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Inspection on 26/05/05 for 18 Aqueduct Road

Also see our care home review for 18 Aqueduct Road for more information

This inspection was carried out on 26th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service user was observed to receive friendly and professional support from care staff. A sample of the service user`s record indicated that he had begun to settle into the home having first arrived during August 2004. Discussion with staff found that there were some signs that the service user was trying to communicate verbally and work was being taken with a Speech and Language Therapist to develop a communication dictionary to enable the service user to communicate effectively. Further examination of the service user`s record indicated that there had been initial problems with inappropriate behaviour but these had declined over the last eight months. Staff showed an awareness and understanding of the service user`s needs. They have completed all mandatory training topics and additional training was being completed in areas such as the use of Makaton sign language, accredited medication training and awareness of autism. Observations made confirmed that staff were aware of how the service user indicated his choice such as having a shower when the service user went to a drawer in the office and pointed to a bottle of shampoo and shower gel. It was good to see the service user being able to maintain some independence when carrying out domestic tasks such as vacuuming the lounge or doing his laundry. In addition to the communication dictionary staff have been using photographs of key objects and people connected with the service user. Care plans were found to be detailed and covered all aspects of the service users daily routine, likes and dislikes. There were also detailed guidelines in place for communication, management of behaviour and the use of rectal diazepam medication if the service user were to have a seizure when out with staff. A sample of the menus for the service user indicated that his specific dietary requirements such as Halal food were being met and links were being made with a Community Dietician to look at ways to promote healthy eating as the service user was assessed as being overweight. A sample of staff recruitment records were found to be well structured with all required documents such as proof of ID, CRB disclosures, two references, job application forms and evidence of qualifications. There were also written inductions in place.

What has improved since the last inspection?

There had been some improvements in the management of the service user`s medication. Evidence that prescriptions had been photocopied prior to dispensing were seen and that the medication procedure had been amended and updated to reflect current practice. These were requirements from the previous inspection. The service user has benefited in having his care plan reviewed and the comments made by various professionals involved with the service user, were positive in their view that there had been improvement in how the service user had adjusted to his new home, along with an improvement in his behaviour. This was also confirmed when talking to staff on duty. One commented that the service user had started to call her first name in order to receive attention. One of the requirements from the previous inspection was for the service user to have access to check up with healthcare professionals such as the GP Optician, Dentist and Chiropodist. A sample of the service user`s record found that the service user had been treated by a chiropodist and appointments had been booked for the service user to see a Dentist and Optician.

What the care home could do better:

CARE HOME ADULTS 18-65 Aqueduct Road, 18 18 Aqueduct Road Shirley Solihull B90 1BT Lead Inspector Joe OConnor Unannounced 26 May 2005 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 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 Stationary 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. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Aqueduct Road, 18 Address 18 Aqueduct Road Shirley Solihull West Midlands B90 1BT 0121 474 3197 0121 430 5132 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Robinia Group PLC Ms Tracie Hammond Care Home 2 Category(ies) of Younger Adults, Learning Disability registration, with number of places Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Ms Hammond obtains NVQ Level 4 in care and management by September 2005.. Date of last inspection 22 November 2004 Brief Description of the Service: The service at Aqueduct Road consists of a domestic three bedroomed house located in a residential area of Shirley Solihull. It is registered to accommodate two service users who have a learning disability and a diagnosis of autism. The property is within walking distance of a local park and other community facilities in the locality. Solihull Town Centre is accessible by bus as is Birmingham City Centre. Shirley Railway Station is a ten minute walk from the Home. The premises consist of two single bedrooms one of which has an en-suite bathroom. There is a bathroom on the first floor with a toilet and a toilet is available on the ground floor that is shared on a communal basis. The home has a lounge, dining room, kitchen and sensory room. Upstairs is an office/staff sleep in room. Within the house but accessed seperately is the managers office. There is a well maintained rear garden that is well screened by shrubbery and trees providing privacy for service users. The home does not provide off road parking and there is limited parking along the road. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place during the late afternoon and early evening. There was one service user living in the home at the time of this visit that had very limited verbal communication and was therefore unable to provide an insight into life in the home. The Inspector did have the opportunity to talk to two members of staff including a Team Leader. Care practices were observed, interactions and support from staff. A limited tour of the premises was undertaken. The service user’s care plan and risk assessments was inspected. Staff training and recruitment records were also examined and a number of health and safety records were also sampled. The Inspector was pleased to receive an action plan following this inspection that had addressed the requirements listed at the end of this report. However, the report is based on the evidence seen at the time of inspection. What the service does well: The service user was observed to receive friendly and professional support from care staff. A sample of the service user’s record indicated that he had begun to settle into the home having first arrived during August 2004. Discussion with staff found that there were some signs that the service user was trying to communicate verbally and work was being taken with a Speech and Language Therapist to develop a communication dictionary to enable the service user to communicate effectively. Further examination of the service user’s record indicated that there had been initial problems with inappropriate behaviour but these had declined over the last eight months. Staff showed an awareness and understanding of the service user’s needs. They have completed all mandatory training topics and additional training was being completed in areas such as the use of Makaton sign language, accredited medication training and awareness of autism. Observations made confirmed that staff were aware of how the service user indicated his choice such as having a shower when the service user went to a drawer in the office and pointed to a bottle of shampoo and shower gel. It was good to see the service user being able to maintain some independence when carrying out domestic tasks such as vacuuming the lounge or doing his laundry. In addition to the communication dictionary staff have been using photographs of key objects and people connected with the service user. Care plans were found to be detailed and covered all aspects of the service users daily routine, likes and dislikes. There were also detailed guidelines in place for communication, management of behaviour and the use of rectal Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 6 diazepam medication if the service user were to have a seizure when out with staff. A sample of the menus for the service user indicated that his specific dietary requirements such as Halal food were being met and links were being made with a Community Dietician to look at ways to promote healthy eating as the service user was assessed as being overweight. A sample of staff recruitment records were found to be well structured with all required documents such as proof of ID, CRB disclosures, two references, job application forms and evidence of qualifications. There were also written inductions in place. What has improved since the last inspection? What they could do better: A number of requirements were still outstanding from the previous inspection. There was no evidence seen on the service user’s file of a written statement of terms and conditions, although the staff member on duty presented a version of a contract that was being developed by the acting manager. This was being put together by means of photographs. Another outstanding requirement from the previous inspection was for the wishes and feelings of the service user and family to be ascertained, with regard to illness and death. Part of this consultation was to have involved an interpreter who was able to speak Urdu. However, no progress had been made and it is now important that this outstanding requirement is addressed. A referral had been made for the service user to have access to an advocate. The service user is on a waiting list but there was no evidence to confirm on his records that staff were seeking updates as to the latest situation with the waiting list. The service user did not Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 7 have a manual handling assessment in place. There was also no evidence to confirm that a referral had been made to the Occupational Therapist in order to assess the suitability of their bathing facilities. Improvements were required in the daily records for the service user so that staff provide examples how the service user made his decisions and choices. The management of medication needs improvement. An examination of the Medicines Administration Records or MAR sheets as they are known found that the morning medication for the service user had been administered but there were no signatures to confirm this, and that a prescribed medication called Lorazepam was not included on the MAR sheet. This was an administration error on the part of the supplying pharmacist but had not been picked up by staff responsible for booking in medication received. The need for a staff drug audit or spot check was discussed with the staff member on duty and the comments were received positively. Promotion of the service user’s health and safety will require some improvement. A requirement from the previous inspection was for the Registered Provider to provide written evidence with regard to the safety and condition of the electrical wiring for the premises by 23 December 2004. Written evidence was available to confirm that the wiring system had been tested. However, there was no certificate in place to confirm proof of worthiness. The mains operated smoke detectors had not been tested on a weekly basis during April 2005. While the premises were generally clean and tidy, the carpet in the lounge is in a poor condition and in need of replacing. The décor in the lounge was found to be tired and worn. The furniture in the lounge was in need of a thorough clean. The written complaints procedure must be available that is in an accessible format for service users. There is policy and procedure with regard to physical intervention. This was found to require some amendments to state that where physical intervention was required as a last resort that the CSCI should be notified without delay. The records for food and drink consumed by the service user were found to have gaps and were not consistently dated. There was no evidence to confirm what choices were being offered to the service user. 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. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 5 Service users needs are assessed prior to admission to the Home covering all aspects of their daily living activities. The needs of the one service user presently accommodated is being met through the maintenance of detailed care records and with a committed staff team. The service user does not have a statement of terms and conditions that informs him and his family and representatives of what they are paying for. EVIDENCE: There was one service user accommodated at the time of this visit and he had very limited verbal communication to be able to comment on life in the home. An examination of his care records found that there was detailed information in place as how the individual’s needs were to be met. The service user requires a staffing ratio of 2:1 and an examination the staff rota found that this level was being maintained throughout the day and night. Staff demonstrated a very good knowledge about the needs of the service user with one commenting that there had been significant improvements in the service user’s behaviour over the last ten months and there was evidence that staff have been trying to develop the service user’s communication skills through the use of pictures and symbols. The service user appeared to be relaxed in the presence of staff and appeared well cared for. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 10 Since the last inspection there have been no admissions but the a member of staff confirmed that they had received a referral for a prospective service user. Admission would be dependent on funding being available for a high staff, ratio. Records were in place to confirm that a representative of the organisation had completed an assessment of the prospective service user and there was also a community care assessment completed by a local authority. It was noted that the service user currently accommodated did not have a written contract although a member of staff advised that a contract had been developed in a picture format but acknowledged that this needed development to include the breakdown of the fees and any charges not covered by these. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 &9 A detailed care plans sets out service user’s needs are to be met. This covers the service user’s individual likes and dislikes and how these should be met. Staff encourage the service user to make decisions with regard to his daily routine on a day to day basis but how the service user makes these choices is not recorded. The service user has risk assessments in place that ensure staff are aware of service users when being escorted and guided in the community. EVIDENCE: The service user was found to have a detailed care plan that covered all aspects of his daily living. There was information with regard to the service user’s likes and dislikes and preferences. Specific dietary requirements were highlighted including information that the service user was a Muslim and required Halal food. The care plan showed guidelines on how staff should communicate with the service user through the use of short sentences. There was evidence that the care plan had been reviewed and that a six month review had occurred prior to this inspection. This confirmed in a positive manner there had been improvement with the service user and he had become settled. Care must be taken however, to ensure that guidelines covering the management of behaviour and communication are clearly dated following a review to confirm whether the individual circumstances have been changed or Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 12 not. A sample of the service user’s records found that there were risk assessments in place covering areas such as the use of rectal diazepam in the community and for escorting in the community. Staff demonstrated that the service user is encouraged to make choices on a day to day basis through the use of photographs and symbols particularly with regard to meals and where to go. A sample of the daily recording of the service user indicated there was no evidence of the service user making their choices known. A requirement from the previous inspection was for the service user to have an advocate to speak on his or her behalf. A letter was on file to confirm that the referral had been made but that the service user was on a waiting list. Action must be taken to ensure that this is followed up. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 15, 16 & 17 The service user is given opportunities to communicate his needs and wishes but the need for an Urdu speaking interpreter is still unmet. The service user has access to leisure activities in the community and is able to maintain contact with his family. The service user is provided with a nutritious varied diet that meets his individual cultural needs but further written evidence is needed to confirm that choices are being offered to the service user. The service user’s routine is not subjected to any unnecessary restrictions subject to their individual risk assessment. EVIDENCE: The service user was able to access all parts of the home and there were no limitations on the individual’s daily routine. Staff encouraged the service user to communicate his needs and wishes such as having shower, which the service user seemed to enjoy on a regular basis. A sample of the service user’s records found he was being visited by a Speech and Language Therapist to assist staff in developing an effective communication dictionary. A requirement from the previous inspection was the need for an interpreter who could speak Urdu to provide assistance in undertaking reviews with the family. This had not Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 14 been addressed and there appeared to be no record to confirm whether any contact had been made. It was also noted at the last inspection that staff were due to have training in cultural awareness but so far this had not taken place. There was written evidence to confirm that the service user had access to the community such as going to the shops and was visiting family members with support from staff. Daily recording of staff contact with the service user showed outdoor activities had occurred such as visits to the Lickey Hills and Woodgate Valley Country Park, and an activity centre in Derbyshire that involves an army assault course who staff commented was the service user’s favourite activity of all. There had also been a recent daytrip to WestonSuper-Mare. It was observed that the service user was vacuuming the living room without any prompting from the staff present, which commented that the service user would also do their laundry. A sample of the menus confirmed that the service user was receiving Halal meals in line with his cultural requirements. Records were found to be maintained of what the service user had consumed. However, there were a number of gaps that did not confirm the service user had been offered a choice of meal. The food and drink records were not dated consistently. The service user was observed to be having tea with a member of staff and the atmosphere was found to be relaxed and the service user appeared to enjoy the meal. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, & 20 The service user receives a flexible level of care and support that meets his Individual’s requirements. The service user’s healthcare is appropriately arranged promoting and maintaining good health. Medication management in the home needs to be more robust ensuring the service user’s health and wellbeing is safely maintained. EVIDENCE: An examination of the service user’s care records found they were registered with GP. The records seen relationships are kept with other multi-disciplinary services such as Speech and Language Therapist, Community Nurse, Consultant Psychiatrist. The records also demonstrated where medication reviews had occurred. The care plan for the service user had identified specific needs around epilepsy and there were charts in place that had been documented where any type of seizure had occurred. There were written protocols in place for the use of PRN medication and using rectal diazepam in the community. Appointments had been arranged for the service user to visit a dentist and optician. Other professionals who had contact with the service user was a community dietician to develop a healthy eating programme as there were concerns that the service user was overweight and there was a monthly record being maintained of the individual’s weight. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 16 Information with regard to the service user’s cultural requirements and language had been recorded. Daily recording indicated when the service user chose to go to bed or had a shower. At the time of this the service user requested to have a shower by means of signing and this was supported to do this. A sample of the staff rota indicated that there was an appropriate gender balance of staff supporting the service user. It was noted however, that the service user did not have a manual handling assessment in place. Medication management was to a certain extent good although when examining the Medicines Administration Records (MAR charts) it was noted that a member of staff had not signed in the service user’s morning medication. It had also been found that one medication currently prescribed to the service user, known, as Lorazepam had not been printed on the MAR chart. This was found to be an error on the part of the supplying pharmacist but had not been picked up by the staff member responsible for signing in the medication. The majority of staff working the home have completed accredited medication training. It was noted that a previous requirement for the medication procedure to be amended and updated had been addressed. A procedure was in place for the use of homely remedies. There was evidence that staff were photocopying prescriptions and the service user’s details with regard to any allergies had been noted. Standard 21 was not assessed but it was noted that a requirement for consultation around the service user’s final wishes and that of his family had not been addressed because no interpreter or advocate had been accessed to facilitate this. The requirement has been outstanding since August 2004 and action must now be taken to ensure that this is addressed. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The complaints procedure should be available to service users in a suitable pictorial format. There is an adult protection policy and procedure in line with D.O.H. Guidance No Secrets. There is also a policy and procedure with regard to physical intervention but this will need amending. Service user’s personal allowance is managed in a satisfactory manner enabling a clear audit trail of individual expenditure and final balances. EVIDENCE: Neither the provider nor the CSCI have received any complaints since the last inspection. A complaints procedure is in place but work is required to make this procedure available in a suitable pictorial format. There is a policy and procedure on physical intervention. This will require amending to state that where physical intervention has been used as a last resort then the CSCI must be notified without delay. A copy of the multi-agency adult protection guidelines published by Birmingham City Council was found to be in place since the last inspection. The service user’s financial records were sampled during this inspection. There was a written record of their personal allowance paid, monies spent and for what purpose, with a final balance. Individual items of expenditure had a receipt attached to the balance sheet. Generally the management of the service user’s finances were satisfactory but staff must ensure that the records have two signatures from staff. The service user’s money was found to be held in a secure facility. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28 & 30 The premises are maintained to a satisfactory standard but the lounge should decorated as the décor is tired and worn. Staff observe appropriate infection control practices that ensure the service user’s welfare. EVIDENCE: The Home was found to be clean, tidy and maintained to a reasonable standard. However the décor in the lounge was found to be in need of redecorating as the walls have marks and cracks. The carpet in the lounge was badly stained and in need of replacing. The furniture was worn and in need of cleaning. There is a utility room that had recently been decorated but staff stated that the service user had broken the dining room table and a new one was being purchased that was more robust and suited to the individual’s needs. It was noted there is no written programme of future planned refurbishment of the premises. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 19 The kitchen was found to be clean and tidy and prior to this inspection a visit had been made by an Officer from Environmental Health who was satisfied with management hygiene practices. There is a laundry facility separate from the kitchen and it was noted that the equipment being used was of a domestic type. The provider must be mindful that when the current equipment comes to the end of its working life that a washing machine that has a sluice programme is provided. An assessment for an Occupational Therapist assessment of the current bathing facilities had not been addressed and there was no written evidence to confirm whether any contact had been made. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 & 35 & 36 The organisation offers and provides training to all staff employed to enhance their development. Staffing levels provide the service user with a continuity of care that does not cause disruption to his daily routine. Recruitment practices for staff are maintained to the requirements of Schedule 2 Care Homes Regulations 2001. The interaction between staff and the service user was positive providing a relaxing environment. EVIDENCE: Two members of staff demonstrated a good understanding of the needs of the service user in their care. The service user’s routine was known and respected. Two new members of staff had been appointed since the last inspection. The records were found to be well structured with clear evidence of proof of identity, CRB check, photo, two references, job application form, interview assessment form, contact and evidence of qualifications. New staff had completed a written induction and had received training in first aid, food hygiene, manual handling and health and safety. They had also completed accredited training by Boots Pharmacy in managing medication. The two members of staff spoken to have also completed recent training in the topics listed and had also completed training in adult protection and physical intervention. A training matrix was sampled and it was evident that a number of staff had completed LDAF training and specialist training had been booked Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 21 for topics such as autism, makaton and awareness of epilepsy. Staff records confirmed that supervision had been undertaken every two months. An examination of the staff rota confirmed that the service user was receiving 2:1 support through out the day and night. There is a bank of care staff available to cover any shortfalls in shifts. No staff have left the home since the last inspection, although there is now a vacancy for a team leader and interviews for this post were being undertaken the following day. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41 & 42 There is no longer a Registered Manager in place although appropriate arrangements have been made to ensure the service user and staff receives continuity of support. There is an open relaxed atmosphere that benefits the service user and staff. The records were generally up to date for the safety of the service user but some improvement is required. EVIDENCE: The Registered Manager was recently promoted to a senior position with the organisation. One of the Team Leaders is now acting up as manager and is currently completing the Registered Managers Award. Another Team Leader was on the premises at the time of this visit. She was able to demonstrate her understanding of the service user’s needs and has had a wide range of experience of working with service users who have a learning disability. Comments made were received positively. Both staff stated that they would be able to approach and raise any concerns with the acting manager. One of the staff commented that the Registered Manager had informed them of her Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 23 promotion and felt that during her time as manager she was supportive and ensured that all the staff had been trained. It was noted a representative of the organisation was visiting the home but the visits were not occurring every month. While the service user was unable to comment about life in the home the atmosphere was found to be generally relaxed. Records maintained in the home were found to be generally up to date and locked in a secure facility. The records with regard to health and safety were found to be in need of some improvement. Records for the testing of the mains operated smoke detectors showed they were not being tested every week during the month of April this year. There was evidence that the smoke detectors had recently been inspected and serviced. A staff member on duty stated that a visit had been arranged for a new company to provide new fire extinguishers and a fire blanket. A fire drill had taken place prior to this inspection. A risk assessment for the prevention of fire was in place. A requirement from the previous inspection for a proof of worthiness certificate for the electrical wiring to be sent to the CSCI had not been addressed. The staff member on duty stated that the wiring had been checked shortly before the inspection and some remedial work had to be completed. There was evidence to confirm that an inspection had taken place, but it is of concern to the Commission that this requirement had not been addressed within the timescale set at the last inspection. There was evidence of a monthly record for water temperatures of the outlets used by the service user. There was also evidence that the daily records were being maintained for the refrigerator and freezer. The accident book was examined and it was good to see that there are no significant numbers of accidents involving the service user with only two recorded since the last inspection. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 1 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 2 x 3 Standard No 11 12 13 14 15 16 17 2 3 3 x 3 3 2 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Aqueduct Road, 18 Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 x 3 2 x E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 25 YES 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. 1. Standard 5 Regulation 5(2)(b)(c) Requirement The Registered Person must esnure that the service user has a written statement of terms and conditions. The one that is being developed in an accessible format must include information about the fees and any charges not covered by these. The Registered Person must ensure that the guidelines in the servcie user care plan covering communication and the management of behaviour are dated to confirm these have been reviewed. The Registered Person must ensure that the daily records for the service user state how the servcie user has made his choices with regard to life in the home. The Registered Person must ensure that the service user and his family have access to an Urdu speaking interpreter to assist in more efrective communication during reviews. The servcie user must also have access to an advocte. The Registered Person must ensure that the records for the Timescale for action 26 July 3005 2. 6 15(2) 26 July 2005 3. 7 12(2)(3) From 26 May 2005 4. 11 12(3)(4) (b) 26 July 2005 5. 17 12(3) From 26 May 2005 Page 26 Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 6. 18 13(4)(5) 7. 20 13(2) 8. 20 13(2) 9. 20 13(2) 10. 21 12(3)(4) 11. 22 22(1) 12. 23 13(7)(8) food consumed by the service user indicate where choices have been offerred. These must be dated on a daily basis. The Registered Person must ensure that the service user has a manual handling asssessment in place. Outstanding requirement Timescale 23 December 2004 not met The Registered Person must ensure that the MAR sheets are signed as soon as the servcie users medciation has been given. The Registered Person must ensure that any dispensing errors on the part of the supplying pharmacist is addressed without delay. The Registered Person must undertake a spot check of staff administering medication to ensure that any erros are addressed ensure that staff trained to administer medication are still competent to do so. The service user and his relatives wishes with regard to ageing, illness and death is recorded in the servcie users file. Outstanding Requirement Timescales of 10 August 2004 and 23 January 2005 not met. The complaints procedure must be made available in an accessible format for the needs of the service user living in the home and for prospective service users The Registered Person must ensure that policy and procedure with regard to physical intervention is amended to state that where restraint has been used as a last resort that the CSCI is notified without delay. 26 June 2005 From 26 May 2005 From 26 May 2005 From 26 May 2005 26 July 2005 26 August 2005 26 August 2005 Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 27 13. 24 23(2)(b) 14. 28 23(2)(b) The Registered Person must provide the CSCI a written programme of planned refurbishement of the premises. The lounge is in need of redecorating and the carpet is in need of replacing. The furniture is also in need of cleaning. The Registered Person must ensure that the visits undertaken by a representative of the organistion occur on a monthly basis. The Registered Person must provide the CSCI provide proof that the hard wiring for the premises is in working order. Outstanding Requirement. Timescale 23 December 2004 not met. Failure to provide sufficent evidence will result in enforcement action being taken. The Registered Person must ensure that the testing of the smoke detection system is recorded on a daily basis. Action Plan was received on 9 June 2005 addressing Immediate Requirements left at the service following inspection on 26 May 2005. 27 July 2005 An Action Plan Required 27 July 2005 From 26 June 2005 15. 39 26(1) 16. 42 13(4) 23(2) (c ) 26 June 2005 17. 42 13(4) 23(4)(iv) From 26 May 2005 18. 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 29 Good Practice Recommendations It is recommended that the Registred Provider ensures that the bathing facilities have been assessed by an OT. This is to ensure that the bathing facilites meet the needs of the service user currently accommodated and for prospective service users. Outstanding Good Practice Recommendation. E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 28 Aqueduct Road, 18 2. 30 It is recommended that when the current washing machine reaches the end of its working life that it is repalced with a model that has a sluice programme. Aqueduct Road, 18 E54 S43650 18 Aqueduct Road V229351 260505 Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 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. 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