Inspection on 15/05/08 for 16 The Slieve

This is the latest available inspection report for this service, carried out on 15th May 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.

Similar services:

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 27/09/2008.

CARE HOME ADULTS 18-65 16 The Slieve Handsworth Wood Birmingham West Midlands B20 2NR Lead Inspector Kerry Coulter Unannounced Inspection 15th May 2008 09:10 16 The Slieve DS0000071277.V364829.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 16 The Slieve DS0000071277.V364829.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. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 16 The Slieve Address Handsworth Wood Birmingham West Midlands B20 2NR 0121 507 1939 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) enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Ms Sonia Gordon Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only; Care Home Only (Code PC) To service users of the following gender female Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability (LD) 4 The maximum number of service users to be registered is 4. Date of last inspection Not applicable. Brief Description of the Service: 16 The Slieve is a large detached house situated at the end of a wellmaintained cul-de-sac in the centre of Handsworth Wood. The house has been extended and adapted to meet the needs of adults with learning disabilities and some physical disabilities. Three of the four bedrooms are situated on the ground floor, and the fourth on the first floor. There are appropriate bathing and showering facilities on both floors, which are accessible to people who live there. The home offers accommodation, which includes a communal lounge, dining area; kitchen and well maintained gardens to the back of the home. The service users guide recorded that the fees that are charged to live at the home are £1406.50, however this is based on information dated 2005. The reader may want to obtain more up to date fee information from the care service. Copies of CSCI inspection reports are kept in the home’s office. These are available on request. 16 The Slieve DS0000071277.V364829.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 two stars. This means the people who use this service experience good quality outcomes. The visit was carried out over one day; the home did not know we were going to visit. This was the homes key inspection for the inspection year 2008 to 2009. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and the manager completed a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Survey forms were received from one person who lives at the home and three relatives, some of their comments are included in the report. Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The people who live at the home, the manager and staff on duty were spoken to. Some people living at the home were unable to fully communicate their views about the service. Therefore time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. The home is owned by Bromford Housing Association and managed by Lonsdale (West Midlands). Previously Bromford were the registered providers however the home was reregistered in December 2007 and Lonsdale are now the registered providers. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The service user guide needs to be updated to make sure it reflects the current fees for living at the home, so that people have all the information they need. Individual fire risk assessments should be improved to take into account people’s mobility needs or ability to hear the fire alarm, to ensure they are kept safe should a fire occur. Where handwritten amendments to the directions on medication administration records, these should be signed by two staff to ensure the amendments are accurate. A copy of the complaints procedure should be on display in the home so that all visitors know how to make a complaint. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 7 A review of the staffing arrangements is needed to ensure there are enough staff on duty at all times to meet people’s needs. The area manager should visit the home monthly and write a report about the home, to make sure it is being well run. 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. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 8 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 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 9 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 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have most of the information they need so they can make a choice as to whether or not they want to live there. EVIDENCE: People were seen to have a copy of the statement of purpose and service user guide in their bedroom. The service user guide included information about the home to include staffing arrangements, the complaints procedure. Some of the information was in picture form so making it easier for people to understand. A licence agreement detailing the fees to live at the home was included in the guide. However the information regarding fees was dated 2005 and so needs review to make sure that people have up to date information. The Annual Quality Assurance Assessment (AQAA) was completed by the manager before the inspection visit. This recorded that ‘The home operates a thourough admissions process, which spans over several weeks, from the initial referall through to the admission. The potential individual can expect an off site assessment, several visits to the home ranging from day to overnight stays and weekends experiencing a range of acitivites on each visit. We look at compatibility and consult and involve existing residents throughout the transition process. The individual can also expect a 4-6 weeks review to 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 10 discuss how the individual has settled and get feedback from the staff, social workers and family.’ The admission process was looked at the last inspection in June 2007 following the admission of a new person into the home. It was found at that inspection that the person had been fully assessed prior to them moving in to ensure that the home could meet their needs. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have most of the information they need in care plans and risk assessments so they know how to support individuals to meet their needs whilst ensuring their safety and well being. The people living there are usually supported to make choices and decisions about their day-to-day lives. EVIDENCE: The care provided to two people was case tracked. Each person had an individual care plan that detailed how staff are to support the person to meet their needs. These included areas of supporting the person with their personal care, self-help skills, eating and drinking, mobility, health needs, finances, contact with their family and friends, communication and leisure opportunities. Plans contained information about people’s likes and dislikes and personal preferences so that staff had information about how people like to be supported. Where people are able to they had signed their care plan to say that they agreed to it. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 12 Plans sampled were detailed and had been regularly reviewed to make sure the information was up to date. Review meetings had been held for both individuals who had been given the opportunity to attend the meetings along with their relatives. Throughout the inspection staff were observed to encourage people to make decisions about things such as what time to get up in the morning, what they wanted to drink and if they wanted to go out. Care plans recorded some decision making by people, for example if they wanted a key to their bedroom or if they wanted to vote in local elections. One person has a monitor located in their bedroom so that staff can hear if they have a seizure and provide support. The care plan does record the use of the monitor but it was not clear if the individual had consented to its use, as it affects their privacy. A recent quality and performance report completed by the provider also recorded that a consent form was needed for the use of the monitor. Key workers had met with the individual monthly to consult with them about things they would like to do, records are kept of the meetings. One record that was sampled said that the individual had said they would like their hair cut and styles, as a result a hair appointment had been booked for the individual. Group meetings had been held with the people living there on a regular basis. People had talked about activities, holidays, the home, the complaint procedure and birthday celebrations. Records included individual risk assessments. These detailed how staff are to support the person to be as independent as possible whilst minimising any risks to their health, safety and welfare. Risk assessments had been regularly reviewed and updated if necessary. Risks that had been assessed included manual handling, falls, choking, bathing, using the kitchen and accessing the community. Each person had an assessment regarding fire but they were very similar for each individual. One persons assessment did not take into account their mobility needs or ability to hear the fire alarm at night when not wearing their hearing aid. The assessments should be reviewed so that they are more specific to the individual to make sure people are moved as quickly and as safely as possible should a fire occur. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at the home experience a meaningful lifestyle and are offered a healthy diet that they enjoy. EVIDENCE: The two people who were case tracked had an individual activity programme, this had been written containing information from the assessments of needs, which did record their choices, likes and dislikes with regard to social occasions, pastimes and hobbies. For both individuals the majority of planned activities took place within the home. Care plans and discussions with staff indicate that for one individual this is due to their current health needs and for the other individual it is due to personal choice. Activities on offer to people include walks, progressive mobility, visits to the library, shopping, cinema, college and lunch out. One person is going to the theatre in September. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 14 Activities that people would like to do are discussed with people at group meetings and on a weekly individual basis when activity programmes are agreed. One person has recently said they would like to go bowling and staff said they will be arranging this soon. Staff rotas showed that during the morning shift there are three staff on duty, yet only two in afternoon. The manager and deputy said that if more staff were needed to enable community activities to take place then extra staff would be put on the rota. However these arrangements would not ensure there would be enough staff if people decided to go out on the spur of the moment. This is further reported upon in the staffing section of this report Holidays have been planned for people. One person is going to Chester, another person said they were going to Spain soon and was really looking forward to going on an aeroplane. They said they had already been shopping with staff to buy some new clothes for their holiday. During the morning of the inspection visit one person went out with staff to post a letter they had written to a relative, another person was relaxing in the lounge reading a newspaper. One person was being supported in the kitchen to make a cup of tea. Staff said that activities in the afternoon were limited due to a staff meeting taking place however some people were seen colouring or helping out with the laundry. Most people have regular visits from their relatives or friends. Records sampled and discussion with the Manager showed that staff also support individuals to maintain contact with their family and friends through letters and phone calls. The people at the home plan the weekly food menu at meetings with support from the staff. Menus seen offered a healthy and varied diet. Staff advised that the menu could be changed daily if the people at the home did not want what was on the menu for the day. The cupboards, fridges and refrigerators contained a good supply of food so that options are available. One person spoken with said that ‘the food is good’ and confirmed they got a choice of what to eat. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal and health care support in the way they prefer and require so that their needs are well met. EVIDENCE: On arrival at the home we found that people who lived there were not yet up and dressed. Staff said this was because people were not going out that morning and they had chosen to have a lie in. Staff were later overheard assisting people to get out of bed and get dressed. Staff were heard to be verbally encouraging to people, lots of positive prompts were given in a friendly manner. All the people living there were clean, well presented and dressed according to their age, gender, the weather and the activities they were doing. People had individual styles of hair and dress. One person was wearing a necklace and earrings, this followed their care plan that said they liked to wear jewellery. One relative commented ‘my sister I feel is very well looked after’. Care plans sampled detailed how staff are to support individuals to meet their personal care and health needs. Personal files provided evidence that people 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 16 living in the house are supported to access primary health care and are referred to members of the multi-disciplinary team for specialist support as required. When people are unwell records show that advice is sought from the GP or other health professionals as appropriate. The outcome of health appointments that people had attended were recorded so that staff could follow any advice given. Care plans have been completed and kept up to date for people’s specific health needs, for example epilepsy. The home manages all medicines on behalf of the people who live there. Staff who administer medication have received training to do so, an assessment of their competence to administer medication is also undertaken. Each person had a medication administration record, detailing the name of their medication, when it is to be taken and how much. Staff had signed all medication administration records appropriately. On some occasions staff had made handwritten amendments to the directions on the records, these should be signed by two staff to ensure the amendments are accurate. Some people are prescribed PRN (as required) medication. Protocols were in place that stated when and why the medication should be given to the individual so it is not misused which could have a negative impact on the person’s health. One person at the home has epilepsy and is prescribed diazepam when required. The protocol for the its administration records that only one staff is trained to administer this and that other staff would need to call for an ambulance. The deputy manager said that an additional two staff had now received this training but were now awaiting assessment to ensure they are safe to administer it. One person who lives at the home has a serious illness, records show that health professionals are currently involved in this person’s care. The GP has recently referred the person to the hospital to see if further treatment is an option. Pain reliving medication has recently been prescribed and the use of stronger medication for the future has been discussed. A satisfactory care plan was in place regarding the illness so that staff have information on how to meet the persons needs. Care records were sampled to see if people had been consulted about their wishes on death, for one person a record of their wishes was available. For another person there was no record, the deputy manager said neither they nor their relative had been consulted as yet. Given the older age and health needs of some people who live at the home, staff should consult with people so that illness and death is dealt with how the individual would wish. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the people living at the home are protected from abuse, neglect and self-harm. EVIDENCE: The commission has not received any complaints or concerns about this home since it was reregistered in December 2007. The complaint log and discussion with the manager indicates that the home has not received any complaints directly. The home has a satisfactory complaints procedure, this is in an easy read format with some pictures, making it easier for people to understand. People are consulted to see if they have any complaints at some of the residents meetings. People have their own copy of the complaints procedure as part of the service user guide in their bedrooms. One person who lives at the home said they knew how to make a complaint. Relatives said they were aware of the complaints procedure and that the home responds to concerns. A copy of the procedure is not on display in the home, it is recommended that one is available so that all visitors to the home know how to make a complaint. Staff have completed training in adult protection and the prevention of abuse so they know how to protect the people living there from abuse, neglect and self-harm. Staff spoken with said they would always report any suspicions of abuse to the manager. The home has policies in place to protect people and also has a copy of the Birmingham multi agency adult protection guidelines. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 18 Systems are in place to safeguard the monies of people living at the home. Receipts for expenditure were available and numbered. Staff count and check the balance of monies held and checks of the money and records are also completed when a senior manager from Londsdale visits the home. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 19 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, 26, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: A lot of work had been done to improve the environment for the people living there. All communal areas and some bedrooms had been redecorated, it was homely in style with ornaments, pictures and photographs of the people who live there on display throughout the home. The lounge is not that large, this will need monitoring to ensure the space continues to meet people’s needs as one person uses a waling frame. This means there would be little space left if other people needed such aids in the future. One person who lived at the home let us look at their bedroom, they said they were happy with their room. It was personalised according to individual needs, culture, gender and preferences. Décor, furniture and bedding was seen to be in good condition so that it was a nice room to spend time in. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 20 New kitchen flooring has been fitted as previously the flooring was raised where it had been joined and this presented a risk to the safety of all people who are in this area. New dining chairs have been purchased recently, this means that the kitchen and dining area are now in good order providing a safe environment for people. People have most of the aids they need to be as independent as possible. Staff call bells are fitted in bathrooms and bedrooms so that people can call for assistance if they need it. Grab rails are fitted by toilets and the bath can be raised or lowered so that people can get in and out safely. New hand rails have been fitted in the hallways, staff said this was following advice from the physiotherapist that these would aid one person’s mobility. As stated earlier in this report one person has a listening monitor in their bedroom so that staff can hear if they have a seizure and come to their aid. Consideration should be given to other types of equipment that would give the person more privacy and independence. It is recommended that staff consult with the epilepsy nurse to ensure they have the right equipment to meet the person’s needs. The home was clean and free from offensive odours throughout. Hand wash and hand towels were provided in all toilets and bathrooms to minimise the risk of cross-infection. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are generally sufficient to ensure that an effective, competent and supervised staff team who can meet individual’s needs support them. The people living there are protected by the home’s recruitment practices. EVIDENCE: Support to people is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Members of staff demonstrate that they have a good personal knowledge of the individuals in their care. The Annual Quality Assurance Assessment completed by the manager recorded that 90 of the care team are qualified to the appropriate National Vocational Qualification or equivalent. Two staff who work at the home are qualified nurses. This ensures that care staff have the skills and knowledge to meet the needs of the people living there. One relative commented ‘I am happy with all the staff’. One person who lives at the home said that staff always treated them well and listened. Discussion with the manager and sampling of staff records shows that people are supported by a staff team who know them well. No new staff have been 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 22 recruited to the home since the home was reregistered. There are normally three staff on duty in the morning, two in the afternoon and at night one waking and one sleeping in to provide support to the people who live at the home. Staff spoken with said that the staffing levels generally met peoples needs. However it was not clear if two staff in the evenings were enough to enable people too go out regularly. The provider’s quality and performance report recorded that the current staffing arrangements did not meet people’s needs. Unfortunately the report did not detail why. The manager was asked what this referred to and said it was about having a manager covering two homes. A review of the staffing arrangements is needed to ensure they meet people’s needs. Recruitment information for three members of staff were looked at. These provided evidence of an appropriate process, and necessary information was in place on files, as required to ensure people are protected from having unsuitable staff working with them. Records of training that staff have received are kept and were generally up to date. Staff spoken with indicate they are satisfied with the training they receive. Staff have received training in food hygiene, manual handling, adult protection, infection control, first aid and fire safety. Some staff have also done training in epilepsy, dementia and healthy eating. There is a rolling programme of training and records showed that some staff had been booked to do refresher medication training, dementia, autism, bereavement and the Mental Capacity Act. Minutes of staff meetings showed that these are held regularly and one was arranged for the afternoon of the inspection visit. This ensures that staff are aware of any changes to individual’s needs or within the organisation that will affect them or the people living there. Most staff have regular supervision but records showed that for a minority of staff the frequency needs to be improved. This will ensure that staff are well supported in their role and their training and development needs can be identified. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 23 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, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the people living in the home generally benefit from a well run home. EVIDENCE: The manager of the home is registered with the commission. In addition to managing 16 The Slieve she also manages another small home on the same road. Consequently she splits her time between both homes. A deputy manager is in post who has some responsibilities for completing records such as care plans. The rota showed that the deputy does not have any specific time delegated for undertaking these tasks. It would be beneficial if the deputy manager was allocated some days on the rota for undertaking management tasks. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 24 The manager demonstrated a good knowledge of peoples needs throughout the visit. The annual assessment form (AQAA) was completed to an adequate standard by the manager and received on time. All staff spoken with said that the manager was very approachable and they would feel confident in raising any concerns with her. The home has quality assurance systems in place and these are being improved so that they involve people who live at the home more. The manager said that the provider is setting up a residents forum to involve people in getting their views of the service. Questionnaires are also being sent out to people who live at the home and their relatives. The provider has completed a quality and performance report for the home identifying areas where improvements are needed. This includes staffing arrangements and more community access for people who live at the home. Some areas identified for improvement have been completed already, such as new dining furniture. The manager said that an area manager for Lonsdale visits the home regularly. However since the home was reregistered in December 2007 there was only one report for April available. Monthly monitoring visits of the home should take place with a report available so that the provider ensures it is being well managed. Staff at the home complete regular health and safety audits to make sure that people are safe. Staff test the fire equipment regularly to make sure it is working. An engineer regularly services the fire equipment to ensure it is well maintained and in good working order. A fire drill to ensure staff know how to respond in the event of a fire occurring had taken place in February. The landlord’s gas safety certificate was in date to show that gas appliances are safe. Certificates were available to show that portable electrical appliances had been checked. The electrical hard wiring certificate showed that electrical installations were safe. Staff test the water temperatures weekly to make sure they are not too hot or cold and so people are not put at risk of being burnt. Staff test the fridge and freezer temperatures daily to make sure they are within the limits for safe food storage. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 25 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 2 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 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 2 3 3 2 X X 3 X 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Not applicable as first inspection since home reregistered. 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. 1 2 3 Refer to Standard YA1 YA7 YA9 Good Practice Recommendations The service user guide needs to be updated to make sure it reflects the current fees for living at the home, so that people have all the information they need. The use of the listening monitor should be agreed with the person and a record kept of their agreement in their care plan. The individual fire risk assessments should be improved to take into account people’s mobility needs or ability to hear the fire alarm, to ensure they are kept safe should a fire occur. Where handwritten amendments to the directions on medication administration records, these should be signed by two staff to ensure the amendments are accurate. Given the older age and health needs of some people who live at the home, staff should consult with people so that illness and death is dealt with how the individual would wish. A copy of the complaints procedure should be on display in DS0000071277.V364829.R01.S.doc Version 5.2 Page 27 4 5 YA20 YA21 6 YA22 16 The Slieve 7 8 9 YA29 YA33 YA36 10 YA39 the home so that all visitors know how to make a complaint. It is recommended that staff consult with the epilepsy nurse to ensure they have the right equipment to meet the needs of one person who has epilepsy. A review of the staffing arrangements is needed to ensure there are enough staff on duty at all times to meet people’s needs. The frequency of supervision for some staff needs to be improved. This will ensure that staff are well supported in their role and their training and development needs can be identified The registered provider’s representative should do monthly monitoring visits of the home so that they can form an opinion about the standard of care provided to people and produce a report on the outcome. The report of the visit needs to be available in the home. 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 © 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 16 The Slieve DS0000071277.V364829.R01.S.doc Version 5.2 Page 29 - 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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