Inspection on 01/08/07 for The Old School House (Madeley) Ltd

This inspection was carried out on 1st August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old School House (Madeley)... 24/09/09

The Old School House (Madeley)... 16/10/06

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

CARE HOME ADULTS 18-65 The Old School House (Madeley) Ltd 17 Church Street Madeley Telford Shropshire TF7 5BN Lead Inspector Sue Woods Key Unannounced Inspection 1st August 2007 10:00 The Old School House (Madeley) Ltd DS0000067605.V342652.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 The Old School House (Madeley) Ltd DS0000067605.V342652.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. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old School House (Madeley) Ltd Address 17 Church Street Madeley Telford Shropshire TF7 5BN 01952 580 629 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) The Old School House (Madeley) LTD Ms. Sharon Ann Pound Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (excluding nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following category: Learning Disability (LD) 10 The maximum number of service users to be accommodated is 10. 2. Date of last inspection Brief Description of the Service: The Old School House is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of ten people with learning disabilities. The registration was increased in April 2007 to include an extension of four bedrooms and a communal lounge area as well as a new laundry room. These rooms have not yet been occupied. The home is situated in Madeley, Telford. There are shops and other amenities within easy reach of the home. The home currently comprises of ten single bedrooms, six with en-suite facility, two lounges, dining room, kitchen, one bathroom upstairs and one upstairs toilet, one downstairs toilet, shower, Jacuzzi and two laundry rooms. The Old School House is now owned by ‘The Old School House Limited’ following a de-merger with Bru-Ley Homes Limited. The responsible individual is Mr Amarjit Sanghera. The Registered Manager is Ms Sharon Pound. Information is shared with service users in the service user guide and in house meetings. A formal quality assurance system seeks feedback into the running of the service provided from the people who live at the home and their families. Fees, at the time of the last inspection of the home, ranged from £750 to £1700.Up to date information was not available at the time of this inspection although the facility manager is to publish fees within the service user guide. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of The Old School House took place on 1st August 2007 with a return visit on 2nd August to meet with the people who live at the home. In total the inspection lasted five hours. The inspection reviewed all 22 key standards and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the fieldwork activity the inspector met with everyone who lives at the home, staff and managers. Surveys were left for anyone wishing to contribute to the inspection process following the first inspection visit. Three were completed by people living at the home and seven from staff. Prior to the inspection visit the registered manager, the facility manager and key staff from the senior team completed and returned an Annual Quality Assurance Assessment (AQAA). Information contained within this document was seen to reflect the service offered by the home. What the service does well: The service provided at The Old School House is very much focused on the individual needs of the people who live there. Staff feel that the home does well at supporting people to meet their personal care needs. Staff are well trained and committed to delivering a high quality service. People who live at the home are actively involved in all decision-making processes and activities are described as ‘excellent’. Care files and other records are very well maintained and systems have been developed to enable staff to ‘go the extra mile’ in relation to monitoring and working with health care professionals to effect positive changes for the people they support. A relative of someone living at The Old School House says that the home is ‘overwhelmingly good’ The food at the home is excellent and people enjoy a variety of homemade cooking. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 6 It is a strength of the home that the people who live there are supported by a strong staff team who, in the majority, have worked at the home for many years and know the people very well. In written feedback as part of the inspection staff were described as a ‘Dedicated and caring staff team’. It was also stated that staff ‘work well as a team’ and one person said The Old School House was a ‘wonderful workplace’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 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 Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place to enable the successful admission of a new service user to the home. EVIDENCE: Since the time of the last inspection of the home there have been no new admissions. However given that in April 2007 four additional rooms were added to the home to bring the overall occupancy to 10 the inspector reviewed the admissions procedure. The admissions policy and procedure was clearly laid out and refers to the need for all appropriate paperwork to be obtained prior to any admission. The facility manager stated that the registered manager and her senior team would be involved in decision making in relation to any admissions and compatibility would be assessed with the people who already live at the home. The facility manager will update the Statement of Purpose to reflect current arrangements within the home in relation to the accommodation. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Person centred care and support plans enable staff to offer the people who live at The Old School House choice and assist with decision making as well as delivering care in a way that they prefer. Risk assessments ensure that support is given in a safe manner. EVIDENCE: As part of the inspection process the inspector was able to speak with everyone who lives at the home, observe daily life and review care plans. One care file was reviewed in detail at the time of the first inspection visit and extracts were seen from others. The file reviewed contained very detailed information that provided the basis of the care plan. The care plan was person centred and contained pictures and personal information to enable staff to be aware of individual support needs and preferences. Goals had been identified following reviews and were broken down into steps for completion The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 10 Regular meetings are held for the people who live at The Old School House in order for them to discuss future plans, activities and holidays as well as other issues that affect the running of the house. People who spoke with the inspector said that they make decisions about ‘everything’. One person had suggested fishing in a recent meeting and this has already been actioned with photos to demonstrate that they had enjoyed a good day out and caught a lot of fish. Individual risk assessments were seen to support care plans. There was evidence that they had been reviewed. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12, 13, 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. Service users lead full and active lives with opportunities to participate in new and exciting activities of their choice. Service users benefit from a balanced and varied diet. EVIDENCE: People who live at the home told the inspector of numerous activities that they take part in and pictures of some trips are prominently displayed in the hallway. Everyone said that they enjoy days out and group holidays. One person felt that activities were good and one person commented via the survey form that he particularly enjoys going to the shops. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 12 Service users confirmed that they were involved in deciding where they went on holiday this year, whether or not they take part in leisure activities and what they do during the day. Over recent months everyone working and living at the home said that family contact has improved significantly. A regular newsletter supports communication between the home and families and in a recent survey carried out by the home families commented that they valued this contact and requested photos be included in it. This suggestion has already been actioned. People who live at the home are also supported to visit and have telephone contact. The food at the home was said, in a group discussion, to be excellent. People gave examples of their favourite meals and it was evident that people enjoy a range of culinary dishes from the traditional to the exotic. One staff member was praised for his cooking skills and the inspector was offered a cake made by one of the men living at the home. The environmental health officer visited the home recently and reviewed kitchen safety and menus. She was satisfied with arrangements The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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 people who live at The Old School House benefit from a knowledgeable staff team who support them in ways that they prefer. Effective monitoring and recording systems in relation to personal and health care needs of the people living at the home ensure that health care professionals can accurately review needs and make changes in the best interests of the individual. EVIDENCE: Staff feel that the home does well at supporting people to meet their personal care needs. Staff work creatively to ensure people who live at The Old School House have the best possible care and support. Care plans detail health care appointments. Records are also maintained of outcomes of medical appointments. Records are monitored by the manager and analysed by the facility manager to identify changes in behaviour or health. At the time of the inspection the facility manager was able to demonstrate how such an analysis was used at a recent medication review by The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 14 the health care professional to effectively review a service user’s medication with a positive outcome for the individual. As the registered manager and the staff team were out during the first inspection visit medication arrangements were not reviewed on this occasion however a recent Regulation 26 visit had identified that a required change in relation to the receipt of medication into the home had been improved to safeguard people receiving medication from the chemist. The homes AQAA states that within the last 12 months: ‘The home’s medication policy has been improved and reviewed. The PRN Protocol has been implemented and reviewed with the healthcare professional. All documentation has been methodically filed and kept up to date’. In discussions with the registered manager and a senior staff member this was supported with them giving examples of how they have recognised issues and addressed them offering better protection for people living at the home. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are protected by staff being aware of procedures for managing concerns and complaints and by operating an open and accountable system of supporting service users to manage their money. EVIDENCE: The home has received no complaints in relation to the service within the last twelve months. A file is available should a complaint be raised to record basic information and outcomes. People living at the home feel that staff listen to them and there were numerous examples, previously identified within the report, to support this. The facility manager is keen to record compliments made about the home in a book and she shared examples of compliments received as part of the annual quality review of the home from relatives. All staff have received training, and updated training, in relation to adult protection. Staff who spoke with the inspector said that management arrangements have empowered them to share views and express any concerns they should have. The financial personal recording sheet for one person living at the home, chosen at random, was seen by the inspector. Records detailed that regular The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 16 personal allowance payments are received by the individual. Transactions were well recorded and receipts were retained wherever possible. The only restraint within the home, as recorded on the AQAA, was very detailed and other incident forms seen had been professionally completed. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 17 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): Standard 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The numerous improvements made to the standard of the environment have impacted positively on people who live at The Old School House who have a clean, well-maintained and safe place to live. EVIDENCE: Since the time of the last inspection of the home an extension consisting of four ensuite bedrooms and a communal area has been registered by CSCI. The extension is not yet occupied but the facility manager stated that before it was used the shower fittings would be installed. Existing areas of the home continue to be redecorated and upgraded to a high specification. People living at the home told the inspector that they liked their rooms. One person described the home as ‘clean comfortable and cosy’. Staff, via the survey forms, stated that they felt that within the last six months improvements have been made to the environment and one staff member commented on the ‘excellent maintenance and upkeep of the home’. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 18 On the day of the first inspection visit people who live at the home had gone out for the day and the facility manager had taken the opportunity to get all of the carpets cleaned. All areas of the home were seen to be clean. The facility manager is currently investigating arrangements for securing the perimeter of the home. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The people who live at The Old School house benefit from being supported by a well trained and committed staff team enabling their needs to be effectively met within the home. EVIDENCE: Staff on duty at the time of the inspection were positive about their roles and felt well supported. Written feedback suggested that they received good training opportunities and this was supported by staff training records. Records seen were up to date and well maintained. The facility manager follows up when refresher training is required and staff attend training as required. Staff felt that ‘Training courses have been good’. It was reported that all staff now have an NVQ qualification There are currently no staff vacancies at the home and they do not use agency staff. It is a strength of the home that the people who live there are supported by a strong staff team who, in the majority, have worked at the home for many years and know the people very well. There have been no new staff The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 20 recruited since the time of the last inspection and therefore staff files were not reviewed. The senior staff member on duty at the time of the second inspection visit identified recent training opportunities and how he had put his learning into practice offering effective support to people living at he home as a result. Staff on duty again spoke positively of the changes to the senior management. A supervision planning chart on the wall reflected staff feedback that they receive regular supervision. In written feedback as part of the inspection staff were described as a ‘Dedicated and caring staff team’. It was also stated that staff ‘work well as a team’. One person said The Old School House was a ‘wonderful workplace’. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 21 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): Standard 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who live at The Old School House benefit from being supported by an effective management team enabling them to lead a good quality of life. The health and safety and welfare of service users and support staff is promoted and protected. EVIDENCE: The Old School House is managed by an effective team who have individual strengths and areas of expertise that compensate each other and jointly support professional managements system. The manager spoke with the inspector and demonstrated an in-depth knowledge and understanding of the care and support needs of the people who The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 22 live at the home and also of her staff team. She receives effective supervision and support and felt confident to share ideas for improvement with the proprietor. Regulation 26 visits are carried out by the home’s previous Registered provider. At the time of the inspection the inspector information relating to the financial arrangements of the home was not available. However it was suggested to the facility manager that the people who live at the home should know how much the service costs and what they get for their money. She committed to establish this information and share it with the people who live at the home. Health and safety arrangements in relation to fire safety were reviewed as part of this inspection and found to be adequate with regular and recorded checks being made. The fire officer inspected the premises as part of the registration process for the new extension and also found arrangements to be satisfactory. It was reported that the Environmental Health Officer visited the home last week and the inspection had been positive although the report is not yet available. Senior staff and managers have the access to professional consultants to offer advise on all aspects of running the home and these have been effectively utilised. The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 24 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. Extracts may not be used or reproduced without the express permission of CSCI The Old School House (Madeley) Ltd DS0000067605.V342652.R01.S.doc Version 5.2 Page 26 - 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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