Inspection on 19/12/05 for 218 Stourbridge Road

This inspection was carried out on 19th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

218 Stourbridge Road 05/02/07

218 Stourbridge Road 04/08/05

218 Stourbridge Road 17/03/05

218 Stourbridge Road 14/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Stourbridge Road, 218 218 Stourbridge Road Bromsgrove Worcs B61 0BJ Lead Inspector D Lewis Unannounced Inspection 19th December 2005 4:30 Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stourbridge Road, 218 Address 218 Stourbridge Road Bromsgrove Worcs B61 0BJ 01527 579611 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) Worcestershire Mental Health Partnership NHS Trust Mr Wayne Stanley Casey Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: 218 Stourbridge Road is a traditional detached house approximately one and one half miles from Bromsgrove town centre, providing a home for up to five people with mental health needs. There is easy access to public transport and the town centre, including the Bromsgrove Mental Health Resource Centre. The home includes ground floor bedroom and bathroom facilities. Service users have their own furnished bedrooms with two lounges (one where smoking is allowed), a dining room and kitchen shared by the household. The home aims to provide a homely environment promoting independence and dignity. Service users receive care and support to live as ordinary a life as possible in the community. The manager, Wayne Casey, had begun working in the home at the end of January 2005, and was registered in June 2005. The registered provider is the Worcestershire Mental Health Partnership NHS Trust. The responsible individual is Ms Ann Bennington. The Trust has been the registered provider since July 2004. Before this date, they were the staffing provider only. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For a more complete picture of the home, this report should be read together with the report of the last inspection when other standards were assessed. This routine unannounced inspection took place on a Monday in the late afternoon and evening, over 2¾ hours. The aim was to follow up progress since the last inspection and to see what the home was like during the evening, with most people at home. The inspector met the 4 service users who were in the home, and 2 staff members. One person was celebrating his birthday and had a cake which was shared. There was a comfortable friendly atmosphere in the home. What the service does well: What has improved since the last inspection? What they could do better: The Trust has not given contracts to the people living in the home. A bathroom has been scruffy, with a shower that does not work, for a long time. The home needs to find a suitable way of regularly consulting service users and others (e.g. family) about the service provided by the home. The manager and the Trust must ensure that health and safety checks are done regularly. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 6 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. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 The written information about the home had not yet been updated to include a sample contract / terms and conditions. The Worcestershire Mental Health Partnership NHS Trust had not provided contracts to the service users. EVIDENCE: The inspector saw copies of the statement of purpose and service users’ guide, which had not been updated with contract / terms & conditions or service user views. The inspector was told that the Trust had still not issued contracts to service users, despite having been responsible for provision of care for nearly 18 months. This meant that there was ongoing lack of clarity for service users as to their rights and responsibilities, which could potentially cause significant difficulties. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Service user plans were in place and service users were involved with them. EVIDENCE: Service user plans sampled were suitable, and a detailed plan had been put in place for a service user with diabetes. A service user said he was very involved with his own service user plans. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Food was mainly chosen by service users, was suitably healthy and was enjoyed by service users. EVIDENCE: The inspector saw records of food, which indicated a variety of meals, with a suitably healthy diet. Service users each chose a meal every week, thus providing variety and choice. Options were available if there was a meal which someone disliked, although this was not usually an issue. One service user cooked for the household on a weekly basis and others were involved to varying degrees with food shopping and cooking. There was a Christmas menu on display, and one service user had a birthday cake which he was sharing with staff and other service users. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication was being generally well managed. The inspector advised some improvements. EVIDENCE: (Standard 19 – it was noted that a care plan had been put in place for management of one person’s diabetes) The inspector saw medication records, including assessments for selfmedication, and checked the medication cupboard. All seen was mostly fine, except for 2 missed antibiotics with no explanation on the chart (although staff explained the reasons for missing the doses) and a couple of non-medication items stored in the medication cupboard. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 12 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): 22 Service users were confident that their views and concerns were listened to. EVIDENCE: The complaints procedure was satisfactory and service users said they would be happy to talk to staff if thay had any concerns. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 13 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 The home had sufficient space, and was warm, clean, comfortable and homely. One bathroom was shabby and needed refurbishment. The garden did not have a boundary, so had an institutional atmosphere. EVIDENCE: The inspector saw most of the shared areas of the home, which were warm, clean, well maintained and free from odour. There was a separate smoking lounge. Work to address fire safety requirements had now been done. During the last inspection it was noted that one bathroom had an out-of-order shower and was shabby, with missing tiles and no hand-towel holder and no blind on the window. The home was on an open plan site shared with other healthcare facilities, and the garden was open plan, which detracted from the “homely” feeling. No changes had been made to these aspects of the home. One service user had told the inspector on a previous visit that the home was very cold in the winter. The problem had been rectified and the home was warm during this visit, which was on a cold winter evening. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 14 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): 33 Staff levels were acceptable. EVIDENCE: There were sufficient staff on duty. The inspector was told that extra staff were provided on evenings when service users had an activity planned outside the home. One service user said they would feel more secure with an extra staff member on duty overnight, in case of emergency. Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 15 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): 39 Quality assurance was still in the development stage, though a consultation exercise had been done. Service users felt staff listened to their ideas. EVIDENCE: A quality assurance consultation exercise had been carried out but with limited response from people consulted, so was to be reviewed. Service users confirmed they had weekly meetings, where they were invited to air any concerns or make positive suggestions. A suggestion to go to the cinema regularly had been acted on by staff. (Standard 42 - the inspector did not find evidence in the home of legionella testing since 2003.) Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 16 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 2 2 X 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 2 X X X X Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 17 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 YA1 Regulation 4 Requirement The statement of purpose must be amended so that it includes all the information detailed in regulation 4 and schedule 1. (Specifically, it needs to include the homes terms and conditions.) (Previous timescales of 30.6.04, 31.3.05 and 31.10.05 not met) 2 YA1 5 A Service User’s Guide, which includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service users and their families.(Specifically it needs to include service users’ views on the home and a standard contract.) (Previous timescales of 30.6.04 31.3.05 and 31.10.05 not met.) Service users must be provided with contracts which met the requirements of standard 5. (Previous timescales of 30.6.04, Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 18 Timescale for action 31/03/06 31/03/06 3 YA5 5 31/03/06 31.3.05 and 31.10.05 not met.) 4 YA24 23 Necessary maintenance and refurbishment must be carried out on the bathroom next to the upstairs office. (Previous timescale of 31/12/05 not met.) The registered manager must prepare a training matrix for staff, showing what training they have already done, and what further training is needed. A copy of this should be provided to the Commission. (Previous timescale of 31/10/05 not met.) A staff training and development programme must be put in place, to ensure that all members of staff receive foundation training to National Training Organisation specification within 6 months of appointment to their posts. (Previous timescale of 31/10/05 not met.) The draft quality assurance system must be implemented. (Previous timescale of 31/10/05 not met.) The registered provider must ensure that the required safety precautions for prevention of legionella are carried out, and the evidence is available in the home. (Previous timescale of 30/09/05 not met.) 31/03/06 5 YA35 18 31/03/06 6 YA35 18 31/03/06 7 YA39 24 31/03/06 8 YA42 13 31/03/06 Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 19 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 YA28 Good Practice Recommendations The registered provider should consider a way of marking the gardens boundary to make it more domestic and less institutional. (Carried forward from January 2005) If any dose of medication is missed, the reason for this should be clearly recorded on the MAR chart (medication administration record). Non-medication items should not be stored in the medication cabinet. 2 3 YA20 YA20 Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stourbridge Road, 218 DS0000061839.V274544.R01.S.doc Version 5.1 Page 21 - 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. 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