Inspection on 30/08/05 for Mclaren House

This inspection was carried out on 30th August 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 but made no statutory requirements on the home.

Other inspections for this house

Mclaren House 29/05/08

Mclaren House 14/05/07

Mclaren House 05/07/06

Mclaren House 16/01/06

Mclaren House 09/02/05

Mclaren House 15/09/04

Mclaren House 18/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 McLaren House 93 Bratt Street West Bromwich West Midland B70 8SH Lead Inspector Mike Kirton Unannounced 30 August 2005 th 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. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service McLaren House Address 93 Bratt Street, West Bromwich, West Midlands, B70 8SH 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) 0121 500 5430 0121 500 5430 Mrs Paulette Shirley Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th February 2005 Brief Description of the Service: Mclaren House is registered to provide residential care for 9 people aged between 18 and 65 who are experiencing mental ill health. The aim of the home is to provide a rehabilitation service to enable its users to return to living independently in the community. There are however no set limits and this may be over a long period of time. The home is a three storey mid-terraced property situated close to West Bromwich town centre with easy access to all local amenities and transport networks. There is parking space for 2 cars at the front of the property and gardens at the rear. Accommodation is provided over three floors. On the ground floor there is an office, staff toilet, one single bedroom, lounge, dining room, conservatory (smoking room), kitchen, laundry and two toilets. On the first floor there are four single bedrooms and a bathroom with toilet. The second floor has two double bedrooms. Plans are in place to refurbish the home and create two en-suite double bedrooms on the second floor and one toilet with shower on the ground floor. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six hours and included discussions with the proprietor, acting manager, six service users, and three staff members. Additionally one service users file and fourteen staff files were examined including a new employee. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 6 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 McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 7 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) 1,2,3,4,&5 Improvements are needed to the homes statement of purpose and service users guide, as these are both important documents, which provide new and existing service users all the information they need about McLaren House. Although service users feedback is very good and there is evidence of excellent care practices, admission procedures must be followed in order to protect the health and safety of all service users and staff. EVIDENCE: The homes statement of purpose and service users guide was examined. They both require updating to include all the required information as outlined in the minimum standards. Once completed, they should be made available in appropriate formats, to anyone receiving or requesting accommodation at the home. Copies of this inspection report must also be made available. The most recent admission to the home was done so without a full assessment carried out or up to date information received from other professionals involved in their care. No care plan or risk assessments had been implemented or contract completed. Visits to the home had been made and a referral form received however these were several months before admission and out of date. Referral and admission procedures for the home also require reviewing and must reflect practices carried out. This may also serve as a checklist to ensure minimum standards are followed correctly. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 8 Service users met during the inspection felt they were receiving a very good level of care. There were also significant improvements made to individuals independent living skills and the management and staff were committed to ensuring that needs were being met. Comments received included ‘I like it here’, ‘the home is very comfortable’ and ‘I can just get on and do my own thing’. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.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) These standards were not fully assessed on this occasion however requirements remain outstanding from the last inspection. EVIDENCE: McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.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) 11,12,13,14,15,16,&17 The home provide excellent opportunities for service users to be involved in activities both inside the home and out in the community to develop their individual skills. Service users encouraged to be independent and are free to plan their own activities with support provided if needed. EVIDENCE: McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 11 Service users were observed to be involved in learning practical skills including preparing meals and housework tasks. Those spoken with described many opportunities to become involved in community activities and attend training courses. This included local colleges and day centres where subjects such as cooking and computer skills can be followed and specialist employment training centres for landscaping and gardening. Staff provision at the home is of a high level and adapted to individual’s requirements. When needed this takes place in the form of 1 to 1 support. Service users are able to pursue their own interests and hobbies and arrange their own leisure activities both inside and outside the home. A recent visit to Dudley Zoo was arranged using public transport and other activities are organised, including group discussions, board games and trips to local amenities. Friends and relatives are able to visit at any reasonable time and can be seen in the privacy of their own room. Keys are provided for individual’s rooms and staff ask permission before entering. All bathrooms have locks fitted, with an override device to be used only in emergencies. Mail is delivered unopened and their correct form of address is used. Service users were observed to be coming and going from the home as they wish and are able to develop relationships outside the home. Responsibility for daily activities and housework tasks are clearly displayed and recorded in individual care plans. Service users are involved in the purchase and preparation of meals. There is a varied menu available with a rota implemented for individuals to receive assistance with cooking their own meal. Food and drink are accessible at all times with a choice on when and where to eat. Nutritional assessments still need implementing to ensure individual needs are assessed. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.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) These standards were not fully assessed on this occasion however requirements remain outstanding from the last inspection. EVIDENCE: McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.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 must improve on their current procedures dealing with complaints and adult protection to ensure the health and safety of service users and staff. EVIDENCE: The homes complaints procedure does not meet the required minimum standards. This must include contact details for the Commission and be clearly displayed. An updated adult abuse policy and procedure must be updated to include current practices making it clear what actions are needed in the event of a serious allegation. A copy of Sandwell’s current policy, the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets must be obtained. The accident book was examined. Entries were not been made as required and the Commission was not being notified of incidents as required under Regulation 37. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.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) These standards were not fully assessed on this occasion however requirements remain outstanding from the last inspection. EVIDENCE: McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The home ensures there are always more than sufficient staff on duty who are experienced in working with the service users. Action however must be taken to ensure recruitment procedures are followed and all training required for staff to carry out their jobs safely is provided. EVIDENCE: The homes staffing rota and 24 staff files were examined and discussions took place with the acting manager and 3 staff members. In addition to the manager there are at least 3 care staff on duty between 07:45 and 20:45 hours and as many as 5 when needed for individual activities with service users. During the night there are 2 care staff on duty. All staff are provided with a job description, contract, and copy of the General Social Care Council standard of conduct and practice. All those met were aware of their roles and responsibilities and felt supported by the manager. They also demonstrated considerable knowledge and experience of working within a care environment and had undertaken recent training. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 16 All potential employees are required to complete an application form before being short-listed for interview. Staff files contained a copy of these including notes taken during the interview and proof of identification. There was however significant gaps in the records retained by the home. In some cases this included no criminal record check or two satisfactory references. New employees are required to complete an induction course and if not already qualified apply for NVQ 2 in care. Individual training plans must be implemented and maintained for all employees with any identified gaps met through the homes training plan and schedule. Supervision must also be maintained to at least 6 sessions a year with an annual appraisal. The recruitment, induction and training policy and procedure must be updated and reviewed. McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.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) These standards were not fully assessed on this occasion however requirements remain outstanding from the last inspection. EVIDENCE: McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 2 2 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 2 3 3 2 Standard No 31 32 33 34 35 36 Score 3 3 4 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 McLaren House Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 19 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. Standard 1 Regulation 4,6 Timescale for action The homes Statement of Purpose 01/11/05 and service user guide needs to include all the information required under the minimum standards. This is an outstanding requirement from the last inspection. Comprehensive assessments must be completed for all perspective service users before admission. Requirement 2. 2 14,15 01/09/05 3. 3 14,15 4. 4 14 5. 5 17 Assessment information including a current Care Programme Approach (CPA) care plan and assessment must be received before admission. The home must be able to 01/09/05 confirm in writing that they are able to meet service users needs before admission. The home must update its 01/11/05 admission procedure in line with current practices and minimum standards. Statements of terms and 01/10/05 conditions or contracts must meet the minimum standards and be completed with all service Version 1.40 Page 20 McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc 6. 6 14,15 7. 9 12,13,14, 15 8. 14 12(3), 16(2)(m) 9. 17 12,13,14, 15 10. 22 22 11. 23 12,37 users. The use of advocates should be used if necessary. This is an outstanding requirement from the last inspection. Care plans must be implemented upon admission clearly stating how all assessed needs will be met. Long and short-term goals must be identified and monitored. This is an outstanding requirement from the last inspection. Risk assessments must be developed, completed with service users upon admission and reviewed as needed. Particular attention must be given to issues of violence and aggression. This is an outstanding requirement from the last inspection. Service users must have an annual 7-day holiday included as part of the basic contract price. This is an outstanding requirement from the last inspection. Service users nutritional needs are assessed and any action is recorded in their care plan. This is an outstanding requirement from the last inspection. The complaints policy must be updated and state that the CSCI can be contacted at any time of the process. This is an outstanding requirement from the last inspection. The homes whistle blowing and adult protection procedures must be updated. Staff must sign to state they have read and understood the procedures. 07/09/05 07/09/05 01/01/05 07/09/05 01/10/05 01/11/05 & 30/08/05 McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 21 12. 24 16,17 13. 14. 34 35 19 19 15. 16. 36 39 19 17 17. 39 17,24,36 This is an outstanding requirement from the last inspection. Incidents must be recorded in the accident book appropriately. Regulation 37 reports of notifiable incidents must be sent to the Commission. The home must implement a planned maintenance and renewal programme covering the fabric and decoration of the property including dates for further building work to be undertaken. A copy must be submitted to the Commission. This is an outstanding requirement from the last inspection. All staff must have a police record check (CRB & POVA) and 2 satisfactory references. All needs identified through individual training plans must be met. Copies of qualifications must be kept on file. Supervision must be provided at least 6 times a year with an annual appraisal. The furniture and fittings in bedrooms must meet the minimum Standards unless not required by the service users or there is a health and safety issue. This is an outstanding requirement from the last inspection. Quality assurance procedures need to be implemented and systems used to obtain and record the opinions of the service users, friends, relatives, visitors and others. This is an outstanding requirement from the last 01/10/05 30/08/05 01/01/06 30/08/05 01/12/05 01/12/05 McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 22 inspection. 18. 40 12,17,18 All policies as listed in Appendix 2 of the standards are implemented and reviewed. These should be signed and dated by the manager and by all staff once they have read and understood them. This is an outstanding requirement from the last inspection. 01/02/06 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 Good Practice Recommendations McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill B62 8DA 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 McLaren House E55 S4784 Unannounced McLaren V247264 300805 Stage 4.doc Version 1.40 Page 24 - 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. 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