Inspection on 16/10/06 for Wales Street

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 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 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

Wales Street 22/11/05

Wales Street 03/06/05

Wales Street 18/10/04

Wales Street 15/04/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Wales Street 12 Wales Street Rothwell Kettering Northants NN14 6JL Lead Inspector Mrs Irene Miller Unannounced Inspection 16th October 2006 15:30 Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 1 Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 2 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 Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 3 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. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Name of service Wales Street Address 12 Wales Street Rothwell Kettering Northants NN14 6JL 01536 713513 NONE 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) Royal Mencap Society Mr James Kelsey Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: 1. The home may provide care to the one service user who has reached the age of 65 and therefore falls within registration category LD (E) Date of last inspection Brief Description of the Service: 12 Wales Street is a 4-bedded home providing personal care for Adults with a Learning Disability. The home is owned by the Royal Mencap Society and is located in the town of Rothwell. The home is situated near to the main thoroughfare, close to a pub, shops and other town facilities. The home was originally two separate dwellings that had been developed into one property and offers fairly spacious communal areas, a fully fitted kitchen, and single bedrooms for Residents. There is a communal bathroom and one of the bedrooms has an en-suite bathroom. There is also a downstairs toilet. All bedrooms are located on the first floor, there is no lift access and the therefore Residents need to be independently mobile. There is a garden to the rear of the property. The current weekly fee is in the region of £304.61 Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This inspection was a ‘Key Inspection’ that focused on the key standards under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for adults (18-65). Prior to the inspection the Commission for Social Care Inspection (CSCI) sent out to the home a pre-inspection questionnaire for completion by the registered manager, and feedback cards for distribution to service users, relatives and healthcare professionals that visit the home. The pre inspection questionnaire was returned back to the Commission for Social Care Inspection prior to the inspection and provided information on the management systems in place within the home. Comment cards received by the Commission for Social Care Inspection from service users, relatives and healthcare professions provided information on the general satisfaction of the people that live at the home and those that visit at a personal and professional level. The primary method of inspection used was ‘case tracking’ that involved selecting two residents, reviewing their individual care plans (that sets out how the home aims to meet their personal, healthcare, social and spiritual needs), and tracking the care they received. Policies, procedures and records in relation to staffing, complaints, medication and general maintenance and upkeep of the home were viewed, and discussion took place with residents and staff and general observations of care practices were made. The inspector spent two hours planning the areas to focus on at this inspection, based upon information gained from reviewing the homes service history, the last two inspection reports and information from the pre inspection data collection systems. The inspection took place over a period of approximately four hours. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 7 What the service does well: 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. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 8 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 Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 9 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. Information about the home is made available for prospective service users and their families, to enable them to make a decision as to whether the home could meet their needs and aspirations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users at the home have lived there for many years, and there had been no recent admissions to the home. Through discussion with the staff it was established that in general the admission process follows phased introductory visits to allow new service users time to adjust to their new surroundings and to allow existing service users time to adapt to a new person moving into the home. The homes statement of purpose and service users guide is made available to all prospective service users and their representatives. Assessments of service users needs included specific specialist support required and identified the level of staff support required for the service users to live as independent a life as possible. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 & 9 Quality in this outcome area is good. Service users are encouraged and supported in leading as independent a lifestyle as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans were very person centred, and contained information on the service users physical, personal and emotional needs, individual aims and objectives had been identified to support service users to maximize their independence and the care plans had been regularly reviewed. A keyworker support system was in place to provide individual 1-1 support for the service users. Through observation it was established that the staff were very skilled in communicating with the service users and were fully aware of each service users method of non-verbal communication. Through discussion with the staff on duty, it was clear that they had an in-depth knowledge of the individual personalities of each service user. There was a homely atmosphere Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 11 within the home and the service users appeared relaxed and at ease with the members of staff. Risk assessments had been drawn up for each individual service user dependent upon the hazards that posed a specific risk to individuals, such as risks of scalding from hot drinks, falls and using domestic electrical appliances. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 & 17 Quality in this outcome area is good. Service users are enabled to lead fulfilling lifestyles both in and outside of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Leisure time and social activities were person centred through identifying service users individual preferences. Some of the service users attended the Kaleidoscope club that takes place each fortnight and provides entertainment such as Disco’s, and evening entertainment, leisure and social activities were accommodated such as visiting friends and family, attending local evening social events, and going clothes and food shopping. Within the home activities were focused around normal everyday living activities. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 13 One service user liked to spend time within the office area with staff and this was facilitated, another service user liked to spend time looking through their personal collection of holiday brochures within their bedroom Visits to see friends and family were encouraged, on the evening of the inspection one service user had been out to visit their cousin, transport and staff support had been provided by the home to facilitate the visit. All of the service users had recently had a short break to stay at a holiday cottage at Lincolnshire, this had been arranged whilst the home was having some work done to the gas and heating system within the home. Service users were supported in taking annual holidays and holidays that had taken place since the last inspection were to Disney Land Paris and Majorca. The service users attend local day centres, on the day of inspection one service user has been on their rest day from the day centre and had spend the day with their keyworker doing an activity of their choice. Each service user had a designated day for carrying out general household domestic tasks, such as vacuuming, polishing and tidying of their own bedrooms. On the evening of inspection one of the service users was busy cleaning and hovering their bedroom with the support of one of the staff on duty. The service users rights to experience personal relationships, was recognised and treated with sensitivity and respect. Service users nutritional needs were closely monitored, following healthy eating plans, and service users were encouraged to participate in food preparation and in setting up and clearing the dining table, washing up etc. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 14 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): Standards 18,19 & 20 Quality in this outcome area is good. In general the service users personal and healthcare needs are met, however due to a shortfall in the recording of medication service users could be at risk of their healthcare needs not being fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans there was information on the personal and healthcare support required by each service user, personal care daily routines were recorded and records demonstrated that any concerns in relation to changes in the service users health were brought to the attention of the appropriate health care professionals The homes policy on medication was to record on the medication administration records (MAR sheets) when a service user did not require ‘as required’, medication such as pain relieving medication. This was initially seen as good practice by the inspector, however on further examination of the Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 15 medication administration records (MAR sheets) it was established that the entries indicating which medication had not been given during the day, was being completed retrospectively at the end of the day, this responsibility had been placed on the member of staff working on the evening shift. The staff were reminded that the person that holds the responsibility for administering medication to service users on each given shift is accountable for their actions and they must be the person that signs the Mar sheets for medication that has been given to service users or as in this case not given. A medication that was no longer in use had been returned to the dispensing pharmacy, however no record was available of when the medication was returned or the quantity of tablets returned. The above areas of concern in relation to the medication storage and administration records were discussed at the time of the inspection with the staff on duty. Training in the administration of medication was provided by the organisation and the staff confirmed that the manager was in the process of accessing further medication training for the staff. Service users had full access to a local General Practitioner and records were available of optical, dental and podiatry treatment received. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 16 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): Standards 22 & 23 Quality in this outcome area is good. There is a complaints system in place for service users and their representatives to raise any concerns or complaints they may have about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was a complaints system in place, and work was in progress in introducing a new care planning and support package, that contained written and pictorial information for service users. The commission for Social Care Inspection had received one complaint about the home since the last inspection visit and were satisfied that the complaint had been appropriately investigated following the homes own complaints procedure. Records within care plans indicated were staff support and intervention was needed to protect service users from potentially abusive situations both internal and external for the home. The Northamptonshire Inter Agency Policies and Procedures on the Protection of vulnerable Adults was available within the home for guidance on the reporting procedures should there be any allegations of suspected or actual abuse take place. Wales Street DS0000012949.V316369.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): Standards 24 & 30 Quality in this outcome area is good. Service Users live in a home that is home is well maintained, clean and homely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is of a domestic layout situated in a residential area within easy travelling distance to the town centre and local community resources. The building was originally two separate dwellings, that had been converted into one dwelling, this has resulted in the house having changes in floor levels throughout, risk assessments were in place to identify tripping hazards for individual service users, and the steps had been made more visible with the use of high visibility safety tape to alert service users where changes were present in the floor levels. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 18 Work was taking place on redecoration and refurbishment of the home, some service users individual bedrooms had been redecorated and some were in the process of redecoration. Redecoration was also in progress within the communal areas of the home. The staff and service users confirmed that the colour schemes and items of furniture purchased for the home had been chosen through consultation with the service users, through making available swatches of fabrics, colour charts and catalogues. New kitchen units had been fitted and the walls were awaiting redecoration, the area was seen to be clean and free from any dust and debris. Within the kitchen area the homes management had acted upon a recommendation made by the Fire Safety Authority to fit self closing devices to fire doors. During August a new heating and boiler system had been installed, whilst the work was being carried out all the service users and staff went for a short break to a holiday cottage at Lincolnshire. The redecoration and refurbishment process throughout the home was assessed to have been well managed, with disruption to service users kept a minimum. Records of building upkeep, fire, water, gas and electrical tests were available within the homes maintenance records. Service users individual bedrooms were clean pleasant and contained personal items such as ornaments, pictures and photographs. Wales Street DS0000012949.V316369.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): Standards 32,34 & 35 Quality in this outcome area is good. Support is available for service users, from a team of staff that are appropriately trained and fully aware of their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing level at the home was sufficient to meet the dependency needs of the service users living at the home. There was one temporary staff vacancy to cover for maternity leave, and staff confirmed that an advert had been placed locally for the post to be filled. On the evening of the inspection visit the staff on duty were both established members of staff employed by the Royal Mencap Society. Through discussion with the staff and observation of care practices it was judged that the service users were being cared for by staff that were skilled within their respective roles and fully aware of the service users needs. Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 20 Training was provided to all staff from a trainer employed within the organisation, and mandatory training was provided in, food hygiene, fire awareness, first aid, medication and adult protection, and staff were supported in achieving the National Vocational Qualification level 3 in care. In addition to statutory training, service user lead training was provided, in areas such as epilepsy and challenging behaviour. The registered manager was not available within the home during this inspection visit, therefore the inspector could not gain access to confidential staff recruitment files. Information supplied through the pre inspection questionnaire on staff turnover indicated that no new staff had started working at the home since the last inspection visit by the Commission for Social Care Inspection. Wales Street DS0000012949.V316369.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): Standards 37, 39 & 42 Quality in this outcome area is good. The home is run in the best interests of the service users and their health safety and welfare is protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes philosophy is to support the service users in leading as independent a life as possible within their individual capacities and capabilities. The record-keeping practice was in general good and the administration records seen were up to date and regularly reviewed. However there was concern about the practice of staff signing service users medication administration records (MAR) sheets retrospectively, during a sample check of the homes medication systems it was established that the homes policy on Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 22 medication was to record on the MAR sheets when a service user did not need ‘as required’, medication such as pain relieving medication. This was initially seen as good practice by the inspector, however on further examination of the MAR sheets it was discovered that the responsibility for recording of ‘as required’ medication that had not been given throughout the day, had been placed on the member of staff working on the evening shift. The staff were reminded that the person that holds the responsibility for administering medication to service users on each given shift is accountable for their actions and this person alone must signs the Mar sheets for medication that has been administered to service users or as in this case not given. A medication that was no longer in use had been returned to the dispensing pharmacy, however no record was available of when the medication was returned or the quantity of tablets returned. Organisational policies and procedures were fully accessible to service users and staff. Monthly audits carried out by the homes management check on the homes policies and procedures, to ensure that the services users health safety and welfare is promoted and protected. In addition a lay assessor visits the home to conduct unannounced visits under regulation 26 of the Care Standards Act 2000, where service users and staff are consulted with and a limited tour of the building conducted, these visits provide a snap shot of the overall conduct of the home at the time of the visit, records of the visits were available to sample check. The service users care plans and risk assessments were regularly reviewed and updated, and a new format was in the process of being introduced that would improve on the level of information within the care plans further. Staff said that they enjoy working at the home, that it was very rewarding. Wales Street DS0000012949.V316369.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 3 33 X 34 3 35 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Wales Street DS0000012949.V316369.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. 1 Refer to Standard YA20 Good Practice Recommendations Where the homes medication policy is to record when residents have not been administered with “as required” medication, the member of staff responsible for the administration of service users medication at the time should make a record on the medication record sheet (MAR). that the prescribed medication has not been given. Records of all medication returns to the dispensing pharmacy should be available giving the date of return, the name of the drug and the quantity of tablets or liquids returned. 2 YA20 Wales Street DS0000012949.V316369.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Wales Street DS0000012949.V316369.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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