Inspection on 16/02/06 for The Links

This inspection was carried out on 16th February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Links 14/03/05

The Links 30/11/04

The Links 06/03/04

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 The Links 252 The Broadway Dudley West Midlands DY1 4AP Lead Inspector Ms Linda Elsaleh Announced Inspection 16/02/06 10:30 The Links DS0000025029.V278470.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 The Links DS0000025029.V278470.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. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Links Address 252 The Broadway Dudley West Midlands DY1 4AP 01384 459651 01384 257574 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) Shaw Healthcare (Specialist Services ) Ltd Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 5 LD and up to 5 MD. Date of last inspection 05/07/05 Brief Description of the Service: The Links is owned by Shaw Healthcare (Specialist Services) Ltd. The home is situated near to Dudley town centre, and has local shops and amenities close by. It is accessible by public transport and limited off-road parking is available. The property is two semi-detached houses adapted for use as a care home for people with a learning disability, who may also have additional mental health disorders. It is centrally heated throughout and furnished to a reasonable standard. The bedrooms are situated on the first floor and there is access to toilet and bathing facilities. There are no en-suite facilities, and the home is not suitable for people with a physical disability. The communal rooms consist of lounge areas, dining room and a large conservatory, which is also the designated smoking area. A split-level garden is located at the rear of the property. A pay phone is available in the hallway for ‘residents’ use. The home provides a range of in-house and community accessed activities, and utilises various healthcare resources within the local area. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out on 16th February 2006. The purpose was to assess the home’s performance against some of the key standards in the National Minimum Standards for Care Homes for Adults (1865) and report on the progress made to address requirements made at the previous inspection. The current manager took up post in July 2005 and was registered as manager by Commission for Social Care Inspection (CSCI) in January 2006. Relevant records and documents were examined. Discussions took place with the manager, staff and some of the service users. The inspector is pleased to report the home has addressed the requirements made at the last inspection, with the exception of two that were not assessed on this occasion. Seven new requirements were made during this visit. On arrival the atmosphere within the home was relaxed and friendly. A tour of the premises found it to be clean and free of odour. Comments made by service users and relatives were positive about the service. What the service does well: What has improved since the last inspection? The home has produced an annual maintenance and redecoration programme. The work undertaken includes the repair of the garden wall at the front of the premises and the eradication of the malodour in a bedroom. Staffing levels are being monitored on a regular basis to ensure all service users needs are being met appropriately. Accredited training has been arranged for staff responsible for handling service users’ medication. Regular fire safety training programmes are being provided to all staff. An annual appraisal system has been introduced and completed for all staff. Copies of the visits made to the home under Regulation 26 of the Care Homes Regulations 2001 are forwarded to CSCI. The Links DS0000025029.V278470.R01.S.doc Version 5.1 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. The Links DS0000025029.V278470.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 The Links DS0000025029.V278470.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, 2, 3, 4 & 5 In order for prospective service users to make an informed choice about where to live the home needs information about the service it provides in suitable formats. Prospective service users’ needs are identified through the home’s comprehensive assessment procedure. The prospective service user is informed of how her/his needs will be met. Introductory visits and overnight stays are arranged to meet the prospective service user’s needs and wishes. The home must provide each service user with a suitable written contract/statement of terms & conditions. EVIDENCE: The home’s Statement of Purpose was reviewed September 2005 and the Service User Guide is in the process of being reviewed. The manager stated attention is being given to producing the Service User Guide in formats that are suitable for the people for whom the home is intended. A current copy of the Statement of Purpose and Service User Guide (once produced) is to be forwarded to Commission for Social Care Inspection (CSCI). The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 9 Examination of the records, and discussions with the manager, demonstrates that a comprehensive assessment is carried out on the needs of prospective service users. This is discussed with all relevant agencies and a detailed Service User Plan is produced. Introductory visits are arranged to meet the individual needs and wishes of prospective service users. The manager is aware of the need to review the admission criteria and assessment procedure for the home. Individual contracts/statement of terms & conditions must include the information detailed in Standard 5.2 of the National Minimum Standards for Care Homes for Adults (18-65). The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 10 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, 7, 8 & 9 Service users are aware of their assessed needs and are encouraged to identify their own personal goals. They are assisted to make informed decisions about different aspects of their lives and supported to take controlled risks within the context of their individual plans. However, where decisions are made on their behalf the home must ensure these are discussed at reviews. The home regularly consults with service users on how the home is run. EVIDENCE: Service users files contain detailed care plans and risk assessments. Where risks are identified, information is provided on how these are to be managed and/or what action is to be taken to minimise the risk. The home reviews progress made with service users on a monthly basis. Regular reviews are also held with relevant professionals and the service user’s family/ representative. The records show, that in order to protect a service user, there are occasions when their right to make some decisions and movements have been restricted. Such restrictions are only implemented following discussions and agreement with all relevant agencies/people. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 11 The records show, and discussions held with the manager and staff confirmed, that restrictions placed on at least one service user has not been discussed at the subsequent reviews. Staff have a good awareness of service users’ needs and how these are to be met. With the exception mentioned above, service users are encouraged to make their own choices. Service users who express a wish to meet with an independent advocate are assisted to do so. Regular residents’ meetings are held to enable service users to express their views on how the home is run and raise any issues of concern. Service users are provided with a questionnaire in advance of these meetings. This enables service users who lack confidence when in a group setting to express their views. An agenda is compiled for the meetings and minutes taken. The majority of service users manage their own personal allowances. The home has a system for the safe keeping of money and valuables on the service user’s behalf, if they wish. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 12 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): These standards were not fully assessed during this inspection. EVIDENCE: There were no requirements made at the last inspection and no issues of concern were brought to the attention of inspector during this visit. The Links DS0000025029.V278470.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 & 20 Support is provided to service users on an individual basis. The home has suitable systems in place to support service users to receive routine healthcare checks and arrange appointments with their individual consultants. The home manages the medication on behalf of all current service users. However, to ensure service users are suitably protected the home must review its procedure for the safe handling of medication. EVIDENCE: Service users are able to make known who they wish to assist them with their personal care. The records examined and conversations held confirm current service users require minimal assistance with personal care. Changes in the level of personal care being provided to some service users was identified by the home during the last inspection, but had not been recorded on the care plans. These changes have now been appropriately recorded and care plans revised to reflect this. Service users’ are encouraged, regardless of their mental health state and subject to any restrictions agreed, to make choices on a daily basis and to follow their own routines. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 14 Medical conditions and associated mental health needs are appropriately identified in assessments and are included in the care planning/risk management system. Records show service users healthcare needs are generally being met. Records are kept of service users’ dietary intake and their weight is monitored periodically. Service users’ medication is provided, where applicable, in a monitored dosage system (MDS) by the local pharmacist. The pharmacist visits the home on a regular basis to monitor the use of this system and provide pharmaceutical advice. Records are kept of all medicines received, administered and leaving the home. Information is held on the service users’ files about possible side affects. Risk assessments in relation to the individual’s ability to take responsibility for their own medication is also available. Team Leaders and nominated support workers who are responsible for medication are in the process of completing their training/update training. The home has addressed requirements made at a previous inspection in respect of medication. The home has recently reviewed its medication procedure, however, it has omitted to include details of action to be taken in the event of an error being made. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 15 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 & 23 The home has systems for ensuring service users’ views are listened to and acted upon. The home should provide service users with information in formats suitable to them about how to make representation and how the home and/or organisation will respond to their concerns. Service users are protected from abuse, neglect and self-harm by robust procedures and staff who have received training in adult protection issues. EVIDENCE: The home’s complaints procedure details how to make a complaint and how these will be dealt with. However, it is not provided in user-friendly formats. The manager stated work is being undertaken to produce the homes internal complaints procedure in pictorial form. The adult protection policy/procedure complies with the Department of Health (DOH) guidance ‘No Secrets’ and in accordance with the Public Disclosure Act 1998 (whistle blowing). The home has made two reports under the Protection of Vulnerable Adults Procedures to the local authority adult protection unit and both have been satisfactorily dealt with. All staff have attended adult protection training within the last two years. The home has a policy and procedure for managing service users’ financial affairs. The manager does not act as an appointee for any service user. Suitable systems are in place such service users’ money and/or valuables are placed with the home for safe keeping. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Service users live in homely and safe environment. However, some improvement work is required. EVIDENCE: The home is clean, tidy and free from malodours. The communal areas are furnished and decorated to a satisfactory standard, with the exception of the conservatory, which is in need of refurbishment. Some bedroom furniture needs to be repaired/replaced. A problem with the hot water supply was reported at the last inspection and has yet to be rectified. The inspector was informed that arrangements are being made for the system to be replaced. Repairs have been carried out to the garden wall at the front of the premises. Staff reported the floor covering in the kitchen was being replaced later this month (February) and a new carpet was being fitted in one of the bedrooms. Officers from the local fire service and environmental health agency have visited the home during the last two years. Their manager stated there are no outstanding requirements or recommendations. The Links DS0000025029.V278470.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 & 36 Service users are cared for and supported by a competent and stable staff team. The home has suitable systems in place for supporting staff to carry out their duties in a sensitive and professional manner. EVIDENCE: Service users spoke positively about the advice, guidance and support provided to them by staff. The inspector observed good interaction between staff and service users. All care staff hold the National Vocational Qualification (NVQ) Level 2 in care for which the home is to be commended. The manager arranges for additional client-centred training to be provided. The staff team consists of a senior team leader, 4 team leaders, 12 support workers, a clerical assistant and a maintenance worker. With the team there is a good mix of skills and experience. The rotas show appropriate staffing levels are maintained and, where necessary, these are increased to meet the changing needs of the service users. There have been no new staff appointments since the last inspection. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 18 Shaw Healthcare provides an induction programme for new employees. The manager arranges for staff to attend mandatory and client-centred training. The home has nominated a member of staff to provide routine in-house health & safety training. A record is kept of all training completed by staff and details of their qualifications. A training needs assessment has been carried out which is linked to the home’s Statement of Purpose and service users’ care plans. A training programme is being identified for the forthcoming year. Support workers receive regular planned supervision from a team leader. The manager monitors the quality of these sessions and carries out the annual appraisals. The manager is advised to ensure supervision sessions regularly cover the issues detailed in Standard 36.4 of the National Minimum Standards for Care Homes for Adults (18-65). The manager has reviewed the home’s systems for supervision and training. Therefore, these standards will be more fully assessed at subsequent inspections. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The manager has demonstrated effective leadership and management skills in the running of this home. The home’s procedures and practices ensure service users health, safety and welfare is promoted and protected. EVIDENCE: The observations made, discussions held and records examined during this inspection demonstrate that the manager provides service users with a good standard of care. A representative of the organisation visits the home on a regularly basis. These visits are usually unannounced and a written report on the conduct of the home is produced. As required by Regulation 26 of the Care Homes Regulations 2001, a copy of the report is forwarded to the CSCI. A detailed assessment of the home’s quality assurance and monitoring systems will be carried out at the next inspection. The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 20 A random sample of maintenance and service records was examined and found to be satisfactory. The home has suitable health & safety policies and procedures, systems are in place for carrying out environmental risk assessments and staff are provided with regular health & safety training. The Links DS0000025029.V278470.R01.S.doc Version 5.1 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 Standard No Score 1 2 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 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 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 4 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X X X X 3 X The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 22 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 YA1YA22 Regulation 15, 22 Requirement The Service User Guide, complaints procedure & any other relevant information must be available in formats suitable for the people for whom the home is intended A copy of the home’s Statement of Purpose & Service User Guide to be forwarded to the CSCI The home’s must review its admission criteria & assessment procedure Service users must be provided with suitable written contracts/terms & conditions Any decisions made with or on behalf of a service user, such as monitoring/restricting movement or choice, in order to protect them must be discussed at subsequent reviews Procedure for the safe handling of medication must include details of what staff must do in the event of an error or emergency Timescale for action 08/06/06 2 3 4 YA2 YA5 YA6 4, 14 5 15 08/06/06 08/06/06 08/06/06 5 YA20 13 13/04/06 The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 23 6 7 YA24 YA24 23, 16 16, 23 The hot water system must be replaced Damaged bedroom furniture must be repaired/replaced 06/07/06 08/06/06 8 YA35 9 YA39 The conservatory must be redecorated & refurnished 13, 17, 18 Induction & foundation training must meet Sector Skills Council specifications and documentation to be available to confirm this (Not assessed) 24 An annual development plan must be produced which is based on a systematic cycle of planning-action-review and reflects the aims and outcome for service users (Not assessed) 08/06/06 08/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA36 Good Practice Recommendations The manager is advised to ensure supervision sessions regular cover the issues detailed in Standard 36.4 of the National Minimum Standards for Care Homes for Adults (18-65). The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 24 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: 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 The Links DS0000025029.V278470.R01.S.doc Version 5.1 Page 25 - 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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