CARE HOME ADULTS 18-65
29 Byron Street West Bromwich West Midlands B71 1NP Lead Inspector
Lesley Webb Unannounced Inspection 11th August 2007 09:00 29 Byron Street DS0000004826.V345661.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 29 Byron Street DS0000004826.V345661.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. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 29 Byron Street Address West Bromwich West Midlands B71 1NP 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) 0121 553 2443 NONE Pioneer Care Limited Mr Paul Jones Care Home 3 Category(ies) of Learning disability over 65 years of age (3), registration, with number Physical disability (1) of places 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To include 3 service users whose ages may range between 60 and 65 years of age and above at any one time. 1st August 2006 Date of last inspection Brief Description of the Service: 29 Bryon Street is a semi-detached property, leased from the Local Authority, and operated as a Home by Pioneer Care Ltd. Set in a quiet residential area of West Bromwich, two miles from the Town centre, it is close to local facilities and well served by public transport. The Home provides care and accommodation for up to three adults who have a learning disability. Two of the Residents are over the age of 65 years, one of whom also has a physical disability. Accommodation comprises a dining area, lounge, kitchen, and toilet on the ground floor, with three bedrooms, ‘a sleeping-in room’, a bathroom and toilet on the first floor. There is a Wessex vertical lift leading from the lounge area directly into the bedroom of the Resident who has a physical disability. There is parking on the road in front of the property and there is a large, partly paved garden to the rear with access to both areas facilitated by ramps. The Home provides a range of in house and community based activities for Residents. A statement of purpose and service user guide are available to inform residents of their entitlements. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector undertook this visit over one day with the home being given no prior notice. During the visit time was spent talking to residents, staff, examining records and observing practices and interactions between people before giving feedback about the inspection to the registered manager. There are currently two people living at this home. Both individuals’ records were examined. Both residents completed questionnaires with assistance of staff during the inspection. Information from these and from documentation supplied by the home prior to the inspection was also used when forming judgements on standards of service provided. Fees charged for people living at the home ranges from £592.30 to £601.60 per week. Fees charged do not cover items such as hairdressing, private chiropody, newspapers and magazines, personal toiletries and clothing. The inspector was shown full assistance during the visit and would like to thank everyone for making her welcome. What the service does well:
Prospective residents considering this home have the information needed to decide on its suitability. There is a home information pack that contains information such as house rules, complaints procedure, quality assurance questionnaires and the resident handbook. Many items of information have been produced in a pictorial format in order that information is accessible to residents. Staff that the inspector spoke to demonstrated good knowledge and understanding of assessment processes explaining that no new resident is being considered until the current residents have been on holiday in September due to the amount of time required to complete pre-admission assessments and visits to the home. Residents are supported to make choices and involved in decision-making. Throughout the inspection members of staff were observed encouraging residents to make choices about day-to-day matters, such as what meals to have, and what they wanted to do on that day. Residents are able to make choices about their life style. One resident informed the inspector that he chooses not to attend any formal day care provision, stating, “I’m retired now, I deserve to have a rest at my age”. Both residents talked happily about their forthcoming annual holiday to Spain.
29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 6 The home is good at ensuring the dietary needs of residents are met. Residents have the choice of eating at the dining table or in the lounge. There is no set menu plan as residents choose meals on a daily basis that promotes choice and individuality. The staff and manager should be commended for the efforts made to ensure the personal and health care needs of residents are met. Both residents are of an older age but in excellent health with records evidencing staff ensure they receive regular support from various health care professionals. Neither resident is taking any medication. This is particularly good as one resident is over 70 years of age. The other resident was on regular medication when he first moved to the home but this has now ceased, again evidencing the homes excellent support in this area. Both residents confirmed in questionnaires that they completed during the inspection that they know who to speak to if unhappy and know how to make a complaint, with additional comments recorded as ‘if I have any complaints I make it to the staff or manager’. Relationships between staff and residents appear good. Staff were observed talking to residents in friendly way and lots of laughter was heard. One resident informed the inspector, “staff are very nice, nothing too much trouble for them”. Throughout the inspection the registered manager demonstrated knowledge, competency and commitment to his role. Feedback received from staff and residents was extremely positive regarding the management of the home. For example one resident stated, “I’m glad I came to live here, it’s wonderful; staff and Paul the manager are wonderful”. What has improved since the last inspection?
The manger and staff should be congratulated for the efforts made to improve care planning documentation since the last inspection. Both residents now have essential lifestyle plans (a form of person centred planning) that give details of likes and dislikes, family contacts, medical issues, history, communication, personal details, hygiene and preferences. Since the last inspection the manager has introduced ‘Talk Time’. This is where he sits with each resident and talks to them, asking if they are happy or have any concerns. This offers further assurances to residents that they can raise concerns or issues and that these will be acted upon. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 7 The home has undergone major refurbishment enabling residents who live there to do so in a safe, well-maintained and comfortable environment that encourages independence. This includes refurbishment of the kitchen and bathroom, electrical re-wiring, replacement of the central heating system and fitting of interlinking smoke alarms. Staff now receive regular supervision sessions also an annual appraisal (meeting a previous requirement). In addition to this staff meetings take place, that inform and advice staff of issues and events relevant to their roles. Since the last inspection questionnaires have been introduced for staff and stakeholders. These along with the residents questionnaires have been analysed and the findings incorporated into the development plan for the home (meeting previous requirements). 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. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents considering this home have the information needed to decide on its suitability. They have their needs assessed and a contract that clearly tells them about the service they will receive. EVIDENCE: As in previous inspections there is a statement of purpose that covers all of the required subjects. The inspector was also shown a home information pack that is maintained in each residents room that contains information such as house rules, complaints procedure, quality assurance questionnaires and the resident handbook. It was pleasing to find that many items of information have been produced in a pictorial format in order that information is accessible to residents. There is currently one vacancy at Bryon Street. Staff that the inspector spoke to demonstrated good knowledge and understanding of assessment processes explaining that no new resident is being considered until the current residents have been on holiday in September due to the amount of time required to complete pre-admission assessments and visits to the home. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 10 There is a comprehensive assessment tool that can be used for assessing prospective new residents including an independent living skills task assessment entitled ‘my step towards a future’. The two residents living at the home completed questionnaires with assistance with staff during the inspection. Both state they were asked if they wanted to move into this home and received enough information so could decide if it was the right place for them. An additional comment was made of ‘I am happy here’. A previous requirement to ensure that the statement of conditions of residence are developed to meet all of the requirements of the National Minimum Standards 5.2 for example including any details of additional charges is partly met and now becomes a good practice recommendation. On examination all residents’ case files were seen to contain a copy of terms and conditions of occupancy that contain the majority of elements required by the National Minimum Standards, for example they include details of the bedroom occupied and are signed by the registered manager, advocate or resident. It was however noted that neither contained information regarding the fees charged for living at the home despite an area of the contract allowing for this information to be included. The manager explained that this was an oversight on his part and agreed to amend to ensure residents and their representatives are fully informed and their legal rights protected. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The manger and staff should be congratulated for the efforts made to improve care planning documentation since the last inspection. Both residents now have essential lifestyle plans (a form of person centred planning) that give details of likes and dislikes, family contacts, medical issues, history, communication, personal details, hygiene and preferences. A requirements was made at the previous inspection to review and expand existing care plans to ensure that all aspects of personal and social support and health care needs are included in greater detail. Upon examination of the care planning documentation the inspector found that although improvements to care planning documentation has been made plans are still missing for some identified needs such as support for one resident with a catheter bag and for residents requiring support with their finances.
29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 12 As at previous inspections plans were found to be regularly reviewed to ensure residents’ needs are appropriately monitored by the home. Staff also complete daily records that give brief overviews of residents wellbeing, times of rising and retiring, activities, appointments and meals taken. A recommendation regarding these is made later in this report under standard 14. Residents are supported to make choices and involved in decision-making. Throughout the inspection members of staff were observed encouraging residents to make choices about day-to-day matters, such as what meals to have, and what they wanted to do on that day. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability and communication needs. All staff that were interviewed demonstrated excellent knowledge and understanding of involving people with communication needs in decision-making processes. As with care planning, generally risk assessments processes and documentation is good. Some improvements however must be undertaken to ensure risk assessments as completed for all identified needs (this requirement was identified in the previous inspection and remains in place). For example one persons file has documentation regarding their communication needs but no corresponding risk assessment is in place. As the inspector explained to the manager care plans and risk assessments should correspond to ensure a holistic approach to care management occurs. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their life style. Social, educational, cultural and recreational activities meet individuals’ expectations. EVIDENCE: Information supplied by the home prior to the inspection states ‘we support service users to achieve maximum independence through a variety of stimulating activities and community outings to reflect their own needs and preferences. We support and encourage one service user with his spiritual needs, meals offered promote choice, variety and cater for special dietary needs, we show respect and dignity to each service user, listen effectively’. Evidence gathered through examination of records, discussions with residents and staff and indirect observations confirms this information to be accurate. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 14 For example residents informed the inspector of activities that they undertake both individually and as a group, staff were heard asking residents their preferences at lunch and when being offered drinks and care planning documentation details preferences and needs in relation to activities and religious needs. As at previous inspections staff encourage residents to maintain their independence. For example during the visit residents were seen taking their own cups into the kitchen for washing up and helping staff. One resident informed the inspector that he chooses not to attend any formal day care provision, stating, “I’m retired now, I deserve to have a rest at my age”. Residents informed the inspector about their favourite leisure pursuits. For example, one resident stated that he liked watching his favourite programmes on television, is supported to go and watch local cricket matches by staff and remains a devoted church goer, and talked about the social as well as the spiritual benefits of visiting his church. Both residents talked happily about their forthcoming annual holiday to Spain. Each resident has a daily diary in which staff record their activities. Upon examination of these the inspector found that in many instances records are quiet basic. For example recordings include ‘went out with X’ and ‘popped out with X’. It is recommended that these be expanded to ensure they demonstrate in full that residents are supported to lead full and active lives based on their individual needs and capabilities. Daily routines are flexible according to the individual preferences of residents. For example residents informed the inspector that they can choose what time to rise or retire and that staff consult them with regards to times of eating. The home is good at ensuring the dietary needs of residents are met. Residents have the choice of eating at the dining table or in the lounge. As at previous inspections residents confirmed that they enjoyed the meals provided and stated their preferences that on examination of daily food records confirmed that they were offered their favourite foods. There is no set menu plan as residents choose meals on a daily basis that promotes choice and individuality. Nutritional screening tools are in place that are reviewed at least annually. It was pleasing to see that staff encourage healthy eating with fresh vegetables and produce. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The staff and manager should be commended for the efforts made to ensure the personal and health care needs of residents are met. Information supplied by the home prior to the inspection states ‘we are a committed care team that knows each residents needs, treat service users with respect and dignity, monitor and act on change of needs, escort service users to health professionals appointments, offer appropriate support, monitor and provide equipment and aids and ensure staff attend appropriate training sessions when required’. This information accurately reflects circumstances within the home. For example both residents are of an older age but in excellent health with records evidencing staff ensure they receive regular support from various health care professionals. Each resident also has a health action plan in place and regular weight check records as aids to health management. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 16 Further evidence of the homes excellent systems for managing health care is the fact that neither resident is taking any medication. This is particularly good as one resident is over 70 years of age. The other resident was on regular medication when he first moved to the home but this has now ceased, again evidencing the homes excellent support in this area. However staff still receive training in the safe handling of medicines, which is an excellent initiative. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns and have access to a robust, effective complaints procedure. Generally residents are protected from abuse. Further improvements to one aspect of financial support and recruitment records will offer greater protection. EVIDENCE: As at the previous inspection there have been no complaints received about the service during the last twelve months. There is a comprehensive complaints procedure that has also been produced in a pictorial format in order that information is accessible to all residents. Since the last inspection the manager has introduced ‘Talk Time’. As he explained this is where he sits with each resident and talks to them, asking if they are happy or have any concerns. Records confirm this was introduced July 2007. The inspector congratulated the manager regarding this, recommending that ‘Talk Time’ be offered to residents on a regular basis (for example monthly) as a further assurance to residents that they can raise concerns or issues and that these will be acted upon. Both residents confirmed in questionnaires that they completed during the inspection that they know who to speak to if unhappy and know how to make a complaint, with additional comments recorded as ‘if I have any complaints I make it to the staff or manager’. All staff have received training in vulnerable adult abuse. Policies and procedures for the protection of vulnerable adults are in place along with a copy of the Local Authority vulnerable adult abuse guidelines.
29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 18 No residents exhibit challenging behaviour or require any physical interventions. Some further improvements to recruitment records are required to offer further protection to residents (see staffing section of this report for further details). There are procedures in place with regard to residents’ financial affairs. The manager states that he does not act as appointee for any residents. Residents need varying levels of support to manage their finances. There are personal expenditure sheets to record all financial transactions with double signatures obtained from staff. Petty cash vouchers and receipts are obtained for larger cash purchases. Residents receive smaller sums of money to spend according to their wishes although they require support from staff. Records are entered on to the personal expenditure sheet of when they receive this money although receipts and petty cash voucher are not deemed necessary. Records indicate that a resident is assisted to withdraw money from their bank account, which is then taken to the head office of the company to pay for their fees for living at the home. Records also state that money is then received from the head office two days later for the resident to use, as it is their personal allowance. The inspector questioned this practice, asking why the resident cannot bring their personal allowance straight from the bank and why their personal allowance has to be taken to the head office only to be returned to the resident later. The Acting Manager was unable to answer this, agreeing that this should be investigated and clarified. All monies checked were correct and corresponded with amounts detailed on personal allowances sheets. As mentioned in other parts of this report action must now be taken to ensure care plans and risk assessments are in place that support the financial needs of residents. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the physical design and layout of the home enables residents who live there to do so in a safe, well maintained and comfortable environment that encourages independence. EVIDENCE: Since the last inspection the home has undergone major refurbishment. This includes refurbishment of the kitchen and bathroom, electrical re-wiring, replacement of the central heating system and fitting of interlinking smoke alarms. A tour of the premises was undertaken including the viewing of residents’ bedrooms, all of which were freshly decorated and furnished to a good standard. Residents’ bedrooms were individualised with personal possessions, photographs, televisions and stereo equipment. The communal areas were bright and airy with comfortable and homely furnishings. There is a large, secluded garden to the rear with an abundance of potted plants and outdoor seating.
29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 20 All parts of the home were seen to be clean and hygienic. The laundry is sited in an outbuilding. This was found to require attention, as the walls and flooring are not sealed, consisting of brick and concrete resulting in them being porous and not to infection control guidelines. It was noted by the inspector that no written procedure for the sanitising of mops and their storage is currently in place. It is recommended that a system for storage and sanitising of mops be introduced to ensure infection control standards are promoted. It is also recommended that the home obtain the recently updated guidance ‘Infection Control Guidance in Care Homes’ again to ensure its systems for the management of infection protect residents. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 21 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): 31,32,34,35 and 36. Quality in this outcome area is adequate. 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 live there. Some improvements to recruitment records will offer greater safeguards to residents. EVIDENCE: As in previous inspections staff at Byron Street present as interested in their jobs, motivated and committed to the welfare of the people living there. Staffs spoken to were aware of residents’ individual needs and had a grasp of knowledge of disabilities and conditions of individuals in general. Relationships between staff and residents appear good. Staff were observed talking to residents in friendly way and lots of laughter was heard. One resident informed the inspector, “staff are very nice, nothing too much trouble for them”. Information supplied by the home prior to the visit states that ‘we support services users with competent and qualified, committed and supervised staff’. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 22 The home should be congratulated for the numbers of staff holding a National Vocational Qualification, with the majority of the staff employed at the home having obtained this or due to undertake. The records of four members of staff were examined to assess if the homes recruitment practices protect residents. All contained an enhanced Criminal Records Bureau (CRB) disclosure. Some omissions were found. For example one persons records did not include an application form, another only had one reference and for another person neither of their references were care related. It was also noted that one person is employed at the home who has a foreign passport. This states it is due to expire later this month. No other records were in place that demonstrate if this person has been granted citizenship or if they have a work permit. This was brought to the managers attention, with the inspector instructing that the employment status of this person must be explored and records maintained that demonstrate they are legally entitled to work; to ensure residents are protected in full. Requirements were made at the last inspection regarding recruitment documentation. One of these is now met but the other remains in place, with the inspector explaining that full and accurate recruitment records must be maintained that demonstrate residents are protected by the homes practices. There is a training and development system in place that ensures staff receive appropriate training and induction in order that they have the skills and knowledge to support residents. Staff files sampled contained certificates for challenging behaviours, disability awareness, equal opportunities in addition to other mandatory training. Examination of staff records confirms that regular supervision sessions are taking place and that all staff also receives an annual appraisal (meeting a previous requirement). In addition to this staff meetings take place, that inform and advice staff of issues and events relevant to their roles. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, with effective quality assurance systems that allow the home to measure if it is meeting its aims and objectives. EVIDENCE: Throughout the inspection the registered manager demonstrated knowledge, competency and commitment to his role for which he should be congratulated. Feedback received from staff and residents was extremely positive regarding the management of the Home. For example one resident stated, “I’m glad I came to live here, it’s wonderful; staff and Paul the manager are wonderful”. As in previous inspections Mr. Jones’s management approach is conducive to promoting an open and positive atmosphere for both residents and staff.
29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 24 Good quality assurance systems are in place that allow the home to measure if it is meeting its aims and objectives. These include regular maintenance and health and safety audits, visits undertaken in line with Regulation 26 of the Care Home Regulations and service user satisfaction questionnaires. Copies of these were contained within the service user guide and examination confirmed that residents are happy with the support provided by staff at the home. Since the last inspection questionnaires have also been introduced for staff and stakeholders. These along with the residents questionnaires have been analysed and the findings incorporated into the development plan for the home (meeting previous requirements). All previous requirements relating to health and safety are now met. For example there is weekly testing of the smoke alarm system and water temperatures are recorded for hand basins in residents bedrooms. Maintenance records for all areas of the building demonstrate that generally repairs are carried out within appropriate timescales and a sample of maintenance and records were examined and found to be up to date. There is mandatory training for staff. Examination of the training records which was cross referenced with a sample of training certificates confirmed that staff have undertaken all of the required disciplines in statutory training which is an excellent achievement. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 25 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 3 3 X X 3 X 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(1) Requirement The home must ensure care plans are in place for all aspects of personal, social support and health care needs in order that residents needs are met in full. Previous timescale part met. The home must ensure risk assessments are in place for all identified needs to minimize risks to residents. Previous timescale part met. The home must review the situation regarding a named residents personal allowance being taken to head office and then returned to the home two days later to ensure the residents rights are not compromised. Improvements to the laundry flooring and walls must be made to ensure they promote good infection control measures. The home must ensure recruitment records are in place in respect of persons carrying
DS0000004826.V345661.R01.S.doc Timescale for action 31/10/07 2 YA9 13(4)(c) 31/10/07 3 YA23 13(6) 01/09/07 4 YA30 13(3) 01/12/07 5 YA34 19 30/09/07 29 Byron Street Version 5.2 Page 27 on, managing or working at a care home as listed in the Care Home Regulations 2001 to ensure residents are protected by the homes recruitment procedures. Previous requirement part met. 6 YA34 19 The employment status of a named person must be explored and records maintained that demonstrate they are legally entitled to work; to ensure residents are protected in full. 30/09/07 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 YA5 Good Practice Recommendations To ensure that the conditions of residency include fee details to ensure residents and their representatives are fully informed and their legal rights protected. That activity recordings in the daily diaries be expanded to ensure they demonstrate in full that residents are supported to lead full and active lives based on their individual needs and capabilities. That ‘Talk Time’ is offered to residents on a regular basis (for example monthly) as a further assurance to residents that they can raise concerns or issues and that these will be acted upon. That a system for storage and sanitising of mops be introduced to ensure infection control standards are promoted. That the home obtain the recently updated guidance ‘Infection Control Guidance in Care Homes’ again to ensure its systems for the management of infection protect residents.
29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 28 2 YA14 3 YA22 4 YA30 5 YA37 It is recommended that the home be enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Local Office West Point Mucklow Trading Estate Mucklow Hill Halesowen 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 29 Byron Street DS0000004826.V345661.R01.S.doc Version 5.2 Page 30 - 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!
