Inspection on 29/11/05 for Willes Road

This inspection was carried out on 29th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willes Road 18/07/08

Willes Road 19/11/07

Willes Road 04/07/07

Willes Road 11/07/06

Willes Road 19/05/05

Willes Road 26/10/04

Willes Road 14/05/04

Willes Road 03/02/04

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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 26 Willes Road 26 Willes Road Leamington Spa Warwickshire CV31 1BN Lead Inspector Martin Brown Unannounced Inspection 29th November 2005 09:45 26 Willes Road DS0000058002.V269783.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 26 Willes Road DS0000058002.V269783.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. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 26 Willes Road Address 26 Willes Road Leamington Spa Warwickshire CV31 1BN 01926 336437 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) Turning Point Mrs Samantha Ann Wilkes Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager must sucessfully copmlete the Registered managers Award and NVQ level 4 by 1st November 2006. 5th October 2005 Date of last inspection Brief Description of the Service: This house is home to five young people who have significant learning difficulties and complex behaviours. All are able bodied. The service offers 24hour staffing and high levels of intensive support and personal care. 26 Willes Road is a Georgian detached house that has been divided into two separate, self-contained dwellings. The top two floors provide three bedrooms (one with en-suite), two lounges, one dining room, kitchen, laundry, one bathroom and separate toilet and staff office for three people with severe learning difficulties. The basement provides accommodation for two young men. There is a rear entrance, two bedrooms, one bathroom, a small lounge and a small kitchen. There is a storage space that has been converted into an office come laundry. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is of the second unannounced inspection of the year at this home, and should be read alongside the previous inspection report, for a fuller picture. Where key standards have been assessed on the previous inspection and have been seen to be met, these have not necessarily been inspected on this occasion. The inspection took place over four hours on a week day morning/afternoon. The inspector was made welcome by the staff, service users, and the manager. All service users were seen at some point during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Work has to be completed in improving the environment. Ultimately, there is still a large question mark over the suitability of the home in the long-term as a residential establishment, and of the desirability of a number of people with such complex needs living together. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 6 A number of Vulnerable Adult referrals over the past few months have highlighted staffing issues. It is anticipated that improvements in overall morale, guidance and staffing will ensure these will not recur. 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. 26 Willes Road DS0000058002.V269783.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 26 Willes Road DS0000058002.V269783.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): These standards were not assessed on this occasion, as it has previously agreed that there are to be no new admissions to the home. EVIDENCE: 26 Willes Road DS0000058002.V269783.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): 9 It is also pleasing to note that planned risks are taken in supporting service users to be out and about in the wider community, rather than unnecessarily limiting opportunities and experiences, because of the challenges they may pose. EVIDENCE: The key standards in this section were seen to be met at the previous inspection, and were not fully inspected on this occasion. It was noted that work is continuing on communication dictionaries, and that ‘active support plans’ are helping to provide a more planned structure to service users’ days. The home continues to support service users to go into the wider community; risk assessments provide guidance on what support is needed. A number of notifications from the home have detailed inevitable difficulties encountered from time to time, but also show how these have been satisfactorily managed. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 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): 13,14,17 The home continues to support service users to access the local community, and to take part in activities outside the home. Service users could arguably benefit from a greater number of regular, planned activities. The development of ‘active support plans’ should help address this. EVIDENCE: These standards were met at the previous inspection, and were not fully assessed on this occasion. A midday meal was taken with two service users. One service user’s enthusiasm, and another’s reluctance to eat, were dealt with calmly and consistently by staff, in accordance with guidelines. A variety of healthy, wholesome food is available. Two service users were in the house throughout the inspection. I was informed that both would be going for a short trip out later, if they were happy to do so. Two other residents went out shopping, and one went out to tour a local castle. Two service users continue to be supported to deliver some weekly newspapers locally. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 11 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): 18,19 The home continues to work well to meet the high and complex needs of individuals, within the constraints of meeting these needs within a group setting, where some people’s needs can often be antagonistic to others. EVIDENCE: These standards were seen to be met at the last inspection. The same limitation remains; namely that a group setting of individuals all with complex needs may not be the ideal setting for the majority of people there. The manager advised that a more individual living arrangement is still being pursued for one previously identified person, but that this would only go ahead if the benefits of such a move were clearly identified and agreed. Staff on the day of the inspection were observed to be offering appropriate support in a variety of situations, and demonstrated a good knowledge of individual needs and how to meet them, or, in the case of agency and relatively new staff, where to go for guidance. Staff and management were able to knowledgeably discuss the needs of individual service users, how they are met, and the progress they are making. Staff photographs, suitably protected, in the hallway, serve as a useful point of reference to some service users. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has mechanisms and strategies in place to protect service users, and by encouraging greater integration with the wider community and with outside agencies will enable even better protection in the future. EVIDENCE: These standards were met at the last inspection. There have been a number of Vulnerable Adult issues, which the home, with the full involvement of the relevant agencies, has striven to resolve fairly with the prime concern of ensuring the safety and welfare of service users. The complaints log also contained compliments concerning care and support provided in the home. Staff were seen to be attentive to service users’ concerns, and are aware, with the support of individual knowledge and written guidance, of behaviours and actions that would give rise for concern. Where there have been concerns over service user safety, appropriate strategies have been put into place. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 13 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): 24,25,26,27,28,30. The staff and management have made some progress on their own in improving the environment. The manager needs to ensure that long-awaited work now takes place as planned, and in a way that causes as least disruption as possible. EVIDENCE: There has been some improvement in the environment, instigated by the home itself, whilst waiting for repairs and refurbishments to be started by the Primary Care Trust. The rear lounge is being converted to a sensory room; the improvement there is already dramatic. The front lounge and the dining room are both far brighter and airier following the removal from in front of the house of a diseased tree that had been blocking much of the light. ‘Clutter’ had been removed from the back garden, and the laundry ceiling, subject of a previous immediate requirement, had been repaired, although not yet repainted. Major refurbishment, notably the basement bathroom, the fire escape, plasterwork in the basement, as well as previously noted refurbishment and redecoration needs, is still to be done. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 14 During the inspection, details of dates for this work to be done were e-mailed from the landlord to a very happy manager. The home was generally clean and free from unpleasant odours. In certain areas, however, notably ledges and skirting boards, an accumulation of dust and dirt, was noted in places. Radiator covers are in need of repair/replacement. The manager advised that suitable replacements and funding for these had been identified. The door strip under the dining room door was ‘lifting’ and was pointed out to the manager as a potential tripping hazard. 26 Willes Road DS0000058002.V269783.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): 34,36 More recruitment is benefiting service users by enabling there to be a more consistent, permanent staff team, with less reliance on agency workers. Regular supervisions will better enable the management of the home to provide support and guidance to all staff. Clearer information from the organisation’s Human Resources regarding the status of staff in respect to criminal record checks will better ensure service user safety. EVIDENCE: A sample of recruitment documentation was looked at and seen to be satisfactory. A relatively new staff member was spoken who confirmed that a satisfactory introductory induction period was in process. In situations where Criminal Records Bureau checks were awaited, and ‘POVA first’ checks had been requested, the manager showed me as evidence, an e-mail from the organisation’s Human resources stating that ‘minimal checks’ had been done. This did not make it clear whether was meant that a satisfactory POVA first clearance had been obtained. The manager acknowledged that staff supervisions were not yet taking place within the required minimum of once every two months; she is hoping to achieve this with the support of a deputy. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 16 A permanent deputy was recently appointed, but left after a few weeks. An experienced agency deputy is currently in post up until the New Year. A probationary period review for one of the newer staff was seen to be satisfactory. The standard regarding staff training was met at the previous inspection; it was noted on this occasion, in respect to the management of challenging behaviour, that staff are all undertaking ‘Timian’ training, which is British Institute of Learning Disability accredited, with four staff still to complete this. 26 Willes Road DS0000058002.V269783.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): 37,42 The home is benefiting from the attentions of a full-time, registered manager. Health and safety within in the home has improved, but will remain compromised until environmental improvements are completed. EVIDENCE: A permanent manager is now in post, having now being successfully registered as such. Staff were complimentary of the leadership, guidance and support she is providing. Fridge/freezer temperatures are recorded, and are now within acceptable limits. The kitchen door now has an appropriate fire closure on it. The environmental shortcomings, notably those involving the fire escape, the bathroom window, and radiator covers, previously noted, have a detrimental on the safety and welfare of all those in the home. 26 Willes Road DS0000058002.V269783.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 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 2 2 2 2 x 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 26 Willes Road Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 1 x DS0000058002.V269783.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 Regulation Requirement Timescale for action 30/12/05 YA42YA28YA27YA24 23 2 YA24 23 Agreed renovation work must proceed, without delay. This includes the provision of a safe rear fire escape, the complete renovation of the basement bathroom, the replacement of the upstairs bathroom window by one that is safe for use, the renovation of the front lounge, of plasterwork in the basement lounge, the repair of radiator covers, and repainting and repair throughout the house, as identified. The manager is confirm start dates, and completion dates, for this work. The door strip under the 10/12/05 dining room door requires attention. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 20 3 YA34 19 4 YA36 18(2) The home must be able to demonstrate, where appropriate, that it has had confirmation of ‘POVA 1st’ checks, and not just ‘minimal checks.’ Staff supervision must take place at least every two months. 30/12/05 30/01/06 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 21 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 Refer to Standard 12,14 Good Practice Recommendations More planned, regular, activities should be scheduled for people living in the home. It is anticipated that the further development of ‘active support plans’ will facilitate this. 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 26 Willes Road DS0000058002.V269783.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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