Inspection on 04/08/05 for 218 Stourbridge Road

This inspection was carried out on 4th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

218 Stourbridge Road 05/02/07

218 Stourbridge Road 19/12/05

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 18-65 218 Stourbridge Road 218 Stourbridge Road Bromsgrove Worcestershire B61 0BJ Lead Inspector Debra Lewis Announced 4 August 2005 11:00 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. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 218 Stourbridge Road Address 218 Stourbridge Road Bromsgrove Worcestershire B61 0BJ 01527 579611 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) Worcestershire Mental Health Partnership NHS Trust Mr Wayne Stanley Casey Care Home 5 Category(ies) of MD Mental Disorder - 5 registration, with number of places 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration other than those referred to on the previous page. Date of last inspection 17 March 2005 Brief Description of the Service: 218 Stourbridge Road is a traditional detached house located 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. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 ½ hours on a Thursday. The aim was to look at what progress the home had made since the last inspection, when they had been asked to make significant changes. The inspector met with the registered manager, with some care staff and with 3 service users. The inspector also checked records, care plans and policies. The home had 5 service users and no vacancies. What the service does well: What has improved since the last inspection? Much had improved since the last inspection. There were now enough staff to help service users with leisure activities. Staff were helping service users to think about trying different activities, not just day centres. People’s medication was being kept safely. It was now clear how people could make a complaint. Staff were now aware of how to help protect the service users from abuse. The home was starting to regularly ask service users what they thought of the home. Staff employment records were now kept in the home. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 6 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. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5 Most, but not all, required information was available to prospective service users. Service users still did not have contracts. EVIDENCE: The inspector was given copies of the revised statement of purpose and service users’ guide. Both almost met the standard, but the statement of purpose did not include a statement of terms and conditions (currently unavailable from the Trust), clear aims and objectives, or details of the room sizes. The service users’ guide did not include service users’ views on the home (not yet collated as part of the developing quality assurance system), or a standard contract (currently unavailable from the Trust). The home was full and there had been no new service users since the last inspection. The Trust had not yet provided service users with a contract. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Service user plans contained most of the necessary information about their assessed needs and goals. Service users normally managed their own money, and made their own decisions e.g. about social activities, food choices. Service users were supported to take ordinary risks such as going out unaccompanied, and were given suitable training or advice to help them manage risks. EVIDENCE: The inspector sampled service user files and found they contained a comprehensive collection of information, including assessment of needs, goals, social activities records, individualised risk assessments, as well as ongoing care plans. There were signed forms where service users chose to manage their own money. Restrictions, e.g. managing money and cigarettes, were agreed and recorded. The inspector advised that a full care plan for managing one person’s diabetes was needed, which should include details of frequency of checks and of the required diet. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 10 Service users confirmed that they managed their own money, went out alone and made every day choices and decisions. It was also seen how decisions had been made (e.g. where to go on holiday) by service users, facilitated by staff. Risk assessments included information about giving road safety training, and giving other advice relevant to risks taken. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 11 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) 12, 13, 14, 15 and 16 Service users were beginning to consider undertaking training courses, when they felt able to do so, as well as taking part in more community activities and leisure activities. Visitors were welcome and family contacts supported. Service users were respected in their daily lives. EVIDENCE: Staff had begun working with service users to look into possibilities for further education, training or voluntary work, but were being careful not to “overload” people with too much change at one time, so this was an ongoing process. Along the same lines, staff were beginning to gradually help service users to find alternative activities in the community, to replace their current regular dependence on specialist day centres. The home had much improved staffing levels, including sometimes 2 staff on duty during the evening (although only till 7.30pm unless a specific activity was planned). This enabled staff to accompany service users on leisure 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 12 activities of their choice, e.g. going out for meal or to a cinema. Key workers had been focussing on finding out more about service users’ preferences for leisure. A holiday was planned for 2 service users (paid for from other budget surplus, as the placing authority’s payments did not include provision for holidays). The other service users did not wish to accompany them. The home was now keeping records of leisure activities for each service user, which was good practice. Service users were taking part in new activities, such as aquaaerobics and visiting the cinema for the first time. Regular weekly film nights were being held in the home. The inspector heard from service users and saw letters to relatives confirming that visitors were welcome and family contacts supported. Service users were treated with respect by staff, called by their preferred name, had freedom of movement and access, were clear about their responsibility for household tasks and about rules on smoking. One service user had a pet cat which he cared for himself. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Personal support, physical and emotional healthcare needs were mainly being met, although not all details of care for someone with diabetes were recorded. One service user took care of his own medication and others did so in part. The registered manager was intending to do further work to see if some people could take more control themselves. EVIDENCE: Service user plans included detailed plans for supporting service users with personal care, physical health and emotional well being, although there were not full details for diabetes care. There were records of medical appointments, including psychiatric input. The inspector saw risk assessments for service users who held (partially or completely) their own medication. Service users showed the inspector locked storage where they kept the medication and discussed how they felt about managing their own medication. The inspector saw service user signed consent to take, or manage themselves. The inspector did not check on medication managed by staff on this visit, but it had been satisfactory on the previous unannounced inspection in March. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home had a suitable complaints procedure. The procedure had been provided to service users and relatives, and service users felt able to raise concerns. There was a suitable policy on protection from abuse. Almost all staff had received training on this. EVIDENCE: The inspector saw the revised complaints procedure. Service user files included copies of letters to service users and relatives, setting out the complaints procedure. Service users said they would feel comfortable with telling staff about any concerns they had. The inspector saw the policy for protection from abuse. All staff except the registered manager (who was on a waiting list) had attended training in this subject. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The home had sufficient space, and was clean, comfortable and homely. One bathroom was shabby and needed refurbishment. The garden did not have a boundary, so had an institutional atmosphere. The inspector was told the home was cold in the winter; this was due to be partly addressed. EVIDENCE: The inspector saw most of the shared areas of the home, which were clean, well maintained and free from odour. There was a separate smoking lounge. Work to address fire safety requirements was to begin at the end of this month. One bathroom had an out-of-order shower and was shabby, with missing tiles and no hand-towel holder. 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. One service user told the inspector the home was very cold in the winter. The registered manager confirmed that the heating did not work reliably and was not due to be repaired, but it was hoped that replacing the double-glazing would improve the situation. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 16 There were signed forms in service user files, in which service users had said they did not want all of the required items in their rooms, e.g. wash hand basins. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 17 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) 33, 34, 35 and 36 The home was fully staffed to a suitable level, but could do with more staff on duty during the evenings. Regular staff meetings were held. Staff recruitment followed good practice. Staff had access to training, but there was not a clear record or plan for the team as a whole. There was not a suitable structure for foundation training. Staff were being supervised and appraisals were being done. EVIDENCE: The inspector saw staff rotas, which showed sufficient staff on duty including during evenings and weekends, although there was one vacancy (and an inherited backlog of annual leave) so the home was less well staffed at present. The registered manager agreed that ideally there would be more than one staff member on duty later in the evening, when service users are at home. The inspector was told that staff meetings were well attended and staff felt able to participate. Staff took turns in chairing meetings and were able to contribute to the agenda, both of which are good practice. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 18 The home had one new staff member. There was evidence of all necessary pre-employment checks and procedures; the registered manager was only waiting for a photograph and a copy of her birth certificate. The inspector sampled other staff records, which were satisfactory. Staff confirmed they had copies of the GSCC code of conduct. The home had individual, but not team, training and development records and plans. They now had a suitable induction training structure, which complied with the TOPSS specification [TOPSS now called Skills for Care]. There was not yet a similar structure for foundation training. Supervision was now being done regularly and the registered manager was aiming to have completed 6 sessions fro each staff member by the end of the year. Appraisals were being done. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 37, 38, 39, 40, 41 and 42 The registered manager was experienced and was a qualified mental health nurse. He was doing his NVQ4 managers’ training, which was due to be completed by next year. He was leading the team through changes in how they work with service users. The home had begun implementation of a quality assurance system, though it was not yet fully functional. There were suitable policies and procedures. Required records were in place. Health and safety was being generally well managed, with some details to be followed up by the registered manager with the Trust. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 20 EVIDENCE: The registered manager was suitably experienced and was a qualified mental health nurse. He was doing his NVQ4 managers’ training, which was due to be completed by early next year. He had revised various practices in the home and was leading the team in giving further consideration to how working practices affect service users. He had introduced ways of consulting service users (e.g. a suggestion box in addition to regular service user meetings), and was committed to obtaining staff training in equal opportunities / antidiscriminatory practice. Staff were becoming more involved in the home, e.g. becoming fire wardens, and this was welcomed. The home had developed a draft quality assurance system, shown to the inspector, and had begun using service user surveys. The home had a wide range of policies and procedures provided by the Trust. Those seen were appropriate for the home. Most records were checked and were in place. Comprehensive risk assessments were seen, for individuals and for the home generally. Testing of the water for prevention of legionella was overdue (last done in July 2003). The registered manager had alerted the Trust facilities department but as yet had no response. No other omissions re. health and safety were noted. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 1 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 218 Stourbridge Road Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 x x E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 22 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 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 and 31.3.05 not met) 2. 1 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 and 31.3.05 not met.) Service users must be provided with contracts which met the requirements of standard 5. (Previous timescales of 30.6.04 and 31.3.05 not met.) 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 23 Timescale for action 31.10.05 31.10.05 3. 5 5 31.10.05 4. 5. 6, 19 24 15 23 6. 24 23 7. 35 18 8. 35 18 9. 10. 39 42 24 13 A detailed care plan must be put in place for the management of a service users diabetes. Necessary maintenance and refurbishment must be carried out on the bathroom next to the upstairs office. The registered provider must take steps to ensure that the home will be kept acceptably warm during the winter months. 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. 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. The draft quality assurance system must be implemented. 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. 30.9.05 31.12.05 30.9.05 31.10.05 31.10.05 31.10.05 30.9.05 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. Refer to Standard 13, 33 28 Good Practice Recommendations The home should ensure that staff are regularly available in the home during the evenings, when most service users are at home. The registered provider should consider a way of marking E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 24 218 Stourbridge Road the gardens boundary to make it more domestic and less institutional. (Carried forward from January 2005) 3. 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 25 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 218 Stourbridge Road E52 S61839 218 Stourbridge Road V240786 040805.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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