities such as art / craft based pursuits or games. The communal areas look out over the Home’s extensive garden, which also provides an attractive outdoor space for use when the weather permits. The Home is kept clean and tidy, and a good standard of hygiene maintained. Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 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): 34, 35 & 36 General practice in relation to recruitment of staff offers protection to people who use this service. A current training and development plan is required so as to assess fully the training needs of the staff team. Staff are supported and supervised appropriately. EVIDENCE: Staff files were sample checked and found to contain all the necessary documentation, including proof of identity and Criminal Records Bureau check. However, files should also contain a recent photograph of each staff member, and this must be rectified where necessary. It is known that the service has a strong commitment to training and information provided on the day of the inspection supports this. However, a current staff training and development assessment and plan is now required. This should show all training and qualifications completed by every member of staff, and highlight any gaps (including “refreshers”). The schedule should show when outstanding training is to be delivered, and by whom. Records of staff supervision demonstrated that formal supervision is above standard. The Inspector was also advised that the current system is under Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 18 review and it is hoped to introduce a more detailed format shortly, and improve opportunities for shadowing, job coaching and staff development. Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 19 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): 37, 38, 39 & 42 The senior management team in the Home is appropriately qualified or working towards gaining necessary qualifications. The management style is both open and inclusive. The views of people who use the service are actively sought, but it is recommended that quality assurance and monitoring systems be developed further. General practice promotes the health, safety and welfare of people using the service. EVIDENCE: The Registered Manager is working towards gaining NVQ level 4 and the Registered Manager’s Award. One Deputy Manager is already qualified to NVQ 4 and also has a degree in Psychology, while the other Deputy has also begun Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 20 study for NVQ4. The style of management is open and inclusive, and the general approach very positive. The service does not at present utilise any formal quality assurance and monitoring system to evaluate the success of the service in achieving its aims and objectives. However, it should be acknowledged that practices such as the availability of the comments box and the use of the “grumbles book” referred to earlier, are supplemented by the use of a questionnaire that is sent out to guests on an annual basis. It is recommended that the Organisation gives consideration to formalising these processes, and considers how this information might be analysed and the findings made available to all interested parties. Safety records were also sample checked. The fire alarm and emergency lighting systems, and fire-fighting equipment have all been serviced, and the fire risk assessment reviewed. The alarm has been tested weekly, and fire evacuation practice carried out quarterly, with records kept as appropriate. Written recommendations from the local Fire Officer have been complied with, and automatic fire door closure devices have been delivered and are to be installed shortly. The landlord’s Gas Safety Certificate and the five-year electrical hard wiring certificate are both in date. The specialist bathing and lifting equipment has been serviced, and legionella testing carried out on the water supply and storage. Daily checks have been carried out on the fridge and freezer temperatures, with records kept as required. Packages of food stored in the fridge were labelled with the date of opening. Items covered by COSHH were stored securely. Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 21 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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 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 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Emscote House Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X 3 X DS0000016726.V259365.R01.S.doc Version 5.0 Page 22 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. 1 Standard YA6 Regulation 15 Requirement Develop care plans as indicated in the main body of this report, to include specific details about how support should be given, and to set goals with measurable outcomes. Produce a staff training and development plan, to include for each staff member: Qualifications gained and training completed. Highlight any gaps, including refreshers. Indicate when outstanding training is scheduled, and who is to deliver it. Forward the plan to CSCI. Develop Quality Assurance and monitoring systems for the service, so that results may be analysed and shared with all parties concerned. Timescale for action 31/12/05 2 YA35 18 (1c) 31/12/05 3 YA39 24 (1-3) 31/12/05 Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 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. 1 Refer to Standard YA6 Good Practice Recommendations Develop clear communication guidelines for people with communication support needs and place them prominently on individual care plans. Seek to develop person centred approaches, in keeping with “Valuing People” Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Emscote House DS0000016726.V259365.R01.S.doc Version 5.0 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. 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!