Latest Inspection
This is the latest available inspection report for this service, carried out on 15th September 2008. CSCI found this care home to be providing an Good service.
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 Wales Street.
What the care home does well Clear support plans are in place and needs are met. Support workers are knowledgeable about the needs of people who use the service. People using the service have a range of daily activities that they are actively supported to participate in. People using the service are supported to access community resources.Meals are always freshly prepared, healthy and varied. Meals are shared with support workers providing a family environment that is relaxed and comfortable. The home is maintained to a high standard and people using the service have access to individual rooms that reflect their personal preferences. Communal areas enable a range of activities to be undertaken within a family setting. The support workers show a high level of commitment to the work and bring a range of skills to support individual`s needs. Support workers state that `Mencap provides good training` and that `It is a good place to work` The support team are very knowledgeable about the needs of people using the service. Support workers feel well supported by managers What has improved since the last inspection? Medication recording is meeting required standards. What the care home could do better: National Minimum standards have been met at this inspection. CARE HOME ADULTS 18-65
Wales Street 12 Wales Street Rothwell Kettering Northants NN14 6JL Lead Inspector
Judith Roan Unannounced Inspection 15th September 2008 2:45 Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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 Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Wales Street Address 12 Wales Street Rothwell Kettering Northants NN14 6JL 01536 713513 NONE H3025@mencap.org.uk 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) Royal Mencap Society Tracey Luck Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may provide care to the one service user who has reached the age of 65 and therefore falls within registration category LD(E) 16th October 2006 Date of last inspection Brief Description of the Service: 12 Wales Street is a 4-bedded home providing personal care for Adults with a Learning Disability. The home is owned by the Royal Mencap Society and is located in the town of Rothwell. The home is situated near to the main thoroughfare, close to a pub, shops and other town facilities. The home was originally two separate dwellings that has been developed into one-property and offers fairly spacious communal areas, a fully fitted kitchen, and single bedrooms for Residents. There is a communal bathroom and one of the bedrooms has an en-suite bathroom. There is also a downstairs toilet. All bedrooms are located on the first floor, there is no lift access and the therefore Residents need to be independently mobile. There is a garden to the rear of the property. The current weekly fee is in the region of £304.61 Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views of the service provided. This process considers the services capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two people who use the service and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The Inspector also received questionnaires completed by the four people who use the service and six staff. The questionnaires provided good feedback about the quality of care and service. The homes registered manager also completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CSCI. The inspection was unannounced and was undertaken during the afternoon and evening lasting 5 hours. An annual service review was completed in February 2008 and this did not change our view of the service. People using all said that they felt safe at the home and knew whom to contact if they were unhappy. They also said that there is good information about the service and that support staff listen to them and provide them with the care they need. One person said ‘I am happy and like living here’ ‘ I go out to places I like with support from staff’ What the service does well:
Clear support plans are in place and needs are met. Support workers are knowledgeable about the needs of people who use the service. People using the service have a range of daily activities that they are actively supported to participate in. People using the service are supported to access community resources. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 6 Meals are always freshly prepared, healthy and varied. Meals are shared with support workers providing a family environment that is relaxed and comfortable. The home is maintained to a high standard and people using the service have access to individual rooms that reflect their personal preferences. Communal areas enable a range of activities to be undertaken within a family setting. The support workers show a high level of commitment to the work and bring a range of skills to support individual’s needs. Support workers state that ‘Mencap provides good training’ and that ‘It is a good place to work’ The support team are very knowledgeable about the needs of people using the service. Support workers feel well supported by managers What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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 Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5, Quality in this outcome area is good. People using the service are fully assessed to ensure that the service can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been two new admissions to the service since the last inspection. All people living at the service have their needs reassessed as part of the ongoing review process. Additional needs are highlighted and appropriate action is taken to provide the support. Over the past year meetings with people using the service are held and information is available in an easy read format. There is a clear statement of purpose & service users guide that is to be developed to be easy read. Files contained tenancy agreements and contracts about the support individual’s receive. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. Support plans are person centred and demonstrate involvement of people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are in place for people who use the service and are reviewed on a regular basis to ensure that support workers are updated with changes. The manager confirmed within the AQAA that ‘ Support workers have improved the recording within the care plans on discussion sheet, of individuals want to go in their Person centered plans and what they have done to achieve this.’ The manager also stated that future plans would be to have risk assessment in an easy read format. People using the service are fully involved and supported in developing person centred plans, which clearly state their preferences, goals and dreams. People spoken to during the inspection confirmed that they were involved and had signed their plan. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 10 Weekly meetings are held to assist people with personal choices. People using the service are supported to attend house meetings to ensure that they are included within the decision making process for future activities and events. These regular forums ensure that there is continuous development. It was observed that there is good communication between support workers, ensuring that information is shared appropriately. The files are stored securely within the office to ensure that confidentiality is maintained. The outcomes for people using the service support are positive and that needs are being met within the systems in place at the home. In observation of practice and discussion with support workers it was evident they are very knowledgeable about the needs of the people they support. All the support workers confirmed that there induction included a period of working alongside another experienced support worker until they had demonstrated that they were competent and confident in meeting people’s needs. Risks within activities are identified and support workers ensure that the appropriate level of support is available to ensure safety and to develop independence within activities that is related to an individual’s ability. Files contained comprehensive risk assessments related to a range of activities for the individual person. People using the service are encouraged to be as independent as possible with appropriate support. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. A wide range of personal, educational and social options are available and promote individual development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individuals have a weekly activities programme that is updated to take account of various events and personal choices. New activities are tried out to extend the choices and experiences for each person. Since moving into the service all of the individuals had become fully involved in activities within and outside of the home. During the period of observation it was noted how individuals were supported with everyday activities around the house to enable them to be included and to take on joint responsibility for their environment and their belongings. Careful planning is undertaken for all activities to ensure that people who use the service and support workers are protected and enjoy the experience. Experiences are good, varied and meet individuals cultural needs. People are supported to attend church to fulfil their religious needs.
Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 12 It was noted that several people have day care opportunities and are supported to experience community facilities. Leisure and bus passes are obtained to reduce the financial impact on people using the service with their chosen leisure options. Holidays are planned each year and people using the service are supported as required by the service. Two of the residents were away at the time of the inspection. Meals are served in the family style dining room and people are supported as needed in a discreet and positive. The evening meal was freshly cooked and healthy. Individuals are supported to make healthy choices and have a balanced diet, with opportunities to have the occasional treat. Support workers have a good understanding of the needs for people who use the service and use the meal times to develop communication skills with each other. Meals were seen to be an important social event at the home. The standard of food prepared at the home is good. The AQAA confirms that ‘ A staff member has attended health awareness and healthy eating training and is now passing on their knowledge to staff and people using the service about healthy options on chosen menu items.’ Good communication with families is maintained by supporting individuals to contact them, support workers keep them informed, involved and make them welcome at the home. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. People using the service are positively supported to access local and specialist healthcare services. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People using the service are supported to have regular health checks and there is evidence on files that healthcare appointments are made. The AQAA confirms that people using the service have ‘Staff support for regular appointments with a range of relevant Health care Professionals dependent on need.’ ‘Provide individualised care to the people support that they are happy with and promotes their independence and skills. The care plans seen during the inspection state how personal support is provided to ensure that people are supported in the way they prefer and require thus promoting privacy, dignity and independence. A monitored dosage medication system is in place and meets the needs of the people using the service and assists support workers with the process. The physical and emotional health needs of people using the service are well met by the policies and procedures in place and good links to health care professionals. It was observed that staff actively supported the health care
Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 14 needs of one individual during the evening. The daily notes confirmed that this was undertaken routinely and maintained their present well being. Personal support is provided in a discreet manner, with people using the service preferences being a top priority. Medical profiles for people who use the service are clear to ensure that support workers have up to date information about a medical condition and prescribed medication. The manager confirms within the AQAA that ‘health actions plans have been reviewed care plans are clear and staff have undertaken training inn areas of Mental capacity Act, Epilepsy awareness, Dementia care and supporting people with end of life and bereavement.’ They would like to see the development of ‘more accessible formats for medication profiles and information on health care issues to discuss with people using the service ’. All medication is stored in a locked facility and records are maintained. Only support workers that have undertaken certificated training administer medication. The staff files seen at the inspection confirmed this. Observation of care practice indicates that safety is maintained. All incidents are recorded on file to show how the manager/support workers have reviewed practice to minimise future risks. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. Practices within the service fully protect people who use the service and ensure that they are listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has comprehensive policies and procedures in relation to handling concerns and complaints. People who use the service are observed to ensure concerns are noted and brought to the attention of the manager through meetings. Support workers undertake abuse awareness training as part of their induction/ foundation training. This is updated by a yearly online refresher course. We checked out their understanding during the inspection, which was good. There have been no complaints since the last inspection. The home has an accessible complaints policy. The manager states that, ‘The Service has a regular Lay visitors who have been visiting the service for a number of years. They know two of the Service users well and are given the opportunity to comment on the service and any concerns after each visit’. Families are aware of the complaints procedures and know how to raise concerns they have with the manager or managers in Mencap. Recruitment procedures ensure that support workers working at Wales Street are security checked with files supporting that Criminal Record Bureau disclosures have been undertaken. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. The home provides a warm family setting with individual space that is well maintained clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is two houses joined and made into spacious accommodation for the people that live there. It provides comfortable and accessible accommodation for all the people using the service. The décor is well maintained and there is good outdoor space that provides an attractive courtyard and maintained garden. The AQAA confirms our findings that ‘All people using the service have their own bedrooms which they are encouraged to decorate to their individual taste.’ Ddecisions are made in house meetings about the communal areas within the home. The home provides an environment that reflects normal family life. There are adequate rooms to enable everyone to have their own personal space. The several communal areas are used for joint activities and each bedroom has sufficient room for personal hobbies. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 17 Individual bedrooms are personalised, comfortable and well maintained. People using the service are supported in maintaining their rooms to a high standard of cleanliness and safety. It was evident during the inspection that daily living tasks are completed with people using the service and that no activity is undertaken without their involvement. The dining room can accommodate all of the people living at the home where meals are eaten as a family but individuals have a choice to eat in the other communal area of the home. Records confirm that all maintenance checks are carried out to promote a safe environment. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. Staff skills and recruitment practices fully ensure that the needs of people who use the service are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The support worker team have a sound knowledge base about the needs of people that use the service. Through observation during the inspection the staff team showed that they had a range of skills to support individuals and were proactive in developing everyday living skills. In reviewing the files of support workers it was noted that all contained evidence that recruitment check had been undertaken. The files all contained application forms, two references, identity checks and an enhanced criminal record bureau disclosure. In discussion with the manager it was established that there is a full complement of support workers that improves the homes ability in meeting the wider needs of people who live there. The AQAA confirms that there has been ‘ a consistent well trained and dedicated staff team who have developed positive relationships with people who use the service.’
Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 19 There are always sufficient support workers on duty to provide support for individuals. Levels of support are increased for planned outside activities and holidays. In staff surveys it was noted that one member would like to see rotas developed so activities could be ‘ more spontaneous’ and ‘they would like some more time to carry out administrative tasks. Files confirmed that support workers have completed induction and other core training. Training is available for all support workers and staff confirmed that they receive good support from management. The AQAA confirms that there are ‘Regular supervisions and staff have a ‘yearly Performance development review’. 66.6 of the permanent staff team hold National Vocational Qualifications (NVQ) at level two or above with a further member current completing a NVQ level 2 course. All mandatory training is completed and updated. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. The service is managed in the best interests of people who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been a change of manager since the last inspection. The Annual Quality Assurance Assessment has been returned and contains clear data in support of the inspection. The new manager has demonstrated that they have been able to reflect of the service’s practices and make development plans with people who use the service and the support staff. A comprehensive quality assurance system is in place that records the view of people using the service and families. The manager confirmed that regular quality checks are completed ‘The registered manager completes a Monthly compliance sheet which helps to assure quality and checks that all standards are being met on a monthly basis this includes health and safety checks.
Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 21 Senior manager as part of the quality assurance system also visits the home. The manager was able to provide evidence that health and safety checks are well managed. Files contained risk assessments to minimise risks for individuals. Support workers receive updates on all health safety training with files containing copies of manual handling, first aid, fire & food safety certificates. Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Wales Street DS0000012949.V372278.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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