Inspection on 14/09/05 for Favor House

This inspection was carried out on 14th September 2005.

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

The inspector found 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 1 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 11/01/06

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 Dianne Thompson Unannounced 14 September 2005 11:00 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Favor House Address 38 Walter Nash Road, Kidderminster, Worcestershire DY11 7BT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01562 637435 Mr Trevor Burgess Mrs Faith Burgess Mrs Margaret Rowles Care Home 7 Category(ies) of LD Learning disability (7) registration, with number of places Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1 February 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 registered providers for one other home. The home is a converted house 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. The home was opened in 1983 and has two double bedrooms and three single bedrooms. One double bedroom has an ensuite toilet. The home is on two floors. There is an attractive garden area, which is accessible to the service users and much used in the summer months. The home is managed by Mrs M Rowles who is supported by a deputy manager. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday morning. At the time of the inspection some service users and the home’s manager were away on holiday, and three service users were at home with a member of staff. Time spent preparing for the inspection involved reading previous reports and the history of the home. The inspector was given a tour of the home, which included all rooms, bedrooms and grounds to the home. Time was spent with the member of staff on duty and meeting with service users at home at the time of the inspection. All were open, helpful and co-operative throughout the inspection. Records and service user files were examined. What the service does well: What has improved since the last inspection? Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 6 The ground floor shared bedroom has had a new shower fitted to the ensuite bathroom. The home has provided all service users with a copy of its statement of purpose, charter, service user guide and a copy of the contract. This meets the requirement of the previous 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. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5 The home provides all service users with a copy of its statement of purpose, charter, service user guide and a copy of the contract. This ensures that all information about the home is available for all service users in preparation for and when they move into the home. EVIDENCE: Two service user files were examined, and both contained a copy of the homes charter and service user guide, agreement and contract. The statement of purpose was also included. A copy of the statement of purpose is available to all staff and is displayed on the notice board. It is evident that the statement of purpose was reviewed in January 2005. This meets the requirement of the previous inspection. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8, 9 Files are informative and contain completed, reviewed and up to date care plans for service users. Information in individual files promotes consistency of care for all service users, although the files need reorganising to make sure information is more easily accessible. Service users are encouraged and supported to try things out as part of an independent lifestyle: this is facilitated through the home’s comprehensive risk assessment procedure. EVIDENCE: Individual care plans are completed and service user reviews take place regularly. Information contained in personal files is detailed and informative, although the files need reorganising. The current filing system is muddled and confusing, e.g. medical appointment letters are found in both medical and correspondence sections. Time was spent with two service users in the home. They said they do things around the home, such as cleaning and polishing, washing up and helping with some cooking. This was observed during the inspection. There are comprehensive risk assessments in individual personal files and cover areas such as going out alone. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 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 standard(s) 11, 12, 14, 15, 16, 17 Service users are supported in a variety of activities in and out of the home, thus providing opportunities for personal development. The inspector observed day-to-day operations within the home, particularly staff and service user interaction. The home encourages and supports service users in maintaining their relationships with family and friends. A menu plan and records show that a nutritious and balanced diet is provided. EVIDENCE: The home provides a wide range of activities for service users, both in-house and within the local community. Day service activity schedules are produced in picture and symbol format and a copy is available in service users file and on their notice boards in their bedrooms. Service users attend the local college in Kidderminster for a Life skills course. The course is due to start a new term during September 2005. Service users also attend Wesley Place day centre, the Elms SEC and the O’Dell centre. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 11 In house activities include karaoke, birthday parties and celebrations and dayto-day household tasks. External activities include trips to Malvern theatre, swimming, concerts at the NEC and NIA in Birmingham, bowling, Bewdley Carnival (one service user took part in one of the floats on a lorry), going to the pub, Drayton Manor Park, playing skittles, going to the cinema, and visiting the Severn Valley Railway. At the time of the inspection three service users were on holiday at Butlins in Minehead, accompanied by the home’s manager. One service user was due to stay with his parents for a few days. Other service users had been to Butlins on holiday during August 2005. The home encourages and supports service users in maintaining their relationships with family and friends. There is evidence that service users regularly make visits to their families. Service users appeared relaxed and comfortable in their home, and were treated respectfully by staff on duty. ‘Food here is all right, very nice and we can choose’, were some of the service user comments. Sausages, potatoes, swede and gravy were on the menu for the evening meal. The inspector was invited to join service users for lunch. A choice of sandwiches and drinks was available and offered to all. A menu plan and record of food and drinks taken is held on personal files and indicate that a nutritious and balanced diet is provided. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, Personal and healthcare needs are clearly identified in care plans. This provides detailed information and works to promote consistency of care and support for all service users. Two people are signing alterations to medication charts: however the reason for any alteration to medication needs to be recorded. Regular reviews of protocols should be completed even where no changes occur. EVIDENCE: There is evidence that personal care assessments have been completed and information is available for staff about the service users preferences. An epilepsy protocol, which is dated March 2004, needs to be reviewed and dated. This should be completed even where no changes to the protocol need to be made. Well person checks are being completed on a regular basis (bi-annually) or more often as required. Medication charts are being completed. When alterations to medication occurs, the MAR sheet should be signed and an explanation recorded on the reverse, e.g. medication was discontinued on 13/6/05. It was not possible to locate a reason or explanation. On one service users file the consent to medication statement needs to be dated and signed. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 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 standard(s) 22, 23 The home has a suitable complaints procedure and relevant policies and procedures for protecting vulnerable adults. These procedures ensure the welfare and safety of all service users is maintained. Staff observe, listen to and respond to the service users in a courteous and respectful manner. EVIDENCE: The member of staff on duty requested and checked the inspector’s identity before allowing access to the home. This was commendable and ensures the safety of all within the home. Service user meetings take place each month and the minutes are signed as agreed by all service users. Staff observe, listen to and respond to the service users in a courteous and respectful manner. The home’s complaints procedure is evident on notice boards in service users bedrooms and on the notice board in the office. The complaints procedure has been produced in symbol format for service users. There is also a copy of the home’s policies and procedures for Adults At Risk on the notice board in the staff room. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 30 Favor house provides suitable accommodation for people with learning disabilities. The home is in a residential area of Kidderminster and convenient to local services and facilities. The home is a comfortable, clean and hygienic environment, which offers service users safety and security. EVIDENCE: The home is located in a residential area of Kidderminster close to local amenities with access to the bus route into town. The inspector was given a tour of the home. Favor House consists of a large kitchen, lounge, three single bedrooms, two shared bedrooms and sufficient bathrooms and toilets to meet the needs of all service users. There is a separate utility room. The ground floor shared bedroom has had a new shower fitted to the ensuite bathroom. All bedrooms are personalised and demonstrate service users independence and choice of décor. There is evidence of service user involvement in service user meeting minutes. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 15 The emergency fire exit on the first floor is through a service users bedroom. An alternative and less intrusive emergency exit should be considered in consultation with the fire safety officer, e.g. exit through the staff room. It is not possible for the service user to ventilate the bedroom, as the only means of ventilation is through the open emergency exit door. Relocating the fire exit and replacing the door with a suitable window will improve privacy and ventilation to the room. The communal rooms are comfortable and well furnished and provide adequate space for shared activities. There is an enclosed garden to the rear of the property with easy access. This garden is fully paved with small border areas. One of the service users does the weeding and maintains the garden. A service user told the inspector ‘this is a happy home’. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Regular staff training is provided to ensure that staff provide appropriate care and support to meet individual service users needs. EVIDENCE: ‘Staff here are good and there are always enough staff for us’, the service users told the inspector. A training schedule was seen which provides evidence of recent and planned training courses, such as ageing process, abuse, communication, first aid, food hygiene, manual handling, life plans and health and safety. The inspector was informed that one member of staff had completed NVQ II in care in July 2005 and the registered manager is an NVQ assessor. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health, safety and welfare of service users is being protected through regular monitoring and checks on all equipment. Regular fire drills are completed to ensure all service users are familiar with the procedure in the event of a fire. It is considered good practice however to identify and record all the names of all service users and staff present for each fire drill which takes place. EVIDENCE: There is a regular maintenance programme operating within the home and evidence is available which demonstrates that repairs are actioned within a reasonable time scale. Fire checks are completed as required, with effective procedures and record keeping. There is a fire procedure and exit plan situated by the fire panel. This plan is supported by fire symbols located by fire extinguishers throughout the home. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 18 When a fault is identified during regular checks staff record and report to maintenance. The home is advised that follow up action and date of completing any repairs should also be recorded in order to indicate that work has been completed. At present only reporting faults to maintenance is recorded in the file seen. It is evident that fire drills are completed monthly. It is good practice however to identify and record the names of all service users and staff present for each fire drill which takes place. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 4 x 3 3 4 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Favor House Score 2 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA20 Regulation 13 (2) Requirement Where changes to medication are made a reason or explanation must be provided. Timescale for action 31st October 2005 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. 3. 4. Refer to Standard YA20 YA20 YA42 Good Practice Recommendations 5. 6. YA42 YA42 Consent to medication statements should be dated and signed by service users and/or their representatives, and the home. Epilepsy protocols should be regularly reviewed, signed and dated. Consideration should be given to relocating the emergency fire exit on the first floor of the home, in consultation with the fire safety officer. Emergency fire exit is currently through a service users bedroom. All service users and staff present during fire drill should be identified to ensure all receive regular drill practice. A record of completion of all fire equipment faults reported to maintenance should be maintained. Favor House E52 S18504 Favor House V246018 140905.doc Version 1.40 Page 21 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. 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