Inspection on 06/02/07 for 4 Greswolde Park Road

This inspection was carried out on 6th February 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Greswolde Park Road 06/12/05

4 Greswolde Park Road 27/04/05

4 Greswolde Park Road 17/11/04

4 Greswolde Park Road 12/07/04

4 Greswolde Park Road 29/03/04

4 Greswolde Park Road 15/12/03

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 Greswolde Park Road, 4 Acocks Green Birmingham West Midlands B27 6QD Lead Inspector Peter Dawson Key Unannounced Inspection 6th February 2007 10:00 Greswolde Park Road, 4 DS0000016989.V325733.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 Greswolde Park Road, 4 DS0000016989.V325733.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. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greswolde Park Road, 4 Address Acocks Green Birmingham West Midlands B27 6QD 0121 765 4630 0121 765 4630 goldy@tiscali.co.uk 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) Birmingham Multi-Care Ms Anne Tucker-Browne Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years That the registered manager completes the NVQ Registered Managers Award by March 2006. 6th December 2005 Date of last inspection Brief Description of the Service: This is a dedicated respite care unit accommodating up to 4 people usually for a period of up to one week. Residents have a learning disability and some aphysical disability. There are good facilities for wheelchair users. 4 Greswolde Park Road is a large traditional type house, situated in a quiet residential area close to the centre of Acocks Green Birmingham that has a variety of shops and other community resources. Public transport services operate close to the home, which is not conspicuously identified as a residential unit. Accommodation is provided in four single bedrooms that are situated on the first floor. A comfortable lounge and separate dining room are located on the ground floor. The dining room is also used for administration, as there is no office. Bath facilities are situated on the ground floor and shower facilities are located on the first floor. The home is adapted for wheelchair use and there is a shaft lift, suitable for a wheelchair plus a member of staff. The premises has a range of aids and adaptations to assist with mobility which include level access, hoists including ceiling tracking, toilet and bath aids, adapted beds, and other equipment to assist with eating. The home maintains high standards of cleanliness, decoration and maintenance and appears comfortable and homely. There is a garden at the rear of the home that is secure and has been organised so respite service users can enjoy it during fine weather. Greswolde Park Road, 4 DS0000016989.V325733.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 by one inspector on one day from 10 am. – 5.30pm. A Pre-inspection questionnaire was returned to CSCI prior to the inspection and provides a basis of some information in this report. Only 2 people were in residence receiving respite care at the time of this inspection, neither had verbal communication it was not possible therefore to have a feedback of the service from them. However from observations of interactions with staff it was clear that a means of communication was established in non-verbal ways and there was positive engagement with staff. No feedback forms were supplied by CSCI to the service, therefore no written comments received from relatives. There was an inspection the whole of the physical environment and standards and maintenance were high. Records relating to the inspection process were examined and included: Care plans, risk assessments, fire records, medication records, staff files and other records. The Registered Manager was present virtually throughout the inspection and provided helpful information and dialogue. What the service does well: This service provides an excellent facility of respite care for up to 4 people with a severe learning disability and high physical needs. The home provides an annual service to 26 people. There is a shaft lift, hoisting facilities in most areas and a range of equipment to assist daily living. The environment is very pleasing, appealing and homely. It is well-presented throughout. It is extremely well maintained. The garden area is large, secluded and well equipped with good level access from the house and providing an additional dimension during the summer months where residents can relax and roam safely. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 6 The atmosphere is friendly and relaxed. The manager takes a positive lead in the home and staff spoken to were well motivated and committed to resident care. The home caters for varied diets and cultural needs. A person resident was provided with Halal and vegetarian meals. The service works closely with relatives and day centre staff to provide a seamless service. Continuity is provided with continuing care at day centres attended and attempts to provide continuity in social and recreational activity where possible. Carers and involved prior to and if they wish, during respite periods. A verbal and written report on the stay is always given to carers at the end of the stay. Introductions to the home are gradual and unhurried, allowing resident, carer and staff the opportunity to make an informed and reasoned decision about the suitability of the home. What has improved since the last inspection? The standard of decoration and maintenance is exceptionally high. The programme of redecoration has continued. The statement of purpose has been amended to include all required information. The use of covert medication for a resident has ceased, with liquid medication provided as an alternative. Moving & Handling assessments are in place for all residents as required in the last report. Medication administered at day centres is recorded in MAR sheets as a comprehensive record of all medication provided for each resident. Personal expenditure of residents is now recorded on their individual records. All bedrooms now have a lockable facility for personal/valuable possessions. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 7 There has been updated training for staff in Moving & Handling and Adult Protection as required in the last report. Supervision is now provided face-to-face on an individual basis for all staff at least 6 times per year. Supervision records reflect this. The Registered Manager completed the Registered Managers Award by the required timescale of March 2006. Visits by the providers representative under Regulation 26 include consultation with residents where possible. 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 Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 9 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 Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 10 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): Standards 1 - 4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information to enable choice of home are good. The pr-admission procedures and assessment process is excellent, enabling potential resident, relatives, staff and the home to ensure the suitability of the service and that needs can be met. EVIDENCE: A requirement of the last report to amend the Statement of Purpose has been met. The sizes of rooms and the fact that nursing care is not provided at Greswolde has been added. A copy of the statement of purpose is readily available in the home for visitors or potential users of the service. A copy has been given to CSCI. All information is current and relevant and provides adequate information to inform about the suitability of the home for respite care purposes. There is also a copy of the Service Users guide available. Copies of the above are also available in large print or audio tape upon request. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 11 Pre-admission procedures were inspected and found to be good. This is clearly a cruical part of the service provided by the home. An example was of a recent referral for respite care where there was a history of some challenging behaviours. A referral was received from a Social Worker, Manager visited the family for informal chat (securing relative as interpreter), sought the views of day centre staff, spoke to CPN, arranged brief visit to Greswolde to assess reactions and had arranged further visit. In fact this visit took place at the end of the inspection 2 relatives came with the potential resident for tea, thereby extending the amount of time in the home and assessing the needs of the person and reactions of other residents. No promises were made about admission but a further short visit was to be re-arranged when the relatives would leave the person alone at Greswolde for 1-2 hours to see the reactions, relatives would have to be contactable by telephone. This process enables to home to make a judgement about meeting the needs of the person who can also experience and his reactions known about a possible short-stay. This procedure is normal practice of gradual introduction to the home and ongoing assessment with limit of time. Progression would be to an overnight stay. In the instance above the Manager had already made the decision that in the event of overnight stays an additional waking night care worker would be required. The local authority was agreeable and would pay the costs. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 12 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): Standards 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were satisfactory. Risk assessments should be signed and dated. Residents without speech are assisted by staff to make decisions. EVIDENCE: The care plans of the 2 people in residence on respite care were seen. Both have had previous periods of respite care and care plans at the time of the last admission had been reviewed and updated. Risk assessments were in place but had not been signed and dated as required in the last report. Care planning information was comprehensive. More complex needs have additional printed instructions for care outlining specific areas of more complex need - these included: elimination, personal care needs, breathing, eating & Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 13 drinking, epilepsy protocols etc. The cultural dietary needs of a resident were documented. A new format is being used gradually as residents return on respite, these are more person-centred plans with greater personal detail. Daily notes were seen and to a good standard. There is a daily report for each of the 3 staffing shifts. There are 2 versions of this – one remains with the care plan, the other containing a summary of daily the report is given to parents/carers at the end of the respite care period. The home works closely with day centres during the period of respite care. – Day care continues in the existing setting to allow continuity. A report from the day centre the previous day had been sent to the home including information about two “near misses” – the poor mobility of the person had resulted in concerns about safety. This was useful information the home could act upon (the person was admitted for respite care on the day prior to the inspection). A requirement was made at the last inspection to avoid the use of covert medication and to see possible liquid medication as an alternative. This was done and liquid medication prescribed. The level of decision making can relate to the residents capacity and skills. There were only 2 people in residence on this inspection, neither able to verbally express their views, but non-verbal communication methods were used to involve them in the daily routines. A member of staff was asked about food choice and menu planning she said “they choose” indicating that residents made the decisions about their choice. Where preferences are known they are recorded in care plans. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 14 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): Standards 11 – 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home caters well for the diverse and complex needs of this changing respite care group. Continuity of care is important and achieved. EVIDENCE: The chosen lifestyles of residents are documented and known. Most people come to Greswolde for 1 week respite care, although some may come for 1 night, a weekend or longer than a week. This is tailored to the needs of the resident and carers. The implications are that the home has to cater for a diverse and changing continuum of social, recreational and emotional care needs. In addition to the extremely varied physical care needs and sometimes difficult behaviours of residents. At the time of this visit there were only 2 people in residence attending for 1 week respite, having arrived the day prior Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 15 to the inspection. Both had high physical needs - both wheelchair users, neither had verbal communication. They continued to attend the day centre they attend when at home and on the evening of the inspection one resident usually goes to an evening club – outing to community, assisted by Birmingham Multi-care organisation – the other resident was asked he would like to go too and arrangements made to collect them both for an evening out. Specialist transport required and provided. There are 26 people who have periods of respite care at Greswolde throughout the year – all have individual and diverse needs. The home caters for the social and recreational needs of these people well. All continue to attend the day centre they attend whilst at home. There are external trips to cinema, theatre, bowling, shopping, meals at restaurants and cafes. Some resident have eating needs, personal care needs and behavioural traits. This means that venues have to be carefully selected and planned –and needs change weekly with new intake of residents. The home manages this well and provides a positive and personal service for its changing residents. The garden area is large, very private and south facing. It is used considerably in the summer months, has good seating and shade. There is level access from the house. Residents are reported to continually use and enjoy it in the summer. Family links are an important part of the care and service provided by this home. Families are involved in assessments, admissions and care planning. They are involved in planning respite periods, have discussions with staff prior to admission to report/discuss any changes in the persons needs. They are invited to visit during the respite period if they wish or can have regular reports also if they prefer. Some relatives need the break as consistent carers and this is accommodated if preferred. Relatives are given a written account of the weeks stay and kept informed about progress and need. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 16 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): Standards 18 - 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is given respecting the principles of care. Health care needs are documented and known to staff. There is a safe system of medication in the home. EVIDENCE: There were 3 requirements in the last report relating to these outcomes. These have all been addressed satisfactorily. Examination of records showed that personal care needs were clearly defined in care plans and the actions required to meet needs also clearly stated. In the sample seen there was a care plan with clear instructions for the management of a residents epilepsy. Rectal diazepam was prescribed and available and staff had appropriate training in relation to its administration. Training is specific both to the person and to staff – there is no “blanket” Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 17 protocol/training. Midazolam is also prescribed in some instances and there has been staff training in its use. Residents generally have high dependency needs. Health care issues seen were well documented. All residents are registered temporarily with a local GP practice if needing care by the GP during their stay. A good service is reported from the local GP and also from the specialist and learning disability clinical nurse specialists available locally. It was noted in daily notes that a resident admitted the night prior to the inspection was found to have bruising. This had not been recorded in detail. Body charts are available for this purpose and must be used to record location, size, degree of the bruising. Personal care was observed to be given to the 2 people in residence respecting their privacy, dignity and choice. This was seen in actions of moving and handling, eating, toileting needs etc. Care planning information was observed being followed in these instances. Epilepsy care was well defined in care planning information and providing protocols for actions in the event of seizures. Many of the residents attending for respite care have seizures or potential for seizures. All residents (unless there are specific reasons for not doing so) are checked by waking night staff at half-hourly intervals throughout the night. There were monitoring alert systems in place specifically for those residents likely to have nocturnal seizures. There has been staff training in epilepsy care. The medication system was inspected. The short-stay requirements of people in this service do not allow MDS (Monitored dose system) of medication. All medication is brought from home, checked with carers and MAR sheets handwritten by staff – information replicating the prescribed instructions. Records were accurate and satisfactory. Following a requirement of the last report MAR sheets now record medication held and administered by the day centre. There is a diminishing count of medication and this is checked each day by staff at handover to ensure there are no errors. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 18 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): Standards 22 & 23 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place. Measures are in place to protect residents from abuse. EVIDENCE: There is a copy of the complaints procedure with the Statement of Purpose outlining the procedures for making complaints. There is also a pictorial complaints procedure in the home for residents able to interpret it. No complaints have been received by the home or by the Commission in the past year. There has been staff training in the Protection of Vulnerable Adults. Staff on duty understood the procedures for reporting suspected or actual abuse. There is a leaflet in the home produced by Health & Social Care outlining the broad definitions of abuse and the procedures for reporting suspected abuse. This includes whistle-blowing. All staff have a copy of this leaflet and sign to confirm acceptance and understanding of the procedures. Following a requirement of the last inspection residents personal expenditure is now maintained in individual records rather than in bound-book form. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 19 Physical interventions/restraint are not used in this home. Any incidents affecting the lives of residents are reported to CSCI under Regulation 37. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 20 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): Standards 24 - 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good standard, homely comfortable and safe environment. There are good facilities to accommodate people with physical disabilities. EVIDENCE: The presentation of the home is good. There is a high standard of decoration. The ground floor is redecorated one year the first floor the next. The result is a good well maintained environment. The standards of furniture, fittings and equipment throughout the home are to a high standard. The character of the building is maintained and there is a homely, domestic feel to the home. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 21 The house is detached and also has a well-maintained exterior. A large proportion of residents are wheelchair users and there is good ramped access to the front of the building. There is a large private garden to the rear, much used in the summer months and have level access directly from the dining and rear entrance door. There is an assisted bathroom with toilet on the ground floor. This doubles as the laundry area and has washer/dryer used at specific non-bath times. An additional fire sensor was installed here in view of increased risk in this area. There is a spacious lounge, dining room and kitchen on the ground floor also. On the first floor there are 4 bedrooms and a walk-in shower room with toilet. Bedrooms are of varying size, the smallest is slightly below 10 sq.m.(9sq.m). Bedroom sizes are defined in the statement of purpose as required. All bedrooms are bright, well furnished and have TV/Video supplied by the home. Only 2 were occupied on this visit. Personalisation is limited only because residents stay generally for 1 week. Since the last inspection a lockable facility has been provided in each room (previous requirement) to accommodate personal/valuable items. All rooms are lockable if residents choose to do so. Access can be gained in an emergency. There are a large proportion of wheelchairs users attending for respite care and good facilities to accommodate them. There is a shaft lift large enough for wheelchair and carer. Good access throughout the building for wheelchair users. Bathroom and shower room are assisted facilities and there are adaptations to toilet areas. All areas of the home were exceptionally clean and hygienic. Domestic duties are carried out by staff only when residents are at day-centres away from the home this is a rule all staff understand. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 22 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): Standards 31 – 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures are to required standards. Staff training has been carried out to comply with previous requirement. Supervision of staff has improved. EVIDENCE: There were 3 requirements relating to these outcomes at the time of the last inspection : They were to provide staff training in Moving & Handling and Vulnerable Adults protection, to ensure POVA checks were carried out and all staff to received regular 1:1 supervision. – All have been satisfactorily addressed. A total of 280 weekly staffing hours are provided. This allows for 2 staff on duty throughout the daytime and one waking night care support worker. Additionally the Registered Manager works in the home full-time. The Manager has discretion to employ 2 waking night care workers if the dependency levels of the resident group demand this. There are currently 6 Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 23 care staff plus the Manager. There are 2 vacancies. Three people have obtained NVQ2 or above. All permanent staff have completed LDAF and 5 are now registered to undertake NVQ3 at Solihull college. Staff on duty showed a good level of professional competence and ability. The 2 residents receiving respite care did not have verbal communication but staff were seen positively engaging with them and there were very positive responses clearly discernable from facial expressions, hand signs and general demeanour. Staff seen have the required skills of communication. Staff files were seen and all required documents under Schedule 2 were in place. The two staff files seen were people previously employed by the providers in a domicillary care setting who had also worked at the home as “bank staff” over a long period of time before their permanent appointment. Presently gaps in the rota due to vacancies are covered either by existing staff or bank staff employed by the providers. All have knowledge of the operation of the home and experience of a large number of respite care residents. Supervision records were seen and it was clear that all staff had supervision at least 6 times per year. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 24 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): Standards 37 - 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the required qualifications and experience to run the home. The home is well managed and in the interests of residents. EVIDENCE: The Registered Manager is a dual qualified nurse (RGN RMNH) having working in relevant settings in hospitals and the Health Trust. She has been managing this home for 2 years and approved as the Registered Manager. It was a condition of her appointment that she completed the Registered Managers Award by March 2006. She did complete the award by the defined time. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 25 The Manager takes a positive lead in the home and monitors closely the care, practice and development of staff. Her wide experience of working in similar client group settings is evident. She has high standards and very positively pursues them. Her skills in dealing with a visiting prospective resident and his family during the inspection, showed a natural and professional ability and a high level of competence in this area of work. Visits are undertaken monthly and unannounced by a senior representative from Birmingham Multi-care (providers) and reports left in the home were seen. They contained all required information. Other feedback about the service is obtained from annual questionnaires sent to all carers and there is a residents questionnaire in picture/symbol format. It was suggested that the Manager should consider giving all carers a feedback form at the end of each respite period. A verbal update is given to carers of the progress of the placement and relatives asked for their verbal views. Records seen were completed to a good professional standard. A range of policies/procedures are in place and have been generally reviewed in the past year. Fire records were seen and all required checks had been carried out in relation to the alarm system and equipment. There had been regular fire drills involving all members of staff on at least a 3 monthly basis. Fire training is usually 6 monthly and staff sign to confirm drills and training. There were pictorial copies of the procedures to be followed in the event of fire. The Fire Officer visited in December 2006 and no requirements made. The Manager discussed the evacuation procedures further with the Fire Officer at that time who endorsed the procedures in place. The use of the lift in the event of fire was also discussed. The procedures for evacuation of the building in the event of fire appear adequate and have been endorsed by the Fire Officer. The Manager and Deptuy are both approved Moving & Handling Trainers. All staff receive annual training from them. A requirement of the last report to update Moving & Handling training for some staff has been addressed. The Inspector was concerned that the Training in place for the Trainers expired after 3 years in December 2007. The usual practice is for trainers to undergo annual updated training and this is certainly recommended in this instance. COSHH items are locked in a cupboard in the kitchen area and relevant data sheets are available. The home has secured a system for Health & Safety - including food hygiene recording. This include list of all daily food provided, testing of food Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 26 temperatures etc. Unfortunately recent records were not in place and this will be addressed by the Manager. All required notifications to CSCI under Regulations 37 had been made. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 27 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 4 5 X 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 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 2 3 X 3 3 2 3 3 2 x Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 28 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. Standard 1 2 3 YA9 YA19 YA42 Regulation 13(4) 12(1) Sched 4(13) Requirement All risk assessments must be signed and dated. Detailed records must be kept of all observed injuries & relevant body map. Ensure daily record of food provided is kept and food temperatures checked. Timescale for action 28/02/07 07/02/07 07/02/07 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 2 Refer to Standard YA37 YA42 Good Practice Recommendations It is recommended that carers are given feedback questionnaires at end of placements to add another dimension to quality assurance. It is recommended that approved moving & handling trainers have annual updated training. Greswolde Park Road, 4 DS0000016989.V325733.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Greswolde Park Road, 4 DS0000016989.V325733.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. 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