Inspection on 31/07/07 for 44 Sedgley Road

This inspection was carried out on 31st July 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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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 Sedgley Road Woodsetton Dudley West Midlands DY1 4NG Lead Inspector Jayne Fisher Key Unannounced Inspection 31st July 2007 09:20 44 Sedgley Road DS0000068643.V342014.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 Sedgley Road DS0000068643.V342014.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 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 44 Sedgley Road Address Woodsetton Dudley West Midlands DY1 4NG 01902 887630 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) Swan Village Care Services Limited Mrs Jacqueline Margaret Matthews Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection New service Brief Description of the Service: 44 Sedgley road is a 5 bedded detached property situated in a residential area, on a main road in the Woodsetton area of Dudley borough. The home was registered on 31 January 2007 to provide care for up to five adults who have a learning disability. 44 Sedgley Road is located close to Dudley town centre and is within easy access of a local nature reserve. There is good access to community facilities and public transport bus routes. The property offers five single en-suite bedrooms well in excess of the minimum space requirements, some with a lounge area. There is a communal lounge on the ground floor, and there adequate WC’s, bath and shower facilities through out the building. There is an easily accesible garden at the rear with a small car parking space which is shared with another adjacent care home. Information regarding fee levels was provided by the manager on 31 July 2007 which are £2,500 per week. This does not include extra services such as private health and dental care, hairdressing, entrance fees for outings and activities. These are all available at extra cost to the residents. A statement of purpose and service user guide are available to inform residents of their entitlements. 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 09.20 a.m. and 3.30 p.m. with the home being given no prior notice. The home is newly opened and we met and spoke with the one resident who has recently been admitted. We interviewed the registered manager and two staff members who were on duty. We looked around the home, examined records and observed care practice. We also looked at all of the information that we have received about this home since it was opened six months ago. What the service does well: The home has a team of qualified and enthusiastic staff who have a good knowledge of the needs of the people in their care. The atmosphere was friendly and welcoming through out our visit and the resident looked happy and at ease with staff who were seen to be supportive and encouraging. Staff help residents enjoy a varied and stimulating lifestyle. They are able to participate in a range of activities within the home and local community, following their own hobbies and interests. Residents are encouraged to be independent and can make their own drinks and snacks when they wish. They can choose what they want to eat and there is a healthy range of food from which they can make their choices. The staff are very good at helping people stay in touch with their family. This includes making phone-calls and receiving visits. There are very good systems in place to ensure that any health care needs are quickly identified and appropriate treatment is sought. Residents have access to a range of health care specialists. The home is clean, light and airy and is decorated and furnished in a modern style. Bedrooms are very large and spacious. They were well decorated according to the resident’s individual tastes, interest and age. New staff are only recruited following the appropriate clearance checks which offers protection to residents. There is a range of on-going training for staff to undertake so that they can met the specialist needs of residents. Male and female staff are employed so that people have a choice of who they wish to support them. Residents benefit from a home that is run in their best interests by an experienced and dedicated manager. 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Sedgley Road DS0000068643.V342014.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 Sedgley Road DS0000068643.V342014.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 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about whether or not they want to live in the home. Potential residents’ needs and goals are assessed before they move in to see whether it is a suitable place for them to live. EVIDENCE: The manager showed us the statement of purpose. This is comprehensive and informative. There are a couple of areas which need updating as they are inaccurate. The document states that residents can smoke in the lounge and that nursing care is provided. The manager agreed to change this. There was a service user guide on display in the foyer. It was also very helpful and informative. There were some details which were inaccurate regarding former staff however the manager showed us an updated document and agreed to display this. There is also a very useful pictorial service user guide for residents. We saw that residents are given a ‘welcome pack’ containing all of these documents and other important information. The manager told us that residents can keep this in their bedrooms if they wish. 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 9 Since officially opening in January 2007 the home has now admitted one new resident. She came to live at the home four weeks ago. We chatted to staff and the resident who told us that introductory visits had been carried out. Staff had also visited the previous home where the resident had lived. There were detailed records completed. We asked the resident what she liked about living at her new home and she replied “I like X” (referring to her key worker). We looked at the resident’s case file and saw that the manager had obtained relevant documentation from the placing officer. She had also completed an in depth assessment of her own. We reminded the manager that the Care Homes Regulations 14(1)(d) require the registered person to write to the resident confirming that the care home can meet their needs following the assessment. 44 Sedgley Road DS0000068643.V342014.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provide staff with the information they need to know in order to support the resident to meet their needs, goals and aspirations. The resident is supported to make choices about her daily life and is enabled to take risks within a risk assessment framework. EVIDENCE: Although the resident has only been admitted to the home four weeks ago, we saw that there are already a range of care plans which have been developed. There are two folders. One contains health care information and relevant support plans related to this subject. The second folder contains care plans regarding topics such as showering and bathing, communication, personal hygiene, choosing clothes, oral hygiene, personal grooming, nail care, night time routines, privacy, supporting relationships, daily life skills, activities and behavioural support. 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 11 Care plan formats are also easy to understand with agreed support needs, short term and long term goals and detailed interventions required to meet the needs identified. The resident who is able to read and write according to staff is signing the care plans to demonstrate her understanding and agreement. Through out our visit we saw staff supporting the resident to make her own decisions for example she chose when to have her shower and what assistance she wanted from staff. There is a support plan in place which is entitled ‘supporting me in decisions’. As well as a communication plan in place the manager has also asked the resident’s family to compile a list of words which are familiar to the resident which is an excellent initiative. The manager has also arranged for the resident to receive the assistance of an advocate. We saw that the resident is enabled and supported to take risks; for example making her own drinks and snacks. There are a range of risk assessments in place and these are being developed along side care plans. For instance current risk assessments include showering and bathing, making drinks and challenging behaviour. 44 Sedgley Road DS0000068643.V342014.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that residents experience a meaningful lifestyle to include participation in a wide range of activities. Contact with relatives is actively promoted. Residents are provided with a balanced and varied diet. EVIDENCE: We saw the resident involved in various activities through the day. When we arrived in the morning the resident was chatting and singing along to music with her key worker and later went to her room with a member of staff to play on her computer. In the afternoon the resident went out for a picnic in a park accompanied by staff. We looked at the resident’s activity programme. The key worker explained that this is planned weekly with the resident. We chatted to her and she confirmed that the activities identified, were those which she enjoyed. There were a range of in-house and community based 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 13 activities with lots of access to the local community. For example during one week there were plans to carry out housework tasks, walks to the shops, watching movies, arts and crafts, bus trips to local towns, a pub lunch, going to the cinema and a visit to a local beauty spot. Very detailed daily reports completed by staff demonstrated that a wide range activities did take place. The key worker told us that there are plans to look at a college placement when courses restart in September. The resident likes to do arts and crafts and these were on display in her room and in the house. The resident confirmed to us that she has contact with her family. There was evidence of lots of family involvement and visits contained within daily report sheets. During our visit a family member telephoned to enquire as to the welfare of their relative and spoke with the manager. Staff confirmed that the resident is also able to maintain telephone contact. We saw that daily routines are flexible and promote independence. For example, the resident was able to make her own drinks and snacks and also made drinks for the visitor. Bedrooms and bathrooms are fitted with privacy locks. The resident told us she did not have a key to her bedroom and staff said this had been offered. There were pictorial signs on the bedroom door to knock before entering. The key worker was understanding of peoples’ rights and told us “she knows when to shout don’t come in when we knock. Every one is entitled to their privacy”. The welcome pack given to residents contained a range of policies in pictorial formats informing residents of their rights for example with regard to voting, advocacy and opening of correspondence. Through out the morning of our visit we saw and heard staff interacting positively with the resident. We looked at the weekly menu which was displayed in the kitchen in written and pictorial formats. There were two choices for every meal. There was a varied and balanced diet provided for the resident including meat, fish, vegetables, salads, pasta, rice, traditional English foods and spicy meals. A bowl of fresh fruit was available in the lounge. The resident told us that she prefers burgers and although these were on the menu, it was pleasing to see that they are home made therefore encouraging a more healthy diet. There are good records maintained by staff of what options the resident chooses from the daily menu. There is a nutritional screening tool in place and this was completed upon the resident’s admission. It was suggested that it may be also beneficial to include the body mass index calculation in this tool. We gave advice as to how this may be carried out and staff contacted the community dietician to obtain further information. 44 Sedgley Road DS0000068643.V342014.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require and their health needs are very well met. The systems for the administration of medication require slight improvement to ensure resident’s medication needs are safely met. EVIDENCE: We looked at daily reports completed by staff which demonstrated that the resident can choose when to go to bed and when to get up in the morning, times are varied and flexible. There were very detailed support plans in place regarding how the resident likes to receive support with a range of personal care needs including nail care, grooming and helping to choose clothing. We chatted to the resident who said “I like it here, I like X” (referring to her key worker). There are male and female staff available so that residents can have a choice about who they want to support them. The manager told us that she was sensitive to resident’s gender preferences with regard to staff and would be recording her observations in relevant care plans. 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 15 Our observations and examination of daily reports confirmed that staff are fully aware of the need to promote the resident’s dignity for example by ensuring appropriate clothing and underwear is worn. Although only recently admitted to the home very good efforts have already been made to establish the health care needs of the resident. For example, the manager has taken the resident to visit her General Practitioner (G.P.) who has carried out a health check as part of a health care action plan. A checklist of actions has been devised with regard to making appointments to see health care specialists, attending health care screening and other routine appointments. The manager is monitoring these and signing them off when they are completed. For example, for the forthcoming week a ophthalmology check had been arranged. Care plans are in place for specific health care issues. For example, there is a detailed support plan in place for management of epilepsy, accessing health professionals and supporting the resident with clinical procedures. We looked at medication management and generally found some good practice although improvements are necessary in certain areas. For example, there are detailed guidelines in place for ‘as and when required’ (PRN) medication. However, as we discussed with the manager, these would benefit from identifying the maximum doses within a twenty four hour period and the number of consecutive days that PRN is administered before further medical advice is sought. The manager discussed some of her concerns over the amount of medication that the resident had been receiving on her admittance to the home and agreed to arrange an appointment to seek further clarification with the psychiatrist. We saw that the resident is prescribed Midazolam to be administered as and when required, by the buccal route. Whilst staff have not yet had to administer this medication, this type of procedure is considered to be a specialist technique as it is invasive. The manager confirmed that staff had not received training from a healthcare professional in line with guidance issued by CSCI regarding ‘training care workers to safely administer medicines in care homes’. There is no written invasive policy or protocol in place regarding administration of this medication. There was no written risk assessment. We also discussed the need to obtain residents’ consent to administration of medication and to record this in their care plans (or to make decisions in their best interests if this is not possible and record outcomes). The manager stated that half of the current staff team have not received accredited training in the safe handling of medication and are involved in administration of medicines. However, training is booked to take place in September and October 2007 and in the interim the manager has given guidance and carried out competency monitoring assessments which she was able to show us. We saw that the medication policy had been signed by three 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 16 staff and the manager told us that all staff were going to sign this document to denote that they had read and understood it. There were detailed records of receipt of medication into the home although some medication had been returned to the pharmacist and had not been recorded. The manager agreed to take appropriate action. We noted that the storage of keys to the drug cabinet could be safer and the manager immediately took appropriate action. There were no gaps in the medication charts however we did suggest that when medication is administered later than the time identified on the medication chart, that staff record the actual time the medication is given. 44 Sedgley Road DS0000068643.V342014.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. The home has a satisfactory complaints procedure which ensures residents views are listened to and acted upon. There are systems in place to protect residents from abuse with only slight improvements necessary. EVIDENCE: There have been no complaints received about 44 Sedgley Road since it was opened. There is a comprehensive complaints procedure which is openly displayed within the home. There is a pictorial complaints procedure for residents and copies are held in their ‘welcome packs’. We saw that there is a safeguarding policy and a copy of the Department of Health’s guidance ‘no secrets’ held in the managers office. There is no copy of the Local Authority safeguard and protecting vulnerable adults policy on the premises. We discussed this with the manager who is aware that she needs to obtain a copy. We interviewed staff and they gave good responses regarding how to deal with any potential incidents of abuse. One member of staff has undertaken training in vulnerable adult abuse awareness and during interviews two other staff said that they had had training with their former employers. As we discussed with the manager it is recommended that all staff receive this training. The manager told us families are responsible for managing residents’ money and staff offer guidance and support. We saw that there was a detailed support plan and risk assessment in place. It was pleasing to see that the 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 18 manager had arranged for a resident to open a bank account in order to encourage independence. Where money is held on behalf of a resident there is a personal expenditure sheet in place. We checked this and saw that generally all transactions made on behalf of the resident were signed by two staff. There is a daily audit and balance of all monies held with records maintained on a handover sheet. We saw that on a couple of occasions the daily check had not been completed. The manager told us that this was because staff were currently familiarising themselves with the new procedures. We checked the monies held and this did not balance with records. There was a slight discrepancy of £0.10 p. The manager discussed this with staff who thought some monies may have been retained by the resident following a shopping trip. We agreed that this was good practice but needed to be identified on the balance sheet. We noticed that on occasions residents pay for their own meals when out in the community in place of meals provided by the home. The manager stated that there is a weekly activity budget identified for the resident and that when this is exceeded, the resident is then responsible for covering the cost of some of the activities including meals. The service user guide does not include this information and there is no written protocol or details in the terms and conditions of occupancy which the manager said had yet to be drawn up. During interviews staff were unclear as to the total sum of this weekly activity budget. We suggested to the manager that details need to be written in relevant documentation. 44 Sedgley Road DS0000068643.V342014.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. Residents live in a comfortable and attractively furnished home with spacious bedrooms. There are systems in place to sufficiently protect residents against the risk of cross infection. EVIDENCE: We toured the premises and a resident showed us her bedroom. The bedroom was very spacious and decorated according to her tastes, interest and age. Staff told us that when she originally moved into the home she did not like the colour of the room and this was therefore decorated. Discussion with the resident indicates she is happy with the decor. All bedrooms are ensuite, large and airy. Communal areas are decorated and furnished to a very good standard. There is an enclosed patio area and separate attractive garden space in which the resident had planted her ornamental sunflowers There were some recommendations made by CSCI when the home was opened and we saw that these had mostly been carried out. The only exception is that 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 20 the loft hatch accessible in one resident’s bedroom needs a suitable locking mechanism. On the day of our inspection the home was clean, hygienic and free from offensive odours. There is a small laundry area adjacent to the kitchen which has impermeable walls and flooring. Mops and buckets were stored in this area but were not dried inverted and we suggested the manager purchase a suitable rail. We also suggested that a risk assessment be completed due to the close proximity to the kitchen, as extra precautionary measures may be necessary when the home is fully occupied and dependent upon residents’ needs. At present there is no requirement for clinical waste disposal. We saw that communal areas and toilets had supplies of liquid soap and paper towels. One resident’s bedroom carpet despite being only recently fitted was slightly stained. We discussed with the manager the necessity for including a regular deep cleaning programme on the current cleaning schedule. 44 Sedgley Road DS0000068643.V342014.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): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in sufficient numbers by an enthusiastic and qualified staff team. Recruitment and selection procedures are robust and offer safeguards to residents. EVIDENCE: The manager told us that three of the six support staff employed hold an NVQ qualification and all remaining staff have been put forward for this training which was verified by staff who we spoke to. We interviewed staff and they demonstrated a good understanding of their roles and responsibilities. A key worker gave good examples as to how she positively and sensitively manages any challenging behaviour. The manager is aware that some specialist training needs to be provided and that the range of this training will be very dependent upon the future residents’ needs, as and when they are admitted to the home. We recommended that some initial training take places with regard to epilepsy awareness, the Mental Capacity Act 2005 and managing challenging behaviour. There are photographs of staff members on display in the foyer with details of their names and roles which is very helpful for residents and visitors. 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 22 We saw that there are currently one or two staff on duty per shift as the resident requires the support of two staff when out in the community. Staff told us that they had recently attended a staff meeting. We sampled two staff files and saw that all the required pre-employment checks had been undertaken. For example there were police clearance checks, two written references and full employment histories. Staff had signed to confirm that they had received copies of their job descriptions. Staff confirmed that they had undertaken induction programmes and we saw copies of these held on their files. Although inductions were seen to be comprehensive, staff had not yet commenced an induction programme provided by an accredited learning disability awards framework (LDAF) provider. The manager told us it was her intention that staff would undertake this award. Not all staff have received training in equality and diversity. There was a useful training matrix displayed on the manager’s office wall. Both staff who we interviewed told us that they had recently received a supervision session. 44 Sedgley Road DS0000068643.V342014.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, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit home that is run in their best interests by a competent and skilled manager. There are quality assurance systems ready to be introduced so that residents can be assured they will participate in the development of the service. Practice and procedures are in place to promote residents’ health, safety and welfare. EVIDENCE: The registered manager is experienced and skilled. She has completed her NVQ IV in care and is currently undertaking her Registered Manager’s award (we met her assessor during our visit). We saw that the manager had a good rapport with both staff and the resident. Staff told us that they felt supported. One staff member told us “she’s totally approachable, and so are all the 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 24 others”. Mrs. Matthews has already introduced some very useful monitoring tools and communication aids for staff such as very informative daily reporting systems. As well as being the registered manager for No. 44 Sedgley Road, Mrs. Matthews informed us that she also has a service manager role for eight other care homes owned by the provider. She told us that this does not impact upon her role at No. 44 and that these responsibilities involve around sixteen of her supernumerary hours per month being spent involved with other services. There was no job description available for us to view and we have asked that one is established and sent to us. The manager demonstrated that she has a quality assurance file in place. Due to the home only recently being opened, and being occupied by one person, the quality assurance systems have not yet had a chance to be fully embedded into the running of the home. Maintenance and service checks were examined when the home was registered and found to be in place. We sampled a couple of records and found these to be up to date. For example, there is weekly checking of the fire alarm system and monthly checks of the emergency lighting. There is a fire safety risk assessment in place and regular fire evacuation drills. The fire officer visited when the home was opened and was satisfied with the precautions in place. He recommended that the fire alarm system be extended to the manager’s office which has been actioned. The manager told us that a further visit has been undertaken by the fire safety office and that there are no works to be carried out. We saw that there is regular checking of the water temperatures. These have fluctuated and contractors have visited to rectify any issues identified. We looked at statutory training for staff and saw that this is an on-going process. Staff have received in-house fire safety instruction and the manager told us she has booked staff to attend further training by a qualified fire safety trainer. The majority of staff have received training in food hygiene, moving and handling, health and safety. It is recommended that all staff receive training in the required disciplines. We looked at food hygiene practice and saw that this was efficient. There is a food hazard analysis, regular testing of cooked food, fridge and freezer temperatures. High risk foods are labelled with the date of opening and stored in the fridge. 44 Sedgley Road DS0000068643.V342014.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 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X X X X 2 X 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NA STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement In order for residents to receive their medication safely: To ensure that staff receive training in the administration of medication by specialist techniques (such as Midazolam by the buccal route) from a healthcare professional. To establish a written protocol and procedure for the administration of medication by specialist techniques, and to discuss and agree this with a healthcare professional. Timescale for action 01/11/07 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 YA1 Good Practice Recommendations To review and amend the statement of purpose and to forward a copy to the Commission (for social Care Inspection). DS0000068643.V342014.R01.S.doc Version 5.2 Page 27 44 Sedgley Road 2. YA20 To further develop PRN guidelines and include maximum dosage within twenty four hours and maximum consecutive days that this medication can be administered before medical advice is sought. To continue to pursue plans to ensure that all staff receive training in the safe handling of medication. To develop a written risk assessment for the administration of Midazolam by the buccal route. To obtain consent from residents with regard to the administration of medication and record this in the care plan. To obtain a copy of the Local Authority safeguard and protecting vulnerable adults procedures. To ensure that all staff receive training in safeguard and protecting vulnerable adults. To ensure that any agreements made with the Local Authority commissioners and resident in respect of a weekly activity budget is detailed in relevant documentation such as the service user guide, terms and conditions of occupancy and support plan. To fit a suitable locking mechanism to the loft hatch which is accessible via a resident’s bedroom (no.2). To include a regular deep cleaning programme for carpets on the cleaning schedule. To ensure that mops are dried inverted. To carry out a written risk assessment identifying control measures for minimizing the risk of cross contamination between the laundry and kitchen areas. It is recommended that staff are provided with a range of specialist training including: epilepsy awareness, managing challenging behaviour and the Mental Capacity Act 2005. To pursue plans to ensure that staff received induction training by an accredited learning disability awards framework (LDAF) provider. To ensure that staff receive training in equality and diversity. To pursue plans to ensure that all staff have received training in food hygiene, first aid awareness, moving and handling, health and safety, and infection control. 3. YA23 4. 5. YA24 YA30 6. 7. YA32 YA35 8. YA42 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 28 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 44 Sedgley Road DS0000068643.V342014.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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