This inspection was carried out on 22nd February 2006.
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. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Westley Brook Close 5,12,14 Westley Brook Close Sheldon Birmingham West Midlands B26 3TW Lead Inspector
Donna Ahern Unannounced Inspection 22nd February 2006 14:40 Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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 Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Westley Brook Close Address 5,12,14 Westley Brook Close Sheldon Birmingham West Midlands B26 3TW 0121 743 2436 0121 743 2436 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) H4037@mencap.org.uk Royal Mencap Society Mrs Maxine Davies Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 12 residents with a learning disability under the age of 65 years. One named service user over 65 years can be accommodated. One named service user with a physical disability and a learning disability may be accommodated at the home. Details regarding how the specific care and social needs of people over the age of 65 years and those with a physical disability, must be included in the service users plan, and be subject to periodic review. 23rd August 2005 Date of last inspection Brief Description of the Service: Westley Brook Close comprises of three individually designed modern houses situated in a quiet cul-de-sac within the residential area of Sheldon. The organisation provides 12 placements for people with learning and physical disabilities, some of whom have challenging behaviour. The premises are situated close to a wide range of amenities, including local shops, library, health centre, Sheldon Country Park and churches of various denominations. There is limited parking available in the cul-de-sac. House number 5 comprises of two single bedrooms and one shared room. There is a lounge, dining area and kitchen, which include a front garden and rear garden with patio area. House number 12 has four single bedrooms, two of which are situated on the ground floor with bathrooms on the ground and first floor. The ground floor bathroom has been adapted to accommodate the needs of a service user with physical disabilities and the ground floor doorways and corridors are wide enough to permit wheelchair access. There is a large rear garden. House number 14 is adjacent to number 12 and has an interconnecting door on the first floor. The home has four single bedrooms and a spacious lounge and dining room. There is a landscaped rear garden with patio area. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over an afternoon and evening. The inspector met all the residents. Risk assessments and Staff training records were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the manager and five support workers. This report should be read in conjunction with the report of the 23rd August 2006. What the service does well: What has improved since the last inspection?
There was evidence of much improvement across all assessed areas. Of the 12 previously raised requirements 10 had been actioned in full one in part and one remained outstanding. The manager has made some of the care hours flexible working to provide one to one support for some of the residents so that they can attend activities in the local community. The Manager was required to action referrals to the Occupational Therapist and the Speech and Language Therapist. This had been actioned and the manager was waiting on the protocols to be sent through to the home for the staff to implement. Improvements had been made to the environment so that it is safe, comfortable and homely for residents. The lounge in house 14 had been decorated and a new sofa provided. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 6 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. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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 Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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): 2 The organisations procedures indicate that prospective residents needs would be fully assessed prior to admission. EVIDENCE: There have been no admissions since the previous inspection. The home had one vacancy. The organisation has an admission criteria to follow in the event of any new referrals to the home. It includes visits to the home and overnight stays. The manager demonstrated a good understanding of the required practice regarding any new referrals to the home. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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 and 9 Minor development of risk assessments was required so that the risks residents face is clearly documented. EVIDENCE: The previous inspection noted that significant progress had been made on developing residents care plans. Support plans had been developed for each resident. They were well presented documents that gave good detail on how each person should be supported and how to promote the person independence. It covered all the person personal support and social needs. The care plans were not fully assessed at this inspection. The manager stated that ongoing reviewing of the care plans was taking place. Some of the risk assessments were assessed including risk assessments for the support required by residents during the night. Minor additions were required so that resident’s needs are documented and followed by staff. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 10 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): 12,13 16 and 17 Residents are supported to access a range of leisure facilities at home and in the local community. EVIDENCE: Most of the residents attend a variety of day care including day centres, college and B.I.T.A. One of the residents does not attend formal day care and has two staff who are employed as day support staff (Monday- Friday) to support them in the home and to access community facilities. They have the use of their own car, which is funded through their mobility money. Care staff support another resident who chooses not to attend formal day care. They said that they enjoy doing their knitting, needlework and likes watching videos and talking to staff. The manager had made some of the care hours flexible working to provide one to one support for some of the residents to attend activities in the local community. The staff involved had done some planning with the residents and had looked at and recorded “what they would like to do” “what they are going to do” and “where they have been” and recorded how the activity went.
Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 11 The provider allocates a budget for activities. The staff support for some activities were being funded out of residents personal allowance for instance the resident would be paying for their costs and the staff members costs if they went to the cinema. This practice must cease and the provider must review how activities are financed. One of the residents showed me their care plan. It had good information about the activities that the person enjoys doing when at home or out in the community. On the evening of the inspection three resident in house 14 went to the pub for the evening. Menus sampled indicated that a nutritious and healthy diet is offered to residents. Drinks and snacks were available. On one of the sampled care plans there was eating and drinking guidelines. The provider had reviewed the practice of residents paying for their own meals when they go out. Planned meals out and takeaways are paid for out of the homes budget if the resident chooses to eat out at other times then they pay for this out of their own money. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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): 18 and 19 Improvement must be made to how residents receive support with their personal care. EVIDENCE: These standards were assessed in full at the previous inspection. Progress on requirements was assessed at this inspection. The Manager was required to action referrals to the Occupational Therapist and the Speech and Language Therapist. This had been actioned and the manager was waiting on the protocols to be sent through to the home for the staff to implement. Following advice from the Occupational Therapist it was assessed that a walk in shower should be provided in House 5. This remains outstanding from the previous inspection and must be pursued with the housing association who is responsible for financing building works. Three male staff was on duty in house 14 supporting two male and one female resident. Gender care issues were discussed with the staff and manager. Guidelines must be in place regarding personal intimate care so that the practice protects both the resident and staff member.
Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 13 Risk assessments for the use of lap belts and wheelchairs must be implemented for all residents who use a wheelchair. Lap belts must be used in accordance with the manufactures details. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 14 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): 23 The Adult Protection Procedure must be further development so that residents are fully safeguarded. EVIDENCE: The Adult Protection Policy required some amendments as raised at previous inspections. The policy must make it clear what the staff role is in the reporting of abuse (section C of the organisations policy). The home had the No Secrets document and the Multi Agency Guidelines in place. The practice of residents paying for staff to support them on activities must cease as highlighted under standard 13. There must be guidelines in place for the funding of activities. Any charges to residents must be specified in the contract and Service User Guide. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 15 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 and 30 The home is safe and comfortable for residents. EVIDENCE: The manager demonstrated an understanding of the need to plan for resident’s future needs and ensure that the house’s where possible meet their changing needs. As stated in standard 18 there are plans in place for a walk in shower in house 5. A full audit of the physical standards was undertaken at the previous inspection. A partial tour of the three houses was undertaken and progress on previous requirements was monitored. The report of 23rd August 2005 highlighted that in house 14 the lounge required painting in areas where the plaster had been repaired. The sofa was torn and required repair or replacement. The kitchen floor covering in two of the house’s 5 and 14 required completion. The toilet in house 5 was in the process of being painted. These had all been actioned. Disposable hand drying facilities were required in the communal bathrooms and toilets this had also been actioned.
Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 16 The hatch from the kitchen to the dining area required the job to be completed to a satisfactory standard. This remained outstanding. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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 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, 33, and 35 Staffing levels were satisfactory. Residents are protected by the homes recruitment policy. Some staff training was required so that staff have the required skills and knowledge to meet residents needs. EVIDENCE: Staffing levels are two staff on duty at core times in house 12 and 14 and one staff on shift at core times in house 5. The manager’s hours and the two deputy manager’s hours are in addition to these. One resident in house 14 has two to one staff support for their day care Monday – Friday. At night there is one staff member on waking night shift in each house. There were 65 care hours vacant, which were in the process of being appointed to. The manager stated that there is some flexibility in staffing levels, which can be increased to support activities. Interactions between residents and staff were friendly and relaxed. Training records for house 5 were seen and certificates were available to evidence completed training. The manager had identified training needs for the staff team including older people and changing needs and race equality. Health and Safety training was scheduled for March 2006. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 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): 37 and 42 The home is well managed. Resident’s health and Safety is promoted and protected. EVIDENCE: Throughout the inspection process the manager presented as open, positive and inclusive. There was evidence of ongoing development and improvement. Progress had been made on addressing previous requirements and an action plan had been forwarded to CSCI. Fire records were examined. The weekly test of the fire alarm and monthly check of the emergency lights were due. These were actioned at the time of the inspection. Fire training takes place every six months. Some further development of the fire evacuation procedure was required so that it includes individual profiles on how to support each resident in the event of a fire. Risk assessments for the environment were reviewed in January 2006. Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 X X 3 X X X X 2 X Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 20 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 3 Standard YA9 YA18 YA18 Regulation 13(4) abc 12(1) a & b 13(4)a-c Requirement Risk assessments required some further development. Guidelines must be in place regarding personal intimate care. Risk assessments for the use of lap belts and wheelchairs must be implemented for all residents who use a wheelchair. The practice of residents paying for staff to support them on activities must cease. There must be guidelines in place for the funding of activities. The Adult Protection Policy and Procedure required some development (Previous requirement September 2004). The hatch from the kitchen to the dining area required the job to be completed to a satisfactory standard. (Previous requirement 31/10/06) A walk in shower must be provided in house 5. Training should be provided for all staff on meeting the needs of Older People who have a learning disability and changing needs of residents and race equality issues.
DS0000016977.V284412.R01.S.doc Timescale for action 31/03/06 31/03/06 30/04/06 4 YA23 13(6) 30/04/06 5. YA23 13(6) 30/04/06 6. YA24 23(2)b 30/04/06 7 8 YA29 YA35 23(n) 18(1)c 31/05/06 30/06/06 Westley Brook Close Version 5.1 Page 21 9 YA42 23(4)c iii The evacuation procedure required further development. 31/03/06 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 Westley Brook Close DS0000016977.V284412.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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