Inspection on 16/04/08 for 10 Roundlea Road

This inspection was carried out on 16th April 2008.

CSCI found this care home to be providing an Excellent 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

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 19/07/2008.

CARE HOME ADULTS 18-65 10 Roundlea Road 10 Roundlea Road Northfield Birmingham B31 1DB Lead Inspector Gerard Hammond Key Unannounced Inspection 16th April 2008 09:00 10 Roundlea Road DS0000070316.V362429.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 10 Roundlea Road DS0000070316.V362429.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. 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10 Roundlea Road Address 10 Roundlea Road Northfield Birmingham B31 1DB 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) FCH Housing and Care Mrs Rebecca Young Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 10 Roundlea Road DS0000070316.V362429.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, to service users of the following gender: either, whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD, maximum number of places 4 of the following age range: from 18 years of age and above. The maximum number of service users to be accommodated is 4. 2. Date of last inspection Not applicable Brief Description of the Service: 10 Roundlea Road is registered to provide accommodation, care and support for up to four people with learning disabilities. The service is run by Friendship Care and Housing, an established provider of care and support for people with learning disabilities in the Midlands. The current group of residents is all male. They have been together for several years and moved to the house in 2007, after it was refurbished specifically to meet their needs. The house is a large two-storey detached property. It is situated in the Weoley Castle district of Birmingham and the area is well served by public transport. There are local shops and a post office in the immediate neighbourhood. On the ground floor of the house is a roomy kitchen leading onto the main living / dining room area. A smaller lounge area is situated off this room, and the garden can be accessed from here via French doors. On this floor there is a level access shower room with WC, another separate WC, a laundry room and a small room used as the office and staff sleep-in room. The upper floor can be accessed by stairs or via the full sized passenger lift. All four single bedrooms are on this floor, together with an assisted bathroom fitted with ceiling track hoist, separate WC and another room currently used for storage. There are no vacancies currently. Information relating to fees and charges should be gained directly from the home. 10 Roundlea Road DS0000070316.V362429.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 3 stars. This means the people who use this service experience excellent quality outcomes. This was the home’s first key inspection for the current year 2008-9. Information was gathered from a range of sources to inform the judgements made in this report. The Manager completed an Annual Quality Assurance Assessment and sent it to us. Previous inspection reports (before the service relocated) and notifications that the service has sent us during the year were reviewed. We visited the home and met with the residents. Unfortunately their learning disabilities and communication support needs meant that it was not possible to seek their views directly. We also spoke directly with the Manager and members of the staff team, and to the relatives of two of the residents over the telephone. We were able to directly observe staff supporting the people in their care. We looked at records including personal files, care plans, staff files, safety records and other documents. A tour of the building was also completed. Thanks are due to the all the people who live at Roundlea Road, the Manager and staff, for their co-operation and support throughout the inspection process. What the service does well: What has improved since the last inspection? 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 6 (This is the first inspection of this service since this home opened in 2007. The move to this newly refurbished property has provided the residents with a much better home environment more suited to their individual care needs.) What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to help them decide if the service is right for them. Their needs are assessed so that their care and support can be properly planned. They have written contracts so that everyone can be clear about what the service should provide. EVIDENCE: Before moving to Roundlea Road all four residents lived together for a number of years in another house in the West Heath area. The physical environment of their former home presented specific problems in meeting their care needs, so action was taken to provide more suitable accommodation. The current house was extensively refurbished so that people’s needs could be more appropriately met. The residents and staff team moved into the new house in the autumn last year (2007). The Manager said that every effort was made to involve people as much as possible in the move to their new home. They were taken to visit the house on a number of occasions, so that they could see the work in progress. One of the residents is a wheelchair user, so he went there specifically to test out getting around the house in his chair, to make sure that it was manageable. Another of the residents was in hospital while work was going on, so staff made up a “scrapbook” of information and photographs for him, so that they could show him how the work was progressing. The Manager said that all of the residents 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 9 chose the colour schemes for their bedrooms and went shopping with staff to buy the soft furnishings for their home. The home has a Statement of Purpose and Service Users’ Guide in place as required. An audio version of these documents is also available. It should be acknowledged that these documents have little relevance to the people who use this service, due to their levels of learning disability and communication support needs. It is intended that this group of residents will remain living together as long as they wish this to be the case, and the accommodation and support available can continue to meet their assessed needs. Sampling of residents’ personal files showed that their support needs have been appropriately assessed and kept under regular review. Files also had written contracts including terms and conditions of people’s residence. These were countersigned by family members where possible. 10 Roundlea Road DS0000070316.V362429.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, 8 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are well supported to get the care they need in ways that suit them and keep them safe. They are supported to do as much for themselves as they can, so as to encourage their independence. EVIDENCE: Sample checking of residents’ personal records showed that care plans were in place as required. Plans are detailed and comprehensive and provide staff with clear guidance about how people like to be supported. There is evidence of good person-centred practice. Plans include individuals’ regular routines, and explain what works best for them, and what doesn’t. Each person has a “Communication Passport”. Plans have been put together using photographs of individuals doing things they value and going to places they like. One man’s “passport” has photographs showing him making the particular gestures he uses to show that he wants a cup of tea, and so on. These are in varying stages of development, and it is recommended that this good work be continued, so as to build up this resource and increase people’s communication opportunities. Care planning is sensitive to people’s cultural diversity. One man 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 11 is a non-practicing Muslim, but staff have supported him to visit a local Mosque and ensure that he has opportunities to eat the Asian food that he likes. Plans are kept under regular review. This is achieved through the completion of a detailed monthly review report (by designated key workers), and represents good practice. It was suggested that making people’s goals more specific might improve this further, and this was discussed with the Manager. It was recommended that this could be achieved by linking goals to the activities that people do. This could help highlight more clearly whether or not goals set have been achieved. There are clear links between people’s care plans and risk assessments. Plans and assessments are indexed and crossreferenced, so that important information can be found easily. Potential hazards are identified and measures put in place to minimise occurrence. Staff were directly observed supporting people to make choices about what they wanted. One man was asked what he wanted to eat for breakfast. To help him choose, the member of staff took all of the cereal packets out of the cupboard, so that he could see them and pick the one he wanted. He was then supported to get his breakfast and encouraged to do as much for himself as he could. Later in the day, a member of staff was seen asking one of the residents what he wanted to do, upon returning home from his day activities. He gestured to show he wanted to watch a DVD and the staff supported him to get the one he wanted from the available collection. People are encouraged to do as much for themselves as possible, recognising their individual capabilities and level of learning disability. 10 Roundlea Road DS0000070316.V362429.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, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents get the support they need to do things they value, go to places they like and keep in touch with people who are important to them. This means that they are able to be a part of the community in which they live. EVIDENCE: The Manager reported that all of the residents have settled well into their new home. Records show that people have been able to maintain important existing links with local day centres. Three of the men attend different centres regularly for structured day activities. One goes each weekday, another attends three days per week and the other goes for two days. The fourth resident has significant physical disabilities and is supported by staff to do a range of activities either at home or in the local community each day. This is to take account of his specific support needs. The move to this house has given all the residents improved opportunities because the physical environment gives them more space and other choices about where they want 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 13 to be. There is a spare room on the first floor. This is currently being used for storage, but it is planned to turn this into an activity room when alternative arrangements have been made for the present contents. This will further enhance people’s opportunities. One of the residents has an Autistic Spectrum Disorder and does not cope well with unfamiliar environments. Having a functional activity room will extend his range of options for doing things he likes in familiar surroundings. The new kitchen is much bigger than the one at the last house. This provides opportunities for people to be more actively involved in domestic activities. One person’s file had a set of photographs showing him having a go at making pancakes. Everyone in the house (staff and residents) is taking part in a sunflower growing “competition”. The seeds have been sown in individual pots and had been germinated and started off growing on the kitchen windowsill, under the close scrutiny of all involved. Staff report that residents show varying amounts of enthusiasm at different times when they try and involve them in domestic chores. People’s different levels of learning disability and physical capabilities have an effect on the degree of success that can be had at any given time. However, staff recognise that supporting people to take part in day-to-day jobs about the house has positive value in terms of active engagement and encouraging people to be as independent as their individual abilities allow. Records also show that people are supported to access the local community on a regular basis. They go to the cinema (one resident particularly enjoys “horror” movies, while another prefers comedies), ten-pin bowling, shopping (both for groceries and for personal items), meals out and to the pub. They enjoy trips out to the Lickey Hills, Cannon Hill Park and go to the city centre (Birmingham), Redditch, Northfield and Weoley Castle regularly. They also make use of a sensory room facility in the local community. This contains a range of equipment designed to provide stimulation to the senses and is particularly beneficial for people with significant learning / sensory / physical disabilities. People also enjoy using such facilities to “de-stress” or just relax. At home they like to watch DVD’s, listen to music and look at magazines. Staff have also made particular efforts to acknowledge the cultural background of one of the residents, who is of Pakistani origin. In addition to ensuring that he regularly gets the opportunity to enjoy Asian food, he has been supported to attend a local mosque. Staff are also trying to engage an advocate for him, as he has no family contact. All the other residents have regular contact with members of their families, either by receiving visits at the house, or being supported to visit them at home. Two of the residents’ parents were contacted by telephone following the inspection visit. Both confirmed that they were able to contact their sons at any time and were full of praise for the support they received from the Manager and staff. Food stocks were examined: these were plentiful and included fresh fruit, vegetables and salad. Records showed that people enjoy a good variety of meals and that their diet is sufficiently balanced and nutritious. As mentioned above, particular efforts are made to ensure that the diet is also culturally 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 14 sensitive: the Manager reported that this did not present any problems, as the alternatives were usually universally popular. The small size of the home means that it is easy to facilitate individual choice and that people chose what they want to eat each day. Pictures illustrating different food choices were displayed on the kitchen cupboards, to help people make their wishes known. As reported above, staff were directly observed supporting people to make choices about what they wanted to eat and drink. 10 Roundlea Road DS0000070316.V362429.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 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People get the care they need so that they can be supported to stay healthy and well. Medication is generally well managed, so that people get their medicines in the right amount and at the right times. EVIDENCE: Staff were directly observed giving support to residents: this was done in a friendly manner, with warmth and respect. It was clear that all involved were at ease and comfortable in each other’s company. People were well dressed in good quality clothing and had been appropriately supported with their personal care. As reported above, individual care plans give staff clear guidance about how people should be supported. Conversations with staff showed that they have a good knowledge of the needs and preferences of the people in their care. Feedback from relatives confirmed this. Sampling of individual records showed that other professionals are routinely involved in residents’ care as appropriate. The support needs of this group of people are high-level and complex. One man suffered a stroke and had to spend several months in hospital as a result. When he returned home he had to use a wheelchair for general mobility and a Zimmer frame in the house. He 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 16 had lost a lot of his independence skills and also his speech. Since then staff have worked hard supporting his rehabilitation. The Manager reported that he no longer needs the wheelchair or frame, and has regained much of his former speech. Through constant prompting and gentle support he has regained the skills he lost while in hospital. Currently he still requires catheter care and the District Nurse manages this. He is prone to infections, but staff are aware of the signs and seek assistance as necessary. His mother said, “He couldn’t have any better care. He’s very happy where he is, back at home. I have got peace of mind knowing he is so well looked after.” Another resident has significant physical disabilities. He uses a wheelchair and has to be hoisted when being moved. His care involves feeding through a gastric tube (PEG device): all staff are trained to manage this effectively. He also suffers from epilepsy, though this is generally well controlled by medication. An epilepsy risk management plan is in place on his personal file, and staff are aware of the action they should take in the event of a seizure. His stoma care is managed by the District Nurse, but staff are also aware of how to do this. His mother visits him regularly. She said, “He’s doing very well. He’s very content, much better than before – I’m very pleased with the care he gets, staff look after him very well”. Sampling of personal files provided further evidence of regular involvement of health professionals in providing for residents’ healthcare needs. These include GP, consultants, epilepsy specialist, District Nurse, Physiotherapist, Chiropodist, Optician, Dietician, and Dentist. Sampled files also has Health Action Plans in place, providing information about how each person should be supported so as to be as well and healthy as possible. These have been developed since the move to the new house, to provide more detail about meeting individuals’ support needs. Each person also has an individual oral care plan and records of weight monitoring on file. One member of staff takes particular responsibility for maintaining and managing the home’s medication stocks and store. Residents have individual locked medicine cabinets in their bedrooms. The home uses the Boots Monitored Dosage System (MDS). The Medication Administration Record (MAR) was examined and had been completed appropriately. The home operates a system whereby two members of staff are present when medicines are given, and both sign the record. This is to ensure that the risk of administration errors is minimised. The record also included samples of the signatures of all staff that administer medication, copies of prescriptions and evidence that stocks are audited regularly. It was noted that there were no protocols in place for PRN “as required” medication in two instances. One was for Fusidin (resident P) and the other was for Hydroxyzine (resident K). This was discussed with the Manager and staff. It should be acknowledged that the Fusidin had only recently been prescribed, and that the Hydroxyzine is an existing daily-prescribed medication (the PRN dose is prescribed as a “back up” and infrequently used). It was suggested that protocols should be put in place 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 17 to ensure that staff have clear guidance about the circumstances in which these medicines are to be given, as a matter of good practice. It is preferable that protocols are signed by the prescribing doctor. Apart from this, medication is generally well managed with records to support this. Medication cupboards were clean and tidy, and kept secure. 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that any concerns are listened to and taken seriously, so that any action required can be taken. Staff have a good understanding of people’s support needs, to make sure they can be kept safe from abuse, neglect or self-harm. EVIDENCE: The service has appropriate policies in place covering complaints (including a CD version) and adult protection. The complex care needs and levels of learning disability of the people who live in this house mean that formal policies have little relevance to them personally. Their communication support needs mean that it was not possible to seek their views on this directly. They are reliant on the vigilance of the staff team and the knowledge they have about them, to ensure their concerns are dealt with and that they remain safe. They depend on staff to notice changes in behaviour, general demeanour or “body language” as indicators that something might be amiss. Conversations with staff showed that they are sensitive to the ways in which individuals communicate discomfort or let them know they are unhappy. Sampling of staff records showed that checks had been done with the Criminal Records Bureau (CRB) during recruitment and prior to staff being employed. Information provided in the AQAA (Annual Quality Assurance Assessment) showed that all staff have received adult protection training. Staff interviewed showed they had a good understanding of the issues and know what they should do in the event of witnessing or suspecting that abuse is taking place. The financial records of two residents were sampled. The amount of cash held 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 19 tallied with the record, and purchases made were validated with receipts, as appropriate. As reported above, the relatives of two of the residents were interviewed over the telephone. Both said that they had no complaints about the care their sons received, and they felt comfortable raising any matters of concern with the Manager or members of the staff team. We have not received any complaints in respect of this service. 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 20 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, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People enjoy the benefit of living in a comfortable, clean and homely place that is furnished and equipped to meet their needs. EVIDENCE: A tour of the building was completed. This service was relocated to Roundlea Road specifically to provide a more appropriate living environment for the residents. The house was extensively refurbished prior to them moving in. The residents played an active role in choosing colour schemes and furnishings for their new home. One of the residents is a wheelchair user, but is able to get around all areas of the house. There is a full size passenger lift to access the upper floor. Downstairs is a large accessible kitchen, designed to provide opportunities for residents to get involved in food preparation and cooking, according to their abilities. This leads into the main living room / dining area, which in turn provides access to a smaller, “quiet” lounge. Both these rooms have 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 21 comfortable furniture and television / music facilities, providing people with options about where they can choose to relax, receive visitors, and so on. At the rear of the property is a small office, which also doubles as the staff sleepin room. On this floor there is also a level access shower room with WC, a separate WC, and a laundry room. Upstairs are four bedrooms, a large assisted bathroom with whirlpool bath and WC, and another separate WC. As reported above, there is another room on this floor, currently being used for storage. There are plans to use this space as an activity room, when alternative arrangements have been made for the articles currently stored there. This will provide additional opportunities for leisure / education activities for all the residents. It is recommended that action be taken to make this happen at the earliest possible time. People’s bedrooms are individually styled and contain personal possessions and effects, including TV, music players, ornaments and family photographs. Particular efforts have been made to include pictures and ornaments that reflect individuals’ interests, background and culture. People have the equipment they need to meet their physical requirements. This includes ceiling track hoists in the bedroom and bathroom, so that they can be moved and handled safely, and ample toilet and bathing facilities. At the back of the house is a pleasant enclosed garden. This can be accessed through French doors in the small lounge. There is a paved area and lawn with borders. There is a small lawn at the front of the house, and limited off-road parking. The house is decorated, furnished and maintained to a high standard, and the Manager reported that, after a period of settling in, the residents are enjoying the benefits of the extra space and improved living environment. The house was clean and tidy, airy and fresh with a good standard of hygiene maintained throughout. 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 22 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 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by a staff team that is well qualified, supported and supervised. EVIDENCE: The core of the staff group in this service has worked together for a number of years, and “turnover” is low. Two staff files were sampled: both contained two written references and evidence that pre-employment checks had been carried out with the Criminal Records Bureau (CRB), as required. Files also contained copies of job descriptions and declarations of fitness to do the job. There were detailed records of induction and of formal supervision, which was up to the required standard (minimum of six occasions in any twelve-month period). It was noted that the number of staff meetings held within the last year was below the recommended frequency, though it should be acknowledged that this coincided with the move to the new house. It is recommended that staff meetings take place at least six times each year. Staff records also contain receipts for the organisation’s code of conduct, and that of the General Social Care Council (GSCC). 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 23 The Manager advised that the staff team is up to complement. There are three staff on duty at times when residents are generally around at home (i.e. mornings and afternoon / evenings) and never less than two. She said that she is able to rota more staff on if the situation calls for it, for example to support particular activities or social outings. There were sufficient staff on duty at all times during the inspection visit, and duty rosters provided further evidence that the home is appropriately staffed. Night cover is provided by two staff (one awake and one sleep-in). Training within the organisation is organised centrally, and in the written response to the Annual Quality Assurance Assessment (AQAA) the Manager said that opportunities for staff to do training had improved. Sampled files provided evidence of regular training. It was suggested that training information should be collated onto a spreadsheet or chart. This should show, for each member of staff, training completed and any qualifications gained. The plan should highlight any gaps and show dates when “refreshers” are due, showing when outstanding training is to be delivered. Presenting this information in spreadsheet / chart format could give the Manager a useful tool for obtaining an instant overview of the training needs of the staff team at any given time, and support future planning. Information provided by the Manager in the Annual Quality Assurance Assessment (AQAA) shows that 75 of the staff team holds qualifications at NVQ level 2 or above, and the remainder are working towards obtaining them. 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 24 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, 40, 41 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People benefit from living in a home that is well run. Checks are carried out to make sure that important equipment is working properly, so as to keep people living and working in the home as safe as possible. EVIDENCE: The Manager is appropriately qualified for her position: she has completed NVQ level 4 in Management and Social Care and gained the Registered Manager’s Award (RMA). She reported that she has applied to study for an MSc (Learning Disabilities) at Birmingham University, to develop her knowledge and skills further. She has a good working relationship with her staff: members of the team said that she is approachable and they felt she supported them well. She demonstrates an open and inclusive style of management, encouraging staff to take responsibility so as to develop their 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 25 skills and confidence. One of the residents’ relatives said, “she organises things well, and she doesn’t miss things”. Another said, “The Manager and staff keep me informed of what’s happening”. Members of staff said, “this is a great place to work”, and “you can speak up, ask the Manager anything” and “we have good back-up systems here”. The home has an appropriate range of policies and procedures in place to support the effective running of the service. Records are well organised, presented and maintained. These are securely stored in a “walk-in” cupboard on the ground floor. A discussion took place about systems for Quality Assurance and monitoring. The Manager said that she received good support from her line manager and produced evidence of visits carried out under Regulation 26 (Care Homes Regulations 2001). She also said that survey questionnaires had recently been revised and had been circulated to interested parties. It was said that this had only just taken place, so to date only one response had been received: this was produced in evidence. The response (from another professional directly involved in residents’ support) said that they had confidence in the Manager, that she is approachable and listens, and that concerns are responded to quickly and people kept informed of the outcomes. It is recommended that this area be developed, so that good work already done can be continued and built upon. Safety records were sample checked. The fire alarm and emergency lighting systems have been serviced, and systems tested regularly, together with firefighting equipment, and a complete written record maintained. A fire evacuation drill has taken place. The local Fire Officer’s audit shows that fire exit doors should be fitted so that they do not require keys to open them in an emergency. The Manager provided evidence that she had reported this to the organisation’s maintenance department, and that this would be dealt with in the near future. The Landlord’s Gas Safety Certificate was in date. A full record was maintained of temperature checks on the fridge and freezer carried out each day. Certificates for servicing of hoists, the assisted bath, passenger lift and Portable Appliance testing of electrical equipment were all seen, and in date. 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 26 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 3 27 4 28 3 29 3 30 4 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 4 3 3 4 3 X 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations Ensure that all PRN (“as required”) medication is supported with a written protocol. This will ensure that staff have clear guidance about the precise circumstances in which such medicine should be given. Develop the spare upstairs room as an activity area as planned, so as to improve residents’ opportunities for doing things they enjoy. Develop the staff training and development plan in a spreadsheet or chart format so as to get an overview of the team’s training needs and aid future planning. 2. 3. YA28 YA35 10 Roundlea Road DS0000070316.V362429.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Office 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 10 Roundlea Road DS0000070316.V362429.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. 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