Inspection on 11/01/06 for Favor House

This inspection was carried out on 11th January 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Favor House 25/10/06

Favor House 14/09/05

Favor House 01/02/05

Favor House 13/08/04

Favor House 08/03/04

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 Favor House 38 Walter Nash Road Kidderminster Worcestershire DY11 7BT Lead Inspector Y South Unannounced Inspection 11th January 2006 09:30 Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Favor House Address 38 Walter Nash Road Kidderminster Worcestershire DY11 7BT 01562 637435 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) Mr Trevor Burgess Mrs Faith Burgess Mrs Margaret Rowles Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 Brief Description of the Service: Favor House provides accommodation and personal care for seven adults with learning disabilities. It is owned by Mr and Mrs Burgess who are the registered providers for this and one other home. Favor House is managed by Mrs Margaret Rowles. The home is a converted house on two floors and is situated on an estate on the outskirts of Kidderminster. There are local shops and a public house nearby, and a bus route at the end of the road. It was opened in 1983 and in addition to a communal lounge, kitchen and dining area there are two double bedrooms and three single bedrooms. One double bedroom has an en-suite toilet. There is an attractive garden area, which is accessible to the service users and much used in the summer months. A service is offered to a maximum of seven young adults of either sex with learning disabilities. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over two and a half hours from 09:30am until 12md. The inspector was assisted by the registered manager Mrs Margaret Rowles and senior lead carer Mrs Heather Mills. Three of the residents met the inspector. The focus of the inspection was on the requirements and recommendations that had been made following the previous inspection, and key standards that were not assessed during the previous inspection this year. A partial tour of the home was conducted and a range of documents, policies and procedures were checked. What the service does well: What has improved since the last inspection? Since the last inspection fire safety records have been improved and some thought has been given to improving one of the bedrooms. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 6 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. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 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 Favor House DS0000018504.V276904.R01.S.doc Version 5.1 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 New residents are not admitted without a thorough assessment to ensure that their needs can be met, they wish to reside in the home and they are compatible with the current residents. EVIDENCE: There had been no new admissions to the home for a long time. There was a policy and procedure that met the standard and it was confirmed that it would be implemented. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 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): 7 Residents are supported and able to make decisions regarding their care, life style and activities. EVIDENCE: Residents were supported in every day tasks. Their opinion was sought and their choices and decisions were respected. The services of independent advocates were obtained when necessary. Support was given to manage personal finances and records were maintained. Personal risk assessments and plans had been put in place where required. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 10 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): 13 Residents are members of the community and participate fully in facilities that interest them. EVIDENCE: The residents confirmed that they had a full social life and made use of community facilities. They undertook college courses, visited shops, libraries, cinemas, pubs, leisure centres and churches. The staff supported their right of access to all public places and used public and private transport as appropriate. Escorts and support was always available if needed. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 11 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 Residents are given the help and support they need to take their medication and maintain good health. EVIDENCE: Following the last inspection a requirement was made that when changes to medication were made a reason or explanation be provided. Due to a mis understanding a separate record had been maintained that did not meet this requirement. However further clarification has now been given and the requirement will be repeated and compliance checked during the next inspection. A recommendation that medication statements should be signed by the resident, their representative and a home representative had not been met. The recommendation for a review of an epilepsy protocol was no longer an issue. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 12 There was a medication policy and procedure and publications available for staff guidance. Staff had been suitably trained. Records were well maintained. However hand written entries on MAR records had not been double signed to ensure accuracy, and entries in the daily records did not clearly indicate how changes in medication come about. Storage was provided in lockable drawers in a metal cabinet. The home did not have a suitable cupboard for controlled drugs or a fridge for when cold storage was required. However the manager confirmed that the home held no controlled drugs and no items that needed cold storage were currently prescribed. In the event that a CD was received then this would need to be stored in a CD cabinet which meets the Misuse of Drugs (Safe Custody) Regulations 1973 and a CD register be brought into use. Occasional items that need cold storage can be secured in a locked secure container in a domestic fridge. However if there is a frequent need then a dedicated refrigerator must be provided. Some of the medication stock had been held in the home for over a year. It is considered to be good practice to return such medicines to the pharmacist and review their need. Fresh supplies can then be obtained if necessary. Medicines that are dispensed in the manufacturer’s packaging can be retained until the expiry date is reached if they are still required by the resident. However all such medicines must remain in the container they were dispensed in until used or returned to the pharmacy. All containers of creams and ointments should be dated when opened and be named and only used for one person. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: These standards were not assessed during this inspection. They were met when previously inspected. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: These standards were assessed during the last inspection and a recommendation was made that consideration be given to relocating the emergency fire exit on the first floor of the home, in consultation with the fire safety officer as the emergency fire exit is currently through a service users bedroom. During this inspection it was confirmed that a fire safety officer had visited the home and a discussion had taken place. The emergency exit is to be relocated to the staff room and the resident’s bedroom is to be fitted with a window within the next few months. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 15 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 Suitable staff are recruited and trained to deliver a high standard of care with due regard for the safety of the residents. EVIDENCE: The home has a stable team that has necessitated no recruitment during the past two years. Due to the limited storage space available in the home it has been agreed with the Commission for Social Care Inspection that all staff records be stored by the registered provider in the sister home and made available to the inspector by prior arrangement. The manager confirmed that the recruitment policy and procedure was fully implemented when needed. Applicants completed an application form. They were formally interviewed and invited to visit the home and meet the residents. Residents were able to sit in on interviews if they wished and their opinions were sought. References were taken up and checks made with the CRB and POVA. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 16 All staff had a copy of the terms and conditions of their employment and their own copy of the GSCC code of conduct and practice. All appointments were subject to a probationary period. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 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): All service users and staff present during fire drill should be identified to EVIDENCE: The home is well managed by an experienced and committed manager. Good systems were in place to support the delivery of care. The fire log was inspected and the records confirmed that safety checks and training were being undertaken at the required frequency. The two recommendations made following the last inspection; all service users and staff present during fire drill should be identified to ensure all receive regular drill practice and a record of completion of all fire equipment faults reported to maintenance should be maintained. These recommendations had been implemented. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 18 The fire risk assessment for the home had been drawn up in July 2004 and the manager said that it would be reviewed this year. The home was working to meet the requirements and recommendations made by the fire officer following his recent visit. Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 2 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 4 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X X X X 3 X Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 YA20 Regulation 13 (2) Requirement Handwritten medication administration records must be double signed to ensure accuracy. Daily records must demonstrate that staff are monitoring the effect of medication and are taking appropriate measures when it proves ineffective or is changed for any other reason. Medication stock in pharmacy containers, that has been in the home for more than a year, should be returned, the need reviewed and if necessary the medication replaced. Other medication in manufacturers packaging must be kept in that container until used. Timescale for action 11/01/06 2 YA20 12, 13 11/01/06 Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 21 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 YA20 Good Practice Recommendations Consent to medication statements should be dated and signed by service users and/or their representatives, and the home. It is recommended that the medication storage is reviewed and improved in line with good practice and legislation when appropriate. 2 YA20 Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Favor House DS0000018504.V276904.R01.S.doc Version 5.1 Page 23 - 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!