Inspection on 28/02/07 for South Street Residential Home

This inspection was carried out on 28th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South Street Residential Home 31/01/06

South Street Residential Home 23/06/05

South Street Residential Home 16/02/05

South Street Residential Home 17/08/04

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 09/07/2008.

CARE HOME ADULTS 18-65 South Street Residential Home 17 South Street Palfrey Walsall West Midlands WS1 4HE Lead Inspector Lesley Webb Key Unannounced Inspection 28th February 2007 08:30 South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 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 South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 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. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Street Residential Home Address 17 South Street Palfrey Walsall West Midlands WS1 4HE 01922 642057 01922 642057 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) www.mencap.org.uk Royal Mencap Society Accord Housing Association Limited Care Home 9 Category(ies) of Learning disability (9) registration, with number of places South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31 January 2006. Brief Description of the Service: 17 South Street is a residential home for up to nine adults with a learning disability. Accord Housing Association owns the premises and the service is run/managed by MENCAP. It is located in the Palfrey area of Walsall and is within easy reach of the town centre. There are also a number of local shops within walking distance, as are a number of community facilities and places of worship. The home is well maintained both internally and externally and blends in well with the surrounding properties. The home has a large back garden and offers car parking space for visitors to the front. It has nine singe bedrooms and a number of bathrooms, showers and toilets. There is one lounge, kitchen and dining area, and a laundry on the ground floor. The ethos for the home is to actively promote the maximum degree of each individual, to enable full access into the community whilst maintaining and building selfesteem. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. The process included analysis of pre-inspection documentation supplied by the home and examination of records required to be held under The Care Home Regulations 2001. Information supplied by the home states that fees range from £422.29 to £793.73 (including direct contributions from service users). In addition to this time was spent talking to service users, indirectly observing interactions between staff and service users, talking to staff and looking at records. At the end of the inspection the acting manager was given feedback on the findings of the visit. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking two individuals care provided at the home. No relatives of service users were available to talk to during the inspection. The inspector would like to thank service users, management and staff for their co-operation and assistance. The discussions and atmosphere through out the inspection was constructive and those involved interacted positively as part of the process. What the service does well: Six service user questionnaires were received by the CSCI prior to the inspection, all state they were asked if they wanted to move into the home and five confirmed they received enough information about the home so they could decide if it was right for them. Additional comments include ‘I came to visit’ and ‘I looked at different homes, I liked this one’. As in previous inspections the inspector found an abundance of evidence that service users are supported to make decisions and are encouraged to participate in many aspects of the home. For example service user meetings occur monthly with discussions including activities, the environment, meals, privacy, jobs around the home, complains procedures and fire evacuation systems. The home should be congratulated for its efforts to promote independent living skills. One service user was observed in laundry room sorting and putting laundry in the washing machine and dryer. Pictures are displayed on the laundry walls as aids to help service users with equipment. This person explained that she enjoyed doing this task, explaining “this is my training day, I did the potatoes the other week, I do lots of jobs around the house and clean my own bedroom”. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 6 As in previous inspections an abundance of evidence was found that service users lead full and active lives. Service users expressed pleasure with the activities in place, with one person showing a photo album and explaining about the different activities and trips he had been on since the last inspection. This same person also showed trophies that he had won playing snooker. Another service user explained that he was still with his girlfriend and showed the inspector ornament he had brought that he was taking to the centre to give to her. The atmosphere within the home is very relaxed and welcoming with an abundance of evidence that indicates relatives and friends of service users are embraced by the home, with service users supported to maintain contact as per their wishes. The inspector was invited to have lunch with the service users. The atmosphere was very relaxed and informal, with staff sitting and eating lunch with service users. Lunch was presented in separate dishes in order that service users can choose what items they want and how much. As in previous inspections staff have excellent knowledge of the personal care needs of service users and observation of practices confirm the principles of respect, dignity and privacy are put into practice. Staff were observed knocking on doors before entering toilets, bathrooms and bedrooms and talking to people in a friendly yet respectful way. Six service user questionnaires received by the CSCI prior to the inspection state they know who to speak to if not happy and know about the complaints procedure. Service users knowledge of the complaints procedure was reinforced during the inspection when one service user informed the inspector that he had put a complaint in. As he explained, “about (mentioned another service user) calling me names at the weekend. Barbara (the acting manager) is helping me to sort it.” At this unannounced inspection South Street was again found to be comfortable, well maintained and clean. There were no offensive odours and the premises offer adequate light and ventilation. The home continues to offer a good standard of furnishings and fittings and is well decorated. Staff in this home are trained, skilled and generally in sufficient numbers to support the people who live here. All six service user questionnaires received by the CSCI state staff always treat them well and listen and act on what they say. Additional comments of ‘I go out with staff’ and ‘the staff are all right’ and ‘they are good people, they look after us’ were also recorded. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: A previous requirement that the home must comply with its own written policies and procedures and service users terms and conditions of residency and provide a minimum 7-day annual holiday remains unmet. The acting manager explained that Mencap provide staff and pay their wages but that service users are still paying for themselves. She also explained that it is Mencaps view that the word ‘provide’ means to arrange and provide staff support but not to fund service users. The inspector examined Mencaps written policy relating to holidays and found it still states ‘costs for service users minimum 7 day annual holiday will be met from the services budget’. Service users statement of main terms and conditions also states ‘a charge of £… is payable by the service user per week as a contribution towards the accommodation, care, food, drink, heating, lighting, laundry and other staff services. The cost also includes for the option of a 7 day annual holiday outside of the home’. In neither of these documents does it state that service user must make a contribution or pay for their holiday. The inspector instructed that Mencap seek legal advice regarding its written policy, the service users terms and conditions and the homes current practices and forward the findings to the CSCI. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 8 Infection control measures in the bathing facilities must be improved to ensure people’s health is not compromised. When touring the premises the inspector was concerned to find a mould like substance in both the downstairs shower room and the upstairs bathroom. This was covering an emergency call lead, in grouting and around the shower base. The home was instructed to seek advice from an infection control advisor and implement any recommendations. 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. The summary of this inspection report can be made available in other formats on request. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 9 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 South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people considering this home have the information needed to decide on its suitability to meet their needs. Admissions policies and procedures, if put into practice will ensure the home can be confident of meeting the needs of individuals. EVIDENCE: Through observations of care practices, discussions with service users and staff and a review of documentation it can be confirmed that as in previous inspections, the home is meeting the assessed needs of service users accommodated there. South Street Residential Home offers long-term placements for people with learning disabilities. The homes certificate of registration accurately reflects the primary care needs of those accommodated. Services offered reflect current good practice and relevant legislation. The acting manager explained that the service user guide and statement of purpose are in the process of being produced in alternative formats including Hindu and Makaton. As she explained, no one currently residing at the home require these documents in these formats, but the home is located in a diverse area where they might be required at some time in the future. In addition to South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 11 this they are also going to be produced on tape and CD. The inspector was shown the service user guide that has been reviewed and now includes the use of photographs, large print and symbols. It is recommended that further detail be included regarding what facilities are included in the fees charged and what are excluded. There have been no new admissions to the home in recent years, however when discussing admission processes with the acting manager she demonstrated understanding of her responsibilities in relation to assessing prospective service users and compatibility of those already living at the home. Admissions and selection policies were examined and found to be detailed. Procedures include consideration of prospective applicants, gathering information, completing of a full needs assessment, being confident of meeting needs, introductory visits and monitoring and view. There has been a vacant room at the home for a number of years with Mencap making the decision not to fill this due to staffing levels and the current needs of people already living at the home. The Commission for Social Care Inspection (CSCI) has been informed that Mencap is now considering filling this bed space. If this is to occur staffing levels must increase (see standard 33 of this report) and the home must ensure compatibility with others already residing there. Six service user questionnaires were received by the CSCI prior to the inspection, all state they were asked if they wanted to move into the home and five confirmed they received enough information about the home so they could decide if it was right for them. Additional comments include ‘I came to visit’ and ‘I looked at different homes, I liked this one’. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: Since the last inspection there has been a major improvement in the format and content of care plans. The new formats are person centred, giving detailed information specific to each person, include goals and aspirations. They also include a break down of tasks in order that staff have sufficient information in order to meet the needs of service users. The use of photographs and different coloured ink make the new plans far more accessible to service users and evidences their involvement in their compilation. Plans in place include those for communication, personal care, community access, nutrition, health and independent living skills. All files sampled contained evidence that plans are reviewed on a regular basis by staff at the home and that risk assessments are in place that support the contents of each plan of South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 13 care. It is recommended that the new person centred plans continue to be developed and implemented. As in previous inspections the inspector found an abundance of evidence that service users are supported to make decisions and are encouraged to participate in many aspects of the home. For example service user meetings occur monthly with discussions including activities, the environment, meals, privacy, jobs around the home, complains procedures and fire evacuation systems. It was noted that since January 2007 the format for recording these meetings has improved, with records now evidencing action taken to address issues raised. The minutes of these are also now available in tape format. All six service user questionnaires received by the CSCI confirm that service users can make decisions about what they do each day and can do what they want during the day, evening and weekend. Throughout the visit the inspector witnessed staff involving and supporting service users to make decisions in a range of areas including choice of clothes, meals, transport and activities. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Apart from the provision of holidays, social, educational, cultural and recreational activities are provided in line with service users terms and conditions of residency. Service users are able to make choices about the lifestyle and supported to develop their life skills. EVIDENCE: The home should be congratulated for its efforts to promote independent living skills. One service user was observed in laundry room sorting and putting laundry in the washing machine and dryer. Pictures are displayed on the laundry walls as aids to help service users with equipment. This person explained that she enjoyed doing this task, explaining “this is my training day, I did the potatoes the other week, I do lots of jobs around the house and clean my own bedroom”. Another service user was observed putting a disposable apron on and explained today it was his job to clean the toilet floor. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 15 As in previous inspections an abundance of evidence was found that service users lead full and active lives. The majority of service users attend both colleges and other educational placements on a daily basis where they participate in a variety of activities including cooking, pottery, computer skills and communication. In addition to this service users make full use of local community activities. These include pubs, clubs, restaurants, cinema, theatre and local shopping complexes. Staff arrange transport for service users such as the Ring and Ride and local taxis companies, while other service users use local buses. Service users expressed pleasure with the activities in place, with one person showing a photo album and explaining about the different activities and trips he had been on since the last inspection. This same person also showed trophies that he had won playing snooker. Another service user explained that he was still with his girlfriend and showed the inspector ornament he had brought that he was taking to the centre to give to her. Six service user questionnaires were received by the CSCI, all stating they are happy with the activities provided. A previous requirement that the home must comply with its own written policies and procedures and service users terms and conditions of residency and provide a minimum 7day annual holiday outside of the home, which they help to choose and plan, remains unmet. The acting manager explained that Mencap provide staff and pay their wages but that service users are still paying for themselves. She also explained that it is Mencaps view that the word ‘provide’ means to arrange and provide staff support but not to fund service users. The inspector examined Mencaps written policy relating to holidays and found it still states ‘costs for service users minimum 7 day annual holiday will be met from the services budget’. Service users statement of main terms and conditions also states ‘a charge of £… is payable by the service user per week as a contribution towards the accommodation, care, food, drink, heating, lighting, laundry and other staff services. The cost also includes for the option of a 7 day annual holiday outside of the home’. In neither of these documents does it state that service user must make a contribution or pay for their holiday. The inspector instructed that Mencap seek legal advice regarding its written policy, the service users terms and conditions and the homes current practices and forward the findings to the CSCI. Also as in previous inspections the atmosphere within the home is very relaxed and welcoming with an abundance of evidence that indicates relatives and friends of service users are embraced by the home, with service users supported to maintain contact as per their wishes. Six service user questionnaires were received by the CSCI, with comments including, ‘I go out with my boyfriend’ and ‘I go out with my mom’. All three requirements identified in the previous inspection relating to relationships have now been met. Care plans have been introduced that support service users in personal relationships, risk assessments have been completed and professional counselling has been provided by the community nurse for individuals in personal relationships. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 16 The inspector was invited to have lunch with the service users. The atmosphere was very relaxed and informal, with staff sitting and eating lunch with service users. Lunch was presented in separate dishes in order that service users can choose what items they want and how much. Records confirm that service users at South Street continue to be offered a variety of meals based on their likes/dislikes. Regular meals, snacks and hot/cold drinks are available. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: As in previous inspections staff have excellent knowledge of the personal care needs of service users and observation of practices confirm the principles of respect, dignity and privacy are put into practice. Staff were observed knocking on doors before entering toilets, bathrooms and bedrooms and talking to people in a friendly yet respectful way. Service users have access to a telephone, are spoken to using a preferred term of address, (which is documented) and arrangements are in place to ensure personal clothing and laundry is returned to its owner. Information supplied to CSCI prior to the inspection states that support services such as general practitioners; district nurses, occupational therapists and dieticians are obtained via a referral system. Also that regular dentist reviews take place, appointments with opticians and chiropodists occur and South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 18 that people have regular health screening as per their needs. Records maintained on the two service users files sampled confirm this information to be true. Person centred health plans are in place. Examination of these found that the contents varied. It is recommended that health action plans be completed in full for everyone. A previous requirement to ensure everyone is offered hearing tests is now met. During the inspection service users were observed preparing for health treatment. One service user explained that she had to go for a blood test this morning, saying, “I don’t like needles”. The member of staff explained why this was needed and the service user said, “I know I need it done to keep me healthy, staff have explained this to me”. Another service user explained, “We are going to the dentist, got to have a filling. I go every six months”. Procedures and practices with the home in relation to medicines and controlled drugs were found to be good with no requirements identified. Medication in the custody of the home is handled according to the requirements of legislation and records are available, of medicines received, administered and leaving the home. It is recommended that a record be maintained of what part of the body creams need to be applied. A previous requirement to assess service users capabilities to self medicate based on individuals abilities and introduce programmes to support people based on those abilities is now met. Three service users now self medicate, all at varying levels. The home should be congratulated for its efforts in this area. The acting manager recognises that risks are involved but that these can be managed whilst promoting a person centred approach in this area. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home are able to express their concerns, and have access to a robust, effective complaints procedure. People living at this home are protected from abuse. EVIDENCE: The complaint procedure is displayed on a notice board, discussed in service user meetings and was also in all service user files sampled (in an alternative format). A book has been introduced (June 2006) where minor complaints are recorded. Examination of this found twenty-nine recorded events (twenty five involving one named service user). The inspector congratulated the home for introducing this forum, explaining that the amount of recordings evidence that service users feel happy to use this to raise issues. The home was however instructed to expand the records maintained in this book in order to evidence action taken for all issues raised. Six service user questionnaires received by the CSCI prior to the inspection state they know who to speak to if not happy and know about the complaints procedure. Service users knowledge of the complaints procedure was reinforced during the inspection when one service user informed the inspector that he had put a complaint in. As he explained, “about (mentioned another service user) calling me names at the weekend. Barbara (the acting manager) is helping me to sort it.” The inspector examined a sample of protection policies and procedures (physical intervention, adult protection and whistle blowing), finding all to be appropriate. Also records and systems for the management of service users South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 20 finances are good, offering protection to those living at the home. Individual allowance sheets are maintained along with receipts for all transactions. Financial support plans are also in place that are detailed and informative. These support individuals living at the home to manage finances based on needs and capabilities. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who live there to live in a safe and comfortable environment. Attention must be given to infection control measures in the bathing facilities to ensure people’s health is not compromised. EVIDENCE: At this unannounced inspection South Street was again found to be comfortable, well maintained and clean. There were no offensive odours and the premises offer adequate light and ventilation. The home continues to offer a good standard of furnishings and fittings and is well decorated. The premises are in keeping with the local community, and offers access to local amenities and transport. All seven requirements identified in previous inspections are now met in full. For example the water damage to the ceiling on the first floor has received attention, the broken toilet has been replaced, the broken door lock on the downstairs bathroom and the torn suite replaced. The downstairs office is currently being converted to a bedroom with en-suite facilities to meet the needs of a service user who as lived at the home for South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 22 several years and whose mobility is deteriorating. Two service users invited the inspector to view their bedrooms. Both were found to be individually decorated with an abundance of personal items. Service users were observed using their own keys to lock bedroom doors when leaving room. One service user explained that their room was recently decorated and furnished, stating, “chose paper myself, and furniture, lovely isn’t it”. Laundry facilities are appropriate and are sited in a separate area designated for the purpose. Equipment provided ensures foul laundry is washed at appropriate temperatures, and the washing machine has a sluicing facility. Laundry facilities do not intrude on resident’s routines, and walls and floors are readily cleanable. Since the last inspection all staff have undertaken infection control training, meeting a previous requirement. When touring the premises the inspector was concerned to find a mould like substance in both the downstairs shower room and the upstairs bathroom. This was covering an emergency call lead, in grouting and around the shower base. The home was instructed to seek advice from an infection control advisor and implement any recommendations. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff in this home are trained, skilled and generally in sufficient numbers to support the people who live here. EVIDENCE: Observations of interactions between service users and staff, discussions with service users and staff confirm that excellent relationships continue to be developed. All six service user questionnaires received by the CSCI state staff always treat them well and listen and act on what they say. Additional comments of ‘I go out with staff’ and ‘the staff are all right’ and ‘they are good people, they look after us’ were also recorded. The home operates at staffing levels of two staff of a morning and afternoon and a person who sleeps in during the night. The acting manager explained that on some days staffing is reduced or increased depending on the amount of service users at home. The home does not employ separate kitchen of domestic staff, with staff and service users undertaking these duties. Staffing hours were discussed with the inspector stressing that the current staffing hours are the minimum that the home can be operated on. As mentioned South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 24 earlier in this report the home is considering filing a bed space that has been vacant for several years. If this should occur the staffing levels must be reviewed and increased. Currently the acting manager attempts to ensure at least twenty-five management hours are completed per week. Examination of staffing rotas found that hours undertaken by the acting manager are not currently recorded in sufficient detail. The inspector explained that both care and management hours must be clearly recorded on the rota as per the Care Home Regulations 2001 Recruitment procedures and documentation are good, ensuring the protection of service users. All of the staff files sampled contained the required documentation as listed in the Care Homes Regulations 2001. Since the last inspection the home has ceased using agency staff and therefore a requirement relating to agency staff recruitment documentation is no longer applicable. Staff training is excellent. A training and development plan and individuals training needs analysis are now in place (meeting previous requirements). Training documentation evidences that all but one person hold up to date certificates for protection from abuse, food hygiene and fire and that all staff employed at the home hold up to date certificates for aggression, risk assessment, medication, moving and handling, health and safety and first aid. Other certificates in place on files sampled include evidence of training in diversity, person centred approaches, dementia and learning disabilities and aspects of ageing for people with learning disabilities. The home should be commended for efforts in relation to staff holding a national vocational qualification. 100 of the staff have achieved this qualification. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. Effective quality assurance systems are in place ensuring the home can meet its aims and objectives. EVIDENCE: Discussions and observations confirm that the home is being managed appropriately. The acting manager is aware of areas that require improving, with evidence that action is taken within appropriate timescales to address deficits. The acting manager, Ms Barbara Onions has been in post since April 2006 and was offered this position on a permanent basis September 2006. She has obtained registration documentation and will be making an application for registration shortly. When asked about her experience and qualifications South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 26 she explained that she holds a national vocation qualification level 3 and about to enrol on level 4 in care. Other training she has completed includes rota management, diversity, supervision and support planning. In relation to experience she states over ten years experience overall in supervisory and management positions. All five previous requirements relating to quality assurance are now met. For example there is now a continuous improvement plan in place that is reviewed every three months, the results of service user surveys and questionnaires are now results linked to the Service Review and the views of families, friends, advocates and stakeholders in the community are also included in the annual Service Review. Quality monitoring includes monthly audits of performance, incident and accident reporting, satisfaction surveys, staff and service user meetings, newsletters and bulletins and the reviewing of the continuous improvement plan. When examining the results of satisfaction surveys the inspector found additional comments of praise such as ‘we have been very impressed with the letters …….has written and the efforts she has made to keep in contact with her family’. The continuous improvement plan for December 06 to March 07 details 24 aims relating to service users, practices, staff and the environment that have been identified from CSCI, service users, Mencap and management. It is recommended that a record be maintained when each aim has been achieved. As mentioned throughout this report there have been many improvements in relation to record keeping since the last inspection, with all those required by regulation now in place. The management of health and safety is excellent in this home. Information supplied to CSCI prior to the inspection states that the fire equipment was checked 16/01/07, the last fire drill took place 18/12/06, gas was serviced 04/04/06, a legionella assessment was completed 02/10/06, an electrical wiring certificate was issued 07/07/06 and emergency lighting tested 05/02/07. Appropriate numbers of staff hold certificates in fire, first aid, food hygiene and moving and handling. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 4 33 2 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 2 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 X 3 3 4 3 X 4 X South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 28 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 YA14 Regulation 5, 13(6) 16(2) Requirement The home must comply with its own written policies and procedures and service users terms and conditions of residency and provide a minimum 7-day annual holiday outside of the home, which they help to choose and plan –not met. Requirement originally made January 2006. Timescale for action 30/04/07 2 YA22 22 3 YA30 13(3) The registered provider must seek legal advice regarding its written policy for holidays, the service users terms and conditions of residency and the homes current practices of instructing that service users fund their holiday. The findings must be forwarded to the CSCI. The home must maintain 05/03/07 comprehensive records of investigations, actions and outcomes for all issues raised by service users. The home must seek advice from 30/04/07 an infection control advisor for the mould in both bathrooms and implement any recommendations made. DS0000020838.V330740.R01.S.doc Version 5.2 Page 29 South Street Residential Home 4 YA33 Sch 4(7) All hours undertaken by the acting manager must be clearly recorded on the staff rota. The record must clearly identify in what capacity hours are undertaken e.g. care/management. 05/03/07 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 5 Refer to Standard YA1 YA6 YA19 YA20 YA39 Good Practice Recommendations That information relating to fee, what is included and what is not is expanded in the statement of purpose and service user guide. That the new person centred plans continue to be developed and implemented. That health action plans be completed in full for everyone. That a record be maintained of what part of the body creams need to be applied. That a record be maintained when each aim in the continuous improvement plan has been achieved. South Street Residential Home DS0000020838.V330740.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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