Inspection on 25/05/07 for 44 Manorford Avenue

This inspection was carried out on 25th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

44 Manorford Avenue 22/02/06

44 Manorford Avenue 19/09/05

44 Manorford Avenue 27/01/05

44 Manorford Avenue 26/07/04

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 44 Manorford Avenue West Bromwich West Midlands B71 3QH Lead Inspector Mr Jon Potts Unannounced Inspection 25th May 2007 10:00 44 Manorford Avenue DS0000004785.V332576.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 44 Manorford Avenue DS0000004785.V332576.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. 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 44 Manorford Avenue Address West Bromwich West Midlands B71 3QH 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 532 2749 Optimum Care Services Tracy Rayers Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: 44 Manorford Avenue is a small residential home, registered to care for three people with a learning disability between the age of 18 and 65. The detached four-bedroom property is situated at the end of a crescent within a residential area close to bus routes into West Bromwich town centre. At the front of the home there is a small garden and parking space, to the side and rear are extensive gardens. The ground floor consists of front porch, hallway, lounge, dinning room, kitchen, laundry, and shower and toilet. Upstairs are the four bedrooms (including staffroom), toilet and bathroom. Care is provided on the basis that it is the service users home and they are involved in all decisions that are made. The size of the home enables staff to provide a high level of support and interaction with each service user to promote independence. Frequent use is made of outside agencies including day centres and advocacy services. The fees for residency are £477.00 per week at present. 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over approximately four hours and involved the inspector case tracking the care of the residents, this involving looking at all records available in respect of their care and ensuring that the care agreed was provided. Further evidence was drawn from looking at other records including training plans, health and safety documentation, statement of purpose and polices and procedures. Residents were involved in the inspection process as were the staff on duty. Information was also received from the home prior to the inspection as well as comments from residents, relatives and significant others via CSCI questionnaires. Whilst the manager was not on duty at the time of the inspection, the inspector has had telephone discussions with her after the date of the visit. The residents and staff are to be thanked for their ready assistance with the inspection process. What the service does well: What has improved since the last inspection? The home has addressed all but one of the requirements from the last inspection and work completed has included: - Issuing staff with new contracts of employment, these detailing that new staff are now subject to a 3-month probationary period. - Gaps in training have been addressed and staff have received various training opportunities since the last inspection including accredited medication courses, this improving their skill and knowledge. - The manager is in the process of reviewing how the staff are supervised, this so as to improve the support that is offered, this critical as they are all lone workers. - Whilst the manager has not yet achieved the appropriate qualification in respect of managing the home, she has enrolled and is near to completing the same. - The homes medication procedure has been revised post inspection in response to comments made by the inspector and now better reflects the steps staff take to protect residents in respect of the administration of medication. 44 Manorford Avenue DS0000004785.V332576.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. 44 Manorford Avenue DS0000004785.V332576.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 44 Manorford Avenue DS0000004785.V332576.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): 1,2,4 5 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Prospective people who may use the service and their representatives have sufficient information needed to decide as to whether 44 Manorford Avenue will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: The home has developed a comprehensive Statement of Purpose and Service User Guide, which is very specific to the resident group and considers the different styles of accommodation, support, treatment, philosophies and services required to meet the needs of the people who currently use the service. The information is in a format suitable to the needs of the current residents with written English combined with images and pictures that support the former. One of the residents stated that information recorded in this way was useful for her. There have been no recent admissions to the home but discussion with staff and documentation evidenced that introduction to new services (such as daycentres) for residents was supported with the use of pictorial information (such as photographs) and this would be considered for new admissions to the home. Comments from relatives and significant others 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 9 indicated that information was always or usually available and if not staff were able to provide the detail that was required. Discussion with staff indicated that all new residents would receive a full comprehensive needs assessment before and through the phased admission procedure. The service was seen to be efficient in obtaining up to date reviews/assessments for existing residents and it was stated this would be applicable to any new admission, where it was stated the manager would insist on receiving a copy of the assessment and care plan carried out under care management arrangements prior to admission. The methods for admission, which would involve discussion between the manager and staff team, are supported by the homes procedures. Staff stated that before agreeing admission the service would carefully consider the needs assessment for each individual prospective person and the capacity of the home to meet their needs, this including consideration as to the matching of the new person with the existing residents which was seen as critical. Prospective people who use services are would be given the opportunity to spend time in the home through day visits building up to overnight stays. All people who use services receive a contract to which they have agreed, it gives clear information about fees and extra charges which is reviewed and kept up to date. This information is meaningful, and is supported by pictorial formats. The documents are also explained to individuals, so they fully understand the information. The use of advocates to support service users is encouraged, with both service users having such a service at present. 44 Manorford Avenue DS0000004785.V332576.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 excellent This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: One of the key principles of the home, and an aim that staff subscribe to is that residents are in control of their lives and have influence on the service they receive. Staff are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. People using the service will as far as possible, with the support of staff, make their own decisions and have the right to take risks in their daily lives. To support this plans have elements related to effective communication, in one instance based on the outcomes of speech therapy assessment. These were found to be accurate, this judgement based on discussion between the inspector and resident. 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 11 The care plan is developed with, and owned by, the individual, based on a full and up to date holistic assessment. The plan has some significant elements that are person centred with individual goals for the person identified that are significant and focus on the their strengths and personal preferences. Staff spoken to were aware of the need to develop the plans further so as to make them more accessible to the residents and to this end have taken numerous photos for use with the plans, this so that the residents can clearly identify what they do and how this fits in with their current requirements and aspirations. Following discussion it was agreed that the availability of a digital camera for the taking of photographs would be an asset and allow the production of images with the homes PC thereby bypassing the time waiting for development of photographs and reducing the cost as well. The local authority has reviewed the care of the residents late last year, with residents having involvement within this process and thereby contributing to the development of their plan and the ongoing review process. Service users spoken to stated they were aware of their plans and had an understanding of their contents. The staff stated that they encourage the individual to be fully involved, this reflected in the practice observed throughout the inspection. The home does not use key workers, this as there is a very small staff group and the use of such would not be seen to offer any tangible benefits beyond the support staff already offer. Staff stated that they are all involved in supporting residents on a one to one basis as and when needed. The current plans are up to date working tools used by the individual and all involved staff and one resident stated that the use of pictures was clearly useful in helping her understand the plan. The case file included risk assessments, which are regularly reviewed. The staff had a ‘can do’ attitude and risks are managed positively to help people using the service lead the life they want and achieve independence where possible. Any limitations on freedom, choice or facilities were agreed with the resident and reflected the person’s best interests, this based on assessments seen. Individuals are supported to know their rights and advocacy services are encouraged to promote these, both residents currently supported by such a service. Residents are continually consulted on how the service runs and have the ability to influence some key decisions in the home. They are involved in decisions about the areas such as staff selection, the day-to-day life of the home, and some future development. Some policies and procedures are developed based on practice that considers residents views and some key information is available in pictorial format. 44 Manorford Avenue DS0000004785.V332576.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): 12,13,15,16 & 17 Quality in this outcome area is excellent 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 meet individual’s expectations. EVIDENCE: In discussion the staff understood the importance of enabling the residents to achieve goals based on their interests and as far as possible have integration into community life and leisure activities based on their own self determination. Residents are able to enjoy a full and stimulating lifestyle based on a variety of options that they are able to choose from. The home was seen to seek the views of the residents through the care planning process and considered their varied interests when planning the routines of daily living and arranging 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 13 activities both in the home and the community. Routines are very flexible and residents can make choices in major areas of their life where they are comfortable doing so, this with the support of staff. The routines, activities and plans are focused on the individual’s choices and regularly reviewed. Routines can be changed to reflect resident’s choices on a daily basis in most circumstances. Residents commented on the fact that they can do what they wish any time of day. The service actively encourages the residents to have involvement in activities in keeping with their likes, dislikes and choices. Day to day activities the residents are involved with assist with maintaining their independence within a risk assessment framework. One relative commented that it was “lovely for us to see (resident) doing things around the house, even making us drinks when we visit”. The service actively supports people who use services to be independent and involved in all areas of daily living in the home including involvement in cleaning, shopping, planning meals, meal preparation and handling their own finances (the later with support and in accordance with detailed guidelines that are supported by procedures). The staff in discussion underlined that the home has a strong ethos that centres on involving residents in all areas of their life, and where ever possible they are encouraged to make informed choices, providing links to specialist support (such as advocates) when needed. This includes developing and maintaining family and personal relationships as and where appropriate. Relatives and significant others stated that the home always or usually assists the resident to keep in touch with them. There is evidence that staff have actively sought information to enable people who use services to access educational and vocational opportunity, and these reflected the choices of the resident, as supported by goals with the care plans. One resident showed the inspector a range of certificates obtained through college placements. Meals are very well balanced and cater for the cultural and dietary needs of the residents. The residents do not require support during meal times beyond planned assistance in helping them prepare their own meals. Mealtimes are flexible and relaxed, staff are available if needed and the homely and domestic style environment allows individuals the time they needed to finish their meal comfortably. 44 Manorford Avenue DS0000004785.V332576.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 excellent 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 needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The residents receive effective personal and healthcare support from a motivated, skilled, well trained and knowledgeable staff group that work in the residents best interests. Staff were found to be aware that the effective provision of support to residents is critical in achieving positive outcomes for them. Resident’s individual plans clearly record their personal and healthcare needs and detail how they will be delivered in conjunction with health action plans completed by the residents G.Ps. Staff were seen to offer care that was resident led. Care Planning showed how the staff would meet the changing needs of the residents. Staff were seen to respect residents preferences and demonstrated in discussion a sound knowledge base in respect of addressing residents individual personal needs when providing support. This would only involve intimate care on rare 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 15 occasions due to the resident’s having maintained their independence in respect of day-to-day intimate personal care. The staff group is all female thereby reflecting the gender of the residents. Staff in discussion were acutely aware of the need to provide privacy to the residents at time them were undertaking personal care for themselves, ensuring that they had access to privacy. Whilst little in the way of aids and equipment is currently required the service has assessed for the need to provide grab rails in the bathroom so as to ensure the residents independence can be safely maintained. The residents have the opportunity to choose their G.P. within catchment areas and were seen to have access to all necessary NHS healthcare facilities in the local community. Regular appointments are seen as important and systems are in place to ensure they are not missed, with these diarised. The home arranges for health professionals to visit residents at home if and when necessary. Relatives confirmed that the health and general care provided to residents was as they expected it should be. Staff members in discussion were aware of how they should respond to changes in mood and behaviour and exhibited a good knowledge of detailed indicators of potentially challenging behaviour as listed in residents case files. The home’s medication policy, procedure and practice guidance has been revised since the time of the inspection, a copy having been forwarded to the CSCI. The revised policy is improved over that seen at the time of the inspectors visit and has addressed all issues raised at the time of the visit. Staff all had access to the policy at the time of the inspection and also understood their responsibilities in respect of medication, as is now detailed in the revised policy. The home strongly promotes independence although residents are supported to take their medication by staff, this with the consent of the residents as documented in the case files. Medication records as seen were up to date and whilst details were handwritten on the sheets by staff these were consistent with the printed labels found on the medication itself. The home did not have any controlled drugs in safekeeping at the time of the inspection. If the home does have controlled drugs then the procedure for handling of these must be added to the procedure. Care staff that give medication were all seen to have the required accredited training. Staff raised concern as to the size of the medication storage cabinet, which was only large enough to enable a week’s supply of medication for residents to be stored safely. The provision of a larger cabinet would be seen to reduce the task of booking in medication every week and thus free up staff time that could be spent with the residents. 44 Manorford Avenue DS0000004785.V332576.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 and have access to a robust, effective complaints procedure. They are protected from abuse, and have their rights protected. EVIDENCE: The home has an open culture that allows residents to express their views, and concerns in a safe and understanding environment. Residents and others involved with the service say that they are happy with the service provision, feel safe and well supported by an organisation that has their protection and safety as a priority. The service has a complaints procedure that is clearly written and easy to understand and is available in formats understandable to residents, with verbal explanation also offered by staff. One of the residents was clear as to the fact that they understood the complaints procedure, the other not so, although did state that staff listened to her and addressed any issues. Others significant to the residents also stated that they understood the homes complaints procedure, although to date have had no concerns as to the service. The home has comment forms freely available to visitors to the home, and the views of residents are formally obtained through service monitoring questionnaires. The complaints procedure is available within the home in the service users guide, this kept freely available by the entrance. It was understood that the 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 17 home would keep a full record of complaints and details of the investigation and any actions taken should complaints be received, although there have been none recently. Whilst there was no copy of the local authorities safeguarding adults procedures available at the time of the inspection (although discussion with the manager since has indicated that the home does have a copy), the home’s own policies and procedures for safeguarding adults were available, these seen to give robust and specific guidance in line with local authority expectations. When staff were spoken to they were clear as to when incidents need external input and who to refer the incident to. The procedures indicate the home understands the procedures for safeguarding adults and will always attend meetings or provide information to external agencies when requested. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. Training of staff in the area of protection is regularly arranged by the Home, this from the local social services department training section. Other training around dealing with physical and verbal aggression has been made available to some staff as needed. 44 Manorford Avenue DS0000004785.V332576.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 through to 30 Quality in this outcome area is adequate 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 home that’s layout and position is good for purpose, and encourages independence. There are concerns as to the safety of the environment with limited essential maintenance compromising what could be a very pleasant home. EVIDENCE: The home provides a physical environment that meets the specific needs of the people who live there. Whilst the home is generally comfortable there are issues around the maintenance of the house, with works identified not always completed. Maintenance tends to be reactive rather than proactive. The homes kitchen is dated and is in need of refurbishment as is the wooden porch, which is rotten in places and requires urgent attention. Staff spoke of having difficulty opening and shutting the front door, which is prone to swell in 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 19 wet weather. The home has had a recent inspection of its electrics, this raising issue in respect of the safety of the wiring and some electrical sockets. A quote has been obtained for the works required but to date has not been carried out. This does raise concerns as to the buildings safety. It was also note that there was a large crack in the garage wall. It is not known whether this compromises the structural safety of this building but as a precaution the manager ensures residents nor staff enter this part of the home. Comment was made by one of the residents, who thought the refurbishment of the kitchen, and the work to the porch would be a good idea. Residents are able to personalise their rooms, this seen when residents showed the inspector their bedrooms, these recently redecorated. It was seen from a tour of the environment that the house was clean, warm, well lit and there was found to be sufficient hot water. It was also noted that all radiators have been fitted with covers to prevent access to hot surfaces. There has been some consultation with service users about the décor, especially for their own rooms. Whilst there are no en-suite facilities there are ample toilets available with only two sharing the upstairs bathroom at present and there has been some adaptation to assist residents to access the bath independently (provision of grab rails). Toilets for the use of people using the service are appropriately located within the home, are easily accessible and in sufficient numbers. All residents have access to single rooms. The small scale of the home, with only a maximum of three residents accommodated allows for a homely unit with a community focus. Both residents were seen to have keys to their rooms and were able to use these areas whenever wished for privacy. Communal areas include a lounge and dining area, which provides ample space for privacy. The kitchen, which is of a reasonable size, is separate to these rooms and allows space for staff and residents to occupy this area at the same time. The house also has a private and pleasant garden area. The home is generally clean and tidy, and there have been no outbreaks of infection. 44 Manorford Avenue DS0000004785.V332576.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 excellent 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: No staff have been recruited since the last inspection, which evidences that the turnover of staff is minimal and as a result there is a real consistency to the service delivered to residents. The service has a robust recruitment procedure that has the needs of people who use the service at its core. The staff spoken to saw recruitment of good quality carers as integral to the delivery of an excellent service. The staff stated that service is highly selective, with the recruitment of the right person for the job being more important than the filling of a vacancy. It was stated that residents would meet any prospective staff prior to employment and would have chance to comment. It was stated that if the residents had issues with a person then these would be taken seriously. 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 21 The service has sufficient staff available at all times to support the needs, activities and aspirations of the people using the service in an individualised and person centred way bearing in mind that the residents have a high level of independence and require prompting rather than hands on assistance. The service is proactive rather than reactive in respect of its training, with planning for the potential needs of residents, staff and national developments in advance. An example of such was the manager referring staff for training in respect of the Mental Capacity Act that has only recently come into force. 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 they demonstrate a thorough understanding of the particular needs of the service users, and can deliver highly effective person centred care. The only area where it was felt the staff would benefit from further input was in respect of equality and diversity. The staff team support each other and share skills and knowledge with colleagues. The roles and responsibilities of staff are clearly defined and understood by the staff. There is some diversity in the staff team and its composition reflects the culture and gender of people using the service. People who use services consistently report that they are having their needs met by the staff team that support them. People using the service also report that they know the staff team well, know their names and are able to communicate with them freely and easily using their preferred method. Comments from relatives and significant others confirms that they feel staff have the skills and experience to look after residents properly and they are very friendly and forthcoming with any queries or questions they are asked. Staff spoken to understood and are aware of the specific nature and uniqueness of the home, its aims and objectives and how care will be delivered 44 Manorford Avenue DS0000004785.V332576.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 & 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 and is developing effective quality assurance systems based on the views of residents and stakeholders. Some maintenance issues compromise health and safety of residents. EVIDENCE: The registered manager is currently studying for her management qualification and based on the outcomes from this inspection is highly competent to run the home and met its stated aims and objectives. The manager is supported by a representative of the company that reports to a committee that has overall responsibility for the strategic and financial planning in respect of the home. 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 23 The manager, based on the comments made by staff, has a clear vision of the home based on the organisations values. Staff spoken to were positive about the manager and they had a clear sense of direction. This evidenced that they were kept well informed as to developments within the home and knowledge of ‘best practice’ operational systems, this through regular training, supervision and a keen interest in continuous improvement of the service. Discussion with the manager after the inspection indicated that she (and the staff) had a positive view of inspection, and were keen to work with regulators in respect of service improvement. The home was seen to have a formal consultation process with the people who use the service and their representatives, as well as there been on going dayto-day consultation. The manager and staff make sure that good practice is modelled and developed throughout the service. An external representative of the company visits the home on a regular basis and written reports are made available to the home and the board of trustees. These reports were seen to consider the service in respect of its impact on the quality of life for service users. The manager ensures that staff follows the policies and procedures of the home, this evidenced by the fact that in discussion with the inspector they had a good understanding of these and had all signed to say so. All the working practices in the home are safe and there have been no recent accidents. The home has a comprehensive range of policies and procedures to promote and protect residents’ and employees’ health and safety. Staff are trained, understand, and consistently follows these, as was evidenced by discussion. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with statutory reporting requirements. The staff have a good understanding of risk assessment processes and this is taken into account in all aspects of the running of the home. Findings from risk assessments were seen to have been followed up although there was as previously mentioned concern as to unaddressed maintenance issues that potentially compromise the health and safety of residents and staff. Health and safety systems are regularly reviewed and updated and are developed on the basis of experience in the home and learning from external developments. An example of this is the introduction of the ‘better food, better business pack’ in respect of food safety. The manager ensures that all staff are trained in health and safety matters, individual training records reflecting this, with evidence of regular updates planned. 44 Manorford Avenue DS0000004785.V332576.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 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 25 CHOICE OF HOME Standard No Score 1 3 2 4 3 X 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 3 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 2 X 3 X X 2 X 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 16,23 Requirement The kitchen cupboards had several doors missing, were looking dated and need replacing. The garage side door that is no longer used needs boarding up securely. These are outstanding requirements from the 27th January 2005. These works must be completed to ensure the kitchen is fit for purpose and a suitably place for residents to cook. The garage side window has been boarded up but not the door, which is a potential risk to residents when in the garden. The provider must ensure that all works identified in the last periodic inspection of the buildings hardwiring is completed so as to ensure the environment is safe for residents. The porch must be refurbished or replaced in accordance with DS0000004785.V332576.R01.S.doc Timescale for action 30/09/07 2. YA24 13(4) c 16(2) h, 23(2) b 31/07/07 3. YA24 23(2) b 31/10/07 44 Manorford Avenue Version 5.2 Page 27 the wishes of residents. 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 YA20 Good Practice Recommendations To replace the homes medication cabinet so that a month’s supply of medication can be ordered and stored at once, this so as to reduce the time spent ordering medication every week and free up more time for staff to spend with residents. 44 Manorford Avenue DS0000004785.V332576.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 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. 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