Inspection on 03/06/05 for Wales Street

This inspection was carried out on 3rd June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wales Street 16/10/06

Wales Street 22/11/05

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 Kathy Jones Unannounced 03 June 2005 08:00 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 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 Stationary 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 D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wales Street Address 12 Wales Street Rothwell Kettering Northants NN14 6JL 01536 713513 Telephone number Fax number Email 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 Only (PC) 4 Category(ies) of Learning Disability (LD) 4 registration, with number of places Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 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). Date of last inspection 18th October 2005 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 D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the morning of a weekday. The inspection involved reviewing information including previous requirements from the last inspection. The pre-inspection information provided some information to inform the inspection and some of this has been included within the report. Comment cards sent out to the home had been distributed to Residents and relatives/visitors. A total of four comment cards were received from Residents with one of these partially completed. Three comment cards were received from relatives/visitors. Some of the information has been included within the report. During the inspection records relating to planning of care needs were sample checked to establish the level of care and protection provided to Residents. Discussions with Residents and Staff and observations of the daily routines and care provided were made. The Registered Manager was not present on the day of the inspection however he contacted the Inspector following the inspection to confirm the action taken to minimise the risk of scalding to Residents. What the service does well: The strength of the home is the Staff team who appear to work well as a team and have developed positive relationships with Residents and are clearly supportive and committed to meeting their needs. Comments from Relatives/visitors confirm that there are also good relationships between them and Staff. Residents are given time and encouraged to communicate their wishes without being rushed. Support from Staff in choosing clothes enables Residents to make appropriate choices and maintain their dignity and self esteem. Routines in the home are relaxed and were particularly so on the morning of the inspection as the day centre was closed. The home is indistinguishable from other residential properties in the area and there is sufficient communal space to allow a choice of activity. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 6 A care plan for the management of behaviours was seen to be clear and detailed and showed that Staff had spent time and thought in developing this based on their knowledge of the Resident. Approval of the plan had also been sought from a relevant health professional. Comments received from Relatives and Residents confirm that they are happy with the care provided however they are clear about the action to take and who to talk to if not. 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 D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 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 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. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 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 standard(s) 6, 9 Care provided is based on individual needs with residents being supported in making choices. EVIDENCE: Care plans which set out the care needs of each Resident are in place. The care plans seen provided a clear and simple guide for Staff of the care needs to be met. The plans in place appeared to be reflective of the individual needs of Residents. For example one plan in place provided Staff with clear information about the type of situations that may trigger difficult behaviours, signs to watch for and actions to be taken to safeguard the Resident and other Residents. The development of this particular plan had involved careful thought about the individual and their needs and was sufficiently detailed to ensure that all Staff following it were able to respond in the same way providing a consistent approach. There has been a very stable Staff team who work together as a team and have got to know the Residents and their needs. Advice was given to ensure that all this knowledge is incorporated in the care plans to ensure that any new Staff are able to provide Residents with consistency of care. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 10 A record of care plan updates showed that these take place annually whereas it is good practice for these to be reviewed as needs change or at least every six months. This regular review of care plans gives Staff and Residents the opportunity of reflecting on the care provided and making relevant changes. Discussions with staff confirmed that Service User’s are encouraged to make decisions and their rights of independence and individuality are respected. Residents were given time to communicate their wishes to Staff and were making decisions in relation to the activities of the day. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15, 17 Residents lead a full life with good family links being maintained. EVIDENCE: Discussion with Residents, Staff and a sample check of care files confirmed that none of the current Service Users are in employment or undergoing formal education or training however they all attend day centres where a range of activities are provided. At the time of the inspection Residents were on holiday from the day centre, which was closed for the week. Routines were very relaxed with all Residents getting up later in the mornings. Staff were assisting Residents to have a bath and with breakfast as and when they woke and were ready to get up. A taxi was ordered to take a Resident and Staff into Kettering town centre to purchase new clothes for a forthcoming holiday. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 12 A Resident showed the Inspector a diary of activities, which is completed by the day centre and the home. Activities included various outings and sailing. The diary also showed access to the community for day to day living activities such as paying rent and assisting with the shopping for the home. The diary is also taken on home visits to keep relatives informed about the activities. Comment cards received from relatives/visitors confirmed that they are kept informed about important matters and consulted about the care. Comment cards received from all Residents prior to the inspection confirmed that they are happy that the activities provided are suitable. Care plans identified activities, which Residents enjoyed, however did not include details of how and when the activities would be made available. Advice was given to Staff to where possible agree the frequency of the activities with the Resident and include this information in the care plan. This information would then need to be fed into the staffing plan to ensure sufficient staff were available for the Resident to take part in the agreed activity. Menus for a two week period were forwarded as part of the pre-inspection information and showed a good variety of meals. Comment cards received from Residents stated that they liked the food and a Resident confirmed this during the inspection. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 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 standard(s) 18,19 Personal care and support is provided in such a way as to promote and protect Residents self esteem and dignity. EVIDENCE: On the morning of the inspection Staff were assisting Residents with personal care according to their individual needs. Comment cards received from Residents confirmed that Staff respect their privacy. Residents were well groomed and photographs of Residents around the home and conversation with a Resident confirmed that they are encouraged to take pride in their appearance. A Resident confirmed that they choose their own clothes with the help of Staff and one Resident was going shopping for new clothes that day. A sample check of a Residents care file and discussion with Staff confirmed that relevant healthcare services such as General Practitioner, dentist, Optician, women’s health checks, Clinical Psychologist and relevant consultants are accessed. There was also evidence that in addition to routine appointments advice is sought as and when necessary, for example the advice of a clinical psychologist had been sought prior to the implementation of a plan to manage difficult behaviours. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 14 Important information regarding individual health conditions had been retained on Residents care files providing Staff with good background information to help understand Residents needs. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Failure to review individual protection procedures may leave Residents without proper protection. EVIDENCE: Three Residents who responded to the question “do you feel safe here” in the comment cards confirmed that they did. The inspector observed good relaxed relationships between Residents and Staff. Residents were not in all cases able to communicate verbally however they were seen to be able to communicate their needs and to be easily understood by Staff. Discussion with Staff indicated that they were clear about the need to report any allegations of abuse through the adult protection procedures. A separate individual procedure for dealing with allegations of abuse that might be made by a particular Resident was reviewed. No allegations have been made and discussion with Staff indicated that the document might no longer be appropriate. The need to review the procedure and ensure that any future allegations are reported through the normal adult protection procedures to ensure proper safeguards for the Resident and Staff are in place was discussed. The pre-inspection questionnaire confirms that no adult protection investigations have been carried out and that no complaints have been received during the last twelve months. Comment cards received from three relatives/visitors confirmed that they were aware of the homes complaints procedure and response from three Residents confirmed that they knew who to talk to if they were unhappy with the care that they received. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27, 29, 30 Premises with the exception of the toilet and bathing facilities provide Residents with a pleasant and comfortable place to live. EVIDENCE: 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 choice of areas and for different activities to take place in the separate areas and there is sufficient space for movement. The communal areas were seen to be clean and comfortably furnished. The downstairs toilet has a partially glazed door, which does not protect the privacy of Residents or Staff using it. Attempts to use a blind or curtain have been unsuccessful due to being removed by Residents. There is one communal bathroom, which was noted to be in very poor condition however Staff advised that arrangements have been made to replace all the bathroom fittings in September while the Residents are on holiday. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 17 The need for aids and adaptations was discussed with Staff who advised that advice had been sought from an occupational therapist regarding the new bathroom in relation to Residents needs. Following discussion with a Staff member about the steps in the garden she was going to discuss with the Manager options to reduce the risk for a Resident with poor sight. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36 Staff work with Residents to give them a good quality of life. EVIDENCE: A requirement was made at the previous inspection for staff to have current contracts of employment, which is a necessary part of good employment practice. Two staff on duty confirmed that they were clear about their roles and responsibilities in relation to Residents and have received contracts, which set out their terms and conditions of employment. Three comment cards received from relatives/visitors stated that in their opinion there are sufficient staff in the home. Discussion with Staff confirmed that staffing levels are kept under review and if Residents needs change or additional support is required for a change in behaviour or for a Resident to take part in a particular activity then this is arranged. The home has a bank of regular relief Staff to call on to cover for holidays and sickness, which enables Residents to be cared for by people who are familiar to them. The training programme was not reviewed during this inspection however discussion with Staff identified that Staff are committed to furthering their knowledge through training. The pre-inspection questionnaire submitted by the Registered Manager identifies that four Staff have completed National Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 19 Vocational Qualifications (NVQ) at level 2 or above. Staff confirmed that some have done NVQ 3 however there has been a delay for others due to funding. Staff confirmed the training they had undertaken was related to working with Adults with a Learning Disability and relevant to working with the Residents at Wales Street. The pre-inspection questionnaire submitted by the Registered Manager also confirms training undertaken and planned relevant to meeting the needs of Residents. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 42 Day to Day management of the home and support for Staff and Residents is good however failure to act on identified areas of risk has the potential to put Residents at risk. EVIDENCE: Discussion with Staff indicated that the Registered Manager provides them and Residents with necessary support and is willing to listen to all points of view. From these discussions it would appear that relationships within the home are open, supportive and professional providing a comfortable and caring atmosphere for Residents. Review of the minutes of a Staff meeting highlighted that Staff had raised concerns about the high temperature of the hot water in sinks and washbasins throughout the home. The minutes indicated that the possibility of fitting valves to regulate the water temperature had been raised with Mencap however no action had been taken. The Inspector and a member of Staff Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 21 checked the water to sinks throughout the home and found the water to be so hot they were unable to put their hands underneath it. Observations of Residents behaviours and discussion with Staff indicated that at least one Resident might be at risk of scalding. A requirement was left for risk assessments to be carried out detailing actions to minimise the risk to Residents until a more permanent solution is implemented. Since the inspection the Registered Manager has confirmed that risk assessments are in place and the fitting of thermostatic valves is being actively pursued for the safety of Residents. The Pre-inspection questionnaire submitted by the Registered Manager provides dates that relevant safety checks were carried out which include checks on fire safety equipment, electrical equipment and visits by the Environmental Health Officer. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x 2 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wales Street Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 2 x D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 23 Yes 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 23 Regulation 13 (6) Requirement Timescale for action 30.06.05 2. 27 23 3. 4. 27 42 12 13 5. 42 13 Individual procedures for managing an allegation of abuse must be reviewed in line with current Adult Protection Procedures. (1)(a) Suitable bathing facilities must be provided for the Service Users.(Previous timescale of 31.01.05 not met) (4) (a) Action must be taken to protect Residents privacy while using the downstairs toilet. (4) (c ) Individual Risk assessments to be put in place detailing action to minimise risk prior to more permanent solution being implemented. (4) (c ) Confirmation of timescales for fitting thermostatic valves or other more permanent solution to be forwarded to CSCI. 01.10.05 01.10.05 06.06.05 08.06.05 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 D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 24 Wales Street 1. Wales Street D C51 C08 S12949 Wales Street V231084 030605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Northamptonshire Area Office Newland House, First Floor Campbell Sqaure Northants, 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. 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