Inspection on 22/11/05 for Wales Street

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wales Street 16/10/06

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 Kathy Jones Unannounced Inspection 22nd November 2005 03:50 Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 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 Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 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. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 3 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.V264325.R01.S.doc Version 5.0 Page 4 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) 3 June 2005 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 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 therefore Residents need to be independently mobile. There is a garden to the rear of the property. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over approximately three hours on the late afternoon/early evening of a weekday. Prior to the inspection the inspector spent one hour reading the last inspection report, the homes service history and planning the areas to be inspected. During the inspection a sample of resident’s records was reviewed to check how their care is planned and supported. Discussions with residents and staff and observations of the daily routines and interactions between staff and residents were made. The registered manager was not present on the day of the inspection therefore the inspector was unable to access staff records. Information relating to recruitment practices and staff induction was elicited through general discussion with staff on duty. Communal areas and the bathroom were seen during the inspection. Following the inspection some information was clarified with the manager and verbal feedback on the inspection given. What the service does well: Staff are professional in their approach and are very aware of their responsibilities in safeguarding resident’s interests. The manager and staff have developed positive relationships with each other and the residents and are very supportive and committed to meeting resident’s needs. Resident’s individual routines and preferences are respected and they were observed to be very comfortable with staff, which was confirmed by a resident. Where residents are unable to make decisions relatives are fully involved and advice and guidance sought from relative professionals. The home is indistinguishable from other residential properties in the area and there is sufficient communal space to allow residents to have some space from each other if they choose. Management of medication was found to be good. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 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. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 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 Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 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): This section of the standards was not reviewed during this inspection. This section of the standards was not reviewed during this inspection. EVIDENCE: This section of the standards was not reviewed during this inspection. Standard 2 the key standard to be inspected during a twelve month period has not been reviewed as it relates to the assessment of prospective residents, which is not applicable, as the home has had no new admissions. Discussion with staff about the changing needs of a resident confirmed that the homes ability to meet the needs of current residents is kept under review. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 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 The care provided and commitment to meeting resident’s needs is very good, further development of the care planning process may increase opportunities for achieving personal goals. EVIDENCE: Review of a residents care plans identified that these provide a clear and simple guide for staff of the basic care needs. Discussion with staff and review of a recent assessment of the residents care needs highlighted that further development of the care plans is required to fully reflect the actions required of staff to meet the residents assessed needs. Particular areas for development are the identification and planning to achieve personal goals, opportunities for decision, making and arrangements for ascertaining and implementing resident’s personal choices. The staff on duty at the time of the inspection were very experienced and observations and discussion with them indicated that they are committed to maintaining residents independence and where possible increasing this. Advice was given that the methods for doing this should form part of the care Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 10 planning process to ensure that residents benefit from a consistent approach from staff and the goals and arrangements to achieve these can be reviewed and revised as necessary. Recent discussions have taken place with the registered manager regarding a resident’s changing needs. The manager, and staff on duty during the inspection were aware of the importance of trying to achieve a reasonable balance between the rights and the overall well being of the resident and identified risks. The resident’s views have been difficult to ascertain due to limited communication however advice and support with the decision making and risk management strategies has been sought from relevant professionals and relatives. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 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): 16 The routines of the home are based on the needs of the individual. EVIDENCE: Three residents were returning to the home from day centres as the inspector arrived at the home with one already at home. Observations of the routines confirmed that each resident has their own routine and their routines and preferences are respected and supported by staff. Some residents appeared to need to have some quiet time and relax, while another wanted to spend time with staff and assist with the household duties. The different needs were respected and the layout of the home enabled the needs to be met. Residents have unrestricted access to all areas of the home and their privacy and dignity is respected. Staff were observed to have built up good relationships with residents and interacted appropriately with residents throughout the inspection. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 12 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): 20 Good systems and practices are in place for the safe management of medication. EVIDENCE: The medication system is well organised and medication is stored in a locked cabinet. A sample check of a resident’s medication against the medication administration records confirmed that medication is appropriately managed and recorded. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 13 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 Staff are aware of their responsibilities in protecting the vulnerable people in their care. EVIDENCE: The Commission for Social Care inspection have received no complaints about the home since the last inspection and staff on duty were not aware of any complaints that had been made. Discussion with a resident confirmed that she had no concerns about the care provided and said she felt able to talk to staff if concerns arose. Staff were clear about their responsibilities in protecting vulnerable residents from abuse and confirmed that a procedure for managing an allegation of abuse for an individual resident has been revised following a requirement made at the last inspection. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 14 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): 27,28 The home was clean, comfortable and in good decorative order providing a pleasant environment for Residents. EVIDENCE: The communal areas were seen to be clean and comfortably furnished. Residents were seen to be relaxed and comfortable in the home and to have free access to all parts of the home. The two separate lounge spaces allow a choice of areas and for different activities to take place in the separate areas with sufficient space for movement. One resident was enjoying some relaxing music in one lounge on return from day centre. A requirement was made at the last inspection regarding a downstairs toilet, which had a partially glazed door, which did not protect the privacy of Residents or Staff using it. This has now been addressed with the door now having solid panels. A resident showed the inspector alterations to the bathroom. The bathroom fittings, which had been in a poor condition, have now been replaced and staff advised that the bathroom would now be re-decorated. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 15 Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 16 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): 34, 35, 36 Arrangements for recruitment and induction of staff are good ensuring they are adequately trained to meet the needs of Residents. EVIDENCE: Staff records have not been available during this and the previous unannounced inspections as the manager has not been on duty. Both staff on duty have worked in the home for some time however discussion with them about the recent recruitment of new staff indicated that staff do not start work in the home until appropriate references have been received. Staff confirmed that new staff are following Mencap’s induction and foundation training which is based on the Sector Skills guidance. Staff confirmed that the induction period is dependent on the needs of the individual staff member and that necessary support is provided. During a telephone conversation with the registered manager following the inspection the arrangements for assessing the competence of new staff was discussed and it appears that an assessment of this is made as part of the induction process. Advice was given to ensure that there is clarity regarding the role and responsibilities of staff during the induction period to ensure that resident’s needs are met. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 17 Discussion with staff confirmed that they receive regular supervision and support sessions with the registered manager, which looks at individual support and training needs in order to ensure that they are properly equipped to meet the needs of the residents. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 18 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): 39 The management style promotes an open, supportive and professional environment providing a comfortable and caring atmosphere for Residents. EVIDENCE: Discussion with staff indicated that the registered manager provides them and residents with any necessary support and guidance. Relationships within the home are open, supportive and professional providing a comfortable and caring atmosphere for Residents. A sample check of the staff rota for November highlighted that the shifts carried out by the registered manager appeared to be all care shifts. During discussion with the manager he advised that this was a temporary problem caused by staff sickness and staff on induction. There was no evidence that the management responsibilities had been compromised to date however advice was given to ensure that this is kept under careful review. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 19 Arrangements for quality assurance could not be fully reviewed during this inspection as the registered manager was off duty. However staff confirmed that regular discussions take place in the staff team about improvements that can be made which take account of resident and relative views and needs. In addition a service manager for Mencap carries out regular unannounced visits to the home to review the care provided. Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 3 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wales Street Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X X DS0000012949.V264325.R01.S.doc Version 5.0 Page 21 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. 1 Standard YA6 Regulation 12(1)(a), 12(2 & 3) Requirement Care plans must include personal goals, arrangements for decision making and opportunities for personal development. Timescale for action 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Wales Street DS0000012949.V264325.R01.S.doc Version 5.0 Page 23 - 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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