Inspection on 09/01/07 for 27 Highfield Road

This inspection was carried out on 9th January 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

27 Highfield Road 13/02/06

27 Highfield Road 24/10/05

27 Highfield Road 12/11/04

27 Highfield Road 02/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 27 Highfield Road Colley Gate Halesowen West Midlands B63 2DH Lead Inspector Mr Jon Potts Unannounced Inspection 9th January 2007 10:40a 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 27 Highfield Road Address Colley Gate Halesowen West Midlands B63 2DH 01384 410581 NONE 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) info@inshoresupportltd.com Inshore Support Limited Vacant Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 MD and up to 3 LD Date of last inspection 13.2.06 Brief Description of the Service: 27 Highfield Road is situated in a residential area of Colley Gate, Near Halesowen. The home is registered to provide care to a maximum of three service users who have been diagnosed as having a learning disability and/or mental disorder. The home is in a favourable position as it is located in a residential area yet is close to a main road with a bus route, a number of shops and other amenities. The home is a large, traditional, domestic type dwelling, comprising of two lounges, three single bedrooms, a kitchen come dining room, a first floor bathroom and a separate shower room. The garage has been converted into usable space, which has become the office. There is also a small and pleasant private patio area to the rear. As on previous inspections, the inspector was impressed with the home regarding its internal fixtures, fittings and furniture. The home is of a generous size, is well presented, well maintained, is clean, homely and has a warm welcoming atmosphere. The staff team consists of an acting manager who is supported by a number of seniors and support workers. The support staff also carry out domestic and catering tasks (supporting service users as appropriate). The acting manager is responsible to a responsible individual and other senior managers with the company that runs a number of homes of similar size and purpose. The charges for accommodation range from £2,117.83 to £3,444.89 and the only additional charges are for hairdressing, toiletries and personal items 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day and involved the inspector assessing the homes performance primarily against the key national minimum standards for younger adults. Evidence was drawn from a number of sources and including case tracking the care for two residents (this involving looking at all the documentation in respect of their care and cross checking this with outcomes), observation of practice, discussion with the acting manager, staff and review of management records. There was some discussion with the residents although this was not protracted. Information was also supplied pre inspection by the home and via resident’s comments cards (that they were assisted with in some cases by the staff). The residents and staff are to be thanked for their assistance with the inspection. What the service does well: What has improved since the last inspection? All but one of the requirements from the last inspection has been addressed with the most significant improvement in the development of the homes systems for self-monitoring and audit. There has also been on-going training of staff in a number of areas including person centred planning and some specific areas of documentation where issues were identified have now been addressed; this with additional risk assessments, collated findings from customer questionnaires and better documented fire drills. Control of confidential information has also been improved with the purchase of a shredder for disposal of redundant paperwork. The damaged kitchen worktop has also been replaced as well as some items of furniture and furnishings as part of the home’s on going maintenance programme. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective people looking to use the service, and their representatives have the information (in a standard written format) needed to choose a home, which will meet their needs. Prospective residents have their needs assessed and opportunity to test drive the service and meet others residents and staff. They also receive a contract, which clearly tells them about the service they will receive, this in written form. EVIDENCE: Whilst there have been no recent admissions to the home, discussion about the process of admission with the acting manager showed that she understood the importance of having sufficient information available to the service user and their representatives, this to allow them to make a decision as to whether 27 Highfields was a home that would meet their needs and preferences. Whilst information was mostly available in written form the home does spend time in introducing the prospective service user to the home through staff spending time with them in their current environment and then allowing stays at the home for meals, overnight, and so on so that they can sample the service and meet other residents and staff. The acting manager saw compatibility between the residents as an important issue. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 9 The homes statement of purpose is a specific document to the home based on a generic format used by the companies other homes (which all offer a similar service). It clearly sets out the objectives and philosophy of the home and includes a range of information about the service provided, the accommodation, staffing (experience and qualifications) how to make a complaint and so on. All residents have a copy of the statement of purpose/service user guide available to them in their case file although the use of a more pictorial based document would be better for the current resident group. Contracts (called lifestyle agreements) were also available and these set out the basic terms and conditions of the service but again would benefit from presentation in a format that would better suit resident communication needs, although it was stated by the manager that verbal explanation suitable to the service users needs would be given. The admission process described by the acting manager was in accord with the homes admission procedure. Admissions are not made to the home until a full needs assessment has been undertaken this including the assessment by experienced staff with involvement of the care manager within this process. Admissions were stated by the manager to only take place following consultation with her by the company so that staff views could be shared. The views of and the compatibility with other residents would also be considered through the prospective residents visits to the home. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and participate in planning the care and support they receive where possible; this to be developed through the use of person centred planning. EVIDENCE: Whilst care plans are not currently developed following person centred planning principals at present staff are currently receiving training in this area. Each resident has a plan that has as far as is possible been agreed with him or her when consideration is given to communication difficulties. Plans are currently in written format although does consider all areas of an individual’s life including daily routines, activities, health, independence and management of behaviours. The current plans identify goals with which the staff would work with the resident to achieve although it was noted that review of the plans did not always highlight the progress a service user may 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 11 have made towards achieving this goal. Whilst the plans do focus on how residents can develop their skills, there needs to be a clear record of the service users progress and achievements documented, this then influencing the plan itself where appropriate. Staff spoken to were aware of the contents of the plans as a working tool. The service does need to develop methods of person centred planning in accord with the communication needs of the residents at the home. There was evidence of regular reviews of the plans through involvement of care managers and representatives although the copy of the one social worker review was noted to have been mislaid. Where available the care plans reflected changes agreed within these meetings. Each care plan was supplemented by comprehensive risk assessments with these taking into account the individual needs of the service users. The tool used for overall assessment did easily identify areas where there was judged to be a high risk through colour coded outcomes. There were some limitations in place, these consistent with the needs of the service users, and clearly documented. There was however no signatures of the resident or their representative (the latter where the resident was in agreement this) that showed their agreement with these documented limitations. There were procedures in place to ensure that arrangements for the resident’s confidentiality were clear and these explained where staff might share information with others, this in respect of safeguarding or promoting the residents interests. Residents are not currently involved in group meetings as the communication needs of some would make it difficult for them to have their say, but the manager stated that there is regular one - to - one discussion to ensure that they were satisfied with the provision of on going care. The acting manager stated that they have tried hard to acknowledge the achievements of the service users. (Example of this is in respect of weight loss – healthy eating). 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities are provided that meet known individual’s expectations. EVIDENCE: The service has a commitment to enabling residents to develop their skills, including social, emotional, communication, and independent living skills. Staff support individuals to work towards achieving goals that will be beneficial to them such as increasing their independence. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 13 Residents have the opportunity to develop and maintain important personal and family relationships, and with the assistance of staff would have access information and specialist guidance about issues such as intimate relationships, this also incorporated within company procedures. Procedures also consider protection of individuals, supporting people to make informed choices. Staff are aware of the need to pay close attention to the residents communication needs and how these manifest themselves, whether verbal or behavioural, with awareness of how this may influence patterns of risk within such as accessing the community to enable residents to fully participate in daily living activities. Some staff have received training in developing communication with residents and others are to receive the same (such as makaton) Residents are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; they have been as fully involved as possible (this varying dependent on ability) in the planning of their lifestyle and quality of life. Education and occupation opportunities are limited due to dependency are present but are wherever possible incorporated with the resident’s daily activities. Support is offered by sufficient and trained staff although it was stated by the acting manager that the lack of drivers in the staff team has caused some difficulties with accessing community based activities, although the company is actively looking to rectify this through recruitment. The home has its own allocated transport, this of import as some residents based on risk are unable to use public transport or taxis. They can however access and enjoy the opportunities available in their local community, such as discos, friends in other homes and local leisure facilities via the homes transport. The service is committed to the principles of inclusion and works hard to promote, and fosters good relationships with neighbours and other members of the community. Where appropriate and able residents are involved in the domestic routines of the home. The staff have ascertained residents likes and dislikes based on the foods they choose to eat and the record of foods provided to residents showed that the menu is varied with a number of choices including healthy options. The meals are balanced and nutritional and cater for the varying dietary needs of the residents. The meal of the day was seen and it was noted to be presented so that it looked appetising. There are occasions where residents do refuse food offered and there was evidence that alternatives are offered, perhaps at a later point in the day if the resident chooses not to eat at the usual mealtime. The resident have access to a well laid out dining area where they can eat with staff and their peers. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual need and the principals of respect, dignity and privacy are applied. There are some areas in regard to the management of medication where in house monitoring has failed to identify shortcomings. EVIDENCE: Specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents. It is recognised that the delivery of personal care is highly individual and must be flexible, consistent and reliable with an emphasis on promoting independence. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 15 Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to changing needs of residents. When ever possible residents are able to have choice about who delivers their personal care. Where possible residents are supported and helped to be independent and responsible for their own personal hygiene and personal care, this set out in care plans. Residents are seen to have access to health and remedial services, staff making sure that where possible residents have regular appointments, sometimes at local health care services or via visits from local health care services. Personal aids and equipment are not generally needed although there has been adaptation to safeguard residents well being within the house (guarding radiators etc). Staff have access to training in health care matters and are encouraged and given time to attend training on specialist areas of work. (Recent examples include epilepsy, use of stesolids, autism). The aims and objectives and policies of the home reinforce the importance of treating individuals with respect and dignity. The home works to an efficient medication policy supported by procedures and practice guidance, and staff are aware of the same. There were however some issues in respect of the recording and stock control of medication that were lacking, one in respect of administration records not matching the actual regime of administration and a second where a cream was not applied as stocks ran out on occasions. Other records were seen to be satisfactory and staff have received accredited medication training as well as in house drugs assessments. There was evidence of some management checks although the above issues had not been identified. Residents are encouraged to have some control of the administration of their medication through the staff encouraging them to apply their own creams where possible, although the administration of tablets is through the staff team, this following risk assessment and with written consent of the residents. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns where possible and staff are aware of the need to monitor resident’s behaviour for signs of dissatisfaction. The home has a robust, effective complaints procedure. Residents are generally protected from abuse, and management are responsive when third parties raise concerns. EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. It was only available in written format at the time of the inspection (although a pictorial version has been seen to be available previously) but has been passed to service users representatives. Discussion with the acting manager indicated that some of the residents had difficulty understanding the complaints process that meant that it was important for staff and management to be aware of any behaviour that indicated dissatisfaction with the service provided. Other service users did have an understanding of how to complain however and the access of the residents to professionals independent of the service (community nurse, psychiatrists, social workers etc) on a regular basis has been known to provide a means by which concerns can be picked up and addressed. The homes procedure makes it very clear of what can be expected to happen if a complaint is made. Unless there are exceptional circumstances the service always responds within the agreed timescale. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 17 The policies and procedures regarding protection of individuals are of good quality and are regularly reviewed and updated. The acting manager and staff are clear when incidents need external input and who to refer the incident to. There was also evidence to support the fact that senior managers take the investigation of any allegations seriously. Training of staff in the area of protection is regularly arranged by the Home. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. The outcomes from any referral are usually managed well with one arising since the last inspection, this now resolved. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26,27, 28 29 & 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment that allows independence. EVIDENCE: The provider and acting manager have ensured that the physical environment of the home provides for the individual requirements of the residents who live there. The living environment is appropriate for the particular lifestyle and needs of the residents and is homely, clean, safe and comfortable. Residents are encouraged to see it as their own home. It is a very well maintained, attractive home, which is accessible to community facilities and services. There are some adaptations in place to meet individual residents needs such as the provision of radiator guards, appropriate and safe furniture etc. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 19 The home is designed to provide small group living where residents can enjoy maximum independence in a discrete non- institutional environment that resembles a domestic dwelling. Residents are fully involved in decisions about the décor and any changes to the accommodation. They have had a choice of the room they live in and the home provides only single room accommodation. The rooms are very well planned and there is easy access to toilet and bathing facilities, no more than two sharing these upstairs and three downstairs. The fixtures and fittings are of a high quality, well maintained and adapted to meet the wishes of the present service users. Individuals personalise their rooms and bring in their own furniture if they wish. There is a selection of communal areas both inside and outside of the home, this means that residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other people who use the service. The kitchen and laundry are designed to enable and promote the involvement of residents in domestic tasks and as part of developing or maintaining selfhelp skills. The bathrooms are homely and include aids and adaptations to meet the needs of the residents. All bedrooms enable privacy and have locks on the doors dependent upon risk assessments. There was evidence from water temperature records and checking the hot water supply that there is always plenty of hot water and the temperature in the home can be changed to meet their personal choice. The home was very well lit, clean and tidy and smelt fresh. The management has a proactive infection control policy and staff understand how to manage infection and maintain a safe and clean environment. Risk assessments and items necessary to support infection control were seen to be available (such as liquid soap and paper towels). 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The service has a highly developed recruitment procedure that has the needs and protection of people who use the service at its core. The recruitment of good carers was seen by the acting manager to be integral to the delivery of a good quality service, with an awareness that equal opportunities has to be offered through the recruitment process. The result of this is a diverse staff team that has a balance of all the skills, knowledge and experience to meet the needs of service users. There is evidence that the staff spoken to demonstrated a good understanding of the particular needs of the service users living at the home. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 21 Management prioritise training and facilitate staff members to undertake external qualifications beyond the basic requirements. The scheme introduces internal developmental training, to complement formal training as part of an ongoing training plan. There have been difficulties reaching the required ratio of staff with NVQ level 2 training although this target should be reached soon assuming that there is minimal staff turnover, this as there are sufficient staff currently undertaking the qualification to allow the home to reach this target on their completion of the same. The one area of training that the service needs to focus on in addition to the above is equality and diversity. The roles and responsibilities of staff are clearly defined and understood, based on accurate job descriptions and specifications that are readily available to staff. The service sees induction and any probationary period as being an extension of recruitment. There are clear systems in place to ensure that there is closer supervision of new staff and the knowledge aspect of induction training is provided by the company through external training provision, with links within this to LDAF (learning disability Award Framework). Where there are vacancies and sickness the home offers extra hours to existing workers (to assist with consistency). Some staff are currently working over their contracted house to cover vacancies that the service is currently recruiting to. There is scope for use of workers from other homes if there is a problem covering gaps in the rota. Due to this there is no use of any agency or temporary staff. The interview and selection process is based upon identified criteria that are closely related to the job being advertised and supports the procedure. Residents are not directly involved in the recruitment process although there is opportunity for prospective staff to visit the home and meet resident’s prior to employment. The acting manager stated that any concerns at this point would be discussed with senior management. All elements of recruitment are accurately recorded and the required documentation is always received prior to the employee starting work. Staffing levels reflect the needs of the residents, and rotas are flexible to fit around the lifestyles of individuals and specific activities. Staff have the skills to communicate effectively with all residents, and on – going training for staff in Makaton is supporting this. This includes all care staff who come into regular contact with service users. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 & 43 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The management of the home, although not at present including a registered manager, is based on openness and respect and has a developing and generally effective quality assurance system developed by the homes senior management. There was some slippage on occasion in respect of some records, although overall documentation seen was to a good standard. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home does not currently have a registered manager, although there is an acting manager in post that is considering applying for registration (with support from the provider). The acting manager has experience from working within the providers homes for a number of years at a senior level and is currently undertaking NVQ training, this to be supplemented by the Registered Managers Award as soon as enrolment is possible. The acting manager was aware of and worked to the basic processes set out in the NMS. Support was seen to be readily available from another registered manager as well as the responsible individual. The manager trains and develops staff that are generally competent and knowledgeable to care for younger adults. The service is planned to be user focused, and generally works in partnership with families of residents and professionals. The home has policies and procedures that set out the aims and objectives of the service. The manager is improving and developing systems that monitor practice and compliance with the homes plans, policies and procedures, this in conjunction with the services Registered Provider. Whilst progress is ongoing, there has been significant improvement seen in this area since the last inspection. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. The home has received a fairly recent inspection from Environmental services and is working to address outstanding issues that have been identified. The service should liaise with Environmental services in respect of any issues that are problematic. The registered person is aware of the need to plan the business activity of the home, and manage the finances and resources to deliver the business plan. The service provider takes responsibility for the home’s accounts and business development. The home has adequate insurance cover. Checks show that records are generally up to date although some limited gaps/omissions were found in recording, including no dates on some behaviour records, not completing records of restraint for every time this occurs, and no signing out of resident’s monies when taken out on activities. The latter needs to be carried out at the time removed from safekeeping as opposed to entering expenditure on return. 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 3 27 3 28 4 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 x 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 2 3 2 3 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 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 YA20 Regulation 13(2) Requirement Timescale for action 28/02/07 2. YA20 13(2) 3. YA32 18 All directions for the administration of medication as detailed on medication administration records must coincide with the dosage of medication given and the times it is administered To ensure sufficient prescribed 28/02/07 creams/ointments are in stock so as to ensure that the home does not run out of the same prior to supply. To continue with staff training in 30/06/07 NVQ level 2 so as to enable the home to have 50 of staff so trained. This repeated requirement was to have been met by the 30.8.06. To progress an application for registration of the acting manager to the Central Registration Unit. To ensure that all necessary records are completed, accurate and dated. Such as: Records of restraint; Records of behaviour; DS0000025001.V325320.R01.S.doc 4. YA37 8, 9, 10 31/03/07 5. YA40 17(2)(3) 28/02/07 27 Highfield Road Version 5.2 Page 26 Signing out of any resident’s monies removed from the home. 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 YA1 Good Practice Recommendations To develop key policies and procedures such as the service users guide and complaints procedure in pictorial or alternative formats that allow easier understanding by the residents. The goals identified in care plans should be revised when there is evidence that these are partly are fully achieved by the service user. The home should ensure that the minutes of multidisplinary reviews for all residents are available. To make greater use of pictorial formats for care planning and develop personal centred plans. All limitations agreed with residents should be signed by the resident or a representative (the latter with the residents agreement) To provide all staff with Equalities and Diversity training To liaise with Environmental services in respect of the home’s last report from the former 2 3. 4. 5. 6. 7. YA6 YA6 YA6 YA6 YA35 YA42 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 27 Highfield Road DS0000025001.V325320.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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!