Inspection on 22/09/05 for ICS 11&12 Wembrook Close

This inspection was carried out on 22nd 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

ICS 11&12 Wembrook Close 30/06/09

ICS 11&12 Wembrook Close 30/11/06

ICS 11&12 Wembrook Close 15/03/06

ICS 11&12 Wembrook Close 02/03/05

ICS 11&12 Wembrook Close 09/08/04

ICS 11&12 Wembrook Close 24/11/03

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 09/07/2008.

CARE HOME ADULTS 18-65 Ics - Wembrook Close, 8 & 12 8 & 12 Wembrook Close Attleborough Nuneaton Warwickshire CV11 4LJ Lead Inspector Maggie Arnold Unannounced Inspection 2:40pm 22 September 2005 Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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 Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ics - Wembrook Close, 8 & 12 Address 8 & 12 Wembrook Close Attleborough Nuneaton Warwickshire CV11 4LJ 02476 327797 01527 546888 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) Individual Care Services Mr Stephen Northcote Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 8 & 12 Wembrook Close operate as a single, linked service, with a shared staff group and manager. May provide accommodation and personal care for up to 5 people in the category of learning disability (3 at number 8 & 2 at number 12). 2nd March 2005 Date of last inspection Brief Description of the Service: 8 and 12 Wembrook Close accommodate up to 3 and 2 residents respectively, in the category learning disability. The houses are situated opposite each other in a small Close. There is one staff group and one manager. Both homes are detached bungalows in a quiet residential area on the outskirts of the town of Nuneaton. The accommodation in each is similar comprising of a shared lounge, kitchen and bathroom. 12 Wembrook Close has two bedrooms on the ground floor. 8 Wembrook Close has two bedrooms on the ground floor and has a further two bedrooms are on the first floor, one of which is used as the office/sleep-in staff room. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Thursday 22nd of September between the hours of 2.40pm and 5.55pm. On this occasion the inspector concentrated on Number 8 Wembrook Close and did not visit 12 Wembrook Close. Two residents were at home and the manager and two care staff were on duty at the time of the inspection. In addition to talking to the residents and manager, the inspector focussed on one set of care plans and accompanying records, two staff records, an interview with a staff member and tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: In order to help monitor and safeguard the well being of the residents the home is to maintain a record of all visitors to the home. The policies and procedures regarding the residents’ finances require some improvement. Of particular concern is the lack of documentary evidence on file to show how the agreement was made regarding the residents’ monthly contributions towards shared transport costs. The home must improve financial records and ensure seek advice about how staff can help residents access their cash. Tippex is not to be used on any statutory records. A risk assessment that meets with the approval of the Fire Safety Officer is required in the event of residents who feel they must leave their bedroom doors ajar at night. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 6 The home must also make sure that all newly recruited staff have up to date references. This also includes persons who have previously worked in the home. 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. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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 Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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&5 Prospective residents’ needs and aspirations are assessed prior to being admitted to the home. This helps to ensure that home is suitable for meeting the residents’ needs. EVIDENCE: Records looked at contained initial referrals and assessments from the placing agencies. The assessments of needs covered all aspects of care as well as including preferences and aspirations. For example, initial assessments included methods of communication, physical and mental care needs, finances and family contacts. Each resident has a contract. The contract advises of the terms and conditions of the placement. It is pleasing to note that the document also includes pictorial details regarding what is not included in the fees. Refer also to the Section headed Concerns and Complaints. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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&9 Detailed care plans and risk assessments ensure that the well being and safety of the residents are being promoted. EVIDENCE: The home has a comprehensive care planning and recording documentation process, which is based on the initial referral from the placing agency. The care plan covers all aspects of care, as well as personal aspirations and changing needs. For example, the care plan seen included details of daily routines, likes and dislikes, strengths and needs, living skills. There was also a daytime activity plan, particular behavioural traits as well as medical information and the management of medication. A contents page and directions throughout the records to guide the reader to additional information made the documents easy to cross-reference. The attention to detail in the care plans and accompanying records, quality of recording and orderly systems were of a very good standard. Individual risk assessments and risk management strategies are in place and there was evidence that these were routinely reviewed. The home adheres to the good practice of making a note of when the next reviews are planned. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 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): 11,12 &15 Residents are supported to take part in a variety of social and leisure activities that helps to promote personal development and appropriate relationships. The home is pro-active in helping residents maintain contact with family members, which helps to foster a sense of identity. The home is required to keep a record of all visitors to the home. EVIDENCE: Each resident has an assessment summary which records their skills and, if so required, support needed from staff. The document covers self-care, work and occupation, domestic, daily living and leisure activities. Records seen demonstrated that residents are supported to maintain and develop social and independent living skills. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 11 In addition to attending day care placements, residents are supported by the home to access various activities. Activities include going to the pub, meals out, visiting family and friends, listening to music, watching television, and relaxing at home. At the time of the inspection one resident was visiting their family. The manager advised that, due to the changing needs of the residents, the home was in the process of reviewing the present programme of social activities. The home must maintain a record of all visitors to the home, including the names of the visitors. This is to include visits from friends and family as well as other professionals and trades people. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 &20 Personal support is delivered in a way that meets the assessed needs of the residents whilst encouraging residents to be as independence as possible. Healthcare and medication policies and procedures help to ensure that the residents’ medical needs are met. EVIDENCE: The skills assessment summary details what, if any, level of support the resident may require. For example, the records seen advised that “…requires help with bathing and washing hair, but washing (face and hands)/dressing requires no assistance”. This helps to promote the residents’ independence and ensures that they only receive support as required. Full details of the residents’ health care needs and how these are to be met, are noted on their individual files. Records are also maintained of any contact with healthcare professionals and the outcome of the visits. Additionally the home makes a note of any incidents, which may affect the residents’ health and well being. The manager and staff were well informed regarding the needs of the residents. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 13 The home is responsible for the management of the residents’ medication. With one minor discrepancy the management of the medication met the Care Homes for Younger Adults 2001: National Minimum Standards. The discrepancy was addressed with immediate effect. It is pleasing to note that the home routinely reviews medication regimes and that information regarding possible side effects of medication is available on the residents’ files. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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): 23 The home’s policies and procedures regarding residents’ money and finances do not fully protect the residents from the risk of financial abuse. EVIDENCE: This standard was fully assessed at the time of the last inspection, which took place in March 2005. One resident’s financial records were checked on this occasion. It was noted that the resident contributes £110 a month towards transport costs. However, there was no evidence on file to demonstrate that this arrangement presented best value for the resident. Nor was there any documentary evidence on file to show that the arrangements had been made in full consultation with the resident’s family and placing agency. The inspector was advised that on certain activities, residents are expected to pay for the costs incurred by the staff member accompanying them on the outing. For example, if the activity is for one resident who is supported by a member of staff, the resident pays the full cost, whereas if it is two residents and one member of staff each resident will pay their own and only half of the costs of the staff. Receipts for a meal showed that the cost of the staff member’s meal did not exceed that of the resident. It is strongly recommended that the home provide the residents with a scale of potential costs that details how staffing expenses are calculated. The resident has a bank account but there were no bank statements on file to verify transactions and balances. The manager advised that the bank no longer provides bank statements. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 15 The inspector contacted the customer services of the bank and was advised that statements were available. The manager of the home was informed and said he would request regular statements. The inspector was advised that the staff accompanied the resident to the bank and that monies were withdrawn via a cash card. Staff members know the pin number because the resident is unable to retain the information. In order to reduce the risk of financial abuse the home is required to restrict the details of the pin number to the absolute minimum number of staff. It is also strongly recommended that the pin number be changed on a regular basis and always be changed when a member of staff leaves Individual Care Services. The home must consider if there is a more appropriate way for the resident to access her money. The home was also advised that Tippex must not be used on statutory records. Mistakes are to be crossed through and initialled and dated by the person making the correction. It is strongly recommended that hard backed books be used for recording details of resident’s finances. The manager advised that residents’ financial records are subject to audits by the financial director of Individual Care Services and an independent firm of auditors. It should be noted that there is no suggestion or evidence of the misappropriation of residents’ finances. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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): 24-28, 30 The residents at No 8 Wembrook Close ’ benefit from living in a homely and comfortable environment. The practice of leaving a resident’s bedroom ajar at night places all persons in the home at significant risk in the event of a fire. EVIDENCE: A tour of the communal areas of the home found it to be homely, comfortable and well ordered. The furniture, décor and soft furnishing were of a good quality and met the needs and preferences of the residents. The residents showed the inspector their bedrooms. The bedrooms were attractively decorated and furnished with good quality bedding of the residents choice. The rooms were personalised with items such as photographs, pictures and soft toys. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 17 A risk assessment is required with regards to a resident’s bedroom door being left open at night. The risk assessment should meet with the approval of the Fire Safety Officer. In compliance with a requirement arising from the previous inspection the rear garden and pathways have been refurbished and lounge carpet has been cleaned. The manager advised that the hallway carpet in Number 12 Wembrook Close had been replaced and garden improved but the inspector didn’t check this. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 18 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): 32, 34 & 36 The failure to adhere to recruitment procedures potentially places the residents at risk. Residents’ benefit from well supported and supervised staff. EVIDENCE: Two care staff and the manager were on duty in Number 8 with one staff member on duty at Number 12. Two staff files were selected for scrutiny and one staff member was interviewed. References were missing for one newly employed staff member. The manager said that he knew the staff member as Individual Care Services had previously employed them. The home must ensure that current references are obtained for all newly recruited staff. The staff member who was interviewed discussed her induction process and confirmed that supervision and staff meetings took place on a regular basis. The staff member also demonstrated a sound knowledge of various policies and procedures. Policies and procedures discussed included fire safety, missing persons, complaints and the control of substances hazardous to health. A discussion also took place regarding the role of a key worker. The member of staff was well informed regarding the needs of the resident for whom she was key worker. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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): 42 Suitably trained staff and a well-ordered environment promote the welfare of residents. The failure to adhere to recruitment procedures and poor fire safety practice potentially places the residents at risk. EVIDENCE: This standard was not fully inspection on this occasion. A tour of the premises found them to be very clean and well ordered with no potential trip hazards. Cleaning fluids and other possible hazardous items were securely stored when not in use. The garden and paved areas have been recently cleared and reordered and are now much safer and more suitable for use by the residents. Discussions with the manager and staff member combined with records seen evidenced that staff receive core training such as Basic Food Hygiene, Emergency First Aid and Fire Safety. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 20 As noted in the body of this report and in the summary headed ‘What the home could do better’, a risk assessment is required regarding a bedroom door is left ajar at night and in the section headed ‘Staffing’, the lack of current references for one member of staff compromises the safety and welfare of the residents. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.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 3 Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 x x 3 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 x 14 x 15 2 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 x 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ics - Wembrook Close, 8 & 12 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000004364.V253312.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 2 Standard YA15 YA23 Regulation 17(2) Sch 4(17) 13(6) 17(2) Sch 4 (9) Requirement The home is required to keep a record of all visitors to the home. The registered person is required to ensure that the present system of a standard charge for transport costs represents good value for each resident. The registered person must review the present procedures in place for the management of resident’s finances and in particular those of the resident referred to in Standard 23 of this report. Tippex must not be use on statutory records. Mistakes should be crossed through and initialled and dated by the person making the correction. 3 YA42YA24 23(4) (c)(i) The registered person must undertake a risk assessment with regards to one of the resident’s bedroom door being left ajar at night. The risk assessment should meet with the approval of the Fire Safety DS0000004364.V253312.R01.S.doc Timescale for action 31/12/05 31/01/06 31/12/05 Ics - Wembrook Close, 8 & 12 Version 5.0 Page 23 Officer. 4 YA42YA34 19(1) Sch 2 (5) The home must ensure that current references are obtained for all staff, including those who have previously worked at the home. 31/01/06 Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 24 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 YA23 Good Practice Recommendations It is recommended that the home provide the residents with a scale of potential costs that details how staffing expenses are calculated. It is strongly recommended that details of a resident’s cash card pin number be severely restricted and be changed on a regular basis. It should always be changed when a member of staff leaves Individual Care Services. It is also recommended that hard backed books be used for recording details of residents’ finances. Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Ics - Wembrook Close, 8 & 12 DS0000004364.V253312.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!