CARE HOME ADULTS 18-65
West Street 10 West Street Rowley Regis West Midlands B65 0DE Lead Inspector
Mr Jon Potts Unannounced Inspection 1st December 2005 14:00 West Street DS0000047472.V270712.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 West Street DS0000047472.V270712.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. West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service West Street Address 10 West Street Rowley Regis West Midlands B65 0DE 01384 410418 01384 410429 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) Inshore Support Limited Mr Andrew Perkins Care Home 2 Category(ies) of Learning disability (2) registration, with number of places West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Application to register a permanent Manager to be made to NCSC by 1 March 2004. 13/6/05 Date of last inspection Brief Description of the Service: West Street is an adapted terraced property that was refurbished for the purpose of providing long term care for two younger adults with a learning disability. The house is positioned in an established residential area within walking distance of the centre of Blackheath. Accommodation briefly comprises of two single bedrooms, bathroom, lounge and kitchen. The building has a private rear garden area. The home is managed by Inshore support, a company that has a number of small homes that have similar aims and objectives to West Street. The staffing in the home consists of a manager, senior support and support workers. The staffing ratio is at least one staff member to one resident at day and night, although this can be higher during daytime hours. The home has an appropriate car allocated for the transport of the residents. West Street DS0000047472.V270712.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 between 2pm and 4pm and involved the registered manager. The inspector met and spoke to the two residents during the course of the inspection. Information/evidence was drawn from some limited case tracking, staff files, and sight of documents, policies and procedures. What the service does well: What has improved since the last inspection? What they could do better:
Whilst there has been input into NVQ level 2 training for staff this has been hampered by turnover of those staff that had completed this training. The manager was advised that staff retention issues need to be explored, this through analysis of information gained from exit interviews. There also needs to be continued development of key policies and documents in appropriate formats dependent on resident’s individual needs. The introduction of personal care planning was discussed with the manager, this an area which the manager would like to develop further. West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 6 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. West Street DS0000047472.V270712.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 West Street DS0000047472.V270712.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): 3 Resident’s needs are monitored through an ongoing reassessment process involving multidisciplinary teams. EVIDENCE: There was clear evidence of the residents’ having involvement with multidisciplinary teams for reviews of their care within the last six months, the outcomes of these reviews indicating that the home was meeting the residents needs. The residents have also had regular separate meetings with such as psychologists and psychiatrists in between their reviews. West Street DS0000047472.V270712.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 Detailed care plans and associated documentation clearly lay out the needs of the residents and the strategies adopted for meeting these, with input from appropriate professional sources. EVIDENCE: Both of the residents case files were seen to contain detailed care plans that related to a number of areas of need, as originally identified within the preadmission assessments and reviews since this time. These care plans were seen to contain very clear and specific information as to the strategies and objectives for the resident and the staff (as a result of the former). There were also clear risk assessments in place, these presented in an easy to digest format and highlighting the main areas of concern with use of a three colour banding. Strategies for dealing with these behaviours were clearly seen to be drawn form the advice of the appropriate medical professionals. The manager stated that care plans are explained verbally by the staff to residents and signatures are obtained, although more appropriate formats for their presentation so as to assist residents understanding would be beneficial. There was evidence that the staff have commenced work on the presentation of the case files to include more pictorial information.
West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 10 The use of personal care planning was discussed, this an area that the manager was looking to develop with the residents so as to enhance the service user focus of the plans. This development of such an approach is to be encouraged. West Street DS0000047472.V270712.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): These outcomes were not assessed at the time of this inspection EVIDENCE: See comment above. West Street DS0000047472.V270712.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): 19 Residents’ physical and emotional needs are met. EVIDENCE: There was clear evidence that the residents were assisted to access health service whether specialised or pertaining to routine health not associated with their learning disability. Activities available also included physical exercise. The residents when seen presented as healthy and well cared for. West Street DS0000047472.V270712.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): These outcomes were not fully assessed at the time of this inspection EVIDENCE: Whilst these outcomes standards were not fully assessed it was noted that due to staff turn over the staff team require training in adult protection. A date for the staff to attend this training has however been identified (for the 13/12/05). The inspector has therefore not raised a requirement in regard to this issue. The inspector saw the disclosures for all the current staff team. West Street DS0000047472.V270712.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): 24 Residents live in a homely, comfortable and safe environment. EVIDENCE: The home is sited in a suitable position and presents as a homely environment in keeping with the provision of ‘normal’ domestic style living. There is no indication that the house is anything other that a domestic home, this ensuring that it blends into the immediate community. The home has a redecoration and refurbishment programme identifying works for the next twelve months. Works identified as at the time of the last inspection were seen to have been carried out this including the redecoration of the kitchen and bedrooms. The house was seen to be maintained to a high standard. West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 15 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 Residents are supported and protected by the homes recruitment policy and procedures. The home has identified how staff skills and knowledge will be developed through its training provision. A good level of input by the provider into staff training is however compromised by the rates of staff turnover. EVIDENCE: The home was seen to have a training plan that clearly identified training staff held, what was booked and what was needed. The majority of staff had received training in the majority of mandatory health and safety areas. There are currently no staff that have completed NVQ level two although there are two currently undertaking the same. The manager stated that six staff are to enrol on this training in January 2006, which would give the home in excess of the 50 ratio, required assuming there is minimal staff turnover. The turnover of staff since the time of the last inspection has created difficulties in respect of meeting the ratio of staff with NVQ level 2, this discussed at the time of the inspection. The manager stated that exit interviews are used with these sent to head office. There was said to be plans to look at contractual conditions of employment in respect of the training provided to staff by the company in the near future. It was suggested that the exit interviews were analysed to identify
West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 16 any trends in staff turnover, this to inform any methods that may be employ to tackle this issue. Three staff files (relating to the some of the most recently employed staff) were checked in respect of recruitment practices, these evidencing that these were satisfactory with all necessary recruitment checks in place. Any employment of staff without disclosure has only occurred following risk assessment, receipt of all other recruitment checks including POVA 1st and discussion with the CSCI. There was seen to be records of the close supervision of staff prior to receipt of their disclosures as well. West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 17 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 The resident’s benefit from a well run home. EVIDENCE: The manager has successfully completed the registration process since the time of the last inspection and was deemed competent to run 10 West Street. He has completed the appropriate qualification, this subject to verification. Based on the outcomes of this and the previous inspection the home is judged to be well run. Systems for the support of the manager by the company were also seen to be in place. West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 18 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 3 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 4 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
West Street Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000047472.V270712.R01.S.doc Version 5.0 Page 19 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 YA32 Regulation 18 Requirement There must be at least 50 of the staff team qualified in NVQ level 2 or three by the identified date. This is a repeated requirement that should have been met by the 30.9.05. To identify reasons for and consider ways in which the turnover of staff maybe reduced. Timescale for action 01/06/06 2 YA33 18 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 4. Refer to Standard YA6 YA40 Good Practice Recommendations To look to develop personal care planning as a tool for involvement of residents in life and care planning. To continue the revision of key policies and documents into formats that would better assist residents understanding of them (for example - care plans, contracts etc). West Street DS0000047472.V270712.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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