Latest Inspection
This is the latest available inspection report for this service, carried out on 27th August 2009. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for 10 Chapel Street.
Annual service review
Name of Service: 10 Chapel Street The quality rating for this care home is: The rating was made on: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Ann Farrell Date of this annual service review: 0 1 0 7 2 0 0 9 Annual Service Review Page 1 of 12 Information about the service
Address of service: 10 Chapel Street Quarry Bank Dudley West Midlands DY5 2DN 01384411153 01384560210 chapel-manager@btconnect.com Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : learning disability Conditions of registration: Black Country Housing and Community Services Group Number of places (if applicable): Under 65 Over 65 5 0 The maximum number of service users who can be accommodated is: 5 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) 4 Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service 10 Chapel Street is a purpose built detached property sited in Quarry Bank, within walking distance of a range of facilities including shops, health services and churches. The building is within its own grounds and has wheelchair access to the ground floor. There are two communal areas (lounge and dining room) and everyone living in the home has a single bedroom. Some aids and adaptations are present as needed for the current resident group. Annual Service Review Page 2 of 12 The registered provider, a not for profit social landlord, offers long stay accommodation at Chapel Street to adults with a learning disability. The provider does not offer short term or emergency care at this home. The home does have its own minibus although there is access to local public transport links through the nearby shopping centre. Whilst the home only has limited parking there is a car park sited opposite for public use. A statement of purpose and service user guide are available to inform people of their entitlements. Information regarding fee levels should be discussed with the manager when making enquiries. There are additional charges for hairdressing, chiropody and toiletries. Annual Service Review Page 3 of 12 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service and from other people with an interest in the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Any relevant information from other organisations. What has this told us about the service? The service sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clearly presented and gave very detailed information. They told us about how they had met Equality and Diversity, which included: All staff attend Equality and Diversity training as part of their core training. All senior staff have received training in respect of the Mental Capacity Act and Deprivation of Liberty Safeguards, so people are supported to make decisions and are protected. The values that underpin The Dignity Challenge are continually promoted at the home and the manager is a Dignity Champion. All staff receive six supervisions per annum to ensure they have a platform to voice their concerns regarding their own role or of the service delivered at the home. All staff new to care complete the Skills for Care Induction. The manager has also implemented an induction pack that is used at the home and equality and diversity is discussed by senior staff with all new support workers. They also attend training that is specialised to the people living in the home which includes Epilepsy, Person Centred Communication, Communication Passports, Autism Awareness, Supporting Challenging Behaviour, Peg Feed Training, Makaton, and Physical Restraints. All staff must be qualified to the Level of NVQ 2 within 18 months of employment at the home and it commences within six months of the start date of employment, so Annual Service Review Page 4 of 12 they have the skills and knowledge to meet peoples needs appropriately. The manager actively recruits a diverse range of people to work at the home to ensure peoples needs are met. Key workers hold one to one person centred planning meetings with people living in the home on a monthly basis, so that all plans are realised and peoples needs met. Staff actively support the religious beliefs of people living in the home. Two people are regularly supported to attend church and are very much a part of their church community plus the local vicar visits the home regularly. People living in the home are supported to attend community groups and events outside the home to provide integration into the community. Everyone is supported to attend different social education centres that are tailored to meet their specific needs. This also allows them to have a separate life from the individuals that they live with at the home. Peoples sexual orientation and needs are sensitively incorporated into their support plans ensuring their dignity, privacy and sexual needs are met. Systems are in place to ensure people have access to information in a format they can understand as stated in the Communication Bill of Rights. For example many pictorial agreements are in place to enable people to understand the documents given to them. Also easy read documents are in place to inform individuals of how they should expect to be treated. Communication support systems are tailored to the individual and a wide range of techniques and support systems are in place to enhance communication. The manager told us they plan to develop these further. Everyone living at the home has a comprehensive support plan that is regularly reviewed and changed as necessary to ensure all staff that support them have a good understanding of their personal needs, preferences, wishes and desires. The home has excellent relationships with outside professionals and work closely with numerous agencies to ensure people living in the home receive the best possible service. This can be supported by the fact that one person has taken part in a study with an outside professional from Ridge Hill due to the remarkable outcomes that have been achieved following support by the staff team. The home has told us of improvements they have made over the past twelve months and these include; A new person moved into the home during the past year, which has been the first for a number of years. Very positive outcomes have been experienced for the new person, which evidences the system worked well. Holidays have been planned by individuals and one person now attends more holidays by themselves to meet their needs. Annual Service Review Page 5 of 12 Staff have introduced many more communication systems, so people can express their needs and wants more effectively. Staff have improved the system to support meetings with people ensuring seasonal events planning is done by them. Minutes of meetings are also evaluated by senior staff before being given to the managers for further evaluation. Staff education on how to deliver a person centred approach has been a major focus and a document has been produced to give staff strategies and guidelines to achieve it. Pictorial support plans have been developed for two people, so they are aware of what is being written about them. Recording and implementation of key worker discussions have been improved, so that action is taken to follow up on discussions and ensure peoples needs are met. Systems are in place to support one person with physiotherapy exercises twice daily to ensure their well being. A desensitisation programme is in place to support some people with the aim of allowing podiatry and one person has been supported to allow oral hygiene. Three people have prescribed glasses that they have been supported to learn to wear ensuring health needs are met. Equipment has been purchased to ensure people are supported to mobilise in the safest possible way. Staff attendance at meetings has improved enabling effective idea sharing and communication throughout the team. One person now has a lockable cupboard within their bedroom and they are the exclusive key holder, so they have a private storage area that only they can access. A new sofa has been purchased for the dining room to create another private area for people to meet with visitors. Chairs have been purchased for all bedrooms, so people have a seating area in their bedrooms making this space more inviting if they wish for private time alone or with visitors. The stakeholder review now has a comprehensive evaluation that is forwarded to all who participated. This enables staff to underpin the development plan with the views of the individuals that use the service. A weekly audit has been introduced, which is given to the manager who can discuss any issues with relevant staff members. The staff supervision system is more robust ensuring all staff receive six sessions per year and includes specific questions relating to the documentation. This provides appropriate support and ensures all staff are up to date with necessary reading. An induction programme has been developed for agency staff to ensure they have a good understanding of the requirements of the people and service provided at the home. The manager has also developed a tool to ensure all staff including agency workers read the necessary documents ensuring staff have the appropriate knowledge. One person is supported to thicken their drinks ensuring their safety when drinking. Specialised eating aids have been purchased to support people when eating and to retain their independence and peoples weight has stabilised. Annual Service Review Page 6 of 12 Medication has been reviewed and new documentation has been produced for the administration of PRN medication, which clearly outlines the strategies used to support people prior to administration and show clear reasoning and justification for administration of PRN medication. All staff administering medication participate in medication competency assessments every two months to ensure that they use best practice. Some staff have enrolled on long distance medication competency courses and attended an advanced medication course. A protocol has been produced to ensure staff act appropriately when a person sustains a head injury. Some staff are now undertaking long distance learning programmes relating to palliative care, death and dying, so they can support people appropriately. A new compliment, comments and complaints system has been introduced that is more accessible within the home. The format for meetings has been improved to ensure all staff know how to positively approach the subject of people complaining to empower them to do so. Staff files have been improved to ensure they include all of the information required, to demonstrate robust staff recruitment and training. A programme of re-decoration has taken place which included peoples bedrooms, the dining room, the hall, stairs and landing. New carets have been fitted in the lounge, four bedrooms, the dining room plus hall stairs and landing. New blinds and curtains have been fitted throughout and fly screens have been fitted in the kitchen. New bedding, quilts, throws, cushions and chairs have been provided in bedrooms. Sensory Astro Ceiling painted in one bedroom, units have been built under all bedroom sinks and numerous pieces of equipment have been purchased to enhance the environment and meet peoples individual needs. The managers have improved interviewing skills through training and experience. Senior staff have commenced NVQ Level 4 in Health and Social Care. All of the team are now either qualified to the level of NVQ 2 or are presently completing the award. Also charts relating to training, staff supervisions, staff reading lists and a new training matrix are readily available to further ensure the quality of the service delivered. Guidance is available in respect of the Mental Capacity Act and Deprivation of Liberty Safeguards. Training ensures staff have the appropriate knowledge and skills to meet peoples needs. The manager has completed the Registered Managers Award and is a Dignity Champion. She has now commenced on NVQ Level 4 in Health and Social Care. A poster about the Data Protection Act 1998 is displayed prominently, so staff are aware of their responsibilities. They have told us about the plans they have for the next twelve months and they told us these include; To reflect on the admission process that took place in January 2009 to see if any improvements can be made for the future and to access any necessary training prior to
Annual Service Review Page 7 of 12 anyone moving into the home, so staff have the skills to care for new people. To expand the use of communication systems, so that everyone can benefit from the skills that have been gained by the staff. Staff are currently in the process of expanding the use of systems and are collecting the necessary photographs and symbols to do this. To improve the key worker system ensuring that all known needs of the individual are met. Provide everyone with a pictorial document that states who their key workers are and what they will support them to do. Extend the use of pictorial care plans and introduce Life Story Books to aid communication and further record the diverse lives that people have. They are working as a team to improve the way spontaneous decisions are made by people living in the home more successfully. They hope to recruit more skilled and experienced staff and driving license holders and reduce the amount of shifts that are covered by agency staff, so people are supported by staff that have a good understanding of their needs. Review the stake holder questionnaire so they have measurable answers, where action can be taken. Improve the system of staff supervision and review the Health and Safety Audit. Increase the amount of spot checks that take place to ensure the quality of the service remains of an excellent standard at all times. Introduce documentation called Daily Living Skills by January 2010, so encouraging people to develop skills that promote independence. Ensure all support plans include clear aims and objectives and continually review all documentation to ensure it remains fit for purpose. Ensure all staff and management have a good understanding of The End of Life Strategy and incorporate into the support that is offered to people where appropriate. Continue to liaise with outside professionals regarding the best way in which to support people, implementing any recommendations as soon as possible. Produce a document that ensures the quality of the medication system. Review induction documents to ensure they are current and up to date and include all necessary information relating to abuse awareness and how this relates to people living in the home. They will continue to educate people living in the home of their rights and how they should expect to be treated and create a culture where abuse is not acceptable. They will support one person to redecorate their bedroom and replace flooring, redecorate the lounge and re-tile the downstairs bathroom to enhance the environment They would like to purchase a karaoke machine and some disco lights in order to provide further entertainment in the home. The manager and senior staff hope to complete NVQ Level 4 successfully.
Annual Service Review Page 8 of 12 We have received surveys from two people who live in the home, one person who visits the home, eight staff and six health and social care professionals People who live in the home told us; They both told us they were asked if they wanted to move into the home and received enough information about the home before they moved in. They told us they always made decisions about what they did each day and they confirmed they could do as they wanted at all times of the day and evenings. They told us they knew who to speak to if they were not happy, and they knew how to make a complaint. They told us the home was always clean and fresh. The relative told us; Support residents to live independently; need more staff to support residents on community outings of their choice Staff told us: Eight staff told us they are always given up to date information about the needs of people living in the home. Eight staff told us the induction training mostly covered everything they needed and they were given training relevant to their role. Eight staff told us they meet with the manager regularly for support. They told us that they were aware of what to do if any concerns were raised. They told us they usually have the right support to meet the different needs of people living in the home. Three staff told us there is usually enough staff on duty and three told us there was sometimes enough staff on duty. They told us the methods of communication always/usually work well. When asked what the home did well they told us; Open and friendly atmosphere. I think the home understands the individual needs of residents. The care plans are extremely informative. The manager is very good at her job. Excellent training. Good support for service users and staff.
Annual Service Review Page 9 of 12 Implements new ideas and good working practice Puts the needs of residents 1st. Encourage residents to have their say and act on the information given. Very client focused. When asked how the home could improve they told us; Increase the number of staff and stop the high staff turnover. Higher staff numbers would increase the number of activities that the service users could participate in. A specially adapted vehicle would be beneficial for some service users. Health and social care professionals told us; Six people told us the assessment ensures accurate information is gathered so the right service is planned for people. Six people told us social and health care needs are properly monitored, reviewed and met by the care service. Six people told us the staff sought advice and acted upon it to meet peoples needs and improve their well being. Six people told us the staff supported people to administer their own medication where possible. Six people old us the staff respected peoples privacy and dignity. Six people told us staff supported people to live the life they chose where ever possible. Six people told us the staff always/usually have the right skills and experience to support peoples needs. Six people told us the service always/usually responds to the diverse needs of individuals. Six people told us the staff responded appropriately if concerns were raised. Comments included; They are very keen to support the individuals that live there in the ways that are appropriate for the individual. They liaise well with services and therapies. One of the best run LD homes in the area. My contact with staff has always been clear and helpful. They are very person centred in thier approach. I am extremely confident with the support they provide. Genuinely care for the people they support and always have their best interest at heart. They provide individual opportunities as best they can given the constraints of staffing levels.
Annual Service Review Page 10 of 12 I find the staff very approachable and considerate to the clients. They seek out information about the best way they can help the individual. All the staff are keen to learn new skills. It is a pleasure to work with Elaine Beardsmore and her team. When asked how the home could improve they told us; They need more experience and training working with individuals with profound and multiple learning disabilities - they have been gaining this through working with us and attending courses. We have received no complaints about the home since the last key inspection. The home has told us they have received no complaints and have made no safeguarding referrals. They told us there had been one incident of restraint since the last key inspection, which was to ensure the person was protected from harm. The home has kept us informed about relevant important information and the action they took to address them through the notifications forwarded to us. We have looked at all the relevant information available and in our judgement the home is still providing a good service. What are we going to do as a result of this annual service review? We are not going to change our inspection plan, and will do a key inspection by 29th July 2010. However, we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 11 of 12 Reader Information
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