CARE HOME ADULTS 18-65
Upland Road, 24 Selly Park Birmingham West Midlands B29 7JR Lead Inspector
Gerard Hammond Unannounced Inspection 15 & 19 December 2005 10:35
th th Upland Road, 24 DS0000016883.V274329.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 Upland Road, 24 DS0000016883.V274329.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. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Upland Road, 24 Address Selly Park Birmingham West Midlands B29 7JR 0121 415 5389 0121 415 5389 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 30th June 2005 Brief Description of the Service: 24 Upland Road is registered to provide accommodation, care and support for up to six people with learning disabilities. The house is a substantial two-storey detached property and is located in an established residential neighbourhood in the Selly Park district of Birmingham. There are six single bedrooms, two of which are on the ground floor. Rooms have wash hand basins, but none have en-suite facilities. Downstairs is the large kitchen, dining room and lounge. There is an additional room at the rear of the house which is used as a quiet room, for activies and as an extra lounge. The house has a bathroom on both floors, each having bath, sink and toilet. There is an additional w.c. upstairs also. Staff accomodation and the office is also located on the first floor. The house is set in its own grounds, and has the benefit of a secure and private garden to the rear of the property. At the front of the house, in addition to the garden, is a large drive offering off-road parking. There is a good range of local amenities and community facilities close by the home, which is well served by public transport. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was the second of the current inspection year, and took place over two visits. This report should be read in conjunction with the one produced following the inspection made on 30 June 2005. Direct observation and sampling of records (including personal files, care plans and previous inspection reports) were used for the purposes of compiling this report. The Inspector saw three of the residents, and formally interviewed the Manager. Two other members of staff were seen informally. What the service does well: What has improved since the last inspection?
Clear efforts have been made by the Manager to meet requirements made at the time of the last inspection. Good work has been done to develop care management practice: statements of need continue to be updated, and care plan information is of good quality. Plans are now indexed and cross-referenced to risk assessments. The new laundry room extension has now been built, and should be fully operational in the very near future. New furniture has been purchased for the front lounge, and the dining room has been decorated. New benches have been provided for the garden, and repairs carried out to the wooden garage. The Manager has submitted an application to become registered, and has continued to address outstanding training issues for the staff team. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 6 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. Upland Road, 24 DS0000016883.V274329.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 Upland Road, 24 DS0000016883.V274329.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): EVIDENCE: There have been no admissions since the last inspection. Key Standard 2 and Standard 4 were assessed at that time and met in full. Upland Road, 24 DS0000016883.V274329.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 Individual plans include good quality information about how support should be given, but further work is required to develop goals appropriately. EVIDENCE: Key Standards 6, 7 & 9 were all assessed at the last inspection. It was reported at that time that a good deal of work had been done to develop care plans, and it was noted that this work has been continued since then. Two plans were sample checked. It was noted that plans were appropriately indexed, and that they were cross-referenced to relevant risk assessments. Ideally this process should be two-way, so that risk assessments are also cross-referenced to the care plan(s) to which they relate. Plans contained good quality information about how support should be given, and this should be commended. It is important that all plans contain sufficient detail to guide the reader in exactly how to provide support, and in sufficient detail. Some attempts have been made to develop goal setting in individual plans, and this now needs to be taken a stage further. Goals currently set tend to be generic. It is important that these are developed so that the desired outcome
Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 10 for each goal can be measured; it should be possible to tell whether or not it has been achieved, when the plan is reviewed. “Promote my independence as much as possible” is fine as a broad aim, but this needs to be supported with specific objectives, to show how this can be done. This might include setting out to teach a new skill, or working towards ensuring that current skill levels are maintained. “Need to be encouraged to participate in activities outside Upland Road” might set a target of offering a specific number and range of activities each week, and recording how this works out in practice. (It was noted that work had gone on in this instance to identify activities and learning opportunities in support of this plan.) Work needs to continue on making individual files as current as possible, by removing old or superseded material, as indicated at the time of the last inspection. It should be acknowledged that this is a work in progress, as plans continue to be updated. Upland Road, 24 DS0000016883.V274329.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): EVIDENCE: Key Standards 12, 13, 15, 16 and 17 were all assessed at the time of the last inspection, and met in full on that occasion. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: Key Standards 18, 19 and 20 were assessed at the time of the last inspection, and met in full on that occasion. As previously observed, the residents and staff appear to enjoy a good rapport. Support is given in a warm and friendly manner and people are treated with respect and consideration. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 13 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): 23 General practice provides protection for residents from abuse, neglect and selfharm, but some staff still need to complete required training. EVIDENCE: Both these standards were assessed at the time of the last inspection, with Standard 22 met in full. Standard 23 was partially met, as five members of staff had yet to complete training in the protection of vulnerable adults from abuse. Information provided by the Manager after this inspection visit indicates that two of the current staff team had completed the training since the previous inspection. Three other members of staff are now scheduled to complete this training by February 2006, and one new starter has yet to be allocated a place. It was noted that the outcome of a complaint made prior to the last inspection visit was not recorded in the Complaints Book. The Operations Manager was contacted during the course of the inspection and the situation resolved appropriately. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 14 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): 28, 30 Residents enjoy the benefit of a homely, comfortable house that is kept clean and safe. Some improvements are required, particularly in communal areas. EVIDENCE: Key Standards 24 and 30 were assessed at the last inspection. Standard 24 was met in full, and Standard 30 partially met. Previous requirements regarding the provision of appropriate laundry facilities remained outstanding at that time. A new laundry room extension has now been built, and the laundry equipment is to be relocated shortly. This is a significant improvement to the Home’s amenities. Some issues relating to communal areas, identified at the time of the last inspection, have been dealt with. Some remedial work has been carried out on the wooden garage at the side of the house, but it was noted that the gate did not close properly and could not be secured. The garage is used for the storage of clinical waste prior to collection for disposal, so this area must be kept secure. An immediate requirement was made that appropriate locks were fitted to achieve this, and also to make arrangements for the skip filled with builder’s waste to be removed from the front of the house. It was noted that the old garden benches have been disposed of and new ones provided.
Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 15 A new suite are showing also benefit and renewal of furniture has been installed in the front lounge. Both lounges signs of their age and should be redecorated. The kitchen would from refurbishment. A copy of the Home’s planned maintenance programme (see Standard 24.12) should be submitted to CSCI. The staff team works hard to keep the house homely and welcoming: the place is kept clean and tidy and general standards of hygiene are good. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 16 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): 32, 34, 35 Residents are supported by staff, who are generally appropriately qualified or undergoing appropriate training, although some training remains outstanding. General recruitment policy and practice supports and protects people living in the house, but documents required must be available for inspection. EVIDENCE: It is known that this Organisation provides a rolling programme of training for its staff. Information provided by the Manager since the inspection visit shows that the Home’s Deputy is working towards NVQ level 3. One member of staff has completed LDAF training (induction level) and three others are due to complete this shortly (January 2006). Most statutorily required training has been completed or is scheduled, but there are some gaps. Recruitment is dealt with from a central location. Two staff members’ personal files were sample checked. It was not possible to ascertain from records actually available for inspection whether or not CRB or POVA checks had been completed. The Manager contacted her Head Office by telephone during the course of the inspection visit and obtained additional documentation by fax. It is important that all documents required by law to be kept on the premises (Care Homes Regulations 2001) are available for inspection at all times. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 17 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 Residents benefit from living in a home that is generally well run. The quality assurance and monitoring system should ensure that all residents’ views are taken into account appropriately, and this should be reflected in the Home’s report. EVIDENCE: Key Standards 37, 39 and 42 and also Standard 38 were assessed at the time of the last inspection (37, 38 and 42 were all met in full on that occasion, and 39 partially met). The Manager is continuing to work towards NVQ level 4 and the Registered Manager’s Award. Since the last inspection, she has submitted an application to CSCI to become the Registered Manager and is due to be interviewed shortly. As noted previously, the style of management in the Home continues to be relaxed, open and inclusive, and the Manager is making clear efforts to develop the service for the benefit of the people living in the house. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 18 The Manager indicated that quality audit information has been submitted to senior managers in the organisation. Regular monthly visits required under Regulation 26 (Care Homes Regulations 2001) have been completed as necessary, and reports submitted. The Organisation should now produce a report of the findings of its quality assurance and monitoring practice, and make this available to interested parties, including CSCI. As previously indicated, it is important that the report demonstrates how residents’ views have been taken into account in this process. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 19 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 2 X X X X Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 YA6YA9 Regulation 15 13(4) Requirement Further develop individual care plans to incorporate goals, with outcomes that can be measured. Complete cross-referencing of risk assessments with relevant care plans. Review whole care package at least every six months, with written record indicating who takes part and how decisions are made. Ensure that all staff complete training in Adult Protection. Outstanding since 30 September 2005. Produce a renewal and maintenance plan for the home, paying particular attention to communal areas in the house. Fit locks to the garage doors and make the area secure. Remove skip containing builder’s waste from the front of the house. (Immediate requirement) Ensure that all necessary documents required under the Care Homes Regulations (2001) are maintained for each person working in the Home, and available for inspection at all
DS0000016883.V274329.R01.S.doc Timescale for action 31/03/06 2 YA23 18(1,c) 31/03/06 3 YA28 23(2) 31/03/06 4 YA34 7(3) 19(4) Sch2&4 31/03/06 Upland Road, 24 Version 5.1 Page 21 times. 5 6 YA35 YA39 18(1,a) 24(1-3) Ensure that outstanding training is completed by all staff members. Produce report following the implementation of Quality Assurance and Monitoring System, ensuring that views of residents are represented appropriately. Make available to interested parties, and forward a copy to CSCI. 31/03/06 31/03/06 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 YA6YA9 Good Practice Recommendations Ensure that only current information is retained on working care plan files. Maintain an up to date index of care plans and risk assessment for ease of reference. Continue development of person-centred approaches and integrate with care plans. Upland Road, 24 DS0000016883.V274329.R01.S.doc Version 5.1 Page 22 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
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