Inspection on 23/07/08 for Florrie Robbins

This is the latest available inspection report for this service, carried out on 23rd July 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.

Other inspections for this house

Florrie Robbins 17/08/06

Florrie Robbins 09/02/06

Florrie Robbins 30/08/05

Florrie Robbins 17/02/05

Florrie Robbins 05/08/04

Florrie Robbins 28/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

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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 08/11/2008.

CARE HOME ADULTS 18-65 Florrie Robbins Penshurst Avenue Handsworth Birmingham West Midlands B20 3DQ Lead Inspector Kerry Coulter Unannounced Inspection 23rd July 2008 08:00 Florrie Robbins DS0000016728.V368951.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 Florrie Robbins DS0000016728.V368951.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. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Florrie Robbins Address Penshurst Avenue Handsworth Birmingham West Midlands B20 3DQ 0121 331 1817 0121 331 1817 alphonsusservices@hotmail.co.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) Mr Roger Murray Mr Paul Murray James White Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 25th July 2007 Brief Description of the Service: Florrie Robbins is registered to provide accommodation, care and support for up to five adults with learning disabilities. The property is a purpose built detached house lying to the rear of one of the Organisations other homes. The house is within walking distance of the centre of Perry Barr, and there is a wide range of community facilities in the area, including shops, pubs, restaurants and places of worship. Public transport links are particularly good, with a choice of several buses, and also a train station. The ground floor of the house is suitable for people with mobility problems. All of the single bedrooms have en-suite shower facilities and wash hand basins. Downstairs are two bedrooms, a lounge, dining room, and kitchen. There is also a bathroom and separate w.c. Upstairs there are three more bedrooms, another bathroom, shower room , and w.c., the laundry, and the office. There is limited off road parking at the front of the house, and a private small lawned garden to the rear of the property. The service user guide for the home records that the fees range from £1000 to £1400 ‘done on an individual basis after a full assessment of needs’. Copies of previous CSCI inspection reports are on display in the home for people who wish to read them. Florrie Robbins DS0000016728.V368951.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 inspection visit was carried out over one day, the home did not know we were coming. This was the homes key inspection for the inspection year 2008 to 2009. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) 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 provisions 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 an annual quality assurance assessment about the home (AQAA). We sent out four surveys to health professionals but did not receive any back. Eight surveys were sent to staff and one was returned to us. 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 visit started at 8am so that we could meet with people and observe staff interacting with them before people went out for the day. All people who live at the home were spoken to. Due to their communication needs most people who live at the home were not able to comment on their views. Discussions with two staff and the manager, a tour of the home and sampling of health and safety records also took place. What the service does well: Staff were observed to give support with warmth, friendliness and patience and treat people respectfully. When needed health professionals get involved to give advice and support so that individual’s health needs can be met. The home was clean and maintained to a high standard making it a nice place to live. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 6 People who live at the home all have their own bedrooms that are individual in style and contain their personal things. People are supported to keep in touch with their family so they do not lose relationships that are important to them. Robust recruitment practices are undertaken so that staff employed are suitable to work with vulnerable people. Regular health and safety checks are done to make sure that equipment is well maintained and does not put the people living there at risk of harm. What has improved since the last inspection? What they could do better: Person centred plans should show how people are being supported to achieve their goals. This will ensure that people are getting the support they need to do the things they want to do. The opportunities for people to take part in activities need to be reviewed so they can do the things they enjoy in the evenings and weekends. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 7 Menus need to be reviewed so that people are offered a healthy diet to maintain their well being. Where people have gained significant weight staff should consult with the dietician to ensure people are at a healthy weight. Visits to the home by the service manager and quality assurance assessments should be conducted at times when people are likely to be at home. This will help to ensure their experiences / views underpin the future development of the home. 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. Florrie Robbins DS0000016728.V368951.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 Florrie Robbins DS0000016728.V368951.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, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have most of the information they need to ensure they can make a choice about whether or not they want to live at the home. People have the opportunity to visit and to try out what the Home has to offer, to support decisions about placement. EVIDENCE: The statement of purpose for the home was on display and people who live at the home have a copy of the service user guide in their care plan file. Since the last inspection the guide has been reviewed so that it includes more pictures and is easier to understand. Information on fees has been added so that people have information about how much it costs to live at the home. The home currently has one vacancy but there have been no admissions to the home since 2003. The Annual Quality Assurance Assessment completed by the manager stated that all prospective service users would be fully assessed and that a trial period would be offered. The admission procedure records that that people have the opportunity to visit and stay over prior to making any decisions about placement. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 10 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 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 so they know how to support people to meet their needs and keep them safe so ensuring their well being. The people living there are usually supported to make choices and decisions about their day-to-day lives. EVIDENCE: The care plans for three people who live at the home were looked at. Previous inspections have identified that care plans should be developed so that they contain sufficient detail so that staff know what support to offer people. Plans have now been improved so that staff generally have the information they need so they know how to support people. Care plans provided information about how staff are to support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs. Information was generally person centred and included Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 11 information about peoples likes and dislikes. Plans did not have much information about people’s goals and aspirations for the future. One person had care plans that were in a different format to other people’s and these plans had a section for goals and aspirations but these had yet to be completed. The manager said that the format was new and that it was under discussion if the format would be used with everyone at the home. The annual quality assurance assessment completed by the manager acknowledged that care plans needed to be reviewed and updated to enhance goal setting for people. People who live at the home have significant communication support needs, so choices tend to be restricted to fairly simple things. Staff have monthly ‘residents meetings’ but participation from some people is limited due to their communication needs. The home is trying to improve methods of communication for people and everyone has had communication assessments completed by a speech and language therapist. Training is also arranged for staff on Makaton, a form of sign language as one person who lives at the home uses sign language as well as some verbal communication. Records and a receipt showed that one person had paid for a new carpet for their bedroom, this is something that the provider should normally pay for. The manager said that the new carpet was bought at the suggestion of the individual’s parents. He said there was nothing wrong with the previous carpet but the parent felt a red carpet would be a nicer colour. The manager said there was no records kept of this conversation. Detailed records are needed to show how this decision was reached and who was involved. Issues such as would the person be reimbursed or take the carpet with them should they move from the home could then be clarified. Records sampled included individual risk assessments. These detailed the support the person needed to be as independent as possible whilst minimising the risks to their safety and well being. Risk assessments had been regularly reviewed and updated where needed so that people were supported appropriately. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home would benefit from the range of activities available being developed so that they take part in activities at times similar to others of the same age, gender and culture. The people living in the home need to be offered a healthier diet to ensure their well being. EVIDENCE: People living in the home continue to access activities outside the home on a daily basis during the week, usually local day centres or the provider’s own day service. People had activity planners that recorded attendance at daycentre, but for evenings and weekends the plans were vague recording ‘in house activity or outing’. As identified at previous inspections records did not show that people had varied activities or accessed the community frequently. Daily records tend to be confined to things like watching TV, getting drinks, and assistance with Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 13 personal care. Separate activity records are kept and these were sampled for everyone at the home for May and June. These showed that people had been on occasional visits to the pub, parks, out shopping or for walks. Some people had been on a day trip to Weston and two people had been on holiday to Minehead. One person at the home said they had enjoyed their recent holiday. Consideration needs to be given to increasing the number of opportunities for evening and weekend activities in keeping with other people of a similar age so that people have an enjoyable lifestyle. The home is good at supporting people to maintain contact with their families. People’s care plans have information on how they are supported to maintain contact with family or friends. One person spends time at their parents home every other weekend. The manager said it had been one person’s 40th birthday so staff had taken him to see his parents and taken them some framed photos of him. We spent time with people whilst they had their breakfast. Everyone had porridge but it was not observed if people had been given a choice. People also had toast, but one person was given bread in line with their care plan as they are assessed as having dysphagia (swallowing difficulties). Often food records for breakfast just said ‘cereal’ so it did not show if people were able to choose different cereals or if everyone had the same thing. For main meals records showed that people all usually have the same meal, but records show that the meals are chosen by people in advance. One staff said the menu is based on people’s likes and dislikes, food is put in front of people to choose from, ‘they will tell you what they want’. Records did not show that people are offered a healthy diet and some people at the home have put on a significant amount of weight in the last six months. Whilst people are offered fruit juice at breakfast and fruit is available to them people have meals that are not always nutritionally balanced. For example in May / June people had chips with their meal 10 days out of 17. A lot of meals were either processed foods or takeaway such as southern fried chicken, sausages, faggots, pizza, fish fingers and grill steaks. The menu’s need to be improved so that people are offered a healthy balanced diet. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 14 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. The personal care and health needs of the people who live there are generally met so ensuring their well being. EVIDENCE: The people living there were well dressed in individual styles of clothing that were appropriate to their gender, age, the weather and the activities they were doing. Staff were directly observed interacting with people who live at the home: their manner was warm and friendly, and support is given in an appropriately respectful manner. Since the last inspection care plans have been improved so that they include more information on people’s personal care needs and preferences. Records sampled showed and staff said that a range of health professionals are involved with individuals where needed to ensure their health needs are met. Records sampled included an individual Health Action Plan. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. The format of the plans has been improved and plans now detail the frequency that people need to attend appointments such as the Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 15 dentist or optician. Records sampled showed that people have regular check ups with the dentist and optician where necessary to ensure they keep healthy and action can be taken if a person’s health is deteriorating. Staff at the home regularly monitor peoples weight. For two people records showed that they had gained over a stone in weight in six months. It was not clear if people were still at a healthy weight as their ideal weight range was not recorded in their health plans. However the annual quality assurance assessment completed by the manager did record that the home intended to implement the use of a nutritional screening tool. One staff said that one person had gained weight recently and so was on a healthier diet, but food records did not show this. Where people have gained significant weight staff should consult with the dietician to ensure people are at a healthy weight. Staff at the home who administer medication have been trained to do so, some staff have had refresher training this year. The home have reported one incident to us where someone was given too much medication in error. The home has taken appropriate action to reduce the risk of this happening again. An audit of the homes medication administration systems has recently been undertaken by the local Primary Care Trust. This found that generally systems in the home were good. The home retains copies of prescriptions so that staff can check the correct medication has been received from the pharmacist. Medication Administration Records (MAR) sampled included a photograph of the person at the front so if unfamiliar staff were giving medication they would know who to give it to. MARs had been signed appropriately indicating that medication had been given as prescribed. The manager had made some amendments to some MARs, the amendments appeared to accurately reflect what had been prescribed. However, it is good practice when making amendments for these to be checked and signed by two staff to ensure they are accurate and people are not put at risk of getting the wrong medication. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 16 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. Appropriate complaints procedures are in place and staff generally have the knowledge and skills they require to protect people from the risk of harm in the event an allegation was made. EVIDENCE: We have not received any complaints about the home in the last twelve months and the home has not received any complaints directly. People who live at the home have a copy of the complaints procedure, this has been improved since the last inspection so that it includes photographs, making it easier for people to understand. As previously recommended a copy of the complaints procedure has been put on the notice board in the hallway, this ensures that visitors to the home have access to the procedure. Staff have completed training in the protection of vulnerable adults and policies and procedures to include whistle blowing are readily available to them. Staff spoken with knew what to do to keep people safe if they had suspicions of abuse occurring. An up to date inventory of people’s belongings is maintained so that staff can track if anything has gone missing and people’s property is looked after. The home holds people’s personal money on their behalf, the finance records of two people were sampled. Receipts were available to evidence any expenditure. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 17 Recruitment records sampled showed that a robust procedure is followed for the protection of people living in the home. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 18 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, 27, 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 tour of the building was completed. The house is maintained to a high standard, and kept clean, tidy and hygienic. Its good that staff undertake a weekly check of the premises so that anything that needs repairing is identified. The maintenance book for the home shows that any repairs are quickly attended to. Since the last inspection the dining room has been redecorated and some new carpets fitted. The lounge is on the small side but as the home has only four people living there at the moment this appears to comfortably accommodate the number of people at the home. All areas of the home were observed to be in good decorative order and homely in style. The kitchen is in good order and was very clean, however it is small in size and would lack space for more than two people to be in there at a Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 19 time. The home has recently been visited by an environmental health officer and has been awarded an ‘excellent’ rating for its food hygiene standards. Satisfactory hand washing facilities were observed in the bathrooms, laundry and kitchen. People’s bedrooms are individual in style and include personal belongings and ornaments reflecting peoples age, gender and culture. Individuals benefit from the provision of en-suite facilities in their rooms, enhancing their privacy and independence according to individual needs. Where needed people have level access to showers and grab rails fitted to walls. At the time of the visit work was being undertaken in the garden to install raised beds, the manager said these will make it easier for people to get involved in gardening activities. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 20 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. The arrangements for staffing, their support and development ensure that the people living there are well supported by staff that know them well. EVIDENCE: Direct observations of staff interactions with people who live at the home provide evidence that they have a good relationship with people in their care and a good general understanding of their needs. It is good that all of the staff team with the exception of one new staff have completed the Learning Disability awards Framework (LDAF) training. Previous inspections have identified that not enough staff have a National Vocational Qualification in care and that progress towards this was slow. This has now improved and the home is using external NVQ assessors and more staff have now completed this qualification. This means that staff have the skills and knowledge to meet the needs of the people living there. Current staffing levels in the home are generally three staff in the morning Monday to Friday and two or three staff in the afternoons when everyone is at home. Staffing in the afternoons has increased a little since the last inspection Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 21 as there were usually only two staff on duty. At weekends there are usually two staff on duty. Every other weekend one person goes to stay with there parents so two staff meets peoples needs. Consideration could be given to sometimes having three staff when everyone is at home as this would mean there would be more staff to take people out. The Annual Quality Assurance Assessment completed by the manager records that the home is currently in negotiations with Social Services for more funding for staffing. Two new staff have started working in the home since the last inspection, one who had transferred from another of the providers homes. Their records were sampled. These included the required recruitment information including evidence that a satisfactory Criminal Records Bureau (CRB) check had been completed. This helps to ensure that ‘suitable’ people are employed to work with the people living there. Staff spoken with said they get the training they need, one commented that training had improved. The training matrix for the home shows that staff get the training they need to meet peoples needs. This includes training in food hygiene, first aid, medication, adult protection, epilepsy, fire, autism and health and safety. Makaton training (sign language) is arranged for staff so that they will have the skills to communicate effectively with one person who uses Makaton. The training manager is putting together a training package for staff on the Mental Capacity Act. This legislation requires an assessment of people’s capacity to be done if there is any doubt that the person does not have the capacity to make a decision about their health and welfare. If they are assessed as not having the capacity an Independent Mental Capacity Advocate (IMCA) can be appointed to help them with this. All staff should be aware of this so that if a person living there needed to make a decision an assessment could be done and they could receive appropriate support if they do not have the capacity. Staff meetings are generally held monthly and formal supervision for staff is regularly scheduled so that staff receive the support they need to carry out the job and receive feedback on their performance. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 22 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. The management arrangements ensure that the people living there benefit from a well run home and their health, safety and welfare is promoted and protected. EVIDENCE: The manager is has the right experience to manager the home and is qualified to NVQ level 4 and holds the Registered Manager’s Award. The manager completed the Annual Quality Assurance Assessment and sent it back to us on time. Requirements made at the last inspection have been met so that outcomes for people at the home have improved. Two staff were spoken with about the management arrangements at the home. Their comments included ‘one of the best places I’ve worked, if I ask for Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 23 something I get it, the manager is very approachable’ and ‘the home is 100 better than when I started, its down to the manager, he is very approachable’. Quality assurance systems are in place. The service manager visits the home and writes a report of their visit to ensure the home is being well managed. Reports provided showed these visits are generally done monthly. Annual audits are also completed. Observation of the last annual audit and recent monthly visit reports showed these had all been carried out when people who live at the home are out. Whilst people’s communication is limited and they may not be able to communicate their views of the service observation of staff interactions is important to make sure that people are happy. Timings of visits needs to be looked at and take into account that people attend day centres during the day. Due to peoples level of understanding and communication needs it is difficult for them to complete satisfaction surveys. Where people have relatives or advocates they have been sent surveys in April 2008. Two had been completed and neither raised any concerns about the home. A number of checks are undertaken regularly by the home to make sure that the health and safety of people living there is maintained. A number of these were sampled. The temperature of the water is usually monitored weekly to ensure it will not pose a risk of scalding to people. Fire records showed that a risk assessment is in place so that the risks of there being a fire are minimised as much as possible. Staff have fire safety training so that they know what to do in the event of a fire. Staff regularly test the fire equipment to make sure it is working. An engineer regularly services the fire equipment to ensure it is well maintained. Certificates were available to show that gas and electrical installations had been checked to make sure they were safe. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 24 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 3 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 3 28 X 29 3 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 2 X X 3 X Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Refer to Standard YA6 Good Practice Recommendations Person centred plans should show how people are being supported to achieve their goals. This will ensure that people are getting the support they need to do the things they want to do. Where decisions are made on behalf of people records need to be available to show the decision has been made in the best interests of the person and has involved an independent mental capacity advocate (IMCA) where needed. People should have more opportunities to take part in activities at times valued by others of a similar, age, gender and culture to ensure they have a good lifestyle. The range of activities available to people to participate in within the community should be expanded and reflect individuals taste and interests. Menus need to be reviewed and staff need to encourage the people living there to eat a healthy diet. This will help to ensure that individual’s health needs are met. DS0000016728.V368951.R01.S.doc Version 5.2 Page 26 2 YA7 3 4 5 YA12 YA13 YA17 Florrie Robbins 6 7 YA19 YA20 8 YA39 Where people have gained significant weight staff should consult with the dietician to ensure people are at a healthy weight. When making amendments to medication administration records these should be checked and signed by two staff to ensure they are accurate and people are not put at risk of getting the wrong medication. Visits to the home by the service manager and quality assurance assessments should be conducted at times when people are likely to be at home. This will help to ensure their experiences / views underpin the future development of the home. Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 27 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 Florrie Robbins DS0000016728.V368951.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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