Inspection on 13/06/05 for West Street

This inspection was carried out on 13th June 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

West Street 18/01/07

West Street 01/12/05

West Street 04/01/05

West Street 08/07/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 West Street 10 West Street Rowley Regis Warley West Midlands. B65 ODE Lead Inspector Jon Potts Announced 13 June 2005 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. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service West Street Address 10 West Street Rowley Regis Warley West Midlands. B65 ODE 01384 410418 01384 410429 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) Inshore Support Limited Mr A Perkins - Acting (application by CSCI) Care Home 2 Category(ies) of LD Learning Disability (2) registration, with number of places West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: West Street is registered for two younger adults with a learning but no physical disability. There is one other condition that is met. Date of last inspection 4/1/05 Brief Description of the Service: West Street is an adapted terraced propert that was refurbished for the purpose of providing long term care for two youger adults with a learning disability. the house is positioned in an established residential area within walking distance of the centre of Blackheath. Accomodation 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 appropraite car allocated for the transport of the residents. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out between 10.10am and 3.35pm and involved the acting manager and later on in the day the two residents and staff. Information/evidence was drawn from case tracking, staff files, and sight of documents, policies and procedures. Information was also drawn from a pre – inspection questionnaire completed by the acting manager and service user/relative questionnaires. What the service does well: What has improved since the last inspection? What they could do better: The company needs to ensure that all staff recruitment checks are consistently carried out so as to ensure all new staff are safe to work with the residents. There needs to be continued consideration given to presentation of key policies and documents in appropriate formats dependent on residents individual needs. The kitchen would benefit from redecoration (as identified in the business plan). The home’s quality monitoring systems would benefit from continued development (as was stated to be planned by the acting manager). West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 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 E55 S47472 WEst Street V225579 130605 Stg 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 West Street E55 S47472 WEst Street V225579 130605 Stg 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) 1,2,3,5, Information about the home and service is available in such as the service user guide and the lifestyle agreement (for individual contractual terms) although these would benefit from presentation in more suitable formats. EVIDENCE: The residents were admitted to the home shortly after registration in 2003 and are accommodated on a long stay basis. The home has a statement of purpose/service user guide in place with evidence seen that one resident had signed to state they had seen the latter document. The acting manager stated that these documents and other written policies, plans and contracts would be verbally explained to the residents and any questions they had answered at request. Development of formats that would assist residents understanding for key policies and documents would however be advisable. The home was seen to have pre-admission assessment information in place from the purchasers of the service (local authorities), this information carried through to the homes care plans and related information, with updates obtained through regular multidisciplinary reviews. The home’s contract (called a lifestyle agreement) was seen to comply with the expectations of the National Minimum Standards and signatures of the residents were seen to be obtained on these. As stated previously however this would be one document that would benefit from presentation in other formats (i.e. pictorial). West Street E55 S47472 WEst Street V225579 130605 Stg 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) 6,7,8,9,10 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. Risks for the residents are clearly identified within a framework for their independence. 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). Tracking of some of the objectives showed clear evidence that these were been met. 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 acting 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. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 10 The home’s business plan detailed that one of the home’s objectives was to develop residents meetings although there was evidence seen of formal processes for consultation and involvement of the residents, not least through day-to-day discussion. Areas where residents could develop their independence were cleared detailed in their care plans and a resident was seen to be able to freely access the kitchen for hot drinks at the time of the inspection. Input from college is clearly targeting the development of resident life skills and increase in independence as a result. One resident stated that they were happy at the home and was clearly looking forward to a planned holiday. (To be funded by the company) The home was seen to have a clear protocol for access to sensitive information and documents are appropriately stored. West Street E55 S47472 WEst Street V225579 130605 Stg 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) 11,12,13,14,15,16,17 The residents have opportunities for personal development within community based activities and education. The residents are given appropriate diets that are balanced and reflect their stated choices. EVIDENCE: The care plans seen and associated documentation clearly showed that residents are involved in appropriate college and community based activities appropriate to their age and peer group. Documentation from such external sources indicated how the residents would have plentiful opportunity for personal development, with support continued within the home. The home has developed a policy on sexuality that is drawn from British Institute for Learning Disability documentation. Arrangements for contact with families are detailed within care documentation and return of one relatives questionnaire (as well as the homes own) evidenced that there are appropriate arrangements in place to facilitate this contact. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 12 The records of foods taken by the residents indicate that they have access to appropriate and well balanced diets. The home does not have a set menu and it was agreed that this was appropriate as meals taken are very much based on resident’s choices on a day-to day basis. It was stated by the acting manager that the residents are encouraged to have involvement in the homes weekly shopping trips. Residents are involved in the domestic tasks in the home with their activity programmes detailing the same West Street E55 S47472 WEst Street V225579 130605 Stg 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) 18,19,20 The residents physical, emotional and healthcare needs were seen to be clearly identified and evidence indicated that the home was meeting these with the incident of challenging behaviour decreasing since admission of the two residents. The home systems for the administration, storage and ordering of medication were judged to be safe with the exception of the need to strengthen the homes policy with the inclusions of directions related to medication given in error. EVIDENCE: Evidence showed records of choices allowed within daily routines in a number of areas, with flexibility within any structured intervention. One resident clearly indicated that they were happy with life at the home, with information in questionnaires sent to CSCI and the homes own indicating that that the residents felt well cared for, were treated well by staff and had their privacy respected. Interaction between the staff and residents seen at the time of the inspection was also appropriate. 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. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 14 The home was seen to have a policy on medication this complete except for details of the action staff should take if medication was given in error. The homes systems for the administration, storage and ordering of medication were judged to be acceptable. Staff are currently undertaking training in the safe handling of medication, this an accredited training package. West Street E55 S47472 WEst Street V225579 130605 Stg 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) 22,23 The home was seen to have robust procedures in place in respect of safeguarding residents and dealing with complaints. EVIDENCE: The home was seen to have appropriate policies in place in respect of complaints, and protection. Discussion with a member of staff clearly indicated that they understood what they should do if witnessing any form of abusive practice or situation. The home has developed a pictorial complaints procedure that carries the phone number for the police, although the acting manager was advised to add the telephone number for the CSCI and the local authorities adult protection officer. These phone numbers are detailed in other written Inshore policies however. There were some issues in respect of staff checks detailed later in this report under staffing. Observation of the residents with staff clearly indicated that they were comfortable in their presence. A questionnaire returned by a service user stated that they knew who to complain to and a questionnaire returned from a relative indicated they were aware of the homes complaints procedure. A spot check of residents monies in safekeeping showed that the home maintained appropriate records and that the monies (kept secured in a safe) balanced with these records. West Street E55 S47472 WEst Street V225579 130605 Stg 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) 24,25,26,27,28,29,30 West Street is overall a comfortable and safe environment that is suitable for the residents accommodated there. 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 and any issues identified by the inspector were already highlighted within this plan, namely the redecoration of the kitchen. The plan also indicates that it was the intention to redecorate the whole house over the course of the year. The home is suitable for the needs and lifestyle of the residents with one of the bedrooms shown to the inspector by one of the residents clearly furnished in keeping with their expressed preferences (although there was comment about the hole in the bedroom door). Both bedrooms are larger than necessary to meet National Minimum Standards. Suitable arrangements were in place in respect of infection control. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35 The home is developing staff skills and knowledge through its training provision so as to ensure residents are supported by competent and qualified staff. There are some limited instances where the homes recruitment procedures have allowed employment of staff without all the necessary checks, this impacting on the overall effectiveness of the homes recruitment process in safeguarding residents. EVIDENCE: Staffing is consistent with the ratios specified in the residents pre-admission assessments this dictating that there is a minimum of three staff during the daytime and one waking and one sleeping at night. The home has from the recent changes in staff been seen to respond to the recommendation that the proportion of male staff should increase (from case review). 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 with the exception of moving and handling. There are currently two out of ten staff who have completed NVQ level two although there were a further six currently undertaking the same which would give the home in excess of the 50 ratio West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 18 required assuming there is minimal staff turnover. Other areas of training related to core skills were also identified as needed for those few staff that did not currently hold them this including abuse, equal opportunities, race, and disability awareness. Three staff files (relating to the most recently employed staff) were checked in respect of recruitment practices, these evidencing that these were satisfactory with the exception of the following: - One member of staff that was employed prior to a POVA (protection of vulnerable adults) list check or enhanced disclosure. - One had a gap in respect of the working history documented. - One whilst having two references lacked one from the last employer. The home was seen to have a structured induction programme in place and discussion with the company’s service manager centred around ways in which an external training company was been employed to provide accredited induction training. The service manager was negotiating with the company for a greater focus on the learning disability award framework. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 37,38,39,40,41,42 The homes systems for self-monitoring have improved since the last inspection, with the homes annual planning process having a clear focus on areas that have a direct link to better outcomes for the residents. There was evidence that overall the health, safety and welfare of the service users is protected by the homes practices and policies. EVIDENCE: The home was seen to have a range of detailed policies and procedures, these available in one of the houses front rooms. These procedures were seen to be signed by the staff. There was evidence that some policies/procedures had been updated or added since the last inspection The homes systems for self monitoring have developed with a designated manager now carrying out monthly audits against formative standards set by the company (these currently with a focus on safe working practices). Whilst West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 20 there is scope to develop these standards for more detailed audits, the work undertaken so far is recognised as a positive step. There was clear evidence of the home consulting with residents and relatives through questionnaires and the homes business plan clearly identified the priorities for the home over the next twelve months. It was clear that the homes business plan has been partly met. Sampling of equipment and health and safety checks was carried out and found to be satisfactory. Risk assessments in respect of safe working practices were also seen to be in place. It was noted however that one minor accident for a resident documented in the case record was not recorded in the accident record as should be the case. West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 West Street Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 2 x E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 22 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. 2. Standard 20 24 Regulation 13 23 Requirement A policy on medication given in error must be developed The kitchen must be redecorated and the trim on the worktop by the cooker replaced as part of these works. Timescale for action 30.7.05 As identified in the homes plans 30.7.05 3. 4. 32 34 18 13 & 19 The hole in the door in L.L.s bedroom must be repaired There must be at least 50 of 30.9.05 the staff team qualified in NVQ level 2 or 3 by the identified date immediate No staff are to be employed unless a POVA check has been carried out and is deemed acceptable (by the company). If there is a need to employ staff without enhanced disclosures, due to compromised staffing levels, a risk assessment must be carried out with details of all the control measures in place to reduce any potential risk. This is to be submitted to the CSCI for review and agreement before staff are employed. The home must also consistently obtain prior to employment details of the applicants full working history and a reference West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 23 from the last employer. 5. 42 18 To provide all staff with moving 30.9.05 and handling training appropriate to their role. (This as planned by the home) All accidents must be immediate documented on the appropraite accident forms as well as in the residents case files. 6. 42 17 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. 2. 3. 4. Refer to Standard 20 20 35 40 Good Practice Recommendations There should be a complete list of staff initials against their names in the medication folder. To revise the medication policy so that it is a more cohesive document. To continue with the plans to revise the homes induction programme to include Learning Disability Award Framework (LDAF) accreditation. To consider 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 E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 24 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA 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 West Street E55 S47472 WEst Street V225579 130605 Stg 4.doc Version 1.30 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!