Inspection on 16/10/06 for The Old School House (Madeley) Ltd

This inspection was carried out on 16th October 2006.

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)... 01/08/07

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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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 Old School House (Madeley) Ltd 17 Church Street Madeley Telford Shropshire TF7 5BN Lead Inspector Sue Woods Unannounced Inspection 16th October 2006 10:30 The Old School House (Madeley) Ltd DS0000067605.V314759.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.V314759.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.V314759.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 6 Category(ies) of Learning disability (6) registration, with number of places The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2006 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 six people with learning disabilities. At the time of this inspection there were no vacancies. The home is situated in Madeley, Telford. There are shops and other amenities within easy reach of the home. The home currently comprises of six single bedrooms, two with en-suite facility, one lounge, dining room, kitchen, one bathroom upstairs and one upstairs toilet, shower, Jacuzzi and a laundry room. 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 has recently been implemented. Fees range from £750 to £1700. The Old School House (Madeley) Ltd DS0000067605.V314759.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 16th October 2006 between 10.30 am and 3.00 pm. 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 inspectors spoke with service users and staff and reviewed records including care plans, rotas and health and safety information. The manager of The Old School House was on duty at the time of the inspection and the whole team were supportive and fully cooperative. What the service does well: Service users are supported by a strong staff team who receive good support and training opportunities. Staff have developed skills, over a number of years, in order to safely support service users with identified medical and personal support needs and this has impacted positively on the lives of those service users. Person centred care and health action plans contain detailed information relating to individualised care and support needs and are constantly being reviewed and updated. Service users have opportunities to access community resources and maintain family links. Service users spoke highly of the manager and the staff team and were very proud of their bedrooms. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 6 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 Old School House (Madeley) Ltd DS0000067605.V314759.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.V314759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An effective admissions process is in place to ensure that the home will be able to meet the assessed needs of service users admitted. EVIDENCE: Since the time of the last inspection of the service there have been no new admissions to the home. Arrangements at the time of the last inspection were satisfactory. Although not inspected on this occasion it was noted that service user ‘contracts’ are currently being reviewed and fees will be detailed in the new documents as well as the range of fees being listed in the service user guide. The Old School House (Madeley) Ltd DS0000067605.V314759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 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 service users 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: One care file was reviewed in detail at the time of this inspection and extracts 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. Care plans are all reviewed twice a year or more frequently if needs change Regular meetings involving service users are held to discuss forthcoming events and plans. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 10 Individual risk assessments were seen to support care plans. The manager said that she now discusses risk assessments at reviews and involves outside agencies in the agreement of risk management strategies. 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. The Old School House (Madeley) Ltd DS0000067605.V314759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. 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 risk assessed activities of their choice. Service users benefit from supported family contact and involvement Service users benefit from a balanced and varied diet EVIDENCE: Service users were keen to tell the inspector about the numerous activities that they take part in. Service users recalled with happy memories their holiday to Wales this year. Two service users told the inspector that they have regular visits from family members and make weekly phone calls to stay in touch. Service users were happy with the support that they receive from staff to maintain these links. It was stated that family members are always welcome at the home and during an informal discussion with the family member of one The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 12 service user she stated that she visited regularly and looked forward to these visits. The home operates a five weekly menu that always offers a choice. The home received the Gold Award for healthy eating in July this year and everyone is rightly proud of this achievement. Staff had a good knowledge of service users likes and dislikes and there was a good supply of fresh fruit readily available. The administrator stated that the recently purchased smoothie maker had been a very popular addition to the kitchen. Staff were also aware of service users individual support needs in relation to how their food is prepared. Service users stated that they liked the food at The Old School House and two service users agreed that their favourite meal is fish and chips. Menus are discussed during residents meetings. The Old School House (Madeley) Ltd DS0000067605.V314759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a knowledgeable staff team who support them in ways that they prefer. Service users are protected by effective systems for the storage and recording of medication EVIDENCE: Health action plans have been developed and implemented. There was recorded evidence that health care appointments take place on a regular basis. Visits to the chiropodist are also recorded. Care plans detail how service users prefer to be supported with their personal care. The arrangements for the administration, recording and storage of medication were seen to be in place and effective. The senior support worker on duty at the time of the inspection stated that all service users are having medication reviews. A protocol was available to support the administration of PRN medication that had been signed by an appropriate health care professional. The homes medication policy was seen to have been developed following the last inspection of the home and the manager and senior staff member were happy that it covered all eventualities. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 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 the following standard(s): 22, 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: A complaints book is kept in the office and although the home has not received any complaints the administrator stated that outcomes would be recorded. One concern has recently been fully investigated by the management team and it was positive to note that it had been well documented and a meeting had been arranged to try to resolve the issue raised and allay concerns in an informal manner. There have been no referrals to adult protection although the manager was aware of the procedure and had received training along with the staff team. There was evidence that the home works closely with families, care managers and health care professionals to address issues and good records are kept. The money tin belonging to one service user was seen by the inspector as part of the case tracking. The total of money in the tin reflected the record. Receipts were available to support purchases and the manager gave examples of how she records transactions when receipts are not available. The manager stated that only herself and the administrator can make withdrawals from bank accounts on behalf of service users. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 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 the following standard(s): 24, 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 service users who have a clean, well-maintained and safe place to live. EVIDENCE: As found at the time of the last inspection of the home there have more improvements made to the standard of accommodation within the home. The kitchen and dining room has been completely refurbished. The kitchen is equipped with all modern conveniences including a dishwasher that is particularly popular with one service user who never liked washing up. There are plans to turn the recreation room into a formal dining room and utilise the lounge area more. On the day of the inspection service users were seen relaxing in all of these communal areas. One service user is having ‘black out’ blinds in his bedroom following a suggestion from a family member. The inspector was invited to look at three service users bedrooms. All were proud to show off their possessions including TVs, DVD recorders and stereo systems. Bedroom furniture has been replaced by new and more modern pieces and The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 16 bedrooms were clean and airy. The manager reported that all windows have now been replaced or repaired. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 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, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well trained and supportive 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. They felt they received good training opportunities and this was supported by staff individual training records and the home’s proposed training matrix for the year. Records seen were up to date and well maintained. The administrator follows up when refresher training is required and that staff attend training as required. There are currently no staff vacancies at the home and they do not use agency staff. It is a strength of the home that service users are supported by a strong staff team who, in the majority, have worked at the home for many years and know the service user very well. Only one staff member has been recruited since the time of the last inspection of the home. Her file was seen to be well organised with all required information readily available. The home is looking at endorsing their LDAF induction and foundation training. The manager confirmed that all staff had had a CRB check and records identified disclosure information. The original disclosures had been prematurely destroyed and so The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 18 the arrangements for retaining CRBs was discussed fully. A disclosure had been obtained to support the latest staff member to join the team. One member of staff on duty told the inspector how he had used the training that he had received during his NVQ level 3 to support a service user through a recent bereavement. Staff on duty spoke positively of the changes to the senior management. Staff training in relation to managing service users with challenging behaviour (MAPA) is to be carried out by Telford and Wrekin Council and the manager stated that they have received a visit from the course coordinator to review their policies and procedures in relation to restraint, redirection and recording of incidents. A supervision planning chart on the wall reflected what staff said about receiving regular supervision. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 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, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by an effective management team. The health and safety and welfare of service users and support staff is promoted and protected. EVIDENCE: The manager of the home is well respected by her staff team who stated that they feel well supported both formally and informally. The manager has responded positively to recent changes within the home. Her commitment to ensuring that service users receive a good quality service is evident. She receives invaluable support from the administrator and has regular contact from the new responsible individual. The manager recently attended training on autism. The organisation has bought in numerous packages of support and feedback in relation to them has been positive. The new organisation is reviewing staff and The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 20 service user contracts as well as carrying out a major review of in-house policies and procedures. Staff have been delegated areas of responsibility within the home. The senior on duty at the time of the inspection had recently carried out training in relation to arrangements for health and safety and food hygiene within the home. The environmental health officer visited the home on 16/06/06 and reviewed arrangements. As a result improvements have been made to COSHH assessment forms. Records in relation to fridge and freezer temperature checks and food temperature checks are very well maintained. The manager reported that the fire officer visited the home within the last two weeks. She stated he was happy with arrangements but the report has not yet been produced. A health and safety audit was carried out for the home on 19th September 2006 by an external agency. Progress is being made to improve quality assurance questionnaires. Accident and incident reporting is cross-referenced to ensure information is stored securely where it is needed. Some minor omissions to the newly implemented forms were identified during conversations and the manager and administrator committed to add boxes to ensure all required information is clearly recorded. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 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 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 3 33 X 34 3 35 3 36 4 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 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 4 X The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 22 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. 1 Refer to Standard YA42 Good Practice Recommendations It is recommended that incident recording forms be reviewed to ensure staff are prompted to record all required information. The Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Old School House (Madeley) Ltd DS0000067605.V314759.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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