This inspection was carried out on 28th February 2006.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report,
but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
18 Aqueduct Road 18 Aqueduct Road Shirley Solihull West Midlands B90 1BT Lead Inspector
Joe O`Connor Unannounced Inspection 28th February 2006 10:50 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 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 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 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. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 18 Aqueduct Road Address 18 Aqueduct Road Shirley Solihull West Midlands B90 1BT 0121 474 3197 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) The Robinia Group PLC Ms Tracie Hammond Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. That Ms Hammond obtains NVQ Level 4 in care and management by September 2005. 26th May 2005 Date of last inspection Brief Description of the Service: The service at Aqueduct Road consists of a domestic three bedroom 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 ensuite 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 separately 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. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place during the morning to mid afternoon. The service user was in hospital at the time of this visit recovering from a chest infection. The Inspector spoke to the new Registered Manager. The service user’s care plan and risk assessments were inspected along with a number of health and safety records. To find out how the service has performed during this inspection year then this report should be read with the unannounced inspection report 26 May 2005. What the service does well: What has improved since the last inspection?
There is a new registered manager who is currently responsible for two other small services within the organisation based in the Solihull area. A deputy manager has been appointed for this service and to the other two services. The manager has addressed many of the requirements from the previous inspection, as did the previous acting manager. The service user now has access to an advocate who will support him in his forthcoming review. There was evidence confirming the organisation had made arrangements for an interpreter to be involved in the review that can speak Urdu and translate for the service user’s family members. The lounge had been decorated and the new manager had placed orders for new furniture and flooring for the hallway and lounge. The kitchen and hallway
18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 6 will be decorated shortly. A new dining table and chairs have been purchased. There was written evidence in place confirming outstanding work with regard to the wiring of the premises had been completed. The mains operated smoke detectors were being tested on a weekly basis. Details regarding the final wishes for the service user in the event of his death had been recorded with the co-operation of the family. The manager had made a referral to an Occupational Therapist to assess the suitability of the bathing facilities for the service user. Work has been carried out in developing a care plan for the service user that was seen to be in a more accessible format combining the use of symbols and photographs. 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. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 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 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The service user has access to information in an accessible/pictorial format informing him about his placement and how much he has to pay for his accommodation. The needs of the service user are presently being met through the maintenance of detailed care records. EVIDENCE: Since the last inspection work has been undertaken in developing the service user guide into a format, which combines the use of symbols and photographs. The copy seen was done individually for the service user including photographs of staff involved in supporting him. There was also an individual statement of terms and conditions (contract) that also used pictures covering what the service user was paying for. A contract was also on file provided by the placing authority. At the time of this inspection the service user was in hospital following a severe chest infection. An examination of the individual service user’s care records indicated that prompt action had been taken when initial concerns about his condition with consultation being made with the relevant medical services. It was good to see that the previous acting manager and the new manager who had recently been registered with the CSCI to manage this service had addressed all the requirements from the previous inspection. Standard 2 not assessed, as there have been no new admissions since the last inspection.
18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6, 8, 9 A detailed care plan has been developed in a suitable pictorial/symbol format setting out how the service user’s needs are to be met. The service user is involved with support from staff in making decisions about life in the home. The service user has a range of risk assessments, which inform staff how any identified risks in the home and the community should be managed. EVIDENCE: Since the last inspection work has been completed in developing a care plan for the service user that combined the use of symbols and photographs. The care plan included details of the service user’s daily routine including the time he prefers to get up and go to bed. It also stated how many staff were required to support him, which was 2:1. There are photographs of the staff involved in supporting the service user but it is recommended where possible that photographs of the service user’s family included. The manager stated she was contacting various healthcare professionals currently involved with the service user to provide photographs. It was noted since the last inspection a record was being maintained on a weekly basis of choices made by the service user including food and activities for the week. Since the last inspection action had been taken in ensuring an
18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 10 advocate was involved in future reviews for the service user. A letter was seen on the service user’s file advising him about the advocate’s role from an advocacy group from Advocacy Matters. There was also written information in place confirming the service had been making arrangements to involve an interpreter for a forthcoming review of the service user to assist in interpreting for his family who speak Urdu. An examination of the service user’s found there were risk assessments in place covering how the service user should be supported in the community and when out in the vehicle. These had been reviewed since the last inspection. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 11, 13, 14, 17 The service user receives appropriate support to communicate his needs and wishes. The service user has access to leisure activities including a holiday in the community, but the daily recording content requires some improvement. The service user’s dietary needs meets his cultural requirements on a daily basis. EVIDENCE: An examination of the service user’s individual daily records indicated he was provided with 2:1 staff support when going out in the community where he also has access to a vehicle. An examination of the records indicated the service user had participated in activities such as swimming, bowling going out to the Bull Ring Shopping Centre, the docks at Gloucester and for walks in the local park. The manager commented that she was now looking to expand the range of activities for the service user including going to a local college. Some improvements were required with the daily recording entries for example some referred to the service user going for a long drive but there was no details as to where. There was a tick box record checklist indicating where the service user had been involved in undertaking domestic such as vacuuming, polishing and doing the laundry.
18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 12 It was noted that symbols and photographs were being used throughout the building to assist the service user to communicate more effectively. A choice board is available in the hallway and lounge, which provides a range of symbols so the service user can choose one indicating what he wanted to do. The manager commented that there seemed to have been greater improvement with the service user’s verbal communication. A recent report from a Speech and Language Therapist confirmed the service user had been making good progress with his communication. The service user had participated in a holiday in Minehead last summer and there was evidence in place confirming the service user had visited the venue prior to the actual holiday. The manager commented that the service enjoyed it a great deal and would be planning another holiday for this year. Improvements had been made with regard to the recording of the meals eaten by the service user during the day. There was evidence that he was receiving a halal diet in line with his cultural requirements as a Muslim. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 18, 19, 20, 21 The service user’s healthcare needs is appropriately arranged promoting and maintaining good health. Medication management has improved promoting and maintaining the service user’s good health. Appropriate steps have been taken in ascertaining the service user’s final wishes. EVIDENCE: An examination of the service user’s care records indicated a requirement for an up to date manual handling assessment had been addressed. It included details stating how the service user should be prevented from having falls. This set out how he should be supported and directed when for example using the bath. An examination of the daily records indicated where the service user had support with their personal care including having a shower and shave. The recording indicated when the service user chose to get up and go to bed. Records were in place confirming the service user had contact with a GP, Dentist, Chiropodist and Optician. There was also evidence the service user had been seen by specialist healthcare professionals including a Community Nurse, Consultant Psychiatrist and Speech and Language Therapist. The service user had his own health action plan in a picture/symbol format setting out how his healthcare requirements should be addressed including details of those professionals providing consultation and treatment. A monthly record was being maintained of the service user’s weight.
18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 14 Medication management had improved since the last inspection. An examination of the Medicines Administration Records (MAR) charts found no gaps in recording of medication. All medication prescribed for the service user was printed on the MAR sheets with photocopies of prescriptions attached. The manager stated staff were undergoing additional medication training provided by the supplying pharmacy. A course pack being completed by a member of staff was seen confirming this. There was documented evidence indicating monthly medication audits were being undertaken. A requirement from the previous inspection for consultation around the service user’s final wishes had been addressed with written evidence confirming that these would be managed and arranged by the service user’s family. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22 The complaints procedure is now available into a more suitable pictorial format. EVIDENCE: Neither the service nor the CSCI have received any complaints since the previous inspection. A new complaints procedure had been developed that combined the use of pictures and symbols. A complaints procedure produced by the organisation was on display in the hallway. A requirement from the previous inspection for amendments to be made to the physical intervention procedure notifying the CSCI of any incidents regarding this being used had been addressed. There was a new copy in place of the adult protection Multi Agency Guidelines published by Birmingham Social Care & Health. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 24, 30 The premises is clean and maintained to an acceptable standard with improvements being made to improve the service user’s quality of life. EVIDENCE: A requirement from the previous inspection for the carpet in the lounge to be cleaned had been addressed. A new more robust dining room table and chairs had also been put in place. The manager has ordered a new suite for the lounge and new floor covering has been ordered for the lounge and hallway. The lounge had been re-decorated since the last inspection. Plans are in place to re-decorate the hallway and kitchen. At the time of this inspection the heating had broken down but the manager provided assurances that work would be carried out today for the work to be completed in time for the service user’s return from hospital which was scheduled for the following day. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The service user receives continuity of care and support with appropriate levels of staffing. EVIDENCE: An examination of the staff rota for the previous four weeks indicated the service user had been receiving 2:1 support throughout the day and night. A team leader has been in post since the last inspection. The manager commented that while the service user was in hospital staff support had to be provided, as the nursing staff did not fully understand his needs. One member of staff has been suspended pending an investigation around performance issues at work. The manager commented that staff were concerned that the amount of overtime available to them had been reduced due to a restructuring of staff support hours within the organisation. Standard 32 was not assessed in depth but in discussion with the manager and when examining the service user guide there was indication that the majority of staff involved working in the service were qualified to NVQ Level 2 and above. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 The service user is now supported by a qualified manager who is committed to improving practice in their best interests. Records are generally up to date protecting the interests of the service user. A representative of the organisation provides regular monitoring of the service ensuring it is being managed effectively. The health and safety of the service user is generally maintained with minor improvements needed. EVIDENCE: The service has a new registered manager who is also responsible for two small services within the Solihull area. She has a qualification in the Registered Managers Award. Additional management support is provided by a team leader. The manager has worked hard in addressing the requirements from the previous inspection and showed a commitment to improving practice. Since the last inspection the visits made by a representative of the organisation were occurring on a monthly basis with reports of these visits available for inspection on the premises. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 19 Generally the records were up to date and locked in a secure facility thus maintaining the service user’s confidentiality. Improvements had been made with regard to the health and safety records. There was written evidence that the mains operated smoke detectors were being tested on a weekly basis. A fire drill and staff training in fire safety had been completed prior to this inspection. It was noted however that the fire risk assessment for the prevention of fire was overdue a review. Documentary evidence was seen confirming that remedial work had been completed for the hard wiring on the premises and that a portable appliance test had been completed since the last inspection. The water tanks had been treated for the prevention of Legionella and a record was being maintained for the temperatures of the water outlets used by the service user. An examination of the accident book indicated three had been recorded since the last inspection and these had been notified promptly to the CSCI. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 20 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 N/A 3 3 4 N/A 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 N/A ENVIRONMENT Standard No Score 24 3 25 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 N/A 32 N/A 33 3 34 N/A 35 N/A 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 N/A 3 3 N/A LIFESTYLES Standard No Score 11 3 12 N/A 13 2 14 3 15 N/A 16 N/A 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 N/A 3 3 3 2 N/A 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 21 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. 1. Standard YA13 Regulation 16(2) Requirement The Registered Person must ensure the daily recording of service users reflect in more detail how they spend their leisure time. The Registered Person must ensure the fire risk assessment for the review of the premises is reviewed. Timescale for action 28/04/06 2. YA42 13(4) 23(4)(v) 28/04/06 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 YA29 Good Practice Recommendations It is recommended that the Registered Provider ensure that an OT has assessed the bathing facilities. This is to ensure that the bathing facilities meet the needs of the service user currently accommodated and for prospective service users. Recommendation. It is recommended that when the current washing machine reaches the end of its working life that it is replaced with a model that has a sluice programme. It is recommended that the Registered Provider include actual photographs of the service user’s family and
DS0000043650.V281642.R01.S.doc Version 5.1 Page 22 2. 3. YA30 YA6 18 Aqueduct Road relatives. 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Birmingham 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. Extracts may not be used or reproduced without the express permission of CSCI 18 Aqueduct Road DS0000043650.V281642.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
