Inspection Report on 71 Partridge Road Cardiff Date of Publication Friday, 2 June 2017 Welsh Government Crown copyright 2017. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk You must reproduce our material accurately and not use it in a misleading context.
Description of the service 71 Partridge Road is registered with Care and Social Services Inspectorate Wales (CSSIW) to provide personal care and accommodation on a respite basis for people over the age of18 whose primary need is their learning disability. The registered provider is Mirus Wales and the registered manager is Justine Tickner. There is a nominated responsible individual to represent the company and oversee the operation of the home. Accommodation and facilities are provided in a detached three bedroom property in the village of Roath. Local shops, pubs and a park are within walking distance and the centre of Cardiff is a short bus ride away. The home has four bedrooms, three guest bedrooms and 1 staff seep over room and a communal bathroom; people have access to two communal areas were they can watch television and there is an open plan kitchen. Summary of our findings 1. Overall assessment 71 Partridge Road provides people with short-term, time-limited breaks away from their family home. People are supported in an environment were they are made to feel at home by a stable staff team who know them well. Whilst at respite people continue to attend day service and are supported to continue to attend groups in the evenings and weekends; this provides people with continuity. The service has a number of checks in place to ensure that people receive a good quality service and there is a commitment to continually improving and developing to benefit those using the service. 2. Improvements People s care files were well organised and care documentation reflected people s personalities and individual likes and dislikes. The service has secured a transport budget to allow people to access the community. The service has a link worker who is nominated to become an inclusive communication co-ordinator. 3. Requirements and recommendations Section three of this report sets out the actions the service provider needs to take to ensure the service meets the legal requirements and it makes recommendations to improve the quality of the service. We made one legal requirement and three recommendations. Page 1
These included the following: Window restrictors need to be in place and working in on all windows above floor level. An up to date local authority assessment needs to be in peoples care files, this should inform the person s care plan. Care documentation needs to be dated to reflect that care plans are up to date and have been reviewed at the required frequency. Total communication training should be delivered for staff and implemented in practice. Page 2
1. Well-being Summary People are supported in an environment were they are made to feel at home, feel comfortable and relaxed. There are positive interactions between staff and guests. The staff demonstrate a good understanding of the needs of the guests being supported in the home. Updated information is provided prior to each visit, which helps inform staff about changes in need and how each person needs to be supported. Our findings Staff have all the information they need to support people well. Although we would recommend that documents are clearly dated and signed. People are supported by a stable staff team of ten, we observed staff interactions on the day of the inspection an found them to be kind and respectfully.. We observed people being relaxed and assisted by staff who clearly knew their needs, likes, dislikes and personal routines. This was also reflected within the care documentation that we reviewed. We were told that prior to a person coming into the service for respite, updated information was provided either verbally or in writing to inform the service about changes in need. This included changes to medication, health and changes to support needs. On the whole comments from relatives were positive. One person we spoke to told us that the service is fantastic. I don t know what I would do without it and another told us I have every faith in the service. However, relatives did comment that it would be beneficial to offer more activities and two relatives spoke about the need for new staff to be familiar with people s care needs. However people generally receive the right care at the right time. People are encouraged to be involved in communal and community activities if they want. The manager said that following feedback within their annual feedback questionnaire, they were looking at ways they could improve activities offered to people. This included a taxi account to allow people to access community activities and a list of activities for people to consider. We saw the latter on the day of the inspection and would recommend that an easy read version is provided; this will allow people to have greater understanding of what is available. During the inspection people had a relaxing evening at home with one person watching television and another using the computer, one person told us that he regularly went swimming whilst attending respite. This was also supported during our discussion with the manager who told us that generally people choose to send time at home relaxing during week days, unless people have clubs that they regularly attend. We were told that during weekends people are offered a variety of activities. Therefore, people have opportunities to do things that are important to them. Page 3
2. Leadership and Management Summary The service is well run and has processes in place to ensure external scrutiny by someone who is not the manager, this supported an ethos of continual improvement. The manager manages two respite services and is supported by a deputy manager in both. Our findings The service is well run and seeks to continually improve and reflect on what they provide. We saw there were clear management systems in place, and a manager and deputy manager at the home. Whilst the manager was based in another service, they told us that they regularly visit the home, carry out staff meetings and do a large amount of supervisions and staff appraisals. We found that the manager had a good knowledge of the service and the needs of people that were being supported. Staff who we spoke to commented that the manager was approachable and felt confident to raise any concerns or issues with her. We reviewed the homes quality assurance system and found the home s senior management reviewed the quality of the service on a monthly basis. This included reviewing care documentation, observing practice and speaking to both guests and staff, alongside reviewing the quality of the environment including health and safety checks, this was generally robust; however we did pick up during the inspection that one of the window restrictors within the bathroom was no working, we addressed this with the manager who has advised that action has been taken. We found that the views of people and their relatives were sort as part of the home s annual Quality Assurance report, which was last published in April 2016. The report expressed a high level of satisfaction however did note that work was needed in expanding activities that people were offered. As a result the service developed a clear action plan. During discussions with the manager we were told how the home is piloting alternative ways to provide respite care and one option being explored was taking someone to a holiday camp. From what we saw and were told we concluded that the service is well run and is always seeking to improve the service it offers. Staff are well supported, trained and treated with respect. We were told that staff received a robust induction which included training and a period of two weeks shadowing. We observed the staff training matrix and found that alongside mandatory training staff also received specialist training that reflected the needs of the people living in the home and included behaviour management, epilepsy, autism and sexuality. Staff that we spoke to during the inspection confirmed that the service had good training, felt supported and they told us how they received regular supervision. We were told that training was revisited every three years to ensure staff were up to date and to capture changes in practice. During our discussions with staff they confirmed how they worked well as a team and felt respected and listened to by the manager. We found that this had a positive effect on staff sickness, which we observed was low. People therefore are supported by a committed and well trained staff team. The service has clear visions and values. We reviewed the home s Statement of Purpose and Quality Assurance reports. These expressed clear aims and values which included Page 4
ensuring people s lives were fulfilled, that people had control over their lives and reflected the services commitment to continually learn and improve. We generally found that the service s Statement of Purpose provided people with the required details including the size of the service, the skills and experience of staff providing support, information about activities and how to raise any complaints. The Statement of Purpose would benefit from being updated to reflect the facilities in the home including any equipment used, provision of meals, laundry management, fire precautions, therapeutic support and how the home meets people s spiritual, cultural, religions and communication needs. Nevertheless people are able to make an informed decision about the service as they are provided with the information they need to do so. Page 5
3. Improvements required and recommended following this inspection 3.1 Areas of non compliance from previous inspections There were no areas of non compliance issued at the last inspection. 3.2 Areas of non compliance identified at this inspection Regulation 13(4) The window restrictor on the bathroom window were not working. Therefore reasonable measures had not been taken to ensure that the home was reasonably and practicable free from hazards. We did not issue a non compliance notice on this occasion because the registered manager confirmed that appropriate action had been taken. 3.3 Recommendations for improvement An up to date local authority assessment needs to be in people s files, this should inform the person s care plan. Care documentation needs to be dated to reflect that care plans are up to date and have been reviewed at the required frequency. Total communication training should be delivered for staff and implemented in practice. Page 6
4. How we undertook this inspection We undertook a focused inspection of the service looking at wellbeing and the quality of leadership and management. During the inspection we spoke to; Two people being supported in the service; Four staff including the manager and deputy manager; Three relatives. We looked at; Two care records of people using the respite service; The Statement of Purpose and Service User Guide; The annual Quality Assurance Report; The medication policy; Staff training; Review of one weeks staff rota s; Compatibility assessment. In addition, we Toured the home; Reviewed medication practice; The Short Observation Framework for Inspection (SOFI) was not used during the inspection as people were able to tell us their views about the service. The SOFI tool enables inspectors to observe and record care to help us understand the experiences of people who cannot communicate with us. However, observations were noted. Further information about what we do can be found on our website www.cssiw.org.uk Page 7
About the service Type of care provided Registered Person Registered Manager Adult Care Home - Younger Mirus-Wales Justine Tickner Registered maximum number of places 3 Date of previous CSSIW inspection 05/06/2015 Dates of this Inspection visit 16/03/2017 Operating Language of the service Does this service provide the Welsh Language active offer? English No Additional Information: